Mitigating risk – dealing with the ‘rookie factor’ in practice nursing
Everyone starts their career – no matter what their profession – as a ‘rookie’. The challenge is to ensure that inexperience doesn’t lead to avoidable harm to patients
Watching Professor Alison Leary’s recent William Rathbone lecture1 made me consider the practical implications of the ‘rookie factor’ in chronic disease management in general practice.
The ‘rookie factor,’ where inexperience could compromise work product quality, is common in many industries. Professor Leary2 suggested: ‘Healthcare services today have ended up with a huge “rookie factor” in which inexperienced people are teaching even more inexperienced people. We need to fill the vacancies, but we also need to fill the ever-widening skills gap that has emerged.’ Nowhere is this clearer than in general practice nursing, and the retirement rate of experienced nurses will only exacerbate this problem.3
Gladwell4 suggests an expert has 10,000 hours of ‘deliberate practice’. The current standards of the NMC suggest a registered nurse should have no less than 2,300 practice learning hours to qualify, of which a maximum of 600 hours can be in simulated practice learning.5 By this standard, a newly qualified nurse has less than a quarter of the experience needed, which is only to be expected, considering the real-life expertise needed to consolidate training. As more newly qualified nurses are welcomed in general practice teams, and the current pre-registration courses are geared towards acute care, any chronic disease management in primary care provided by a newly qualified or new to general practice nurse is at risk of the ‘rookie factor.’
LONG TERM CONDITIONS
Chronic disease and multi-morbidity are some of the biggest socio-economic challenges of our lifetime. People with long term conditions account for about 50% of all appointments in general practice. More working-age people are self-reporting long term health conditions, with 36% saying that they had at least one long term health condition in the first quarter of 2023, up from 31% in the same period in 2019 and 29% in 2016.6 In my view, maximising health to limit personal and health service burdens is a critical role for general practice nurses. Managing the complications of chronic disease, for example, microvascular complications in diabetes, requires skill, and GPNs are well placed to deliver this care. Griffiths7 found higher practice nurse staffing levels were significantly associated with lower admission rates for asthma and COPD, suggesting a skilled nursing workforce is necessary to meet current challenges.
Making mistakes isn’t exclusively down to inexperience, although I was never more aware of my own lack of skills and my inexperience than at the time of my initial registration. While I recognise the rookie factor, we should not scapegoat newly qualified nurses. Nurses who are new to practice and new to chronic disease management (or any new nursing task) need time to develop and consolidate their skills. My particular concern is with all nurses new to chronic disease management.
A recent practice experience highlighted this. A case of a middle-aged male with an HbA1c of 120 mmol/mol came across my desk (non-diabetic HbA1c is below 48 mmol/mol). He had presented to a colleague with classic osmotic symptoms, thirst, polyuria and weight loss, and after taking bloods, they diagnosed type 2 diabetes and started treating it as such. The more experienced among us would take an intake of breath. An increase of HbA1c in a younger person can signify either late-onset type 1 diabetes or pancreatic cancer. Ruling these out is key. To diagnose on symptoms alone, or on the results of a single blood test, is a high-risk strategy. In my opinion, an experienced or safe clinician would not diagnose any condition without necessary investigations.
The idea of risk in general practice is well known: GPNs mostly work autonomously unless there is an issue, and most work is unchecked. Most of the work undertaken in general practice is safe and effective, but minimising and managing risk are still vital.
Professor Leary likens nursing to a profession of vigilance, not task-orientation.1 Being able to deal with the unknown and be reflexive in practice is important. Chronic disease management is a case in point. How often has a person with asthma turned up for a review without recognising the signs that they are exacerbating? How do we address complex health matters in chronic disease? These issues require skill and expertise. Morris8 found that general practice nurses are crucial in reducing lifestyle risk. Ongoing education, funding, and organisational and professional support are needed to enhance their commitment, confidence and capacity; however, their potential is yet to be fully realised.
