Registered Nurse Scope of Practice in Australian Primary Healthcare Settings: A Retrospective Longitudinal Study

Abstract

Background: Registered nurses (RNs) play an important role in providing primary healthcare (PHC) services. Longitudinal evidence on how the RN scope of practice in these settings has evolved over the years is currently missing and is critical in understanding how Australian government health policies have shaped the reality of nursing practice.

Aim: To explore the scope of practice of RNs in Australian PHC workplace in both metropolitan and rural areas and among those with and without postgraduate qualifications during 2015–2019.

Methods: Longitudinal survey data were retrospectively retrieved, collated and analysed using variate and bivariate analyses in SPSS Version 27.0. Composite items were used to combine survey items into seven key areas of nursing practice.

Results: Majority of the 3882 participants were female (n = 3782, n = 97.4%), worked in general practice (n = 2916, 75.1%) and in metropolitan areas (n = 2145, 55.3%) and had completed a short course (n = 2470, 63.6%). A total of 904 participants (23.3%) completed at least one postgraduate degree. There was no significant and substantial difference in the frequency, and preference for frequency, of seven PHC practice areas by participants in different workplace localities, with or without a formal postgraduate degree as well as throughout the 5-year survey period.

Conclusion: The findings on the scope of practice by the RN participants might be explained by the interplay of interprofessional, organisational and institutional factors (more than individual factors).

Implications for Nursing Management: Multilayer strategies targeting interprofessional, organisational, institutional and individual factors should be in place to enable RNs to work to their full capacity and advanced level of education. RNs also need to be included in major policy- and decision-making that affects them to ensure their job satisfaction, retention in practice and contribution to patient health outcomes in PHC are sustained.

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

1. Introduction

Primary healthcare (PHC) is regarded as the most equitable, inclusive and effective approach to healthcare [1]. Indeed, PHC is important to all health systems because it enhances people’s health and well-being; prevents, treats and manages chronic conditions; reduces avoidable admissions to acute care settings; and thus, improves population health outcomes [2]. The importance of PHC is further emphasised where the burdens of chronic conditions have been growing globally and are projected to continue rising [3].

Nurses, especially registered nurses (RNs), play an important part in providing PHC services, alongside other healthcare practitioners [4, 5]. The role and responsibilities of RNs in PHC settings encompass a wide range of activities and services including chronic condition management, coordination of care, health promotion, pharmaceutical management and administrative tasks [5]. Internationally, RNs contribute significantly and positively to patient health outcomes, from care satisfaction and quality of life to self-efficacy and improved health behaviours [6]. They thus have profound impacts and further potential to contribute to the overall PHC system [7].

Evidence suggests that institutional and policy settings can influence the delivery of PHC [8]. In the Australian context, there have been a number of major government and federal policies and strategies focussing on PHC practice over the last two decades [9, 10]. However, there is currently a lack of longitudinal evidence on the evolution of the RN scope of practice in PHC over time. To our knowledge, Halcomb and Ashley’s [11] study appears to be the only research that attempts to describe nurse clinical activities at two different time points (2012 and 2015). Halcomb and Ashley’s research focused on nurses at all registration levels and was limited to general practice (GP) settings. There remains a gap in knowledge about RN practice in other PHC settings and any variation in the scope of practice in different PHC localities, or between those RNs with and without a postgraduate degree. This study has been conducted to explore these aspects of Australian PHC to ensure we target future education, policy and practice strategies to align with the reality of PHC settings. In the context where the Australian Government is developing a National Nursing Workforce Strategy to strengthen workforce sustainability, workforce diversity, addressing challenges faced by nurses in rural, regional and remote areas and career pathway in nursing [12], this study is anticipated to contribute significant evidence to inform these important strategies moving forward. More specifically, this study aims to explore the scope of practice of RNs, including frequency of and preference for key areas of practice, in Australian PHC settings in different workplace localities and among those with and without a formal postgraduate qualification during 2015–2019.

2. Materials and Methods

2.1. Design

A retrospective longitudinal study design [13] was selected to facilitate the analysis of the data that were collected over a period of time in the past.

2.2. Data Collection

This study used the dataset collected through the Australian Primary Health Care Nurses Association’s (APNA) annual workforce surveys during 2015–2019. The survey tool, developed in 2004 and modified in 2015, was intended to describe the demographic and professional characteristics of nurses working in Australian PHC workplaces using various question types and formats. Due to the descriptive nature of a workforce survey and a broad range of topics included, psychometric properties were not established. However, it was piloted among a small group of participants and subsequently approved by a panel of nursing education, workforce, policies and survey development experts in 2015 (see further in Strengths and Limitations).

The surveys were distributed electronically via APNA’s communication channels to their members and subscribers (website, newsletters, quarterly magazines, short messaging service, electronic direct mails and social media platforms including Facebook, LinkedIn and Twitter). The surveys were also distributed to major professional nursing bodies including but not limited to the Australian College of Nursing, the Australian Nursing and Midwifery Federation, the Australian College of Mental Health Nurses, the Coalition of National Nursing and Midwifery Organisations and via Primary Health Networks. Reminders were sent multiple times to improve the response rate. No identifiable information was collected. Following ethics approval, the dataset was securely transferred to the research team from the APNA’s data manager using password-protected LabArchives. The data were collated, cleaned and exported from Excel to Statistical Analysis in Social Science (SPSS) Version 27.0 for subsequent analysis.

2.3. Participants

Participants in this study were RNs and midwives voluntarily participating in the APNA annual workforce surveys during 2015–2019.

2.4. Data Analysis

A thorough analysis plan was developed to make sense of the retrospective data including management of missing data, item grouping and the use of parametric tests. We followed Hair Jr, Black, Babin and Anderson’s [14] approach in examining and addressing a substantial amount of missing data in the dataset. With missing data that were likely nonrandom and/or at construct or person level (i.e., participants did not provide answer to any questions or more than 10% of the questions related to the scope of practice), we separated these cases for further exploration in another publication. With missing data that were random and at the person level (i.e., participants might have forgotten or genuinely missed answering less than 10% of the questions related to the scope of practice), the imputation of mode for ordinal data was performed. This approach resulted in a dataset of n = 4687 cases (from the original n = 7066) that included participants of all registration statuses. In this paper, we only focused on the scope of practice of RNs, and thus, n = 3882 was included for further analysis (see Figure 1).

