Where will all our practice nurses come from?

Paradoxically, as the role of the general practice nurse becomes more pivotal – and interesting – it is becoming harder to ensure continuity of recruitment and retention. But the experience of one CCG aims to reverse this trend with an innovative scheme to attract nurses into primary care

General practice nurses have rising levels of responsibility, and in all four UK countries, the emphasis is on shifting proportionately more treatment from the secondary care sector into primary care settings.¹

The Nursing and Midwifery Council (NMC) recognises that as service delivery changes, nurses are undertaking treatment and care that was once the domain of doctors. Practice nurses are often at the forefront of new and innovative treatments and interventions, but the value and worth of their role can be masked in an overall system in perpetual change and crisis with a focus on acute care.

NHS England’s 5-year forward view² supports the strengthening voice of nurses in general practice, and recognition is finally growing nationally that the unique role and position of the practice nurse, alongside the patient and their family throughout their lives, places them central to the shift of treatment and care that is starting, albeit it slowly, to take shape.

It is a paradox then that despite such a pivotal role in the modern healthcare system many practices are experiencing difficulties in recruiting both nursing staff and GPs, which puts greater pressure on the staff in post. And it is widely acknowledged that the practice nurse population is an ageing workforce, which will put additional tensions in the system.

The NHS Centre for Work Force Intelligence³ identifies the future challenges as:

• Managing the changing working patterns in order to provide 24/7 care in the community
• Managing the changing working environments for nurses providing more care in the community
• Supporting programmes and continuing professional development to increase the numbers of nurses moving from hospital to community settings

In May 2015 Scarborough and Ryedale CCG commissioned a piece of work to consider:

1. Does the age profile of practice nurses locally suggest that there will be increasing difficulties in recruiting sufficient staff?

2. Are the current practice nurses able to access good quality education to prepare them for ever demanding roles?

3. Would purpose designed networking/ educational events better meet the needs of the current workforce?

4. What barriers are there to recruitment?

Before starting the project, a comprehensive literature search was undertaken, which was followed up with calls to the authors who had good practice to share. All fifteen practices within the CCG area were visited to discuss the retirement intentions of their practice nurses and to support the nurses to undertake an assessment of competencies and future development needs using the competency tool developed by Health Education East Midllands.⁴ A discussion with each practice manager and lead nurse identified emerging training needs. The competency framework addresses the common core competencies and the wider range of skills, knowledge and behaviours a nurse needs in order to be a fully proficient practice nurse.

RETIREMENT SHORTFALL

Practice nurses often reported that they did not intend to retire at age 55, so rather than presume this to be the normal retirement age, practices were asked how many years each of their registered nurses intended to work before retiring. We found that almost half of the staff intend to retire within five years. (Figure 1) Some of these staff intend to return to work on a part time basis post retirement, but this still leaves a huge shortfall.

It is imperative that in this changing climate, staff who deliver care do so competently, but reports have highlighted technical skills gaps that need to be addressed.⁵

Lack of opportunities for training and feelings of isolation in practice nurses have also been widely identified.⁶ The competency assessment demonstrated a significant shortfall in higher level skills across a wide range of subjects such as diabetes, anticoagulation, chronic kidney disease (CKD), COPD, rheumatoid arthritis, mental health, minor illness and injury. Nurses reported that they had difficulty accessing education that was relevant to practice, cost effective and delivered locally, and identified topics that they would like to be covered in a networking day to be delivered locally. Scarborough and Ryedale, while located in one of the most beautiful parts of the country, is relatively isolated geographically, and training courses have traditionally been held at distances that have made it largely impractical and expensive to secure regular attendance.

