Professionalism and trust in general practice nursing

This extract from Long term conditions: a manual for general practice nurses does not attempt to define the professional duties of a nurse, but offers suggestions to help GPNs apply professional values to everything from negotiating pay to evidence-based practice

WORKING IN A BUSINESS ENVIRONMENT

Nowadays, a nurse moving into general practice may be employed by the NHS or by a large commercial organisation but most practice nurses are employed by GPs. These doctors own their practices, sometimes alone but more often in partnership. A few skilled and experienced nurses negotiate to invest in the business, becoming self-employed partners, but such a position is still unusual.

The new practice nurse may need a cultural mind-shift, to adapt to a business model where patient care is important but so too is profitability. An efficiently run, high achieving practice will provide a substantial income for its owners, who can then offer good pay and conditions to recruit and retain their staff. Patients benefit too, because well-motivated staff are likely to provide good care.

Here are some ideas for increasing your income, as you gain experience in primary care, so you can make your career more rewarding, in every sense of the word.

• Ask for performance-related pay, perhaps by requesting a bonus at the end of the financial year. Are you worth it? Explain how and don’t be shy.
• To increase your income further, diversify and make yourself indispensable to the practice. Offer to review housebound patients in their homes, code correspondence, draft responses to patient feedback, generate insurance reports, process pathology results.
• Charge overtime rates when you work beyond your normal hours. With external log-on, you may be able to deal with administrative tasks from home.
• Work locum sessions elsewhere, to learn from other teams. Locum rates are likely to be higher than regular pay and there may be tax advantages if you are classed as self-employed for your locum work.
• Become involved in teaching, mentoring and clinical supervision. All nurses have a responsibility to pass on their knowledge, and do this every day with patients and the wider healthcare team. Can you offer student nurses some experience of general practice? Practice nurses sometimes work in isolation and teaching activities can offer great benefits to the nurse, the practice and patients. As you gain experience, you could work towards a university diploma in healthcare education, perhaps by distance learning.
• Get into research. Speak to an academic at your local university or contact the Primary Care Research Network for your region.
• Consider committee work. Some NHS roles are well remunerated and fees are always negotiable.

Many aspects of your working life will be open to negotiation. You should be paid for all hours worked, not just for patient contact time. Can any of your work be delegated?

If you are a woman, you may need to sharpen your negotiating skills, to get your fair share of the practice profits. A study¹ in the Harvard Business Review, ‘Nice Girls Don’t Ask’ found that women, on average, request increased pay 85% less often than men and they ask for 30% less income than men.

To request a pay rise, you will probably need to set up a meeting. You could provide a single page summary of your request, with bullet points stating your case. Be honest and direct about why you want to meet, not apologetic. This gives your line manager time to prepare. When you meet, you can provide written evidence of your achievements and show that you have acted on any previous feedback.

If your employer does not agree to your request, ask what steps you can take to get a ‘yes’ next time and when you can revisit the conversation. The Royal College of Nursing provides excellent advice in their document ‘Nurses employed by GPs: RCN guidance on good employment practice’.²

PERFORMANCE TARGETS

The thoughtful practice nurse will need strategies to deal with imposed challenges. Here are some suggestions for staying positive while dealing with unwanted external demands.

• Make the care of the patient your first concern.³
• Treat each patient as an individual.
• Work within the limits of your competence.⁴ Do not agree to tasks beyond your role, experience or training. Be assertive, quote NMC guidance and request further training.
• Look at your patient more than you look at the computer.⁵ Enter free text after the patient leaves the room.
• Justify your decisions and actions, with confidence. We are allowed to exclude patients from performance indicators, if we give a good reason. Search for Read codes beginning ‘excluded from…’ and type an explanation in free text.
• If a national policy seems wrong, campaign for change – send emails and Tweets, join a committee, build on your existing expertise.
• Establish and maintain good relationships within the practice team and your local healthcare community – we are all in this together. Part-time nurses will need good handover arrangements and will benefit professionally if they can attend practice meetings. If meetings are missed, it may be helpful to read the minutes.

