Are nurses meeting the needs of men in primary care?

Additional keywords: access, barriers, men’s health, opportunistic, primary health nurse.

Discussion about how and why men’s health is considered to be a significant public health issue is frequently raised in the literature both globally and in Australia (Department of Health and Ageing 2010). Worldwide, the average men’s life expectancy is 6 years less than for women (United Nations 2014). Men experience higher avoidable and premature mortality rates from common conditions including heart disease and cancer (Australian Institute of Health and Welfare 2016). The reasons for this increased risk are due to biological sex difference and cultural (gender) factors in the way men live their lives and engage (or not) with health services (Australian Institute of Health and Welfare 2011).

Importantly, in 2008, the world’s first National Men’s Health Policy was developed by the Department of Health and Children (2008) in Ireland. This policy calls for strategies that target interventions at both individual and population levels. The policy identifies best practice across a range of different aspects of men’s health and offers a clear blueprint for promoting optimum health and wellbeing among men.

In a 2009 review of international policy and progress across 11 countries from 3 continents, entitled Men’s health around the world, the following was noted: a considerable disparity in life expectancy in different groups of men within, as well as between, countries; a high level of preventable premature morbidity and mortality; and the importance of targeted activity across men’s lifespan (European Men’s Health Forum 2009).

The Australian Government launched the inaugural National Male Health Policy: building on the strengths of male Australians to provide a framework for improving men’s health. The 2010 policy takes a significant shift in discourse from the previous theoretical frameworks (Department of Health and Ageing 2010), with a greater focus to develop capacity to coordinate action across the workforce sectors as a key driver of change. The policy aims to provide a platform ‘to build critical health literacy among men, promote equitable access to primary healthcare services and better support men’s engagement within the health system’ (Smith and Bollen 2009, p. 98).

However, Australian men continue to die on average 4.2 years earlier than women. Significant health disparities exist for men and an even wider life expectancy gap exists between diverse disadvantaged groups of males (Department of Health and Ageing 2010). Many of the solutions to address the social determinants of men’s health rely on the ability of the health professional workforce to recognise that men have significant potential to take an active role in their health (European Men’s Health Forum 2009). A growing body of literature suggests that primary healthcare nurses (PHCNs) play a critical role in ensuring workforce supply and improving the quality of care and consumer experience (Cheek et al. 2002, p. 6; Halcomb et al. 2013), However, a review of the literature since 1994 found few published works that examine PHCNs meeting the needs of men in primary care or men’s view of the PHCN role. The main aim of this qualitative study was to explore the perception of PHCNs in terms of men’s health services; the second aim was to describe men’s expectation of PHCNs. In the comparative component, the barriers and facilitators to improved access to health services for men were identified.

An exploratory descriptive approach was undertaken to investigate the full nature of the phenomenon as little was known about the area of interest (Polit and Beck 2010). Patton (2002) argued, ‘qualitative researchers seek to understand the perceptions, feelings, and knowledge of people … through in-depth, intensive interviewing’ (p. 21).

A total of 39 participants with 19 PHCNs and 20 men were recruited in 2014. The purposive sample identified PHCNs who were knowledgeable about primary care and men who attended a medical practice where a PHCN was employed. They were recruited from three Medicare Locals (now Primary Health Networks), two regional and one metropolitan, and the Health Issues Centre in Melbourne, Vic., Australia. There were 23 semi-structured individual interviews and 3 focus groups with 17 participants from both cohorts. Interview questions were formulated by the research team based on a literature review. Focus groups and interviews were audio-taped and transcribed verbatim as text responses with speaker gender identified. Data were simultaneously analysed using analysis strategies from Patton’s (2002) themes of qualitative inquiry, 12-step framework. Textual data were managed using NVivo 10 (QRS International, Melbourne, Vic., Australia) software. Individual PHCN and male interviews were analysed first to allow feedback and guided exploration of issues raised to inform the focus groups discussion. Data coding categories and theme generation were discussed and revised. This study utilised the trustworthiness criteria as described in the study by Lincoln and Guba (1985). Ethics approval was received from the Human Research Ethics Committee of Deakin University, Melbourne, Vic., Australia (HEAG-H 94_2013).

The major finding consistent with qualitative work was that PHCNs and men were unclear about the role of the PHCN in men’s healthcare services. PHCNs reported their lack of clarity was due partly to poor knowledge of the concept and definition of men’s health, which affected their confidence to deliver health care and health promotion for men. PHCNs and men described confidence as very important for effective communication and in establishing rapport. PHCNs expressed that their lack of knowledge was affected by their education preparedness in men’s health.

Two (11%) and one (5%) PHCNs in this study had respectively undertaken some form of men’s health or sexual health training, whereas three (16%) PHCNs had completed any health promotion education (Table 1).

Table 1.  Primary healthcare nurse post-basic education in primary care

One PHCN participant stressed that for her to engage men more effectively and provide quality healthcare services, she would need to attend relevant training stating:

I haven’t had any formal training in men’s health or health promotion, and if the right type of education was provided, I would do it. Having worked in GP [general practice] land, I am very aware that it is a very important component of the quality care that a general practice clinic offers or should offer to better engage their male patients [N 23].

All of the PHCNs emphasised the need for an enhanced role for nurses to better engage men in sexual health, assess men’s mental health, and promote health and illness prevention at a primary care and community level. PHCNs wanted to do more in this area. An important finding was that the PHCN participants of the regional focus group and three PHCNs from individual interviews stressed that they had seen an increase in the number of men with mental health issues. However, they had been unable to provide mental health intervention as they lacked confidence and knowledge, and did not perceive mental health care as being within their scope of practice. PHCNs described their feelings of frustration at lacking the clinical skills to provide basic mental health care for male patients.