[figure(s) omitted; refer to PDF]

In the attempt to present findings as succinctly as possible, we created composite variables (items) by closely grouping related Likert-type items and calculating their arithmetic mean scores. This approach is supported by Sullivan and Artino [15], Harpe [16] and Hair et al. [14]. As there is no existing guideline on the scope of practice for RNs in PHC in Australian settings, we used a team-based approach to draw on authors’ expert knowledge of GP, PHC practice, nursing education and statistics to group two initial sets of 42 individual Likert-type items under five domains of APNA’s Career and Education Framework for RNs in PHC [17]. The first set of the Likert-type items was to explore the actual frequency of practice undertaken by the participants in their roles in PHC (never = 0, infrequently = 1, weekly = 2 and daily = 3). The second set of items was to ask their preference for frequency of practice (would like to do less often = 1, would like to do the same = 2 and would like to do more = 3).

The five domains of APNA’s Career and Education Framework for RNs in PHC [17] include (1) Clinical Care, (2) Education, (3) Research, (4) Optimising Health System and (5) Leadership. The first domain, Clinical Care, includes ‘preventive health, early intervention, chronic disease management and end of life planning, within a framework of assessment, planning, implementation and evaluation’ ([17], p. 4). The second domain, Education, highlights the need to enhance the skills and knowledge of RNs to engage community members in order to manage disability and/or illness and to promote wellbeing. The third domain, Research, emphasises ‘the practice of inquiry, quality improvement, research and evaluation, and promotes innovative, evidence-informed problem solving’ ([17], p. 11). The fourth domain, Optimising Health System, focuses on the coordination of care and assisting patients and their families to navigate through care transitions as well as the health system. The fifth domain, Leadership, includes activities such as ‘driving change, acting as a resource for professional organisations, groups and individuals and facilitating and engaging in the dissemination of knowledge beyond own setting’ ([17], p. 17). Due to the limited number of items related to research and leadership activities in the original surveys (further addressed in Strengths and Limitations), we combined the two domains Research and Leadership for the analysis purpose.

After grouping items under the domains, we further grouped initial items into composite items and calculated Cronbach’s alpha to examine the reliability of these domains. As a result of item grouping, two sets of seven composite items were created under these domains (see Table 1). Cronbach’s alpha for the Clinical care and Education domains for both sets of items ranged from 0.721 to 0.878 (except for composite item immunisation in the preference set), indicating satisfactory reliability. Cronbach’s alpha for the remaining domains and item immunisation in the preference set was lower than satisfactory level of reliability (between 0.551 and 0.677) which indicated an area for improvement of the workforce surveys (see Table 1, and Strengths and Limitations).

Table 1

Generation of composite items under the five domains of the Career and Education Framework for registered nurses in primary healthcare.

Domain	Composite items	Original survey items	Cronbach alpha (‘frequency’ items)	Cronbach alpha (‘preference’ items)
Clinical care	1. Maternal and child health checks	1. Antenatal checks	0.721	0.813
		2. Postnatal and infant checks
		3. Child health assessment
	2. Chronic disease assessment, prevention and management	4. Men’s health checks	0.762	0.814
		5. Women’s health
		6. Adult physical assessment
		7. Cognitive assessments
		8. Respiratory assessments including peak flows and spirometry
		9. Cardiac assessment (including ECGs and stress testing)
		10. Diabetic assessment
		11. Assessments of SNAP (smoking, nutrition, alcohol and physical activity) risk factors
		12. Mental health assessment
	3. Immunisation	13. Childhood immunisation	0.888	0.676
		14. Adult immunisation (e.g., influenza and travel)
		15. Cold chain management
	4. Procedural nursing activities	16. Triage	0.784	0.750
		17. Infection control and sterilising
		18. Administer medication/injections
		19. Wound management
		20. Collecting blood specimens
		21. Application and/or removal of plaster
		22. Suturing
		23. Assisting with minor surgical procedures
Education	5. Health promotion and chronic disease education to individuals, groups and communities	24. Diabetes education and management	0.871	0.878
		25. Asthma education and management
		26. Cardiovascular disease education and management
		27. Arthritis education and management
		28. Mental health education and management
		29. Other chronic disease education and management
		30. Delivery of health promotion advice
		31. Patient education on drug, alcohol or smoking cessation
		32. Delivering health education to groups of consumers
		33. Organised health promotion activities
Research and leadership†	6. Activities related to research and leadership	34. Quality assurance/general practice accreditation	0.616	0.640
		35. Policy writing/reviewing
		36. Management tasks (e.g., human resources and finances)
Optimising health system	7. Care coordination	37. Case management, including case conferencing	0.554	0.677
		38. Preparing care plans
		39. Liaising with local health services
		40. Home visiting
		41. Utilise recall and reminder system
		42. Telehealth consultation

^†Relevant to the role and primary healthcare context in accordance to APNA Career and Education Framework for nurses in primary healthcare registered nurses [17].

The composite items were treated as continuous variables according to Harpe [16]. Composite items in the frequency of practice set ranged from 0 (never) to 3 (daily). Composite items in the preference for frequency of practice set ranged from 1 (would like to do less often) to 3 (would like to do more often). These data were not normally distributed. However, as (1) the sample size was substantial, (2) data were from an independent sample and (3) the benefits of parametric tests outweighed that of nonparametric tests, parametric tests were used. We chose to focus on practical and clinical significance instead of statistical significance and thus, do not report $p$ values. For the purpose of this paper, a formal postgraduate degree is considered as nurse practitioner, master in PHC nursing, postgraduate certificate/diploma in PHC nursing, postgraduate certificate/diploma in GP-related areas, master in GP-related areas, professional doctorate/PhD and/or other postgraduate studies.

3. Results

3.1. Demographic and Employment Characteristics

On average, the participants were 48.6 years old (SD = 11.1) and had 22.1 years of experience (SD = 12.2) as a nurse at the time of the survey. Majority of the 3882 participants were female (n = 3782, n = 97.4%) and first qualified in Australia (n = 3332, 85.8%) (see Table 2). Just under two-thirds of the participants (n = 2470, 63.6%) completed a short course relevant to their practice. Among the short courses, nurse immuniser was most common (n = 2099, 54.1%), followed by cervical cancer screening (n = 808, 20.8%) and respiratory nursing (n = 397, 10.2%). A total of 904 participants (23.3%) held at least one formal postgraduate qualification. Of the surveyed formal postgraduate qualifications, postgraduate certificate/diploma in GP-related areas (n = 412, 10.6%) was the most common, followed by postgraduate certificate/diploma in PHC (357, 9.2%).

Table 2

Participants’ demographics and qualifications.

