Background Having nurses take on tasks that are typically conducted by doctors (doctor-nurse substitution, a form of ’task-shifting’) may help to address doctor shortages and reduce doctors’ workload and human resource costs. A Cochrane Review of effectiveness studies suggested that nurse-led care probably leads to similar healthcare outcomes as care delivered by doctors. This finding highlights the need to explore the factors that affect the implementation of strategies to substitute doctors with nurses in primary care. In our qualitative evidence synthesis (QES), we focused on studies of nurses taking on tasks that are typically conducted by doctors working in primary care, including substituting doctors with nurses or expanding nurses’ roles. Objectives (1) To identify factors influencing implementation of interventions to substitute doctors with nurses in primary care. (2) To explore how our synthesis findings related to, and helped to explain, the findings of the Cochrane intervention review of the effectiveness of substituting doctors with nurses. (3) To identify hypotheses for subgroup analyses for future updates of the Cochrane intervention review. Search methods We searched CINAHL and PubMed, contacted experts in the field, scanned the reference lists of relevant studies and conducted forward citation searches for key articles in the Social Science Citation Index and Science Citation Index databases, and ’related article’ searches in PubMed. Selection criteria We constructed a maximum variation sample (exploring variables such as country level of development, aspects of care covered and the types of participants) from studies that had collected and analysed qualitative data related to the factors influencing implementation of doctor-nurse substitution and the expansion of nurses' tasks in community or primary care worldwide. We included perspectives of doctors, nurses, patients and their families/carers, policymakers, programme managers, other health workers and any others directly involved in or affected by the substitution. We excluded studies that collected data using qualitative methods but did not analyse the data qualitatively. Data collection and analysis We identified factors influencing implementation of doctor-nurse substitution strategies using a framework thematic synthesis approach. Two review authors independently assessed the methodological strengths and limitations of included studies using a modified Critical Appraisal Skills Programme (CASP) tool. We assessed confidence in the evidence for the QES findings using the GRADE-CERQual approach. We integrated our findings with the evidence from the effectiveness review of doctor-nurse substitution using a matrix model. Finally, we identified hypotheses for subgroup analyses for updates of the review of effectiveness. Main results We included 66 studies (69 papers), 11 from low- or middle-income countries and 55 from high-income countries. These studies found several factors that appeared to influence the implementation of doctor-nurse substitution strategies. The following factors were based on findings that we assessed as moderate or high confidence. Patients in many studies knew little about nurses' roles and the difference between nurse-led and doctor-led care. They also had mixed views about the type of tasks that nurses should deliver. They preferred doctors when the tasks were more 'medical' but accepted nurses for preventive care and follow-ups. Doctors in most studies also preferred that nurses performed only 'non-medical' tasks. Nurses were comfortable with, and believed they were competent to deliver a wide range of tasks, but particularly emphasised tasks that were more health promotive/preventive in nature. Patients in most studies thought that nurses were more easily accessible than doctors. Doctors and nurses also saw nurse-doctor substitution and collaboration as a way of increasing people's access to care, and improving the quality and continuity of care. Nurses thought that close doctor-nurse relationships and doctor's trust in and acceptance of nurses was important for shaping their roles. But nurses working alone sometimes found it difficult to communicate with doctors. Nurses felt they had gained new skills when taking on new tasks. But nurses wanted more and better training. They thought this would increase their skills, job satisfaction and motivation, and would make them more independent. Nurses taking on doctors' tasks saw this as an opportunity to develop personally, to gain more respect and to improve the quality of care they could offer to patients. Better working conditions and financial incentives also motivated nurses to take on new tasks. Doctors valued collaborating with nurses when this reduced their own workload. Doctors and nurses pointed to the importance of having access to resources, such as enough staff, equipment and supplies; good referral systems; experienced leaders; clear roles; and adequate training and supervision. But they often had problems with these issues. They also pointed to the huge number of documents they needed to complete when tasks were moved from doctors to nurses. Authors' conclusions Patients, doctors and nurses may accept the use of nurses to deliver services that are usually delivered by doctors. But this is likely to depend on the type of services. Nurses taking on extra tasks want respect and collaboration from doctors; as well as proper resources; good referral systems; experienced leaders; clear roles; and adequate incentives, training and supervision. However, these needs are not always met. © 2019 The Cochrane Collaboration.

