In praise of general practice nurses
We can all be distracted by the next ‘shiny new idea’ that comes along but we should not neglect what we already have. Who will fill the gap if we lose the traditional nursing role in general practice?
In recent weeks the media have focused on the lack of GPs and how the shortage is making it difficult for patients to access appointments. All very valid but there is a group of experienced and competent professionals who play an essential role in general practice who seem to be continually overlooked. Why is this? Christine Oldman, chief executive of the Queens Nursing Institute, points out the media concentration on ‘shiny’ new roles.
The nurse’s role in general practice has been in existence for more than 30 years. General practice nurses (GPNs) play an important part in delivering effective patient care, income generation and sustainability. Historically, nurses chose general practice for the opportunity to provide continuity of care to a wide age range of patients, to focus on health promotion, education and early detection, the variety, to move out of the hospital environment, to work in smaller teams and to avoid shift work.
Many nurses undertake tasks that were previously in the domain of the GP. They deal with complexity and co-morbidities, referrals to secondary care, long term conditions, they prescribe, and they have increasing autonomy. In the last two years there has been a marked increase in the number of nurses taking on the ‘advanced’ role, but no corresponding increase in the overall number of GPNs.
There have been a number of national initiatives to address the recruitment and retention of nurses in general practice and in 2016, NHS England (NHSE) commissioned Ipsos Mori to undertake a report looking specifically at this area.1 In March 2017 Health Education England (HEE) General Practice Nursing Workforce Development Plan – Recognise, Rethink, Reform provided recommendations for organisations to take forward the findings from the Mori report.2 This was supported by NHSE’s ‘Leading Change, Adding Value’3 and ‘General Practice: Developing confidence, capability and capacity’.4
The GP Forward View (GPFV) in 2016, identified £15 million pounds to invest in the practice nurse workforce.5 This, together with the GPN 10-point plan in 2017,6 aims to raise the profile of general practice as a career option, including improving access to training, supporting return to work schemes for GPNs and increasing the number of students in practice. However, the tariff made available to practices for student nurses is not currently in line with other Allied Health Professional student posts.
WHAT DO GPNs REALLY THINK?
In February this year is I undertook a survey to obtain current demographic data on nurses employed in general practice across Wessex LMCs, their views on general practice as a place to work, and on the recruitment and retention of nurses employed in general practice.
KEY FINDINGS
Response rate
More than 500 (522) nurses responded to the survey, representing 29% of nurses on the database. Respondents identified their roles as advanced nurse practitioner (ANP), nurse practitioner (NP), practice nurse (GPN), nursing associate (NA) and health care assistant (HCA). Some used the title of respiratory nurse specialist, frailty nurse and nurse lead/manager.
Workforce
Of the 456 qualified nurses that responded, 56% are over 50 years of age, 99% of respondents are female and 76% employed part time. The highest numbers of full-time staff were advanced nurse practitioners (ANPs) and Health Care Assistants (HCAs). Only three nurses were partners in the practice. Many nurses have additional roles in other areas. Nearly a third (32%) of nurses are planning to retire within the next 5 years
Work environment
The vast majority – 89% – of nurses would recommend their practice as a place to work, describing supportive, friendly teams, opportunities for role development, good management and leadership. The small number of negative comments related to poor communication, team changes as a result of mergers and practices becoming larger, workload, no access to training, lack of equipment, pay, not feeling valued or respected, lack of leadership and disorganised practices.
Almost two-thirds (62%) felt stressed at some point during their working week. The most common stressors were patient demand, workload, not enough time to complete administration tasks, understaffing and dealing with complex patients in 10-15-minute appointments.
Respondents were asked what would improve their working day. The most frequent responses were longer appointment times to spend with patients with LTCs and complex problems, and protected time for administration tasks. They also felt GPs and practice staff should have a better understanding of their roles and skills. A number commented that educating patients around the nurses’ roles and skills and encouraging self-care would also help ease the pressure on workload and appointments.
Culture
The greatest satisfaction was derived from making a difference to patient care (according to 79%) and was highly ranked across all groups, followed by undertaking interesting and challenging work that gave a sense of accomplishment and a strong relationship with co-workers, which was rated highest with GPNs. Feeling valued and respected was also important.