Demographic characteristics/qualifications		Frequency	Percentage†
Survey year	2015	697	18.0
	2016	665	17.1
	2017	521	13.4
	2018	1111	28.6
	2019	888	22.9
Years of experience as a nurse/midwife (mean, SD)		22.1 (12.2)
Age (mean, SD)		48.6 (11.1)
Gender	Female	3782	97.4
	Male	100	2.6
Country of qualification	Australia	3332	85.8
	Other	528	13.6
Completion of short course (total)		2470	63.6
Nurse immuniser		2099	54.1
Cervical cancer screening		808	20.8
Respiratory nursing		397	10.2
Diabetes educator		228	5.9
Mental health nursing		116	3.0
Cardiovascular nursing		97	2.5
Completion of postgraduate degrees (total)		904	23.3
Postgraduate certificate/diploma in GP-related areas		412	10.6
Postgraduate certificate/diploma in PHC nursing		357	9.2
Master in GP-related areas		99	2.6
Nurse practitioner		43	1.1
Master in PHC nursing		30	0.8
Professional doctorate/PhD		5	0.1
Other postgraduate studies		240	6.2

Note: N = 3882.

Abbreviations: GP, general practice; PHC, primary healthcare; SD, standard deviation.

^†There were missing data where the total percentage was less than 100%.

A substantial proportion of participants held more than one employment across various settings in PHC (n = 1151, 29.6%). Most of the participants were working in Victoria (n = 1208, 31.1%) and New South Wales (n = 1114, 28.7%), in metropolitan areas (n = 2145, 55.3%) and in GP settings (n = 2916, 75.1%) (see Table 3). Participants reported being employed in 24 other primary health settings, presented in Table 3. Of these, the three most prevalent workplaces were community service not associated with an acute hospital (n = 180, 4.6%), nongovernment organisations (n = 159, 4.1%) and community service associated with an acute hospital (n = 157, 4.0%).

Table 3

Workplace characteristics.

Workplace characteristics	Frequency	Percentage†
Multiple employment	1151	29.6
Employment location
Victoria	1208	31.1
New South Wales	1114	28.7
Queensland	708	18.2
South Australia	320	8.2
Western Australia	275	7.1
Tasmania	110	2.8
Australian Capital Territory	78	2.0
Northern Australia	45	1.2
Multiple states/territories	11	0.3
Employment locality
Metropolitan	2145	55.3
Rural	1426	36.7
Remote	204	5.3
Employment settings (including both primary and secondary employments)‡
General practice	2916	75.1
Non-general practice
1. Community service not associated with an acute hospital	180	4.6
2. Nongovernment organisations	159	4.1
3. Community service associated with an acute hospital	157	4.0
4. Specialist medical room	151	3.9
5. Medicare local/primary health network	100	2.6
6. Aboriginal medical service	96	2.5
7. Consultant/contractor (self-employed)	94	2.4
8. Aged care facility	87	2.2
9. Correctional services/prison	59	1.5
10. University/technical and further education clinic	54	1.4
11. School/preschool	35	0.9
12. Education	30	0.8
13. Refugee health	28	0.7
14. Mental health service/facility	23	0.6
15. Maternal and child health service	23	0.6
16. Workplace health centre	23	0.6
17. Sexual health clinic	21	0.5
18. Military medical facility	21	0.5
19. Boarding house/outreach to homeless	15	0.4
20. Telehealth	15	0.4
21. Palliative care	14	0.4
22. Drug and alcohol clinic	10	0.3
23. Community residential care	9	0.2
24. Social services	7	0.2

Note: N = 3882.

^†There were missing data where the total percentage was less than 100%.

^‡Total of general practice and non-general practice workplace settings greater than 3882 dues to participants’ multiple employments.

3.2. Frequency of Practice

Among the seven areas of practice, immunisation was practised most frequently (with mean scores between 2 and 3, indicating the frequency of practice between weekly and daily). Meanwhile, maternal and child health screenings were practised least frequently (with mean scores between 0 and 1, indicating the frequency of practice between never and infrequently) by all participants. There were no substantial changes in the frequency of practice in all seven areas by all participants over the 2015–2019 period (see Table 4).

Table 4

Frequency of practice by registered nurses by postgraduate qualification, workplace rurality and survey years.

Areas of practice	Postgraduate degree†Mean (SD)		Workplace ruralityMean (SD)		Survey yearsMean (SD)
	With postgraduate degree (n = 904)	Nil postgraduate degree (n = 2978)	Metropolitan workplace (n = 2145)	Rural workplace (n = 1426)	2015 (n = 697)	2016 (n = 665)	2017 (n = 521)	2018 (n = 1111)	2019 (n = 888)
1. Maternal and child health screenings	0.764 (0.752)	0.730 (0.726)	0.759 (0.735)	0.717 (0.732)	0.819 (0.720)	0.727 (0.727)	0.654 (0.692)	0.726 (0.735)	0.746 (0.758)
2. Chronic disease assessment, prevention and management	1.378 (0.603)	1.352 (0.563)	1.295 (0.580)	1.436 (0.557)	1.346 (0.541)	1.297 (0.605)	1.322 (0.558)	1.374 (0.571)	1.415 (0.578)
3. Immunisation	2.228 (1.029)	2.456 (0.839)	2.425 (0.913)	2.414 (0.862)	2.461 (0.831)	2.450 (0.860)	2.290 (0.997)	2.430 (0.888)	2.355 (0.895)
4. Procedural nursing activities	1.599 (0.637)	1.716 (0.552)	1.715 (0.590)	1.645 (0.583)	1.759 (0.572)	1.737 (0.602)	1.596 (0.623)	1.643 (0.574)	1.652 (0.559)
5. Health promotion and chronic disease education to individuals, groups and communities	1.339 (0.625)	1.238 (0.631)	1.221 (0.630)	1.296 (0.624)	1.298 (0.623)	1.279 (0.647)	1.238 (0.612)	1.235 (0.612)	1.267 (0.644)
6. Activities related to research and leadership	1.235 (0.734)	1.147 (0.681)	1.168 (0.696)	1.155 (0.683)	1.118 (0.417)	1.284 (0.735)	1.181 (0.697)	1.154 (0.676)	1.126 (0.675)
7. Care coordination	1.375 (0.552)	1.305 (0.503)	1.855 (0.327)	1.847 (0.301)	1.365 (0.509)	1.359 (0.531)	1.321 (0.517)	1.281 (0.512)	1.310 (0.510)

Note: N = 3882.

Abbreviation: SD, standard deviation.

^†In this table, only formal postgraduate degrees were included in the comparison including nurse practitioner, master in primary healthcare nursing, postgraduate certificate/diploma in primary healthcare nursing, postgraduate certificate/diploma in general practice–related areas, master in general practice–related areas, professional doctorate/PhD and other postgraduate studies. Mean score ranged from 0 to 3 (never = 0, infrequently = 1, weekly = 2 and daily = 3).

