New to general practice nursing? Practice nurse skills: Part 1

This, the first of two articles, provides an overview of essential treatment room skills to give a general flavour of the general practice nurse (GPN) role for nurses new to the specialty or those who are considering a move to primary care

General practice nursing is a unique specialty encompassing a whole range of clinical skills. Nurses new to the field, whether recently qualified or with vast and valuable experience in other sectors, are likely to be encountering a number of skills for the first time. Furthermore, Health Care Assistants (HCAs) in Primary Care are expanding their role to take on more delegated skills. In part 1, we will be looking at the following skills:

• Phlebotomy
• Injections
• Childhood and adult immunisations
• Chaperoning
• Minor surgery assistance

THE NMC CODE

Whatever previous experience nurses bring to any role, maintaining public and patient safety is paramount when taking on the challenges of working in a new environment. The NMC Code reminds us to:

• ‘Recognise and work within the limits of your competence
• 'Ask for help from a suitably qualified and experienced healthcare professional to carry out any action or procedure that is beyond the limits of your competence
• 'Complete the necessary training before carrying out a new role’.¹

CONSENT AND CONFIDENTIALITY

Box 1 highlights the legal requirement of valid consent. The Department of Health‘s 2009 ‘Reference guide to consent for examination or treatment’ provides excellent guidance for patients who lack capacity and also makes clear the law regarding consent of young people under 18 years of age.² Patients also have a legal and ethical right to privacy and confidentiality and, in turn, a relationship with healthcare professionals built on trust. Whenever there are concerns about patient safety, the sharing of information with other healthcare professionals and agencies may be necessary in line with local and national safeguarding policies.¹

TRAINING, MENTORING AND ASSESSMENT

All GPNs should receive appropriate training for any new skill and be assessed to determine competence.³ There is a plethora of accredited training packages and study days, online learning tools, webinars, journal articles and national guidance which can help to broaden knowledge, together with attendance at local GPN meetings and forums. The Practice Nurse Journal website offers a wealth of resources starting with the ‘Essentials’, as well as useful CPD modules. The Royal College of General Practitioners (RCGP) General Foundation General Practice Nurse Competencies and The Heath Education East Midlands Practice Nurse Project Competency Framework and Competency Development Plan both provide useful frameworks for the assessment of learning new skills, consolidating practice and achieving competencies.^4,5 Competence with new skills can be demonstrated through direct observation, reflective accounts, case analysis and feedback from colleagues and patients alike.³ Support through mentoring for nurses new to the speciality is paramount for patient care and for team integration.

TREATMENT ROOM SKILLS

Phlebotomy

Phlebotomy (venepuncture) – inserting a needle into a vein to obtain a blood sample – is common practice in primary care for diagnosis, therapeutic monitoring and the management of long term conditions. Each local laboratory processes specific collecting systems (Monovette, Vacutainer or Vacuette) and practitioners need to be familiar with local procedures, equipment and the associated paraphernalia, as well as undertaking training to be competent in the skill of phlebotomy. Theoretical training programmes for nurses new to phlebotomy should include anatomy and physiology, infection control, use of equipment and procedural technique, phlebotomy-associated first aid and complications. Supervised phlebotomy practice then needs to be undertaken to achieve competence and independent practice. Training packages may be provided by local hospital laboratories, or sourced through accredited training programmes or even in-house.

The practice’s own local policy and protocols should encompass:

• Infection control and hand washing
• Personal protective equipment (PPE)
• Sharps disposal
• Documentation
• Preparation and management of the patient
• Method of the procedure
• Choice of veins
• Awareness of potential problems
• Informing the patient of how to access results

B12 deficiency and injections

Vitamin B12, found predominantly in meat, fish, eggs and dairy, is necessary for normal formation of red blood cells and healthy functioning of the brain and nervous system. When ingested it combines with the protein intrinsic factor (IF) in the stomach to enable it to be absorbed in the distal ileum. Although Vitamin B12 deficiency can be dietary in cause, (e.g. strict vegan diet), it is more likely to be caused by malabsorption of the water-soluble vitamin through:

• Pernicious anaemia (autoimmune gastritis affecting IF production)
• Alcoholism
• Pancreatic failure
• Gastrectomy
• Small bowel surgery
• Crohn’s disease
• Taking metformin, anticonvulsants, protein-pump inhibitors

B12 deficiency can present as anaemia – fatigue, dyspnoea, pallor, palpitations, loss of appetite and weight loss. Other symptoms include neuropathy, mental impairment, depression, irritability, ‘yellow-tinged skin’, glossitis and mouth ulcers. If a full blood count sample shows low haemoglobin and high mean cell volume, further investigation into B12 and folate levels may be warranted. If B12 is prescribed, the usual regime is intramuscular hydroxocobalamin 1,000mcg/1ml on alternate days for two weeks followed by a maintenance dose of the same every 3 months although the schedules may be changed accordingly.⁶ Undesirable effects are rare but include nausea, headache and dizziness.⁷

VACCINATION AND IMMUNISATION

Without doubt vaccination saves lives and prevents serious illness and disability. Training that encompasses national policy and standards provides the foundation for furthering knowledge, the development of practical skills and achieving competence. Undertaking annual updates, keeping up to date with current issues and changes to the National Immunisation Schedules, understanding the handling and storage of vaccines, and accessing the abundance of valuable resources available are essential to the GPNs role. Annual anaphylaxis management and child and adult life support updates are also mandatory. Box 2 provides some essential immunisation resources. The Public Health England publication ‘Immunisation against infectious disease’ – The Green Book – is fundamental to practice.⁷

Vaccination programmes in primary care

The NHS routine schedule of immunisations given in primary care includes:

• Childhood immunisations
• Seasonal influenza vaccine
• Pneumococcal vaccine
• Shingles vaccine
• Pertussis vaccine to pregnant women

Legally, practice nurses can only administer vaccines if one of the following is in place:^9,10

• A signed prescription
• A signed Patient Specific Direction (PSD)
• A Patient Group Direction (PGD)

A Patient Specific Direction (PSD) is a written instruction from a qualified and registered prescriber for a medicine, which details the dose, route and frequency, to be administered to an individually named patient or several named patients. HCAs can only legally administer a vaccine under a PSD.

Patient Group Directions (PGDs) are written instructions to enable the administration of licensed medicines by qualified healthcare professionals to groups of patients who may not be individually identified in advance. Nurses using PGDs must have been assessed as competent to use them and comply with NMC standards.¹¹

The national influenza programme

This seasonal programme is targeted at members of the population who may be at particular risk of severe morbidity and mortality, as a result of influenza (flu). Flu vaccination also reduces hospital admissions, GP consultations and A&E attendance. The children’s programme, whilst providing individual immunity, indirectly protects the wider population through herd immunity.

Each year, influenza vaccines are developed in line with recommendations from The World Health Organization (WHO) taking into account predicted virus strains (subtypes of Influenza A and B) for the forthcoming winter. In primary care, the vaccine is offered each year between September and January to those aged 6 months to under 65 years in clinical risk groups, pregnant women, carers and those aged 65 year and over as well as 2,3 and 4 years olds under The National Childhood Flu Immunisation Programme.^12,13 Adults, and children aged over 6 months and under two years, should receive the intramuscular inactivated influenza vaccine except when there is a confirmed anaphylactic reaction to a previous dose or any component of the vaccine. Unless contraindicated, as detailed in Chapter 19 of The Green Book, the quadrivalent Live attenuated intranasal influenza vaccine (LAIV), is the vaccine of choice for children as it has an higher efficacy and acceptability over the intramuscular route.