EQUALITY AND DIVERSITY

As health workers, we should of course do our best to promote equality, without prejudice or discrimination. You could consider if your practice team is providing accessible and effective care in the following situations:

• Reduced mental capacity
• House-bound
• Mental illness
• Young person without support
• Disability
• Caring responsibility
• Working far from home
• Communication difficulty
• Literacy problems
• Cultural differences
• Poverty
• Ex-prisoner
• Sex worker
• Substance abuse
• Person reluctant to disclose their address
• Homelessness
• Mobile populations e.g. travellers

We are required to work within the law. For example, under the Disability Discrimination Act, your practice will need an arrangement to translate information leaflets into Braille when needed.⁶ Your local council may have a translation facility.

Digital communication (email or text messages) may improve access for certain marginalised patients,⁷ as long as confidentiality can be maintained. Approved standard messages may be best, for medico-legal reasons. Patients should be made aware that it is rarely appropriate to discuss emergency issues by email. Your email signature and out of office reply should include guidance about emergency care.⁸

People who are vulnerable or stigmatised often live in deprived areas, where housing is cheaper. Practices with high levels of socio-economic deprivation will have higher consultation rates and their patients will have more chronic illnesses. Unfortunately funding does not sufficiently address this situation,⁹ and we have to meet the challenges as best we can.

CONFIDENTIALITY

A hospital ward is a relatively public environment, where only curtains may protect a patient’s privacy. In general practice, every consultation takes place behind a closed door. As people get to know and trust you, they will sometimes disclose extraordinarily personal information. Working in a small community, every practice nurse must be hyper-aware of the need for confidentiality.

The NMC Code⁴ states that ‘you owe a duty of confidentiality to all those who are receiving care’ and it goes on to explain the special circumstances when you are permitted to share information, for patient safety or public protection.

CONTINUING PROFESSIONAL DEVELOPMENT

A nurse interested in people will find that general practice is never, ever boring. Because you will encounter new situations every day, it is worth keeping a Learning Diary, to guide future study and provide evidence of reflection for revalidation purposes. An example is given in Table 1.

EVIDENCE BASED PRACTICE

(or The Truth And How To Search For It)

Can patients trust your advice? For instance, in osteoporosis we recommend weight bearing activity. For some patients, this recommendation will cause tedium, inconvenience and expense. To quote Richard Asher,10 ‘Just as we swallow food because we like it, not because of its nutritional content, so do we swallow ideas because we like them, not because of their rational content’.

A systematic review of the literature can take years, but there is a practical way to get information quickly, by typing key words into online scientific search engines. This enables a nurse to search for answers in the consulting room, for the questions which arise during every working day. PubMed and Google Scholar are both hugely powerful. In science, focussing a question is an art. Your key words for a search may include:

1. The problem or the type of patient (perhaps osteoporosis or post-menopausal women)

2. The intervention (in this case, weight bearing exercise)

3. The comparator (sometimes omitted from the search, here could be usual activity)

4. The outcome (fracture is a real outcome which matters to patients, so would be better than Bone Mineral Density)

Our strongest evidence comes from randomised controlled trials (RCTs), arguably the greatest advance in the history of medicine. A comparator makes for a better research study and is essential for an RCT.

In an RCT, the patients are randomly allocated to one of the treatments (interventions) being compared. The patients and researchers should be ‘blinded’, when feasible, which means they are unaware who is in the treatment groups. The more patients, the better the trial. For relevance to your work, the subjects of the trial should resemble your patients as much as possible. So a study from Britain may be more useful for a British nurse than research undertaken in a very different country.

Academic search engines supply peer-reviewed evidence, so are much more reliable than Wikipedia, which can be edited by anyone. Good search engines usually take you to several references, which may include RCTs. Systematic reviews are also noteworthy, because they synthesise the results of several research studies.