Participants without a formal postgraduate qualification practised slightly more frequently in immunisation and procedural nursing activities, while those with at least one formal postgraduate qualification practised more often in the remaining five areas of practice. In terms of workplace rurality, participants working in rural areas were involved in more chronic disease assessment, prevention and management as well as health promotion and chronic disease education slightly more frequently than those working in metropolitan areas. In the remaining five areas of practice, participants working in metropolitan workplaces practised more frequently than their colleagues in rural workplaces.

We attempted to compare the frequency of practice by participants in GP with those in the five most prevalent non-GP settings. These settings included community service associated with an acute hospital (n = 67), community service not associated with an acute hospital (n = 63), (3) nongovernment organisations (n = 37), (4) correctional services/prisons (n = 35) and (5) specialist medical room (n = 25). To reduce the possible impact of recall bias that might be present where participants had multiple employments at different workplaces, we only included participants who worked solely in these five workplaces and did not concurrently hold another part-time position in GP. The main difference was that participants in GP were involved substantially more often in immunisation and procedural nursing activities than those in non-GP settings (see Figure 2).

[figure(s) omitted; refer to PDF]

3.3. Preference for Frequency of Practice

All mean scores except one (activities related to research and leadership in 2016, M = 2.006, SD = 0.374) ranged between 1 (would like to do less) and 2 (would like to do the same), indicating that the participants expressed their preference to practice either less frequently or at the same level of frequency in all seven areas of practice. There were no substantial differences in the preference for frequency of practice over the longitudinal period, between participants with and without a formal postgraduate qualification, as well as between those working in metropolitan and rural workplaces (see Table 5).

Table 5

Preference practice by registered nurses by postgraduate qualification, workplace rurality and survey years.

Areas of practice	Postgraduate qualificationMean (SD)		Workplace ruralityMean (SD)		Survey yearsMean (SD)
	With postgraduate qualification (n = 904)	Nil postgraduate qualification (n = 2978)	Metropolitan workplace (n = 2145)	Rural workplace (n = 1426)	2015 (n = 697)	2016 (n = 665)	2017 (n = 521)	2018 (n = 1111)	2019 (n = 888)
1. Maternal and child health screenings	1.874 (0.440)	1.788 (0.447)	1.770 (0.455)	1.832 (0.430)	1.852 (0.466)	1.879 (0.468)	1.786 (0.403)	1.761 (0.425)	1.745 (0.449)
2. Chronic disease assessment, prevention and management	1.751 (0.330)	1.746 (0.319)	1.736 (0.331)	1.771 (0.307)	1.768 (0.327)	1.791 (0.340)	1.737 (0.311)	1.743 (0.307)	1.711 (0.321)
3. Immunisation	1.895 (0.308)	1.887 (0.312)	1.884 (0.323)	1.898 (0.299)	1.889 (0.315)	1.890 (0.308)	1.862 (0.308)	1.900 (0.301)	1.891 (0.325)
4. Procedural nursing activities	1.830 (0.300)	1.800 (0.283)	1.794 (0.294)	1.826 (0.276)	1.831 (0.287)	1.860 (0.312)	1.800 (0.276)	1.782 (0.275)	1.777 (0.283)
5. Health promotion and chronic disease education to individuals, groups and communities	1.680 (0.365)	1.691 (0.363)	1.678 (0.371)	1.714 (0.354)	1.725 (0.356)	1.742 (0.377)	1.686 (0.354)	1.665 (0.357)	1.650 (0.367)
6. Activities related to research and leadership	1.930 (0.380)	1.941 (0.376)	1.932 (0.378)	1.950 (0.369)	1.990 (0.387)	2.006 (0.374)	1.908 (0.339)	1.914 (0.372)	1.897 (0.389)
7. Care coordination	1.836 (0.328)	1.852 (0.314)	1.855 (0.327)	1.847 (0.301)	1.882 (0.317)	1.912 (0.328)	1.824 (0.299)	1.831 (0.312)	1.811 (0.319)

Note: N = 3882.

Abbreviation: SD, standard deviation.

^†In this table, we only compare participants with those without formal postgraduate qualifications including nurse practitioner, master in primary healthcare nursing, postgraduate certificate/diploma in primary healthcare nursing, postgraduate certificate/diploma in general practice–related areas, master in general practice–related areas, professional doctorate/PhD and other postgraduate studies. Mean score ranged from 1 to 3 (would like to do less often = 1, would like to do the same = 2 and would like to do more = 3).

4. Discussion

In this study, we reported RN participants’ demographic characteristics and formal postgraduate qualifications and their PHC workplace settings during 2015–2019 (see Nguyen et al. [18] [deidentified] for further discussion on longitudinal changes in PHC nursing workforce characteristics). We found no substantial and meaningful changes in the frequency of and preference for the seven areas of practice by RN participants during the survey period, regardless of their formal postgraduate qualifications and workplace localities reflecting very little change in the reality of practice for RNs working in various PHC settings from 2015 to 2019.

4.1. Underutilisation of RNs’ Skills and Competence

Similar to other studies, we found RN’s skill and competence are underutilised in the PHC settings, despite some improvements in the area of chronic health management and health promotion recorded in an earlier study [11]. Interestingly, these improvements found by Halcomb and Ashley [11] were not sustained in the subsequent five years by our RN participants during 2015–2019 (see Table 4). Note that there was a difference in research samples between the two studies. While Halcomb and Ashley’s [11] study involved only GP nurses regardless of registration status, our current study focused solely on RNs in both GP and 24 non-GP workplace settings that are not often reported in the PHC literature. Our study’s focus on only one registration category could perhaps facilitate a more focused look into the reality of nursing practice in this registration category. Meanwhile, the wide range of these workplace settings makes it challenging to obtain an in-depth understanding of the unique demands and challenges of RN work in each of the PHC workplace settings.

4.2. Multilayer Concept of Scope of Practice

The scope of practice of a professional is a multilayered concept [19] influenced by individual, interpersonal, organisational and institutional layers. Niezen and Mathijssen explained

[t]he professional is first deconstructed in terms of essential components: (a) relying on specific knowledge and expertise; (b) belonging to a closed community of people with similar knowledge and expertise characterised by shared norms and values, institutions for socialisation and regulation; (c) this closed nature of the community is considered legitimate by society at large; and (d) discretionary or professional autonomy are allowed at both an individual and community level (2014, p. 152).

So, in order to unpack these factors, we explored our findings (the lack of substantial changes in the frequency of and preference for practice by our RN participants in their PHC workplaces during 2015–2019) against a broader picture by looking at individual, interpersonal, organisational and institutional layers.

