Chronic disease management: the role of nurses in complex patient care

Chronic diseases are one of Australia’s most significant health challenges, with an estimated 15.4 million Australians living with one or more long-term health conditions that impact their lives. Conditions such as cardiovascular disease, dementia, diabetes, back pain and mental health illnesses are among some of the most prevalent health concerns amongst the population.

As chronic diseases also become more common with age, this places a greater demand on a skilled healthcare workforce to meet the needs of people with chronic health conditions across the lifespan. With advanced skills, nurses can play a vital role in providing expert chronic disease management to individuals in this demographic.

This article explores postgraduate courses available to nurses seeking to advance their clinical knowledge in complex and chronic disease care. We also cover the unique value of these nursing roles in the healthcare sector, as well as some of the essential skills nurses should develop to thrive in this specialisation.

Understanding chronic disease in Australia

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What is a chronic disease?

A chronic disease is characterised by a health condition that persists for three months or longer, typically with a slow progression that requires ongoing management and care from multiple healthcare professionals. Chronic diseases may also be caused by a multitude of factors, which can include genetic predisposition as well as socioeconomic, environmental, diet and lifestyle factors.

The nationwide impact of chronic disease

The impact of chronic disease on Australia’s population is substantial. Conditions such as diabetes, obesity, cancer, chronic mental health illnesses and other non-communicable conditions can affect people’s physical, emotional and social health and overall quality of life, with rippling consequences for carers, families and society at large. In fact, chronic diseases are responsible for 90 per cent of preventable deaths in Australia.

There are also specific population groups at higher risk of developing one or more chronic health conditions over their lifetimes. Data from the ABS shows that 50 per cent of all Australians have one or more chronic conditions. It also highlights that women are more likely to develop chronic health conditions compared to men and people living in regional, remote or disadvantaged areas are more likely to experience multiple chronic health conditions.

The Australian Institute of Health and Welfare indicates that an estimated:

• 4 million Australians suffer from chronic back pain, which was a leading cause of disease burden in 2023
• 3.7 million Australians live with arthritis, with incidences higher among older adults in 2023
• 1.9 million Australians live with diagnosed diabetes of all types, with a higher prevalence among males compared to females in 2022
• 1.3 million Australians over 18 years suffered from cardiovascular conditions related to the heart, stroke and vascular system in 2022
• 425,000 Australians live with dementia and 63 per cent of these were women in 2022
• 165,000 new cancer cases were reported in Australia, with 55 per cent of these cases occurring in men in 2023
• Importantly, the total healthcare expenditure for chronic diseases in Australia was approximately $82 billion in 2023

Postgraduate courses in chronic disease management

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For nurses interested in chronic disease management, there are postgraduate pathways available to progress your career in this field:

Chronic disease and ageing

Victoria University’s Master of Nursing (Chronic Disease and Ageing) is a flexible, online postgraduate course for registered nurses seeking specialised skills in complex, chronic and older adult patient care. This course provides nurses with a deeper understanding of chronic and age-related health conditions. It supports the development of targeted interventions for people with comorbidities, applicable to community health, hospital and aged care settings.

You’ll learn a variety of topics covering areas such as health assessment, complex care coordination, health promotion and innovation, mental health nursing and leadership in clinical settings. This course also includes four units dedicated to chronic disease and ageing, including a research project to hone your critical analysis skills and develop an evidence-based nursing practice. You’ll be equipped with the expertise to pursue clinical nursing, senior and leadership roles, such as a clinical nurse specialist, nurse unit manager or a director of nursing.

The University of Newcastle also offers courses relevant to chronic disease and older adult care. The Master of Nursing (Chronic Disease and Ageing) is a 12-month, face-to-face course for registered nurses looking to gain advanced skills to work in multidisciplinary teams, support Aboriginal and Torres Strait Islander health and pursue leadership or management roles in the aged care sector.