A research scan by the Healthcare Foundation in 2011 to investigate levels of harm in primary care suggests a 1–2% risk; while this does not sound unreasonable, for every 100 consultations, one or two people’s lives are negatively affected.9 They also suggest that, due to the lack of research, this is a conservative estimate. During my work as an expert witness, I have the value of hindsight, and a retrospective review of notes is sobering: practice that, in isolation, is deemed acceptable may result cumulatively in a level of harm that is not.
LEADERSHIP AND SUPPORT
Mitigating risk is not an easy fix. Several aspects need to be addressed to ensure the retention of experience and support those new to practice, a strategic balancing act with attention to resources and planning.
Effective nurse leadership in general practice is crucial to ensure all newly qualified nurses and those new to chronic disease management have support. The General Practice Nurse Fellowship programme, part of the NHS Long Term Plan, is a positive step forward. This is two-year support programme for newly qualified or new general practice nurses, with an explicit focus on working within and across Primary Care Networks (PCNs).
Creating specific regulation for preparation of those undertaking chronic disease management is also needed. Currently, there is no guidance on qualifications to manage chronic disease. It is accepted practice to have a diploma. However, the practical application of the learning isn’t always supported. Leadership and management of nurses treating patients with chronic disease needs to be a strategic priority for the integrated care systems due to the potential impact of poor management.
Leadership in primary care nursing is also crucial in identifying the risk of inexperienced nurses delivering unacceptable care. However, much of the focus of nurse management is on practical issues such as annual leave, training and information sharing, with less of a focus on leadership.
While we are all leaders, practice nurse leaders must know about career progression, talent spotting and personalised support to ensure succession planning. This is part of NHS England's Health and Care Professional leadership,10 where it is suggested ’fully inclusive multi-professional clinical and care professional leadership is clearly central to designing and delivering integrated care and meeting the complex needs of people, rather than just treating their individual conditions’.
In my experience, an eye on what the future looks like is lacking when reviewing staff needs. As GP practices are small businesses, their main concern is meeting service delivery needs. Also, as funding is not always forthcoming, it can be difficult for general practice businesses to move away from firefighting increasing demand and expectation.
PCNs could offer support in this matter. PCNs are a building block of the NHS Long Term Plan and enable GP practices to work together at scale with additional funding. However, in 2020, there were just 19 nurse clinical directors in 1,250 PCNs in England,11 a point recognised by the King’s Fund.12 As the GPN fellowship should include PCN working, an opportunity to support staff and share experience has never been more opportune. What is essential is that PCNs can support practices to ensure quality care is delivered through sharing nurses’ experiences.
VALUING EXPERIENCE
Another approach to mitigating the ‘rookie factor’ is valuing the experience present within a team and moving towards more consistent terms and conditions. General practice is not covered by the Agenda for Change, and two nurses doing the same role could be paid differently. An experienced colleague recently disclosed that a newly qualified advanced clinical practitioner (ACP) was being paid £3 more an hour than she was. It was a significant blow to her morale and has helped her to decide to retire, a loss to quality patient care.
Shrewd negotiation of terms and conditions is needed, but has the potential to divide and it is hard for those on standardised NHS pay and conditions to understand. Equating value with pay is not ideal, but GPs need to offer appropriate salaries to attract staff with experience and ability, and not to expect them to undertake training roles out of the goodness of their hearts.
The danger of not providing the necessary support to experienced staff increases the risk of skill attrition due to poor staff retention. Professor Leary13 suggests that retention is currently the hole in the leaky workforce bucket – a critical flaw of the recent NHS workforce plan,14 which places ‘a particular reliance on the workplace as an educator in the apprenticeship model which [in turn] relies on staff retention’. Without experienced staff to train new staff we will exacerbate the rookie factor, with the inexperienced teaching the new generation.