Often you can view an abstract (summary) online but the full article will be behind a pay wall. People who work in the NHS (including practice nurses) are eligible for an OpenAthens account, giving free access to numerous online journals. To register, contact your OpenAthens administrator or follow the links from the NICE website.¹¹

As you read the comments of experts, you will gradually develop your own skills in critical appraisal. To make some sense of statistics, I recommend The Keep it Simple Guide to Evidence-Based Medicine, available to download.¹² Where would we be without statistics? For a start, we would be unaware of the link between tobacco and lung cancer. However, there are some potential pitfalls:

• Graphs – or just pretty pictures? Ensure you understand the labelling of the horizontal and vertical axes, to decide if a change is meaningful.
• Absolute risk reduction (ARR) can sound impressive but is often misleading. The figure you need to see is Relative Risk Reduction (RRR). Take this example: ‘The good news is that our new wonder drug will halve your risk.’ (The bad news is that your risk will be marginally reduced, from two in a million to one in a million.)
• Numbers Needed to Treat (NNT) may not be stated (but are easy to calculate, NNT = 1/ARR). [text] Consider the ADVANCE trial, about blood pressure control in Type 2 diabetes. It does give NNT, telling us we need to treat 200 people for five years to prevent one adverse event.¹³ This is very useful information to help a patient decide whether or not to take a medicine.

Be especially cautious when evidence is presented by a person with a commercial interest. It is very easy to say ‘Sorry, I don’t see reps’. You can emancipate yourself from drug reps: bring your own lunch, join healthyskepticism.org and make your consulting room an advert-free zone.

Consider why industry funds educational events and think about payments to presenters and authors, which can be substantial. We need transparency, without being anti-business. Encourage speakers to declare any financial interests at the beginning of their presentation.

AUDIT

Audit and Significant Event Analysis are both opportunities to write reflective accounts, for revalidation purposes and to improve patient care.

Audit is not research, but it is often based on research findings. An audit topic can be clinical or administrative. For instance, you could audit your time-keeping, with a criterion that patients should not be kept waiting longer than ten minutes after their appointment time, setting a standard of 80%. If you do not meet the standard, a solution might be an empty catch-up slot, mid-session. A standard of 100% would be unrealistic for punctuality, but might be appropriate for an important safety issue, such as having adrenalin available whenever you give a vaccine.

SIGNIFICANT EVENT ANALYSIS

In Significant Event Analysis, the primary health care team make an opportunity to discuss something important that has happened in the practice. Any member of the team can suggest a topic. This could be a successful experience (such as ‘a good death’) or a problem (such as an emergency admission for asthma or a complaint). Ground rules are set at the beginning of the discussion: the meeting is about learning rather than blame, any criticism must be constructive, and the conversation is strictly private. The team’s learning needs are minuted, sometimes with an agreement about future audit.

If you are worried about something that has gone wrong, it might be helpful to reflect upon the details of what happened.

MAKING DECISIONS

The most difficult decisions in general practice tend to be dilemmas. First, it helps to identify the dilemma and devise for yourself a list of all the possible options, always remembering the possibility of compromise. For each option, you can then think about the pros and cons for every stakeholder (patient, nurse, healthcare team, wider society).

If you are faced with an ethical problem, you can analyse the dilemma using the ethical framework proposed by the philosophers, Beauchamp and Childress.¹⁴ They recommend you consider the problem in terms of four ethical principles, which are:

• Beneficence (doing good),
• Non-maleficence (avoiding harm)
• Justice (fairness)
• Autonomy (self-determination, which requires mental capacity)

If still uncertain, you can read about the problem or ask an expert.

Here are some dilemmas, for you to practise your decision-making skills:

• During a consultation, a patient makes a racist remark about your colleague. What should you do?
• Should healthcare be rationed? (for example, very expensive drugs)
• A GP in the practice appears to know very little about the modern management of diabetes. Would you do anything?
• Your patient’s severe asthma attack does not improve with nebulised salbutamol, but he refuses hospital admission. What should the team do?