This course is also offered online for a flexible learning experience, designed to fit your studies around your work and life. You’ll have the opportunity to choose three units from a total of six options, allowing you to customise your course to suit your career goals. Choose from Foundations of Health Promotion, Mental Health of Older People, Ageing and Health, Palliative Care Practice, Chronic Disease and Injury Control and Applied Equity-Focussed Health Impact Assessment.

You’ll also complete two additional elective subjects to complete your studies. For example, you may consider Evidence-Based Complementary and Integrated Health, Leading Change in Practice, Symptom Management in Clinical Practice or Introduction to Pharmacotherapeutics and Prescribing for Health Care Professionals to build important skills relevant to chronic disease care.

Chronic and complex care

The University of Technology Sydney offers a Master of Advanced Nursing (Chronic and Complex Care). This course is aimed at registered nurses interested in improving health outcomes for patients with long-term health issues across various healthcare environments. This master’s degree is a comprehensive course, offering a range of electives to tailor your learning experience based on your interests and career goals.

Alongside eight core units that cover advanced nursing topics, you’ll complete the Diabetes Pathways unit and the Ageing: Health, Illness and Decline unit plus two additional electives. The broad range of elective subjects covers a spectrum of clinical, leadership and management areas.

For example, if you’re interested in a future role in chronic and complex care as a nurse leader, you may consider Organisational Management in Health Care, Fundamentals of Health Information Management, Policy, Power and Politics in Health Care or Quality and Safety Improvement Methods. You’ll be able to propel your nursing career in various roles, such as clinical nurse consultant, nursing educator and nurse researcher.

Why nurses should complete a chronic disease management course

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There are many benefits linked to advanced expertise in chronic disease care for nurses. Understanding what you’ll gain from completing a chronic disease management postgraduate program can help you take a confident step toward progressing your healthcare career.

Here are some of the key benefits of completing a chronic disease management course:

Contribute to better patient outcomes

Courses in chronic disease management allow you to use advanced assessment, treatment planning and intervention strategies with a focus on holistic, person-centred care. You’ll be equipped with the skills and knowledge to provide nursing care to patients with a variety of chronic conditions and at different life stages.

Build an evidence-based and innovative practice

You’ll be able to critically evaluate current research, clinical guidelines and healthcare policies to deliver relevant and informed care. You’ll also gain the skills to design and implement novel care approaches that aim to improve the chronic disease trajectory for patients.

Develop strong clinical leadership and decision-making skills

These courses help you develop advanced leadership and management capabilities to coordinate complex, multidisciplinary care for individuals with chronic conditions. You’ll be able to spearhead initiatives that help improve healthcare delivery in complex, chronic and aged care environments.

Adopt an ethical and person-centred approach

Build an ethical and sensitive nursing framework that advocates for patients’ individual health needs. These courses also align with the World Health Organisation and Australian health authorities' practice principles, which promote equitable and inclusive healthcare for diverse communities with chronic health conditions.

Expand your career through research and education

Develop a strong understanding of research methodology and its application to nursing and health-related questions. You’ll gain skills in research design and contribute to clinical projects that inform nursing practice and policy related to chronic disease and health outcomes. You’ll also build expertise in mentoring and professional development to educate and empower colleagues within clinical settings.

Gain skills to work in multidisciplinary teams

Enhance your communication and teamwork skills to work effectively within multidisciplinary and interprofessional environments specific to aged care and chronic disease care. You’ll also be equipped with advanced skills in leadership, advocacy and expert knowledge of this specialised field. This can help build your authority and initiate change in the broader healthcare context.

The growing demand for expert health professionals in chronic disease care

While there is increased awareness of the importance of preventive healthcare, there are strong career opportunities for healthcare professionals, including nurses, to make a positive impact on the health of Australians living with a range of chronic health conditions.

According to a patient survey by the Australian Commission on Safety and Quality in Healthcare, Australia fares well in delivering high-quality healthcare to patients with chronic disease. The survey, conducted in 2023, sampled 107,011 patients from 19 countries globally. In Australia, 1816 patients were surveyed across 54 GP practices around the country. Compared to other countries, Australia performed equal to or better than the Organisation for Economic Cooperation and Development average across ten measured health areas. The four areas in which Australia excelled were quality of care, coordination of care, person-centred care and physical health outcomes.