Most nurses (80%) felt positive about their workplace, especially among those over 50 years of age, and among ANPs and NPs. Working as part of a team was the most important factor followed by the ethos and culture of the practice and support provided.
There were very few negative responses. No ANPs or NPs recorded negative or very negative responses. Of the small number of negative responses, feeling negative or very negative was highest amongst GPNs over 60 years of age, and feeling ambivalent was also higher in this group. Negative comments related to a demanding workload, time and related stress, lack of equipment, no access to training, uncertainty of the future, pay terms and conditions, not feeling valued and lack of supervision.
More than half, 56%, of all nurses identified they had some gaps in their competencies, skills and knowledge to undertake their role. The most common areas were the management of LTCs, (highest amongst GPNs) women’s health and contraception, mental health, paediatrics (all qualified nurses), triage and minor illness, leadership and management and IT/digital. All nurses recognised that regular updates were vital to ensure competency and safety.
Recruitment and retention
Pay, terms and conditions were identified as an important factor that impacts on the retention and recruitment of nurses in general practice by 49% of respondents. Other comments related to feeling valued and respected, access to training and funding, support and protected time for CPD and consultations.
Eight out ten nurses said the variety of the role was the most important factor that encouraged them to remain working in general practice, followed by job satisfaction and flexibility in working hours and days.
Words such as variety, challenging, rewarding, interesting, satisfying, flexibility and opportunity for development were terms nurses would use to encourage more nurses to work in general practice.
Opportunities for nursing
Clarity of roles and competencies were important and nurses thought their skills and knowledge could be used in different ways. Some nurses felt deskilled and others that their specialist skills could be better used for the benefit of the practice and patients. For example, nurses who had a district nurse or palliative care background felt their skills could be used to undertake home visits.
The development of Primary Care Networks (PCNs), diagnostic hubs and cross boundary working provides an opportunity to address some of these factors. The NHS Long Term Plan talks about the development of Nurse Fellowships to entice newly qualified nurses into primary care and this should be encouraged and supported.7 The emphasis should be on collaborative working, sharing and utilisation of skills and knowledge.
RECOMMENDATIONS
1 General practice as a place to work should be promoted as a preferred choice for students and those considering a change in career. The funding tariff for student nurse placements should be in line with Allied Health Professionals.
2 Students should be exposed to general practice early and more frequently in their training and have a positive experience. Universities should be encouraged to equip those who choose this as a career choice with the skills necessary to undertake the GPN role.
3 There is currently a lack of standardisation in titles, roles, salary, terms and conditions with a disparity between primary and secondary care and this needs to be addressed if we are to retain staff and improve recruitment.
4 Nurses on our database currently use 33 different tiles. There should be a clear link between title, competency and academic levels and this should be reflected in job descriptions.
5 Practices need to consider the elements that attract and retain nurses in general practice, namely: the culture, team working, support, feeling valued, clinical supervision, job satisfaction, variety and flexibility of the role.
6 A high number of experienced nurses with specialist skills retire within the next 5 years, [so] we need to be creative in how we retain this part of the workforce. Funding and time need to be made available to support existing nurses that want to undertake specialist roles.
7 Practices should develop a culture that focuses on the wellbeing of their staff to reduce stress and absenteeism, improve retention and provide them with a coping mechanism to manage the daily pressure they face in the workplace.
8 All nurses have an important role to play in the sustainably and future of PCNs. Practices and nurses themselves should be encouraged to look at how their skills can be utilised and to consider different ways of providing care e.g. integrated nursing teams, group consultations and healthy leg clubs.
9 We should create opportunities for nurses to work across boundaries.
10 Nurses in general practice are generalists with specialist skills: we need to demystify the belief that this is a place for less experienced nurses, and the ‘mature’ female workforce.
11 To attract more people into primary care – including men – we need to look at portfolio careers, and discussion should take place with community and acute trusts to develop a flexible working environment that crosses traditional boundaries.
12 The profile of nursing in general practice needs to be improved and celebrated.
The full report can be found at https://www.wessexlmcs.com/nursingsurveyresultsandpossiblesolutions.
CONCLUSION
There has been negative press over the last few years around general practice, which has mainly focused on the recruitment and retention of GPs and general morale. The high number of respondents from the survey who would recommend their practice as a place to work is encouraging. Practices should be encouraged to ensure that staff are engaged and feel valued, which will have a positive impact staff loyalty and productivity. There will be significant changes and challenges in the next few years in primary care, and all staff need to be involved, understand the impact and be part of the solution.