4.2.1. Individual Layer

Existing literature indicates that RNs may lack knowledge about their own role in PHC which was found to affect their confidence [20, 21] and autonomy in PHC practice [22]. This knowledge deficit was attributed to limited access to professional development opportunities [23] and scattered content of PHC in Australian undergraduate nursing education programs [24]. Murray-Parahi et al. [24] reviewed 29 Australian undergraduate nursing curricula and found that only 2% of the reviewed subject titles consisted of PHC content. The authors found that the content of undergraduate nursing curricula and of clinical placements predominantly focus on acute nursing [24] echoing the findings of a similar review a decade earlier by Keleher, Parker, and Francis [25]. Such prolonged deficit in the educational programs may contribute to misconception among nursing students about the complexities and responsibilities in PHC [26, 27] and potentially disengaging future nursing graduates when considering PHC as a career choice.

In remote/rural PHC, factors attributing to nurses’ sense of unpreparedness were extended to the lack of practice leadership [28] and professional as well as geographical isolation from the larger health system [29, 30]. Where sociocultural characteristics of the rural/remote populations were diverse and unique (i.e., Indigenous or non-English speaking), specialist expertise was limited, and RNs, including those with postgraduate qualifications [31], reported often having to practise beyond their ‘normal’ nursing scope [29, 32].

Despite commonly reported insufficient physical resources and support in rural/remote PHC practice [29, 31, 33, 34], RN participants in our study provided complex nursing care at similar or even higher frequency (in chronic disease assessment, prevention and management) with their counterparts in metropolitan workplaces (see Table 4). Our findings likely reflect the stretch of our RN’s practice in rural workplaces and the need for sustainable (individual, family and professional) support for retention purposes that have been recognised as an ongoing priority in Australia [28, 29, 35] and elsewhere [32].

While researchers have been advocating for postgraduate education pathways for PHC nurses [1, 18], there seems limited practice pathways for 23% (n = 904, see Table 2) of our participants who had already completed at least one formal postgraduate study that mostly aligned with their area of practice (i.e., postgraduate studies in GP-related areas or PHC nursing, see Table 2). Earlier research found that RNs with further postgraduate studies in primary care anticipated an extended scope of practice and involvement in health promotion, chronic health assessment and management, as well as preparing multidisciplinary care plans [36]. However, a substantial percentage of these nurses were not able to experience practice change [36]. This raises the question, if not individual factors then what factors might hinder RN-postgraduate qualification holders in our study from practising to their full potential and capacity: organisational, interprofessional or even institutional?

4.2.2. Interprofessional and Organisational Layers

Organisational factors can influence the scope of practice of nurses in PHC. The role expansion to meet healthcare demands of individuals and communities significantly added to PHC nurses workload and work pressure [29, 32]. At the same time, research evidence suggests that nurses do not want to compromise their scope of practice due to inadequate organisational physical resources, like equipment, information technology facilities and/or retrieval services [29, 31, 34, 37]. Having to provide nursing care that does not meet their own standards and expectations in these resource-poor environments left them feeling frustrated, hopeless and distressed albeit with strong passion for, and sometimes satisfaction with, their rural/remote communities [31, 37] or advantages over working in acute settings [28]. These organisational factors also impeded nurses’ ability to coordinate multidisciplinary care and provide health promotion despite individual and community needs [31, 37]. These factors might explain the reasons our participants did not express preference for higher frequency of the seven areas of practice (see Table 5).

The implementation of RN scope of practice can be further influenced by professional boundaries between nursing and other health professions, especially medicine. In a Spanish context, Blanco-Fraile et al. [22] described the potential professional conflict/confrontation between RNs and doctors, especially when some tasks could be completed by either RNs or doctors (i.e., follow-up/management of chronic conditions that could be performed, or even replaced, by those with nurse practitioner qualification). While some RN participants chose to confront their medical colleagues, others opted to avoid the conflict/confrontation by abandoning some practices within their capacity and compromising their own autonomy [22]. This indicates the impact of perceived competition of interests and benefits on the quality of RN–doctor collaboration and the use of RN expertise.

The quality of RN–doctor collaboration can be further implicated when the PHC practice managers/directors/leaders were also doctors [38–40]. For example, in a survey concerning 1166 participants, Halcomb and Ashley [11] found that only 274 participants reported the ability to practise to their full scope on a regular basis. Meanwhile, 469 participants discussed opportunities for role expansion with their GP employers, and 44.5% of these requests for more complex tasks were unfulfilled [11]. These findings are confirmed in McKenna et al.’s [23] earlier research findings on the impact of organisational leadership/practice management (most often by doctors) on RN’s scope of practice. McKenna et al. [23] further highlighted a controversial issue, reporting that job dissatisfaction related to limited opportunity to practice to their full scope could result in (sometimes early) attrition from the organisation and/or profession. Concurrently, nurses were perceived to not work in a practice long enough for role expansion opportunities to mature [23]. Note that doctor awareness of and support of RN roles could facilitate RN involvement, autonomy and confidence in collaborative care and ultimately, contribute to positive experience in RN practice [20]. This was, however, not always the case [20, 39, 40]. Even when positive supportive relationships between RNs and physicians/practice managers existed, RNs faced another larger hurdle preventing them from practising what was within their capacity and level of education (i.e., postgraduate degree): Medicare funding [36].

4.2.3. Institutional Layer

Funding models in PHC have been considered a key factor influencing the reality of clinical practice for decades both in Australia and elsewhere [8, 36, 41–43]. Since its inception in 1984, Medicare, operating on a fee-for-service model in Australia, has experienced significant transformations aimed at leveraging the involvement of PHC nurses and fostering inclusivity within the PHC multidisciplinary team. These changes have involved the exploration and introduction of various methods of healthcare delivery through the funding mechanism provided by the Medicare Benefits Schedule. This progression has involved the development of specific item numbers for PHC nurse activities, the implementation of team care approaches for chronic disease management and the inception of the Practice Nurse Incentive Program (now transformed into the Workforce Incentive Program in 2020), as well as the introduction of the Practice Incentive Program and Service Incentive Programs. Despite the Australian Government’s intention to support the nursing workforce, the implementation of these programs in PHC practice could harbour challenges to RN’s scope of practice in PHC.

