Medicolegal issues : When to refer
The ability to recognise and work within your limitations is vital for a practice nurse. Kate Taylor, a registered nurse and Clinical Risk Manager at the Medical Protection Society (MPS), looks at the act of referring a patient to a GP or specialist.
Next year will see significant changes for primary care with the abolition of Primary Care Trusts, the development of Clinical Commissioning Groups (CCGs) and compulsory registration with the Care Quality Commission (CQC).
These changes will enhance primary care's role in gatekeeping the services available to patients. Nurses working within general practice are key to these changes and they will need to ensure that they are able to refer patients onwards to GPs, colleagues or to another healthcare provider. Price1 recommends that 'national and local guidelines and protocols act as valuable aids to the referral decision'. Similarly, Edwards2 states 'Best practice guidelines that include evidence-based recommendations for appropriate referrals may improve continuity of care.' Best practice guidelines can provide a consistent approach but what happens outside of these parameters? Nurses working in general practice have to ensure they are able to refer a patient safely and efficiently.
ADVANCED ROLES
In recent years, nursing within general practice has seen a number of new roles emerging, including prescribing and management of minor illnesses, with the introduction of advanced nurse practitioners. The Royal College of Nursing identifies that this has challenged traditional professional boundaries at a time of change and it is imperative that nurses practise safely and protect themselves in the roles they are employed to undertake.3 (See risk management tips.)
Prior to the introduction of advanced roles within nursing, practice nurses were not permitted to order an investigation or refer to a specialist. This was a cause of frustration for both the nurse and the patient, and could result in a delay in treatment. The culture has since changed in relation to this traditional approach to patient care.
CURRENT PRACTICE
The knowledge and skills of practice nurses has expanded, to include the implementation of chronic disease management clinics, with many nurses undertaking further academic study to become experts in key diseases such as asthma, diabetes and heart disease.
However, there are still occasions where nurses need to refer the patient to the GP or appropriate healthcare professional, for example, if a cervical polyp is detected during cervical screening.
The Nursing and Midwifery Council states '...you must recognise and work within the limits of your competence, acknowledging when a particular patient presentation is outside of your level of competence is paramount.' 4
THE FUTURE
The development of CCGs will influence incentive schemes for practices to meet efficiency targets. Referrals may be a part of this, therefore it is important for clinicians to ensure that all referrals are appropriate and follow best clinical practice. Incorrect referrals are inconvenient and potentially unsafe for patients and can be a waste of already stretched resources. Practice nurses need to be mindful of these incentive schemes and ensure that they also adhere to best practice, and maintain high standards of patient care.
VICARIOUS LIABILITY
Vicarious liability is an important legal principle for practices. It is the legal responsibility a GP may have for the acts and omissions of an employee for whose conduct they are legally responsible.
It is likely that a GP would be granted assistance by the MPS with requests related to claims of negligence against any of their employed nurses working at a basic level. It is unlikely that GPs would be granted assistance for such claims against nurses working in extended roles, and for this reason practices are strongly advised to ensure that nurses have and maintain their own indemnity arrangement.7
SUMMARY
The changes to primary care will increase the gatekeeping responsibilities of practice nurses. If carried out safely and efficiently, this can have a positive effect on resources, availability of appointments and patient satisfaction.
With more responsibilities comes increased risk and nurses should be aware of their limitations, referring a patient to a GP or specialist, when appropriate.
REFERENCES
1. Price A, Willliams A. Primary care nurse practitioners and the interface with secondary care: a qualitative study of referral practice. Journal of Interprofessional Care 2003; 17: 239-250
2. Edwards N, Davies B, Ploeg J, et al. Implementing nursing best practice guidelines: Impact on patient referrals. BMC Nurs 2007;6:4.
3. RCN. Advanced nurse practitioners. An RCN guide to advanced nursing practice, advanced nurse practitioners and programme accreditation. 2012; London http://www.rcn.org.uk/__data/assets/pdf_file/0003/146478/003207.pdf
4. NMC. The code: Standards of conduct, performance and ethics for nurses and midwives. http://www.nmc-uk.org/Nurses-and-midwives/The-code/The-code-in-full/
5. Care Quality Commission. Essential standards of quality and safety.
6. Medical Protection Society (2011) Nursing jeopardy cited in Your Practice 2011;5 (4) http://www.medicalprotection.org/uk/your-practice-october-2011/nursing-jeopardy
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