Pneumococcal

Life-threatening pneumococcal infection, caused by the Gram-positive bacterium Streptococcus pneumoniae, is common cause of pneumonia but can also lead to meningitis and bacteraemia. There are two inactivated pneumococcal vaccines available: pneumococcal conjugate vaccine (PCV13) given to infants as part of the childhood immunisation programme and pneumococcal polysaccharide vaccine (PPV23) given as a single dose for those aged over 65 years and adults and children with specific clinical risks. The vaccines contain 13 and 23 capsule (i.e. virulent) types of pneumococcus respectively. Patients with asplenia, splenic dysfunction and chronic renal disease are re-immunised with PPV23 every 5 years as their antibody levels are likely to decline.¹⁴

Shingles vaccination

Shingles is a reactivation of the chicken pox (varicella zoster) virus, which has lain dormant in a nerve ganglion. Reactivation of the virus can be triggered, although not exclusively, by increasing age, malignancy, immunosuppression or stress and affects the nerves and surrounding skin to produce a painful vesicular rash along the line of a dermatome (an area of skin supplied by a single spinal nerve). Post herpetic neuralgia (PHN) and peripheral motor neuropathy, are more prevalent in older people and those with poorer immune symptoms, and can persist for several months or longer. The JCVI recommends that the live attenuated shingles vaccine, given by intramuscular or deep subcutaneous injection, is used for adults over 70 years and has been shown to reduce the burden of illness by 55% and the incidence of PHN by 66.8%.¹⁵ Live vaccines should not be administered to patients with:16

• Immunodeficiency (primary or acquired)
• On immunosuppressive or immunomodulating therapy
• A confirmed anaphylactic reaction to any previous dose of varicella-containing vaccine or any component of the vaccine including neomycin or gelatin.
• Pregnancy

Pertussis (Whooping Cough)

Pertussis vaccination is offered in every pregnancy after the twenty week anomaly scan to provide protection against whooping cough in the newborn until they receive their routine infant immunisations at 8 weeks old.¹⁷

Childhood immunisation

Childhood immunisations are a major part of general practice and it is a GPN’s responsibility to promote the benefits of immunisation.¹⁸ You can find details of the current immunisation schedule at http://www.practicenurse.co.uk/index.php?p1=articles&p2=1318. GPNs with limited paediatric experience may initially find vaccinating children somewhat daunting, but this demonstrates where mentoring – to feel confident and competent – is paramount. Additional considerations include vaccinating individuals with uncertain or incomplete immunisation status, answering parental questions, managing anxious or restless children and providing resources for parents and guardians.

Immunisation technique

Chapter 4 of The Green Book⁸ provides an excellent description of immunisation procedures and injection technique, covering the essential elements:

• Consent, patient suitability and understanding
• Vaccine preparation
• Vaccine administration including injection technique, choice of needle length and gauge, injection site, route, site – all of which can affect the immunogencity of the vaccine and potential for local reactions
• Post-vaccination advice
• Disposal
• Accurate and contemporaneous documentation

SUPPORTIVE ROLE

Chaperone

All practices should have a chaperone policy for the protection of both patients and staff and patients should be alerted to their entitlement to a chaperone through clearly displayed patient leaflets and information points in the waiting room, as well as being offered one at the time of examination. Intimate examinations are especially intrusive, potentially distressing and can make patients feel particularly vulnerable. Local CCGs would be the first point of contact to access training for GPNs, and indeed HCAs. Specifically, best practice for a chaperone is to:

• Be sensitive to the patient’s privacy, dignity and confidentiality
• Ensure that the patient understands the procedure and has given informed consent
• Provide support and reassurance to the patient as necessary
• Be familiar with the procedure, observe the clinician and remain with the patient throughout
• Be prepared to raise concerns about the clinician’s behaviour or actions

Assistance with minor surgery

GPNs assisting colleagues in minor surgery need the appropriate knowledge to ensure the following are carried out:

• Infection control measures
• Preparation of the environment (e.g. lighting) and surgical instruments and equipment
• Patient consent and documentation
• The use of personal protective equipment
• Providing emergency assistance if required
• Providing aftercare of the patient including wound management
• Safe disposal of instruments and clinical waste
• Management of specimens for histopathology
• Advising patients when and how to receive results

GPNs can be hugely supportive to patients to reduce anxiety, providing a distraction during the procedure, acting as a patient’s advocate, allaying fears and ensuring the experience is a positive one.