NETWORKING DAY

The first networking day was arranged in September 2015. It is accepted that lack of time and organisational constraints have a negative influence on nurses’ ability to engage with CPD.⁷ It was therefore decided to hold a full day of events covering a number of subjects that had been identified as part of the training needs analysis in order to maximise the opportunities for practice nurses to engage in valuable CPD while minimising the time they were away from their base. The cost of the day was covered by HEE Yorkshire and Humber and the CCG. Speakers were identified largely from recommendations from the practice nurses themselves. Topics covered a wide range of subject areas such as:

• Female Genital Mutilation
• How to support student nurses in practice
• Shingles vaccination
• Revalidation

A presentation on research into the clinical and cost effectiveness of compression hosiery versus compression bandages in the treatment of venous leg ulcers was particularly well received, and was followed by a practical session from our Tissue Viability Nurse on the effective use of compression hosiery. Linking the theory to the practical application was appreciated by participants.

The revalidation session delivered by Health Education England was timely and allayed many fears. Practice nurses had reported concerns about the demands of revalidation and how their practices might support them. The session dispelled many unwarranted anxieties and gave the nurse practical advice regarding what would be needed, how to evidence practice related feedback, and what was meant by reflection and discussion.

Three-quarters (77%) of all nurses employed by practices attended the first networking day. The day was extremely well evaluated, with comments such as:

• ‘Excellent Day, I will definitely attend future events’
• ‘Good learning multiple topics in one session’
• ‘All relevant, all interesting’.
• ‘A well planned, well executed day’

Practice nurses reported to us their frustration at having insufficient time to undertake projects that were of interest to them. The CCG agreed to fund a facilitator to run a project they chose. During the networking event, potential projects were identified and attendees voted for the project they wanted to be facilitated. The project chosen was to work with the local universities and our local Advanced Training Practice to support practices to take student nurses. At the time only one practice took student nurses on placement, so opportunities to recruit from the new graduate pool were not maximised. Practices recognised that students may not be aware of the scope of a practice nurse’s role as they had no experience of working within practices and may be disinclined to apply for jobs in future. To test out this theory we attended a university careers event and undertook a postcard survey.

The results of this survey demonstrated that only one student had any idea of the role of a registered nurse in practice (her mother was a practice nurse!). Common misconceptions included ‘They just do immunisations and smears don’t they?’ ‘Their role is very limited and there isn’t much career progression’ and ‘as a newly qualified nurse I wouldn’t get a job in a GP practice’ This supports our view that it is essential to have students in practices in order to ensure that practice nursing is seen as a career of choice. We had worked with a local design agency⁹ to produce a banner that listed some of the key competencies that practice nurses may have.

This stimulated much discussion among the students, and after seeing the banner and talking to staff about the competency framework for practice nurses, many expressed an interest in learning more about the role, with seven students intending to apply for posts within practice. Students told us that we needed to work with the university to ensure that clinical examples from practice nursing are given by lecturers (there was a view expressed that few lecturers have experience working in primary care, and lectures are often acute care-focused). They also said that having robust preceptorship and post registration training plans in place would be a great incentive for them to apply for posts.

Over the last 18 months, our local university has introduced changes to its programmes, and primary care is featuring throughout the new courses. The university has actively recruited lecturers with primary or community care backgrounds to teach students. It has invited our Advanced Training Practice to talk to students in their first year to emphasise that nursing is not just delivered in a hospital setting! We intend to continue to work closely with our universities to ensure that this promising start continues to develop, and the CCG team has offered further input to undergraduate and masters’ programmes to talk about the wider and changing context of health and social care in the community setting.

Our project to have students in practice is progressing well: by the end of the year we will have 12 practices taking students for placements. Not only will the students have experience of working in GP practices, but we are also hopeful that they will become ambassadors for the role, telling their fellow students and mentors more about the diversity of practice nursing.

As testament to this theory, we interviewed one of the first students to have a practice placement with us. She was in her third year and knew only one other student who had worked in primary care. Her view of practice nursing was that it would be very dull, and that practice nurses were largely older women who wanted to wind down towards the end of their careers. What she saw was very different: she had not realised that so many practice nurses specialised, saw their own patients, visited patients in their own homes and had undergone considerable amounts of post registration training and development. She was so impressed that she applied for, and was appointed to, her first post in the same practice.