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Barriers and facilitators to the implementation of doctor‐nurse substitution strategies in primary care: a qualitative evidence synthesis

Purpose The adverse health effects from climate change demand action from the nursing profession. This article examines the calls to action, the status of climate change in nursing education, and challenges and recommendations for nursing education related to climate change and human health. Organizing construct Discussion paper. Findings The integration of climate change into nursing education is essential so that knowledge, skills, and insights critical for clinical practice in our climate-changing world are incorporated in curricula, practice, research, and policy. Our Ecological Planetary Health Model offers a framework for nursing to integrate relevant climate change education into nursing curricula and professional nursing education. Nursing education can offer a leadership role to address the mitigation, adaptation, and resilience strategies for climate change. Conclusions An ecological framework is valuable for nursing education regarding climate change through its consideration of political, cultural, economic, and environmental interrelationships on human health and the health of the planet. Knowledge of climate change is important for integration into basic and advanced nursing education, as well as professional education for nurses to address adverse health impacts, climate change responses policy, and advocacy roles. Clinical relevance For current and future nurses to provide care within a climate-changing environment, nursing education has a mandate to integrate knowledge about climate change issues across all levels of nursing education. Competence in nursing practice follows from knowledge and skill acquisition gained from integration of climate change content into nursing education.

https://sigmapubs.onlinelibrary.wiley.com/doi/pdf/10.1111/jnu.12331

Mandate for the Nursing Profession to Address Climate Change through Nursing Education

Aims
To explore the current role of general practice nurses and the scope of Australian nursing practice to inform the development of national professional practice standards for Australian general practice nurses.

Background
Increasing numbers of nurses have been employed in Australian general practice to meet the growing demand for primary care services. This has brought significant changes to the nursing role. Competency standards for nurses working in general practice were first developed in Australia in 2005, but limited attention has been placed on articulating the contemporary scope of practice for nurses in this setting.

Design
Concurrent mixed methods design.

Methods
Data collection was conducted during 2013-2014 and involved two online surveys of registered and enrolled nurses currently working in general practice, a series of 14 focus groups across Australia and a series of consultations with key experts.

Findings
Data collection enabled the development of 22 Practice Standards separated into four domains: 1) Professional Practice; 2) Nursing Care; 3) General Practice Environment; and 4) Collaborative Practice. To differentiate the variations in enacting these standards, performance indicators for the enrolled nurse, registered nurse and registered nurse advanced practice are provided under each standard.

Conclusion
The development of national professional practice standards for nurses working in Australian general practice will support ongoing workforce development. These standards are also an important means of articulating the role and scope of the nurses’ practice for both consumers and other health professionals, as well as being a guide for curriculum development and measurement of performance.

This article is protected by copyright. All rights reserved.

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The development of professional practice standards for Australian general practice nurses

Background: The title, Nurse Practitioner, is protected in most jurisdictions in Australia and in New Zealand and the number of nurse practitioners is increasing in health services in both countries. Despite this expansion of the role there is scant national or international research to inform development of nurse practitioner competency standards. 
Objectives: The aim of the study was to research nurse practitioner practice to inform development of generic standards that could be applied for the education, authorisation and practice of nurse practitioners in both countries. 
Design: The research used a multi-methods approach to capture a range of data sources including research of policies and curricula, and interviews with clinicians. Data were collected from relevant sources in Australia and New Zealand
Settings: The research was conducted in New Zealand and the five states and territories in Australia where, at the time of the research, the title of nurse practitioner was legally protected. 
Participants: The research was conducted with a purposeful sample of nurse practitioners from diverse clinical settings in both countries. Interview and material data were collected from a range of sources and data were analysed within and across these data modalities.
Results: Findings included identification of three generic standards for nurse practitioner practice namely, Dynamic Practice, Professional Efficacy and Clinical Leadership. Each of these standards has a number of practice competencies, each of these competencies with their own performance indicators. 
Conclusions: Generic Standards for nurse practitioner practice will support a standardised approach and mutual recognition of nurse practitioner authorisation across the two countries. Additionally these research outcomes can more generally inform education providers, authorising bodies and clinicians on the standards of practice for the nurse practitioner whilst also contributing to the current international debate on nurse practitioner standards and scope of practice.

Nurse Practitioner competency standards: findings from collaborative Australian and New Zealand research

Mapping to the National Competency Standards for the Registered Nurse

Aims and objectives
This paper reports an integrative review of the literature on nursing competency standards for nurses working in primary health care and, in particular, general practice.