OPEN DOOR POLICY
The ‘rookie factor’ can be mitigated with support on a day-to-day basis. Having an open-door strategy or a structured pathway on how to ask questions about care means that nurses can ask someone in the moment. Alternatively, practices should have agreed approaches to minimise the risk of poor practice due to the rookie factor. I have been fortunate – there has never been a situation where I have been unable to discuss a case with a colleague immediately in an urgent situation.
Pressure to make decisions in the moment, running late in clinic, poor documentation and conflict management are risk factors for errors for less experienced nurses. Furthermore, there are differences of opinion on treatment, and while guidance is available to support clinical decisions, applying it practice can be challenging.
What is important is that clinicians undertaking chronic disease can balance the risks and benefits of any proposed course of action, and that shared decision-making with patients is at the heart of those decisions.
Where there is the risk of a new clinician working outside their scope of experience support needs to be in place. Mitigating the risk of poorly managed chronic disease helps to reduce not only the personal health drain of the disease on the individual – and its impact on their life – but also the burden on the NHS.
Giving permission to ask for advice is important to mitigate the rookie factor but also so we don’t put nurses under pressure to make decisions that may cause harm. In my view burnout as a result of excess workload, poor communication with colleagues and high patient demand can add to the risk of moral injury and poor decision making.
CONCLUSION
The rookie factor can be mitigated by awareness of the need to support newly qualified and new-to-general-practice-nurses. PCNs are ideally placed to support new-to-practice GPNs by sharing the experience throughout their networks. Leadership within General Practice Nursing is key with those with a voice and opinion on shaping good care being encouraged to join the conversation. Valuing experience and ensuring terms and conditions are fair are key to retaining experienced nurses and ensuring their skills are passed on, rather than lost.
REFERENCES
1. Leary A. Thinking Differently about Workforce William Rathbone Lecture; 2023
2. Leary A. The NHS staffing crisis is about the expanding knowledge gap – not just numbers ; 2019.
3. Queen’s Nursing Institute. General Practice Nursing in the 21st Century; 2016. https://qni.org.uk/resources/general-practice-nursing-21st-century/
4. Gladwell M. Outliers. Little, Brown and Company; 2008
5. NMC. Standards for pre-registration nursing programme; 2023 https://www.nmc.org.uk/globalassets/sitedocuments/
standards/2023-pre-reg-standards/new-vi/standards-for-pre-registration-nursing-programmes.pdf
6. ONS. Rising ill-health and economic inactivity because of long-term sickness, UK: 2019 to 2023; 2023
7. Griffiths P, Murrells T, Dawoud D, et al. Hospital admissions for asthma, diabetes and COPD: is there an association with practice nurse staffing? A cross-sectional study using routinely collected data. BMC Health Serv Res 2010;10:276
https://doi.org/10.1186/1472-6963-10-276
8. Morris M, Halcomb E, Mansourian Y, Bernoth M. Understanding how general practice nurses support adult lifestyle risk reduction: An integrative review. J Adv Nurs. 2022 Nov;78(11):3517-3530.
9. The Health Foundation. Research scan: Levels of harm in primary care; 2011.
https://www.health.org.uk/sites/default/files/LevelsOfHarmInPrimaryCare.pdf
10. NHSE/NHSI. ICS implementation guidance on effective clinical and care professional leadership effective clinical and care professional leadership; 2021.
11.Hussain-Mills R. PCNs need nurses for their inspirational leadership; Nursing in Practice, October 2019.
https://www.nursinginpractice.com/professional/pcns-need-nurses-for-their-inspirational-leadership/
12. Kings Fund. How can we develop professionally diverse leadership in primary care? 2022.
13. Leary A. Workforce plan—more a blueprint for the future. BMJ 2023;382:p1515
https://www.bmj.com/bmj/section-pdf/1084758?path=/bmj/382/8390/Comment.full.pdf
14. NHS England. NHS Long Term Workforce Plan; 2023 https://www.england.nhs.uk/publication/nhs-long-term-workforce-plan/