For example, in an Australian study involving both physicians and RNs, McInnes et al. [42] found four funding issues perceived to limit RNs scope of practice in GP, a common workplace setting in PHC. First, contesting priorities were shared by both physicians/employers (prioritising efficiency to compensate operational costs of employing RNs that are not covered by government funding) and RNs (prioritising ethical, holistic and quality care over quantity of short appointments) [42]. Second, items required coconsulting with physicians in areas of nursing expertise (i.e., wound dressing, immunisation or diabetes education) caused contentions among RNs and were believed to hinder practice efficiencies [42]. Third, RNs perceived that physicians had limited understanding of the Practice Nurse Incentive Program and failed to use it to promote nursing autonomy and practice efficiency to enhance patient/client outcomes [42]. Fourth, the limit/reduction of nurse-item numbers (especially as compared to item numbers for a physician trainee in GP) could disadvantage the use of nursing expertise and thus make a small private practice less financially sustainable [42]. Medicare item numbers which could have created professional recognition and income for practice were removed from the funding models, effectively restricting what nursing services RNs could provide even after obtaining relevant postgraduate qualifications [36]. Such limited practice resultantly affected the public view of nursing capacity and contribution [36], which may be detrimental to public health outcomes. In a recent scoping review of nurse-led clinics in PHC, Terry et al. [43] also confirmed the barriers of the complex landscape of regulatory frameworks, policy directives and funding models to PHC nurse practice both independently and collaboratively within interdisciplinary teams. It appears that Australia’s current fee-for-service funding model, according to Bauer and Bodenheimer [41], values volume of service rather than better care with potentially lower cost and, importantly, not compensate high-value services including chronic disease management or health education.

Our findings of nil substantial changes in the frequency of and preference for seven areas of practice during 2015–2019 regardless of participant postgraduate qualifications and workplace localities (see Tables 4 and 5) reflect the influence institutional factors such as medical funding models have on RN scope of practice that has been evident in previous studies [36, 41–43]. Importantly, the quantitative frequency of and preference for frequency of practice do not necessarily reflect the quality of nursing care provided to patients/clients. As mentioned above, RNs emphasised the importance of holistic care [32] and the greater need (than that for multiple short appointments to generate income for practice) to take time appropriately addressing patient complex health issues, to ensure patient understanding and participation in and sustainability of chronic health management [42]. Perhaps, our participants saw the problematic nature of fee-for-service funding model and their responses reflect insights into the complexity of chronic disease assessment, prevention and management and health promotion—the area where they make a difference in individual and population health outcomes. Here, Bauer and Bodenheimer [41] highlighted the necessary movement away from fee-for-service models and towards the addition of payment options (i.e., adding further payment options to compensate high-value performances—in addition to the fee-for-service model) to generate additional revenues for RNs in PHC.

It is important to note that the need to reform funding models has been recognised in other contexts; however, the progress in implementation is not straightforward. Funding fragmentation (the funding divide in medical and nonmedical services) was identified as a common barrier to community-based (interprofessional/multidisciplinary) PHC in both New Zealand and Ontario and Québec in Canada [8]. Changes towards more integrated funding models have been happening, but the implementation has been dependent on the acceptability (or resistance) of the medical profession who often see this as a threat to their interests and thus strong preference to maintain the funding divide [8]. Such resistance also hinders the progress in the formulation, decision-making and implementation of key policies in PHC [8]. In the Australian context multiple major workforce guidelines, policies and strategies are currently being developed that aim to build the capacity of the nursing and midwifery workforce in PHC (such as National Rural and Remote Nursing Generalist Framework 2023–2027 and National Nursing Workforce Strategies). These guidelines, policies and strategies will impact the practice of nursing and midwifery workforce in PHC (such as Medicare Benefits Schedule Review, Regulation and compliance, initiatives and programs) [12]. It is therefore important that RNs practising in PHC understand the facilitators and barriers to their scope of practice in PHC and are included in these policy and decision-making processes. Such involvement of RNs is to ensure that changes in institutional layers intended to be ‘supporting a capable, resilient nursing profession to deliver person-centred, evidence-based, compassionate care to the Australian community across all sectors’ [12] will have a positive impact on RN scope of practice in PHC.

4.3. Strengths and Limitations

The strengths of this study are the rigorous analytical approaches and the sizable longitudinal data set. The conservative handling of missing data was necessary when dealing with retrospective data to afford confidence in the findings based on available and consistent data. The substantial longitudinal data (N = 3882) allowed the observations of longitudinal trends and facilitated subgroup comparisons which gave further insights into the reality and scope of practice of RNs in Australian PHC. We also achieved satisfactory internal consistency of Clinical Care and Education domains, demonstrating that these two domains can contribute a good foundation for future survey instrument development.

This study also has some limitations. First, the data were collected using convenient sampling which might affect the representativeness of the sample and generalisability of the findings. Second, the same sampling strategy was applied annually during 2015–2019 which means the possible inclusion of the same participants over the survey period. This means the trends (or lack thereof) we detected in this study might not truly reflect the actual movement of the nursing workforce in Australian PHC settings during 2015–2019. Third, the self-administered surveys were relatively lengthy, potentially causing survey fatigue that could lead to substantial missing data and reduce the quality of the data collected. Fourth, there were a large amount of missing data, requiring the conservative method of data cleaning. Fifth, only a few questions in the original surveys were related to the Leadership and Research domains. Internal consistency for composite items related to these domains, as well as to Optimising Health System domain, was also below the statistically recommended thresholds. Sixth, the wide range of PHC workplace settings makes it challenging to obtain an in-depth understanding of the unique demands and challenges of RN work in each of the PHC workplace settings. This might mean limitations in the design of the original surveys, indicating the need to redesign workforce surveys in order to effectively capture this important workforce information for future workplace policies and planning.

4.4. Recommendations

As the scope of practice of RNs in PHC is a multilayer concept, strategies to define, develop, sustain and extend it also need to be multidimensional and comprehensive at individual, interprofessional, organisational and institutional levels [44]. Halcomb and Ashley [11] suggest that role reconceptualization is needed to meet the demands of an ever-evolving community. Healthcare funding models need to be reviewed and revised, especially to avoid items of task duplication and to increase Medicare nurse item numbers especially in chronic disease assessment, prevention and management and health promotion to optimise nursing contribution to PHC [29, 44]. Regulations/policies for practice in PHC also need to be reconsidered [44], importantly with the involvement of RNs [5]. Ongoing strategies to work–life balance, adequate staffing and easy access to professional development strategies should be in place to support and retain RNs working in rural/remote PHC environments. Practice pathways for RNs with postgraduate qualifications need to be articulated to entice them to further education. Future research could involve the perspectives of RNs and patients in PHC to improve the visibility of this nursing workforce. Research into cost effectiveness of funding models could potentially influence government’s funding and policy setting to ensure nurses at different levels of education are able to practice to their full scope and capacity for the benefit of the community.

5. Conclusions

The scope of practice of RNs in Australian PHC is multilayered where interprofessional, organisational and institutional factors interplay (more than individual factors). This may suggest why there was a lack of change in practice by our RN participants during the survey period 2015–2019. Current health policy reviews in Australia, including National Nursing Workforce Strategy, need to address these multilayer issues of the nursing and broader health workforce. When nurses are unable to work to their full capacity, skills and level of education (scope of practice), this affects job satisfaction and retention in practice and/or the nursing workforce and potentially patient health outcomes. Our findings contribute to baseline evidence on PHC RN’s scope of practice and can be used for future comparison for the purpose of long-term workplace planning and policy setting in Australian PHC.