Retention and recruitment of nurses is still a challenge. We need to create an environment that encourages new staff and those considering a change in career to see primary care and general practice as great place to work. There are a high number of nurses likely to retire in the next 5 years and we need to consider how we retain these skilled and experienced staff and how to recruit more nurses. It is vital that students are exposed to general practice throughout their training and have a positive experience. As care shifts more into the community environment should there not be a shift in where the learning takes place?
The demand for nurses could create an open market; practices may need to be innovative and creative in what they offer and can provide for their staff. What does good look like? Practices need to be able to define where they are going, what they want to achieve, and to question if they need to change.
The most common reasons practices fail their CQC inspections are in the areas ‘well led’ and ‘safe’. Currently, there are a plethora of nursing and other professional titles and roles that are not necessarily linked to experience, competencies, academic levels or salaries. Specific roles and standards can vary across practices. The lack of parity in terms of salaries and terms of service between primary and secondary care also needs to be reviewed. A comprehensive review which attempts to marry titles, roles and competencies would reduce confusion for employers, individuals, colleagues and patients. The emphasis should be on competencies and professional and patient safety.
Leadership is also about followership: success is dependent on how we treat those we expect to follow us. The challenge is helping leaders in practices to get the most from their employees and colleagues. The evolution of the PCNs is an area where nurses can have an input in innovation and leadership, and this is also one of the four criteria for advanced practice. Leadership is creating a set of behaviours predicated on a set of clearly understood values that more efficiently and effectively drive organisational performance.
The words team, friendly and support were mentioned by most nurses, and this needs to be considered when moving to PCNs. A team looking out for each other and working on developing resilience together benefits everyone. It means someone struggling is less likely to slip under the radar, it is about the context in which they are working, and staff being engaged. It is important to ensure people have a clear understanding of the strategy and how what they do adds value, is meaningful and contributes to achieving that strategy. This is in addition to feeling valued and having the opportunity for personal development. Civility goes a long way.
What about the ‘shiny new thing’ syndrome?
We can all be distracted by the next shiny new idea that comes along. Often these ideas can be very successful and to be encouraged. We already know of the benefits that pharmacists, paramedics and physiotherapists can bring to GP land but please don’t neglect what we currently have that works well. We need to provide the existing nursing workforce with the support, funding and opportunity to develop and thrive. Long term success will be dependent on attracting nurses into general practice and looking after the current workforce. There may be an issue with GP recruitment but there is also a major issue in relation to nurses which must be addressed sooner rather than later. The ‘shiny new thing’ may seem attractive but practices and the media need to consider and reflect on the impact this has on nursing morale. Who will fill the gap if we lose the traditional nursing role in general practice?
Nurses have indicated that general practice is a great place to work and have identified the key characterises of a good working environment. Practices need to be made aware of what good looks like. Nurses are the bedrock of primary care. Their role, skills and features need to be celebrated and they are essential to the sustainability of primary care. Let’s promote and share the nurse’s role, the assets and benefits we bring to practice and importantly patients and to remember we are frequently an untapped resource.
REFERENCES
1. Ipsos MORI. The recruitment, retention and return of nurses to general practice nursing in England, August 2016. https://www.england.nhs.uk/wp-content/uploads/2017/07/recruitment-retention-return-of-nurses-to-general-practice.pdf
2. Health Education England. General practice Nursing. https://www.hee.nhs.uk/our-work/general-practice-nursing
3. NHS England. Leading Change, Adding Value (LCAV) where you work https://www.england.nhs.uk/leadingchange/lcav-in-action/
4. NHS England. General Practice – Developing confidence, capability and capacity, July 2017 https://www.england.nhs.uk/publication/general-practice-developing-confidence-capability-and-capacity/
5. NHS England. General Practice Forward View https://www.england.nhs.uk/gp/gpfv/
6. NHS England. General Practice – Developing confidence, capability and capacity: A ten point action plan for general practice nursing https://www.england.nhs.uk/wp-content/uploads/2018/01/general-practice-nursing-ten-point-plan-v17.pdf
7. Department of Health and Social Care. NHS Long term plan launched. Press release, January 2019 https://www.gov.uk/government/news/nhs-long-term-plan-launched