This survey also revealed important areas for improvement, specifically in mental health support and for those with multiple, complex health conditions and comorbidities. The results of this survey highlight the overall quality of care patients receive from a first-hand perspective and further demonstrate the need for talented and passionate healthcare professionals to make an impact in the chronic disease care sector.

What is the nurse’s role in chronic disease management?

The role of nurses in chronic disease management is important to maintaining a high standard of care. They can apply their clinical expertise, empower patients and help coordinate comprehensive care with other healthcare providers.

Nurses in chronic disease management are able to respond appropriately to the complex care needs of patients at all stages of their diagnosis, treatment and progress.

Some typical responsibilities include:

• Identifying risk factors and implementing strategies to prevent disease progression or complications, such as diet and lifestyle modifications
• Providing nursing care, including developing a personalised plan, monitoring health status and administering medications
• Educating patients to help them understand their conditions, while empowering them to manage their health independently if appropriate
• Assessing treatment effectiveness, monitoring patient progress and identifying early signs of complications
• Collaborating with multidisciplinary teams, including doctors, allied health professionals and community health services to ensure an integrated approach and continuity of care

Rewards and challenges of chronic disease nursing

Working in chronic and complex care offers nurses the opportunity to make a significant difference in people’s lives. To help you understand the field in more depth, there are some rewards and challenges to consider.

Rewards

Meaningful, holistic and patient-centred care delivery

Nurses in this field have the opportunity to build lasting relationships as they support individuals through ongoing health journeys, witnessing real improvements in quality of life, self-management of their condition and overall wellbeing. Central to this field is a holistic, person-centred approach that empowers patients to actively manage their conditions while also supporting their physical, emotional and social needs. Chronic disease management nurses also play a key role in advocacy, health promotion and fostering a safe, culturally-aware environment for patients. When patients feel empowered, understood and as though they have some agency over the care they receive, they can begin to participate more actively, which can help promote a better overall quality of life.

Strong job security in a growing healthcare field

With Australia’s ageing population and rising rates of chronic conditions, the demand for skilled chronic care nurses is expected to expand. This creates strong job security and diverse career opportunities across public and private hospitals, community health, aged care and primary care settings. Beyond clinical practice, chronic and complex care nursing opens pathways for professional advancement and leadership positions. These roles often involve strong management capabilities and collaboration skills across healthcare disciplines. The experience gained in clinical roles can provide a solid foundation for progression into advanced practice, nurse practitioner or nurse educator positions throughout your career.

Challenges

Intellectually and emotionally demanding work

Caring for older adults and individuals with chronic or complex conditions can be clinically demanding as well as emotionally taxing. Chronic disease management nurse jobs require you to develop strong clinical skills to deliver quality care, be precise with medication administration and apply critical thinking to evaluate the best course of action for your patient’s unique health needs. You’ll also support the emotional needs of patients navigating the difficulties of living with a chronic health condition. From patients with cognitive decline due to dementia to the stress and uncertainty associated with chronic cancer, the challenges of working in chronic disease management are an inherent part of the job.

Slower progress and improvements for patients

Other nursing fields, such as acute care nursing or perioperative nursing, can yield more obvious or immediate improvements for patients. However, patient progress and treatment success for people with chronic conditions may be slower and more subtle. Remember, in many cases, it can be a long-game approach to care, possibly particularly for complex health presentations or in older adults. Outcomes may be measured through comfort, quality of life or simply a stabilisation of symptoms. While progress might be gradual, the impact of providing consistent, specialised and compassionate care to patients can make all the difference in their health trajectory and in their wellbeing. Ensure you practise patience and prioritise self-care to remain effective in your role.