Ethics Statement

Ethical approval was sought from and granted by the University’s Human Research Ethics Committee (Project ID: 27762) before the nonidentifiable data were extracted and analysed. The APNA transferred the data to the research team using a password-secured limited-access platform (LabArchives). We used the EQUATOR checklist (STROBE guideline) to guide the preparation of this paper.

Funding

No funding has been received to conduct this study.

Acknowledgements

The authors have nothing to report.

References

[1] World Health Organisation, & United Nations Children’s Fund, A Vision for Primary Health Care in the 21st Century: Towards Universal Health Coverage and the Sustainable Development Goals, 2018.

[2] H. Swerissen, S. Duckett, G. Moran, "Mapping Primary Care in Australia," 2018. https://grattan.edu.au/wp-content/uploads/2018/07/906-Mapping-primary-care.pdf

[3] A. Haakenstad, C. M. S. Irvine, M. Knight, "Measuring the Availability of Human Resources for Health and Its Relationship to Universal Health Coverage for 204 Countries and Territories From 1990 to 2019: A Systematic Analysis for the Global Burden of Disease Study 2019," The Lancet, vol. 399 no. 10341, pp. 2129-2154, DOI: 10.1016/S0140-6736(22)00532-3, 2022.

[4] Australian Institute of Health and Welfare, Australia’s Health 2022: Data Insights, 2022.

[5] A. Norful, G. Martsolf, K. de Jacq, L. Poghosyan, "Utilization of Registered Nurses in Primary Care Teams: A Systematic Review," International Journal of Nursing Studies, vol. 74, pp. 15-23, DOI: 10.1016/j.ijnurstu.2017.05.013, 2017.

[6] J. Lukewich, S. Asghari, E. G. Marshall, "Effectiveness of Registered Nurses on System Outcomes in Primary Care: A Systematic Review," BMC Health Services Research, vol. 22 no. 1, pp. 440-526, DOI: 10.1186/s12913-022-07662-7, 2022.

[7] J. Lukewich, R. Martin-Misener, A. A. Norful, "Effectiveness of Registered Nurses on Patient Outcomes in Primary Care: A Systematic Review," BMC Health Services Research, vol. 22 no. 1, pp. 740-834, DOI: 10.1186/s12913-022-07866-x, 2022.

[8] T. Tenbensel, F. Miller, M. Breton, "How Do Policy and Institutional Settings Shape Opportunities for Community-Based Primary Health Care? A Comparison of Ontario, Québec and New Zealand," International Journal of Integrated Care, vol. 17 no. 2,DOI: 10.5334/ijic.2514, 2017.

[9] E. Halcomb, M. Stephens, J. Bryce, E. Foley, C. Ashley, "The Development of Professional Practice Standards for Australian General Practice Nurses," Journal of Advanced Nursing, vol. 73 no. 8, pp. 1958-1969, DOI: 10.1111/jan.13274, 2017.

[10] R. Lane, E. Halcomb, L. McKenna, "Advancing General Practice Nursing in Australia: Roles and Responsibilities of Primary Healthcare Organisations," Australian Health Review, vol. 41 no. 2, pp. 127-132, DOI: 10.1071/AH15239, 2017.

[11] E. Halcomb, C. Ashley, "Are Australian General Practice Nurses Underutilised?: An Examination of Current Roles and Task Satisfaction," Collegian, vol. 26 no. 5, pp. 522-527, DOI: 10.1016/j.colegn.2019.02.005, 2019.

[12] Department of Health and Aged Care, "National Nursing Workforce Strategy," 2024. https://www.health.gov.au/our-work/national-nursing-workforce-strategy

[13] A. D. Chavez-Rivera, Y. Inostroza-Nieves, K. Hemal, W. Chen, "Chapter 38-Longitudinal Study: Design, Measures, and Classic Example," Translational Surgery, pp. 223-226, 2023.

[14] J. Hair, W. Black, B. Babin, R. Anderson, Multivariate Data Analysis, 2019.

[15] G. M. Sullivan, A. R. Artino, "Analyzing and Interpreting Data From Likert-Type Scales," Journal of Graduate Medical Education, vol. 5 no. 4, pp. 541-542, DOI: 10.4300/jgme-5-4-18, 2013.

[16] S. E. Harpe, "How to Analyze Likert and Other Rating Scale Data," Currents in Pharmacy Teaching and Learning, vol. 7 no. 6, pp. 836-850, DOI: 10.1016/j.cptl.2015.08.001, 2015.

[17] APNA, "APNA Career and Education Framework for Nurses in Primary Health Care-Registered Nurses," 2018.

[18] V. N. B. Nguyen, G. Brand, S. Gardiner, "A Snapshot of Australian Primary Health Care Nursing Workforce Characteristics and Reasons They Work in These Settings: A Longitudinal Retrospective Study," Nursing open, vol. 10 no. 8, pp. 5462-5475, DOI: 10.1002/nop2.1785, 2023.

[19] M. G. H. Niezen, J. J. P. Mathijssen, "Reframing Professional Boundaries in Healthcare: A Systematic Review of Facilitators and Barriers to Task Reallocation From the Domain of Medicine to the Nursing Domain," Health Policy, vol. 117 no. 2, pp. 151-169, DOI: 10.1016/j.healthpol.2014.04.016, 2014.

[20] S. Abou Malham, M. Breton, N. Touati, L. Maillet, A. Duhoux, I. Gaboury, "Changing Nursing Practice Within Primary Health Care Innovations: The Case of Advanced Access Model," BMC Nursing, vol. 19 no. 1,DOI: 10.1186/s12912-020-00504-z, 2020.

[21] T. Bodenheimer, L. Bauer, "Rethinking the Primary Care Workforce—An Expanded Role for Nurses," New England Journal of Medicine, vol. 375 no. 11, pp. 1015-1017, DOI: 10.1056/NEJMp1606869, 2016.

[22] C. Blanco-Fraile, M. Madrazo-Pérez, V. Fradejas-Sastre, E. Rayón-Valpuesta, "The Evolution of the Role of Nursing in Primary Health Care Using Bourdieu’s Concept of Habitus. A Grounded Theory Study," PLoS One, vol. 17 no. 5,DOI: 10.1371/journal.pone.0265378, 2022.

[23] L. McKenna, E. Halcomb, R. Lane, N. Zwar, G. Russell, "An Investigation of Barriers and Enablers to Advanced Nursing Roles in Australian General Practice," Collegian, vol. 22 no. 2, pp. 183-189, DOI: 10.1016/j.colegn.2015.02.003, 2015.