Background
Internationally, there is growing emphasis on building a strong primary health care nursing workforce to meet the challenges of rising chronic and complex disease. However, there has been limited emphasis on examining the nursing workforce in this setting.

Design
Integrative review.

Methods
A comprehensive search of relevant electronic databases using keywords (e.g. ‘competencies’, ‘competen*’ and ‘primary health care’, ‘general practice’ and ‘nurs*’) was combined with searching of the Internet using the Google scholar search engine. Experts were approached to identify relevant grey literature. Key websites were also searched and the reference lists of retrieved sources were followed up. The search focussed on English language literature published since 2000.

Results
Limited published literature reports on competency standards for nurses working in general practice and primary health care. Of the literature that is available, there are differences in the reporting of how the competency standards were developed. A number of common themes were identified across the included competency standards, including clinical practice, communication, professionalism and health promotion. Many competency standards also included teamwork, education, research/evaluation, information technology and the primary health care environment.

Conclusion
Given the potential value of competency standards, further work is required to develop and test robust standards that can communicate the skills and knowledge required of nurses working in primary health care settings to policy makers, employers, other health professionals and consumers.

Relevance to clinical practice
Competency standards are important tools for communicating the role of nurses to consumers and other health professionals, as well as defining this role for employers, policy makers and educators. Understanding the content of competency standards internationally is an important step to understanding this growing workforce.

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Nursing competency standards in primary health care: an integrative review

In our roles as Federal Professional Officers at the Australian Nursing & Midwifery Federation (ANMF) we talk about scope of practice on a daily basis. Every conversation we have about nursing scope raises the question of advanced versus expanded practice. Among the confusion one thing is clear, there is a notable lack of uniformity in the understanding and use of these terms.

Is it advanced or expanded practice

of a paper presented at he 2015 PHC Research Conference, 29-31 July, Adelaide, Australia. Disciplines Medicine and Health Sciences | Social and Behavioral Sciences Publication Details Halcomb, E., Bryce, J., Foley, E. & Ashley, C. (2015). The development of national practice standards for nurses in general practice. 2015 Primary Health Care Research Conference: Program & Abstracts Australia: Primary Health Care Research and Information Service. This conference paper is available at Research Online: http://ro.uow.edu.au/smhpapers/3328 Home > Resources > Resource feed > Item Author(s) Elizabeth Halcomb*, Julianne Bryce, Elizabeth Foley, Christine Ashley Organisation University of Wollongong, Australian Nursing and Midwifery Federation Aims & rationale Nursing in Australian general practice has matured significantly since the Competency standards for nurses in general practice were first published in 2005. The Australian Nursing and Midwifery Federation has recently completed a project, funded by the Department of Health, to revise these Standards and bring them into line with contemporary clinical practice. Methods This mixed methods study used two online surveys of nurses and a series of fourteen focus groups conducted around Australia to collect data. Findings A total of 561 survey responses were received across the two surveys and 200 nurses participated in the focus groups. The final 22 Practice Standards were divided into four domains; 1) Professional practice, 2) Nursing Care, 3) General Practice Environment and 4) Collaborative Practice. These standards outline the broad scope of the potential role of enrolled, registered and advanced practice registered nurses employed within general practice. Relevance to policy, research and/or practice needs Professional practice standards are an important way of defining the role and scope of practice of a profession to both consumers and other professionals, as well as being a guide for curriculum development and measurement of performance. For individual nurses they provide a tool for both performance assessment and planning of professional development. They have clear relevance to policymakers, researchers and those in clinical practice as they provide role clarity that will optimise the contribution of nurses to Australian general practice. Presentation type Resource item http://www.phcris.org.au/resources/item.php?id=8268&spindex=3 1 of 2 25/11/2015 3:37 PM Paper Session theme Education and training Session details 9:30am Friday 31 July 2015, Adelaide Convention Centre Riverbank 7 Citation Halcomb E, Bryce J, Foley E, Ashley C. (2015). The development of national practice standards for nurses in general practice. In: 2015 Primary Health Care Research Conference: Program & Abstracts. Primary Health Care Research and Information Service, Australia. phcris.org.au/conference/abstract/8268 Resource item http://www.phcris.org.au/resources/item.php?id=8268&spindex=3 2 of 2 25/11/2015 3:37 PM

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Julianne Bryce

Papers

Nursing competency standards in primary health care: an integrative review

The development of professional practice standards for Australian general practice nurses

Is it advanced or expanded practice

The development of national practice standards for nurses in general practice

Calling code blue on climate change.