THE HEALTH CARE ASSISTANT (HCA) ROLE

HCAs are invaluable members of the team who have a duty of care to the patients they see for which they are accountable. The RCGP General Practice Foundation Health Care Assistants (General Practice) Competency Framework is an invaluable tool to guide the acquisition of new knowledge and skills for HCAs in Primary Care.^18,19 Successful completion of the Care Certificate, which can be mapped across towards QCF qualifications in Health Care, is now seen nationally as a minimum attainment for HCAs. Any clearly defined tasks that have been delegated to HCAs, for which they have been competently trained and assessed, must be supported by a registered health care professional and the employer. HCAs must work to evidenced-based protocols and standard operating procedures within the HCA Skills for Health Standards code of conduct.²⁰ Skills undertaken by HCAs include doppler ultrasound measurements, spirometry, ear toilet, specific vaccinations (influenza, pneumococcal and shingles but not childhood immunisations), B12 injections, wound care, health screening and health promotion. All health workers need to have the confidence and insight to recognise and work within the boundaries of safe practice at all times, knowing when to refer to senior colleagues and to seek further assistance and advice.

CONCLUSION

The skills of the treatment room nurse are varied. Training, assessment and developing competence are essential to gaining new knowledge and skills, integrating with colleagues and becoming part of the Practice Nurse Team. In part 2 we will look at further skills including cervical screening, ear toilet and wound care.

REFERENCES

1. Nursing and Midwifery Council. The Code. 2015.

2. Department of Health. Reference guide to consent for examination or treatment. 2009.

3. The Royal College of General Practitioners General Practice Foundation/Royal College of Nursing. Updated GPN Nursing standards. 2015.

4. The Royal College of General Practitioners General Practice Foundation. General Practice Nurse Competencies. December 2012.

5. Health Education East Midlands. Practice Nurse Project Competency Framework and Competency Development Plan. 2014.

6. National Institute for Health and Care Excellence. Clinical Knowledge Summaries. Anaemia - B12 and folate deficiency. July 2015. Available at: https://cks.nice.org.uk/anaemia-b12-and-folate-deficiency#!scenario

7. The electronic Medicines Compendium. Summary of Product Characteristics: Hydroxocobalamin 1mg in 1ml solution for injection. Available at: https://www.medicines.org.uk/emc/medicine/31182

8. Public Health England. Immunisation Against Infectious Disease. Chapter 4. Immunisation Procedures. March 2013.

9. British Medical Association. Patient Group and Patient Specific Directions. January 2016. Available at: https://www.bma.org.uk/advice/employment/gp-practices/service-provision/prescribing/patient-group-directions

10. Public Health England. Immunisation Against Infectious Disease. Chapter 5. Immunisation by nurses and other healthcare professionals. March 2013.

11. Nursing and Midwifery Council. Standards for Medicines Management. 2007 (updated 2015).

12. Public Health England. Immunisation Against Infectious Disease. Chapter 19. Influenza. August 2015.

13. Public Health England. The National Childhood Flu Immunisation Programme 2016/17. Information for healthcare practitioners. Crown Copyright 2016.

14. Public Health England. Immunisation Against Infectious Disease. Chapter 25. Pneumococcal. December 2013.

15. Public Health England and Department of Health. Shingles vaccination: training slide set for healthcare professionals. 2013 (updated July 2016).

16. Public Health England. Immunisation Against Infectious Disease. Chapter 28a. Shingles (herpes zoster). December 2013.

17. Public Health England. PHE Gateway number: 2016-063 Re: Change in the timing of pertussis vaccine in pregnancy. 11 May 2016. Available at: https://www.england.nhs.uk/south/wp-content/uploads/sites/6/2016/09/timing-pertussis-vacc-pregnancy.pdf

18. Public Health England. Routine Childhood Immunisations. June 2016. Available at: https://www.gov.uk/government/publications/routine-childhood-immunisation-schedule

19. The Royal College of General Practitioners General Practice Foundation. Healthcare Assistants (General Practice) Competency Framework. March 2014.

20. Health Education England, Skills for Care and Skills for Health. The Care Certificate Framework. Guidance Document. February 2015.

21. Skills for Care and Skills for Health. Code of Conduct for Healthcare Support Workers and Adult Social Care Workers in England. 2013=