Research shows that it is becoming increasingly difficult to recruit experienced practice nurses, or indeed experienced secondary care nurses who have the skills and knowledge to ‘hit the ground running’ in general practice. Many practice nurses work at a very advanced level in order to deliver the high standards of care and service provision demanded by patients, careers and commissioners. It will become increasingly important to ensure that newly qualified nurses have excellent preceptorship within primary care if we are to retain them.

To be effective, preceptorship requires the preceptor to employ facilitative and coaching skills, sharing knowledge and experience, supporting and guiding the preceptee through the transition from student to that of autonomous practitioner.¹⁰ Work undertaken by HEE Yorkshire and Humber suggests the components of a preceptorship programme.¹¹ (Box 1) This document will be used by our practices to ensure that our nurses are effectively supported to grow in confidence and competence.

CONCLUSION

Scarborough and Ryedale CCG is keen to ensure that it hears and responds to what is needed locally by challenging existing ways of delivering education, and developing its own approaches to workforce and organisational development, in partnership with the primary care community. We are only a short way into our workforce development programme, but new doors have opened and have led us along different paths to new opportunities. Each strand takes time to develop and as we do, another connection is made and another opportunity has opened. We are starting to see results, with more undergraduate nurses into primary care placements, high quality locally delivered education, competency frameworks for primary care staff and the start of many other initiatives.

Our journey has taken us across the country following leads and finding like-minded people who have already put something in place, and have been happy to share their knowledge and experience, or are thinking along similar lines and are keen to follow our progress. In our local HEE commissioner, we have found a partner willing to listen and support the local changes we want to make. We know we have more to do, and we know that primary care is facing unprecedented challenges on many levels. We recognise that tackling workforce development, recruitment and retention is only a part of addressing those challenges, but it is a critical one nevertheless.

We know from our work there are plenty of other CCGs on this journey too, and we hope that by talking about our experiences, and sharing a little of what we have done locally, it will encourage others to share their work and to celebrate and embrace the opportunities that can be brought about by being a local CCG, capable of direct action and influence.

REFERENCES

1. RCN. Safe Staffing Levels – a national imperative: The UK nursing labour market review, 2013 www.rcn.org.uk/_data/assets/pdf_file/0018/541224/004504.pdf

2. NHS England. Delivering the Forward View: NHS planning guidance 2016/17 – 2020/21, 2015. https://www.england.nhs.uk/wp-content/uploads/2015/12/planning-guid-16-17-20-21.pdf

3. Centre for Workforce Intelligence 2013. Cited in RCN Safe Staffing Levels – a national imperative: The UK nursing labour market review. www.rcn.org.uk/_data/assets/pdf_file/0018/541224/004504.pdf

4. Health Education East Midlands. The Practice Nurse Project. Competency Framework and Competency Development Plan. https://www.hee.nhs.uk/sites/default/files/documents/The%20Practice%20Nurse%20Competency%20Framework%20and%20Competency%20Development%20Plan.pdf

5. Chappell M, Ford K. Assessing the clinical skills training needs of community healthcare staff. Journal of Community Nursing April 2014;28(2):69-74.

6. Duffin C. Improving career prospects for practice nurses. Primary Health Care 2014;24(2):8-9.

7. Lee N. An evaluation of CPD learning and impact upon positive practice change. Nurse Education Today 2011;31(4):390-5

8. Ashby RL, Gabe R, Ali S, et al. 2013 Clinical and cost-effectiveness of compression hosiery versus compression bandages in treatment of venous leg ulcers (Venous leg ulcer study IV, VenUS IV): a randomised controlled trial. The Lancet 2014;383:871-9. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)62368-5/abstract

9. United By Design at unitedbydesign.co

10. Price B. Successful preceptorship of newly qualified nurses. Nursing Standard 2013;28:51-56.

11. Jackson A. Preceptorship Best Practice Guidance. Supported Practice for New Registrant Nurses in General Practice. Health Education Yorkshire and Humber https://www.hee.nhs.uk/sites/default/files/documents/Preceptorship-Best-Practice-Guidance.pdf