Spotlight on General Practice Nursing: Identifying key training priorities

As the NHS celebrated its 70^th birthday this summer there were plenty of nostalgic memories as we as we all reflected on how things were ‘back in the day’. The NHS has changed so dramatically since its inception in 1948 with technology and advances in medical science largely paving the way.

But the NHS landscape has also been shaped by those who use its services. We know that people are living longer with more complex conditions and this is reflected in the demand for services both in primary and secondary care.

Looking forward

It’s both an exciting and challenging time for those of you who work in a community setting. Whether in mental health, domiciliary, residential, adult or child services your role will be constantly evolving to try to balance the increasing demand with seemingly diminishing resources. And at the heart of it all is the GP Practice. Once known as the ‘family doctor’ the GP practice is now the gateway to all non-emergency services and is home to a multidisciplinary team of healthcare professionals including General Practice Nurses.

Following the 2016 General Practice Forward View (GPFV), NHS England produced a 10 point action plan for General Practice Nursing in 2017. This action plan is designed to provide a highly-skilled General Practice Nursing (GPN) workforce by:

• Raising the profile of general practice nursing as a first destination career
• Improving access to training
• Increasing the number of pre-registration nurse placements and enhancing retention
• Supporting return to work schemes for GPNs and developing career pathways

As Ian Jones, Chief Operating Officer of the Practice Managers Association says ‘change is the only constant within primary care and that’s not a bad thing as we strive for continuous improvement. But there’s no doubt that keeping abreast of change is a continual challenge’.

Keeping abreast of changes

Section 3 of Health Education England’s General Practice Nursing Workforce Development Plan – Recognise, Rethink and Reform recommends that:

• All GPNs should have access to accredited training to equip them for each level of their role.
• All GPNs should have access to quality assured CPD to support career development and inform revalidation if appropriate.

We know that the changing role of GPNs has led to the need for you to have increased skills and knowledge to perform your role safely and competently. These skills are no longer purely clinical; increasingly the GPN role is one of leader, manager, safeguarder, educator and auditor.

Yet with your role expanding and demands on your time never lessening, how do you begin to keep up-to-date? We spoke to arrange of experts in the field, asking them what they saw as the main topics for GPNs to focus their learning on. We hope that you can use this information to direct your ongoing CPD and ultimately help you to feel confident that you are providing and managing an expert service.

With thanks to:

• Lisa Billingham, Humber Coast & Vale Excellence Centre, NHS HULL CCG.
• Linda Goldie, Clinical Director, Primary Care Training Centre.
• Ian Jones, Chief Operating Officer of the Practice Managers Association.
• Julia Neal, Director of Education, Education for Health.
• Mandy Day-Calder, Operations Manager, Charles Bloe Training Ltd.

Key topics in General Practice Nursing

Our experts all agreed that the management of long term conditions remains a cornerstone of General Practice Nursing. However, where asthma, COPD, heart disease and diabetes may once have been the ‘routine’ diseases that you came across, increasingly there is a need for you to develop skills in managing complex and multi-morbidities, frailty and supported self-management.

Clinical skills

Yet of course the GPN skillset extends beyond the scope of helping those with existing illnesses. Your role requires you to be trained in a wide range of clinical skills including:

• Nurse prescribing
• Vaccination and immunisation: vital for keeping the community healthy
• Management of allergies and anaphylaxis
• Screening
• Women’s health including family planning, cervical screening and monitor of post-natal depression
• Men’s health
• Child health
• Travel health
• Mental health
• Wound care / tissue viability
• Monitoring minor injuries
• Spirometry testing
• Therapeutic monitoring
• Health promotion / lifestyle advice
• Management of obese patients
• Cardio vascular disease: risk modification, management, primary prevention, risk assessment, secondary prevention, patient education
• Assessment of chest pain or other emergencies
• End of life care including non-malignant palliative care
• Management of moderate to severe pain
• Telephone triage

To be able to assess what your patient needs, you also need to have finely tuned clinical decision-making skills. We know that no two patients will present the same, many will a range of communication, learning and behavioural needs so you also need to have an adaptable approach.