PHCNs’ current role provided health care for men through immunisation, wound care and health assessments, and they described the most satisfying aspect of their role as the development of therapeutic relationships. This was a helping relationship based on mutual trust and respect, the nurturing of faith and hope, and being sensitive to men’s health needs and their level of health literacy.

Most (16 of 19) PHCNs indicated that the current model of nurse-related Medicare financing was a major barrier to the availability of nursing services and health promotion for men. The current funding model limits nurses to making interventions and participating in collaborative care. This was summed up by the following PHCN:

The whole of primary health care and the GP clinic are structured around the Medicare Benefits. At the moment the GP’s role is acute responsive care, not primary preventive care. It makes it very difficult for them to direct resources towards activities [done by PHCNs] for men’s health or health promotion that they may not see as [financially] beneficial to the organisation [N 23].

Health promotion and illness prevention were stressed by PHCNs as part of their role in men’s health care. These interventions were predominantly opportunistic and unstructured (ad hoc). Two PHCNs commented:

We take any opportunity we can get. When they [the men] walk in for something else, usually we grab them and screen them for their risks of diabetes or kidney disease if we have time [N 17].

The care provided is opportunistic really. We see a lot of blokes that have sectored [injured] the webs of their fingers or some other type of injury and you use that time to try and discuss health promotion with them [N 27].

PHCNs suggested that extending their practice could include the provision of services through places where men gather (Men’s Sheds, gyms, pubs and sporting events).

Men indicated that they were mostly satisfied with their current health care delivered predominantly by general practitioners (GPs) and were receptive to PHCNs providing collaborative clinical health care for them. Men described the barriers and facilitators when accessing primary health care as: lack of understanding of the PHCN role; cost and time; being seen as a whinger or complainer; and the general practice environment. Men stressed that they became annoyed by the cost, waiting time and lack of extended hours. One explained:

You get in when you can and not at the right time of the day [that suits work commitments] that you want. You wait too long to get what you need [prescription or medical certificate]. It costs too much and it kind of works like a ‘drive-through’ [M 2].

Men echoed the PHCNs’ findings and described the importance of inter-professional relationships, effective communication without jargon and PHCN qualities, identified as: the use of humour; a non-judgemental approach; a caring and empathetic approach; and father-inclusive practice.

The men expressed there was potential for an enhanced role for PHCNs in their health care. They stressed that due to the GP frequently being busy, medical practices may need to do things differently, or make access to the allied healthcare team easier. They outlined three ways that PHCNs could assist more in their health care: provide some preliminary care to free up the doctor to have more time to diagnose medical conditions; concentrate more on health promotion and chronic disease management; and provide sexual and mental health care if appropriate.

There is general agreement in the literature that addressing inequities in men’s health requires a multi-sector emphasis on workforce capacity (Collins et al. 2011). This is the first study in Australia to explore both PHCNs’ perception and men’s expectation of the role of the PHCN.

Both PHCNs and men in this study identified several barriers and facilitators to meeting men’s healthcare needs. In an Australian survey of the role of the nurse working in general practice, Halcomb et al. (2008) reinforced the significant effect of Medicare financing on PHCNs’ enhanced practice. PHCNs frequently referred to funding limitations as a major barrier to provision of coordinated care in men’s sexual health, health promotion and illness prevention interventions. Additionally, the changing healthcare landscape in Australia, with increasing importance of conceptualising health and wellbeing across the lifespan, necessitates a holistic perspective and signals the need for PHCNs to evolve in their thinking and practice (Carryer et al. 2015). This creates diverse and exciting opportunities for PHCNs to step into a range of roles in men’s healthcare services with significant implications (e.g. increased education requirement in health promotion and chronic disease management) in providing clinical care (Halcomb et al. 2014).

Men perceived PHCNs could provide some preliminary care to free up the doctor to have more time to diagnose medical conditions and suggested access to allied health professionals would be improved if they were all working in the same facility. They also explained that they would be receptive to PHCNs providing sexual and mental health care if appropriate. Australian and international authors agreed that trust and rapport need to be gained quickly by health professionals, and may easily be lost if care is rushed, particularly if important information is not explained to the patient (Holden et al. 2010; Yousaf et al. 2015). PHCNs, particularly those in general practice, are ideally situated to explain to the patients the importance of their health and wellbeing and the possible consequences of risk-taking behaviour (Peate 2008), thereby creating an opportunity for men’s health needs to be better met.

The current Victorian study comprised a small sample and may not be directly transferable to other nursing or men’s groups, within Australia or overseas. The study provides a snapshot of PHCNs’ and men’s views. Some sampling bias in the results may have occurred as PHCNs already interested in men’s health may have been more likely to participate in the study and no male PHCN was able to be recruited.

This study contributes health professionals’ broader understanding of men’s views of access to health care, and PHCNs’ understanding of barriers and facilitators in meeting men’s health needs. Identifying these factors may enable PHCNs to clarify their role and collaborative approach in the wider context of men’s healthcare services. In particular, this study highlights a gap in perceived nurse education preparedness to embrace the contemporary health needs of men by expanding their work in partnership with men and other healthcare professionals in order to deliver planned, individualised and engaged care.

The findings of our study emphasise essential men’s health issues for key stakeholders; policymakers, healthcare professionals and national organisations for policy development and implementation. Further research should investigate factors influencing how PHCNs can better meet the contemporary health needs of men.

The authors declare that they have no conflicts of interest.