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At the heart of general practice since 1960

Almost an armful

Since practice nurses were introduced their role has widened, as has their value to the practice ­ Deb Farnworth-Wood looks at recruitment, training and development issues facing practices that wish to extend nurses' roles

Practice nursing was introduced in the mid-1980s. At that time, because practice nursing was new, it was difficult to attract nurses from the secondary care sector. As a result, practices had to pay premium salaries and

G grades were common.

Practice nurse posts were largely part-time as their value was still under evaluation and practices were unsure how their roles would develop. By the 1990s it was clear that practice nurses were here to stay, but many practices started to skill-mix their teams, recognising that G grade nurses should be responsible for more complex work with lower grades undertaking some of the lesser-skilled tasks.

This has also lead to the development of highly-specialised practitioners such as doctor's physicians, nurse practitioners and specialist nurses and other lesser-skilled staff.

Despite these significant advances, and the high-profile position that nursing now has in primary care, the majority of practice nurses are still part-time. This is due to a number of factors.

Recruitment problems

Gradual increases in nursing hours have resulted in more part-time posts. Part-time staff provide greater flexibility for cover. The majority of nurses are women juggling other commitments. Part-time most nurses may be, but most practices experience very low staff turnover in the nursing team. This would suggests that practice nursing is an attractive proposition.

There are many reasons for this. Practices are able to offer sociable hours with no night or evening work. There is the potential to adapt the role to suit school hours. Practices now offer a wider range of roles and, importantly, many practices are now able to offer full-time posts that in turn will attract younger, career-oriented nurses.

Yet despite all this, few nurses are coming into the system and there is a potential retirement timebomb. Why are practices experiencing these recruitment difficulties?

It is widely believed by nurses in secondary care that specialist training is required to even enter practice nursing. But there is no training in secondary care that wholly caters to train practice nurses. This is understandable. Why would trusts train their nurses for posts in practices?

There are, however, transferable skills that can be built upon and these include consultation skills, protocol-based working, ability to deal with crises and to assess the urgency of some conditions, basic dressings and treatment follow-up skills. More specific courses relating to management of conditions in primary care can be addressed once the nurse has joined the practice.

There is also widespread belief among hospital nurses that their counterparts in general practice are less supported in terms of training, development and clinical practice. This too may be a legacy of the early days of practice nursing but maybe it is something practices don't do well enough, simply because we don't do it often enough.

Superannuation has also been another historical barrier to recruitment, but now that GP staff are included in the NHS scheme this is no longer the case. Any other preconception about disparity in terms of service should be eliminated once practices adopt Agenda for Change next year.

What is the way forward? Practices need to strategically plan their nursing teams. It is no longer enough to follow local trends or make ad-hoc adjustments to the team.

Workload is increasing; nGMS has had an impact on the whole team, and practices that do not strategically manage their staffing structure may find themselves unable to keep pace with change. With a full year's nGMS experience behind us, practices can assess the impact on workload, identify areas of concern for next year and look at workload issues such as local demographic changes that may be occurring.

The outcome of these assessments should inform the future plan in terms of training requirements, new skills, career paths and team management.

One good way of attracting practice nurses is to distribute fliers around the local hospital, asking for 'specialist nurses'. We did this recently and were pleasantly surprised by the inquiries we received. Not all translated into applications, but we took the opportunity to invite interested parties in for a tour and to talk to them about nursing in primary care. At the very least we have started to break down the barriers and we have had two excellent applications from the process.

Training and development

Training and development of practice nurses has been a source of frustration for practice managers and GPs. Lack of guidance on training needs, and the expectation of nurses for continual training and development, has given rise to tensions between managers and nurses. The managers' role involves allocation of appropriate resources to achieve business goals and this may exclude personal development for staff in areas unconnected with their role.

Annual appraisals are an opportunity to discuss professional development and training needs. But managers find it difficult to appraise nurses, as do GPs. Unless there is a good organisational structure in place, there is no strategic focus on training and development needs with the result that courses and development may be selected on a 'want' rather than 'need' basis. It is also essential to identify an appropriate timescale for training and the experiential learning that is needed to back it up.

Availability of training has ranged from ad hoc courses run by PCTs, local trusts and even drug companies to more formal university courses. Nurses are accountable for their practice to the Nurses and Midwives Council (NMC) and have to maintain a current registration on a relevant part of the NMC Register.

To maintain this registration they are required to adhere to the NMC code of professional conduct, work within their competencies, and undertake a minimum of five days annual training. The wide variation in training available makes it difficult for practices to assess the effectiveness and appropriateness of courses.

Practices tend to be suspicious of training sponsored by drug companies, although some PCTs have lists of accredited courses covering the basic skills needed for clinics such as smoking cessation, asthma and dietary advice.

Course content and calibre of the trainer can vary, so it is essential that these sessions are followed up in-house as a means of validating the learning in the context of the practice. This can be done via a one-to-one with a GP, or by asking the nurse attending the course to present her learning to a larger group ­ perhaps a combination of GPs and other nurses. This is a valuable tool for reinforcing the learning, and at the same time provides a refresher to other team members.

Opportunities now exist for like-minded practices to collaborate on training and development. Such collaboration could include cross-practice tutorials, arranging appropriate courses and even a forum for peer communication. Primary care is known for its entrepreneurial nature and willingness to tackle problems. The continuing development of nursing roles and new models of care is an area in which we can shine.

Deb Farnworth-Wood is the managing partner at

New East Quay Medical Centre, Bridgwater

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