Essential skills for a career in chronic disease management

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To effectively support patients with complex and long-term health conditions, here are some of the essential skills nurses should develop:

Compassion

To provide meaningful care, demonstrating compassion to patients facing difficult health challenges is important. Showing patients that you care and offering empathy can help them feel valued and supported throughout their journey. Compassion also helps foster a patient-centred approach, which ensures the individual is at the centre of the treatment process. This enables them to play an active part in decision-making and maintain agency regarding their treatment. Whether the part you play in their treatment is for a short while or ongoing, they’ll remember the care they received from an understanding nurse who took the time to share in their experience of dealing with a chronic health issue.

Patient advocacy

Being an advocate for your patient is a core part of a nurse’s role. In aged care, hospital or other healthcare settings, patients may be vulnerable, feeling anxious and wondering about their treatment process or their prognosis if they have a serious chronic health condition. This may be amplified for vulnerable people, those with less health literacy and for those with multiple comorbidities, requiring comprehensive support for their health. Patient advocacy involves being a voice for the patient and their best interests, supporting informed decision-making and helping them navigate the healthcare system in what can often be stressful or uncertain circumstances.

Collaboration

The complexity of care needed to address various medical, emotional and social needs typically means you’ll work with other healthcare providers or in multidisciplinary teams. Nurses can use teamwork and collaboration skills and may even play a coordinating role, facilitating care from primary health and allied health providers. This may include doctors, specialists, surgeons, aged care nurses, oncology nurses, speech pathologists, palliative care nurses, occupational therapists, dietitians or physiotherapists. Effective collaboration ensures more effective treatments with outcomes tailored to the patient’s specific needs, while also improving continuity of care between providers.

Cultural competence

Developing skills in cultural competence can help you provide more inclusive and responsive care to patients with chronic or complex health conditions. To do this, it helps to consider the social determinants of health and disease as well as the socioeconomic challenges and disparities faced by diverse cultural groups in Australia. Culture can influence the way an individual views their health, how they interact with health services and professionals and may also impact their perception of treatment. Honing your awareness of the specific needs of your patient in the context of their cultural background can help foster trust and deliver care that aligns with their health, preferences and broader personal needs.

Critical thinking

Managing chronic and complex diseases requires analytical and critical thinking skills. This helps you to make appropriate clinical assessments and determine a suitable approach to care. Developing your capacity to think critically becomes even more important in the context of managing multiple health issues and working alongside other expert health professionals. This valuable skill enables nurses to identify subtle changes in a patient’s condition, evaluate treatment effectiveness, anticipate potential roadblocks to recovery and implement changes accordingly. It is also an essential skill for nurses to develop and helps form part of an evidence-based practice that is safe, effective and relevant to the individual.

Leadership

Building leadership skills aligns closely with the ability to collaborate and coordinate effectively to optimise patient care. It also helps you remain accountable and able to adapt to the evolving needs of patients and your work environment. Getting to know your own leadership style as a nurse can help you identify your strengths and inherent qualities to leverage in your role. It also helps you understand how to work in interdisciplinary teams, encouraging positive dynamics, with direct impacts on patient outcomes. Whether you are a transformational leader who is purpose-led and dynamic, a democratic leader who is fair and non-judgemental or a delegative leader who trusts the input of other experts, effective leadership skills serve your professional role and can positively impact patients living with chronic disease. Are you wondering what your healthcare leadership style might be? Take this quiz to find out.

Advance your career with chronic disease care skills

Postgraduate study in chronic disease management equips nurses with advanced knowledge and clinical skills to help patients achieve better health outcomes, manage complex care needs and reduce the burden of chronic disease on the Australian healthcare system.

If you’re ready to take the next step in your nursing career, you can explore a range of chronic disease management courses, select a course that aligns with your needs and book a call with our Education Consultant who can help you with the enrolment process.

At GlobalHealth Education, we partner with universities to offer postgraduate healthcare courses in a range of fields, including psychology, nursing, public health, health leadership, counselling, social work and mental health. We also showcase healthcare courses from many respected Australian universities. Transform your healthcare career and enquire today.