[24] P. Murray-Parahi, M. DiGiacomo, D. Jackson, J. Phillips, P. M. Davidson, "Primary Health Care Content in Australian Undergraduate Nursing Curricula," Collegian, vol. 27 no. 3, pp. 271-280, DOI: 10.1016/j.colegn.2019.08.008, 2020.

[25] H. Keleher, R. Parker, K. Francis, "Preparing Nurses for Primary Health Care Futures: How Well Do Australian Nursing Courses Perform?," Australian Journal of Primary Health, vol. 16 no. 3, pp. 211-216, 2010.

[26] Z. Byfield, L. East, J. Conway, "An Integrative Literature Review of Pre-Registration Nursing Students’ Attitudes and Perceptions Towards Primary Healthcare," Collegian, vol. 26 no. 5, pp. 583-593, DOI: 10.1016/j.colegn.2019.01.004, 2019.

[27] K. R. B. Calma, E. Halcomb, M. Stephens, "The Impact of Curriculum on Nursing Students’ Attitudes, Perceptions and Preparedness to Work in Primary Health Care: An Integrative Review," Nurse Education in Practice, vol. 39,DOI: 10.1016/j.nepr.2019.07.006, 2019.

[28] E. Kagi, R. Rasiah, M. Moran, "Experiences of Primary Health Care Nurses Advancing Their Careers in a Remote Western Australian Location," Australian Journal of Rural Health, vol. 31 no. 1, pp. 41-51, DOI: 10.1111/ajr.12904, 2023.

[29] Australian College of Nursing, "Discussion Paper: Improving Health Outcomes in Rural and Remote Australia: Optimising the Contribution of Nurses," 2018. https://www.acn.edu.au/wp-content/uploads/position-statement-discussion-paper-improving-health-outcomes-rural-remote-australia.pdf

[30] R. Rossiter, R. Phillips, D. Blanchard, K. van Wissen, T. Robinson, "Exploring Nurse Practitioner Practice in Australian Rural Primary Health Care Settings: A Scoping Review," Australian Journal of Rural Health, vol. 31 no. 4, pp. 617-630, DOI: 10.1111/ajr.13010, 2023.

[31] K. McCullough, L. Whitehead, S. Bayes, A. Williams, V. Cope, "The Delivery of Primary Health Care in Remote Communities: A Grounded Theory Study of the Perspective of Nurses," International Journal of Nursing Studies, vol. 102,DOI: 10.1016/j.ijnurstu.2019.103474, 2020.

[32] H. Park, K. J. June, "The Retention Factors Among Nurses in Rural and Remote Areas: Lessons from the Community Health Practitioners in South Korea," Journal of Korean Academy of Community Health Nursing, vol. 33 no. 3, pp. 269-278, DOI: 10.12799/jkachn.2022.33.3.269, 2022.

[33] H. Beks, S. Clayden, A. W. Shee, M. J. Binder, S. O’Keeffe, V. L. Versace, "Evaluated Nurse-Led Models of Care Implemented in Regional, Rural, and Remote Australia: A Scoping Review," Collegian, vol. 30 no. 6, pp. 769-778, DOI: 10.1016/j.colegn.2023.05.004, 2023.

[34] K. McCullough, S. Bayes, L. Whitehead, A. Williams, V. Cope, "We Say We Are Doing Primary Health Care But We’re Not: Remote Area Nurses’ Perspectives on the Challenges of Providing Primary Health Care Services," Collegian, vol. 28 no. 5, pp. 534-540, DOI: 10.1016/j.colegn.2021.02.006, 2021.

[35] J. Wakerman, J. Humphreys, D. Russell, "Remote Health Workforce Turnover and Retention: What Are the Policy and Practice Priorities?," Human Resources for Health, vol. 17 no. 1,DOI: 10.1186/s12960-019-0432-y, 2019.

[36] C. M. Hallinan, K. L. Hegarty, "Advanced Training for Primary Care and General Practice Nurses: Enablers and Outcomes of Postgraduate Education," Australian Journal of Primary Health, vol. 22 no. 2, pp. 113-122, DOI: 10.1071/py14072, 2016.

[37] A. R. de Oliveira, Y. G. de Sousa, J. P. Alves, S. M. d. Medeiros, C. S. Martiniano, M. Alves, "Satisfaction and Limitation of Primary Health Care Nurses’ Work in Rural Areas," Rural and Remote Health, vol. 19 no. 2, pp. 4938-5010, DOI: 10.22605/RRH4938, 2019.

[38] E. J. Halcomb, Y. Salamonson, P. M. Davidson, R. Kaur, S. A. Young, "The Evolution of Nursing in Australian General Practice: A Comparative Analysis of Workforce Surveys Ten Years on," BMC Family Practice, vol. 15 no. 1,DOI: 10.1186/1471-2296-15-52, 2014.

[39] S. McInnes, K. Peters, A. Bonney, E. Halcomb, "A Qualitative Study of Collaboration in General Practice: Understanding the General Practice Nurse's Role," Journal of Clinical Nursing, vol. 26 no. 13-14, pp. 1960-1968, DOI: 10.1111/jocn.13598, 2017.

[40] S. McInnes, K. Peters, A. Bonney, E. Halcomb, "Understanding Collaboration in General Practice: A Qualitative Study," Family Practice, vol. 34 no. 5, pp. 621-626, DOI: 10.1093/fampra/cmx010, 2017.

[41] L. Bauer, T. Bodenheimer, "Expanded Roles of Registered Nurses in Primary Care Delivery of the Future," Nursing Outlook, vol. 65 no. 5, pp. 624-632, DOI: 10.1016/j.outlook.2017.03.011, 2017.

[42] S. McInnes, K. Peters, A. Bonney, E. Halcomb, "The Influence of Funding Models on Collaboration in Australian General Practice," Australian Journal of Primary Health, vol. 23 no. 1, pp. 31-36, DOI: 10.1071/PY16017, 2017.

[43] D. Terry, D. Hills, C. Bradley, L. Govan, "Nurse-led Clinics in Primary Health Care: A Scoping Review of Contemporary Definitions, Implementation Enablers and Barriers and Their Health Impact," Journal of Clinical Nursing, vol. 33 no. 5, pp. 1724-1738, DOI: 10.1111/jocn.17003, 2024.

[44] P. Nelson, A. M. Martindale, A. McBride, K. Checkland, D. Hodgson, "Skill-Mix Change and the General Practice Workforce Challenge," British Journal of General Practice, vol. 68 no. 667, pp. 66-67, DOI: 10.3399/bjgp18X694469, 2018.