MAKING CHANGES

Professionalism is about maintaining high standards, but also about leadership: defining best practice in accordance with good evidence and then introducing changes.

Here are some thoughts about how to make changes in your practice. If you are a newcomer, you may wish to wait a while and then sell your idea sensitively, to avoid implied criticism.

First you could share the idea at a practice meeting, and talk about the costs and benefits for everyone who will be involved. If you can quote evidence to support your suggestion, so much the better.

Then you could offer to write and circulate a brief proposal, listing practical changes, training requirements and start dates. The proposal might include a SWOT analysis (strengths, weaknesses, opportunities, threats). If work is to be delegated, be sure to ask the views of the person who will do the job, and make sure they will have appropriate training and support.

A formal business proposal could include:

• Title and description of your proposal
• Executive summary, in a few sentences
• Business objectives
• Resources, including all key personnel
• Risks

Work closely with the practice manager and check you have a mandate to proceed. You will need to seek feedback, review progress, praise success and, as always in general practice, solve problems as a team.

PAUSE FOR REFLECTION

Many of the topics in this article fit well with revalidation requirements, linking to the themes ‘practise effectively’ and ‘preserve safety’. You could write a reflective account of any event that made you think. Some people find it easier to use a reflective template. If a situation was complicated or made you feel uncertain, then it would probably be a good topic for reflection.

What went well and what could have been done differently? How did you feel? What are the opinions of other people? And finally, how will you learn from this event, now and in the future?

REFERENCES

1. Babcock L, Laschever S, Gelfand M, Small D. Nice Girls Don’t Ask. Harvard Business Review 2003 [cited 2016 Mar 26]. Available from: hbr.org/2003/10/nice-girls-dont-ask

2. Royal College of Nursing. Nurses employed by GPs: RCN guidance on good employment practice. www2.rcn.org.uk/__data/assets/pdf_file/0009/584829/004583.pdf

3. Good Medical Practice. General Medical Council; 2013.

4. The Nursing and Midwifery Council. The Code for Nurses and MIdwives www.nmc.org.uk/standards/code/

5. Wise J. More computer use during consultations is linked to lower patient satisfaction. BMJ. 2015;351:h6395.

6. Citizens Advice. Duty to make reasonable adjustments for disabled people www.citizensadvice.org.uk/discrimination/what-are-the-different-types-of-discrimination/duty-to-make-reasonable-adjustments-for-disabled-people/

7. Huxley CJ, Atherton H, Watkins JA, Griffiths F. Digital communication between clinician and patient and the impact on marginalised groups: a realist review in general practice. Br J Gen Pract. 2015 Dec 1;65(641):e813–21.

8. Sowerbutts H, Fertleman C. How best to use email with patients. BMJ, 2016 careers.bmj.com/careers/advice/How_best_to_use_email_with_patients

9. McLean G, Guthrie B, Mercer SW, Watt GC. General practice funding underpins the persistence of the inverse care law: cross-sectional study in Scotland. Br J Gen Pract. 2015 Dec 1;65(641):e799–805.

10. Rosenheim, Lord, Asher R, Bean WB. Richard Asher Talking Sense. Jones SFA, editor. London: Pitman Medical; 1972.

11. NICE. OpenAthens eligibility www.nice.org.uk/about/what-we-do/evidence-services/journals-and-databases/openathens/openathens-eligibility

12. Curtis, S. The Keep it Simple Guide to Evidence-Based Medicine. www.nbmedical.com/pdf/KISS%20Guide%20to%20EBM.pdf

13. Van der Leeuw J, Visseren FLJ, Woodward M, et al. Predicting the effects of blood pressure-lowering treatment on major cardiovascular events for individual patients with type 2 diabetes mellitus: results from Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation. Hypertension. 2015 Jan;65(1):115–21.

14. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. Oxford University Press; 2009. 417 p.