Non-clinical skills

Practice nurses are increasingly involved in wider roles within GP surgeries. You now need to be able to adopt a more business-like approach and effectively manage diverse caseloads. So, in addition to clinical skills you need to be proficient in the following non-clinical topics:

• Leadership roles: shaping new models and care, embracing new opportunities, mentoring new staff, training students and conducting appraisals.
• Utilising technology: to support health care management especially in supporting people with long term conditions. Electronic Clinical system reporting and documentation.
• Financial: managing budgets, awareness of GP contracts and how general practice generates income.
• Governance: developing groups consultations and effective auditing.
• Personal safety and safeguarding others.
• Medicolegal / ethical issues
• Avoiding burnout: stress / time management

In addition, Linda Goldie, Clinical Director, Primary Care Training Centre, identified that some GPNs don’t seem to appreciate how research impacts upon the clinical guidelines that they follow. Linda said that ‘if they understood what underpinned the guidelines they may be more appreciative of why, for example, targets are driven.’

Other areas where our experts felt more attention could be given include:

• Communication issues, especially supporting GPNs to develop the necessary skills to deal with people with mental health issues
• Asset based approaches to care
• Utilising the wider multi-disciplinary team

What lies ahead for General Practice Nursing?

Unfortunately, we don’t have a crystal ball so it’s impossible to predict exactly what’s in store for GPNs. However, we do know that demands on services will only increase as more care is being provided by primary care.

On an individual level, it’s likely that your case load will get even more complex and the list of skills that you need to maintain competence in will get longer. On top of the core values, skills and competencies identified in the General Practice Nursing Service Education and Career Framework (Table 1) you will also have to embrace changing and expanding clinical needs (e.g. long-term conditions, dementia, mental health, health promotion etc) as well as non-clinical needs such as mentoring, leadership, resource management, clinical decision making etc.

GPN Skills and Competencies

• Confident in lone working, sometimes in unpredictable situations, and making autonomous decisions, sometimes without recourse to immediate back-up.
• As care is usually provided alone in the consultation room, practice nursing staff must place a greater emphasis on quality assurance and quality monitoring to demonstrate the quality, value, and outcomes of their service as it is not immediately apparent as within a hospital setting.
• Risk assessment and management strategies for working with patients with a range of conditions managed in a variety of environments.
• Adherence to relevant codes of conduct and ability to interpret the codes in the context of general practice nursing.
• Communication skills, both verbal and non-verbal, that articulate care that is negotiated, anticipatory and clearly documented.
• Utilise behaviour change strategies in supporting patients to selfcare and manage their condition.
• Effective team working in situations where teams may not be co-located and cross professional and agency boundaries.
• Comprehensive holistic assessment skills that take account of the patient who will be managing their condition in their home environment and the many variables that impact on care.
• Recognising vulnerability in patients and families and being able to implement strategies for safeguarding or signposting of patients and families for further support.
• Able to reflect on practice and develop strategies for maintaining continuing professional development and ways of sharing learning despite not always being co-located in teams and working alone.
• All practice nursing staff need enhanced awareness of mental health issues as many patients experience poor mental health alongside other physical conditions and may need signposting or support to manage their well-being.
• Increasingly all practice nursing staff must be able to use a range of technology to support patient care.
• Person-centred care that respects dignity, is non-judgmental and value based, encompassing the 6 Cs with care focused on supporting patient self-management of their healthcare needs wherever possible.

On a wider level, for the GPN profession one of the most pressing issues is the volume of nurses approaching retirement in the next few years: in fact, the Queen’s Nursing Institute (QNI) survey revealed that over a third of GPNs are due to retire by the end of 2020.

In his article ‘Trends in practice nursing for 2019’ Ian Jones highlights the plans laid out in the GPFV to increase all members of the General Practice workforce including specific investment ‘earmarked for enhanced retention schemes to help keep the existing nursing workforce and to support a return to work scheme for GPNs.’

In order to increase retention / attract more nurses into the profession it seems that there needs to be clear strategies to help educate and support GPNs at every stage in their career.

NHS England’s Ten point action plan for General Practice Nursing (2017) and Health Education England (HEE)’s General Practice Nursing Workforce Development Plan – Recognise, Rethink and Reform (2017) both expand on the District Nursing and General practice Nursing Education and Career Framework (HEE 2015). It is hoped that these plans and frameworks will help set out a career pathway and improve access to training, skills development, leadership opportunities and professional support.

In addition to supporting frontline practitioners and increasing workforce retention Julia Neal, Director of Education, Education for Health also believes that ‘we need to do far more to make sure General Practice Nursing is recognised for what it is, and that people recognise the growing importance of the role.’

GPNs play such a pivotal role with the community, we need the workforce to feel energised, motivated and respected. So, let’s hope that the next few years sees increased funding, resources and opportunities for GPNs across the country.