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Stressed practice nurse quits before busy surgery

Three GPs share their approach to a practice problem

Three GPs share their approach to a practice problem

Case history

When you come in on Monday the practice nurse, Jill Brown, hands you a letter. She is resigning because she feels stressed and unsupported. You are shocked, as she has been happy to accept responsibility and is a committed member of the team. However, you remember a patient had complained to you that she had refused to check his BP in an asthma review. You ask her what's prompted this, but she bursts into tears and leaves – and her patients are waiting.

1. Dr Alex Williams

'Has she taken on new roles and feels she is not trained for them?'

The immediate problem is the patients waiting to be seen. The receptionist will need to try to contact those who have not arrived to reschedule them or slot in those who have arrived with someone else.

Next take a deep breath and decide what to do. The practice manager should become involved and contact Jill at home to try to discover the underlying problems. Jill feels stressed and unsupported – could she have a mental health problem such as depression or anxiety? She should be encouraged to seek appropriate care (hopefully she is not registered with the practice) and a period of time away from work could be certified.

The practice manager should try to find temporary cover. Hopefully other nurses in the practice may temporarily increase their hours, or there may be locum groups or an agency you could use.

When the dust has settled it would be appropriate to arrange a meeting with the nurse and practice manager to try to resolve some of these conflicts. What was the nature of the complaint and has it been resolved appropriately? Why has she been feeling stressed and unsupported? Does she have a regular appraisal process and a mentor with whom she could discuss these difficulties? We regularly appraise our practice nurses so that problems can be discovered and dealt with.

Has she taken on new responsibilities that she does not feel properly trained for? Could courses help? We found when some of our nurses took on a nurse practitioner role they found the transition difficult and partners had to be sensitive to their needs. We offered an in-house education package and wrote protocols for the common conditions they were likely to see.

A return to work may have to be done in a gradual way with perhaps a less onerous booking interval. It will be necessary to keep a close eye on her performance as she may not be suitable for her role. We don't want to go down a disciplinary route, but will have to ensure we keep meticulous records and follow disciplinary procedures. Perhaps we could reduce her hours or responsibilities.

Alex Williams is a full-time GP and lead trainer in Exeter – he has one protected session per week for practice management

2. Dr Lucy Free

'Other partners may be talking about employment law but you owe her a chance to sort it out '

Oh dear! You'd have to be a total saint not to think 'Why me?!' This is a nightmare – Monday morning, no nurse, guilt, confusion, patient pressure and no easy solution.

Why has she selected you? Are you the managing partner? Are you the most approachable, or did you just get there first? In my practice I'd like to think it was the middle alternative, but that brings the guilt of why this has hit boiling point without you noticing. But did you just not notice, or did she hide it – or has something happened over the weekend to precipitate this crisis?

Now isn't really the time or place to try to sort it out – if Jill has come with a typed letter, it's not a spur of the moment decision and you're not going to solve it before surgery starts.

The immediate problem is her morning list. There will be a couple of starved patients for fasting cholesterols who we can't send home. They could be slotted somewhere without too much trouble, the rest will have to be contacted if possible. But when to re-book them? Not until a reliable replacement can be found – is there someone who covers holidays or a second nurse who can hold the fort?

Whatever the other pressures, you'll have to have an emergency meeting after morning surgery to get the full picture – what different pieces of the jigsaw do others hold? This is a blow to your organised little world – things aren't as they appear. Is she really unsupported or is she incompetent or just not coping?

It's very likely that one of the partners will already be jumping up and down about employment law, but you owe her a chance to sort it out. She's allowed a week off without a sicknote, but invite her in to talk about it – she may have some valid points. A pattern may emerge and you will have to decide whether to deal with it, or to let it go.

Lucy Free is a GP based in Sussex

3. Dr Robin Fox

'We can accept her resignation or explore other options with her'

This is not a good start to the busiest day of the week. Jill's actions appear to have come out of the blue and patients will be pouring in before we know it.

The first priority is to reallocate the poor patients. I would pass this straight on to our senior receptionist who is a whizz at such things. Somehow she seems able to keep all the patients, nurses and doctors happy. Once she has finished this I would ask her to reallocate all the other patients who have booked into appointments with Jill to other members of our nursing team and to ensure no further appointments are made at this point in time.

We have our practice meeting on Mondays and I would ensure that time was set aside to discuss this today with the partners, practice manager and our nurse practitioner who heads our nursing team. We need to discuss today's events, what we are aware of that has lead to them and what our options are, bearing employment law in mind.

The patient complaint to me may be uncovering other issues or indeed the nurse may have been upset as a result of a complaint. Jill sounds like a valuable committed member of the team and her behaviour today seems out of character. We have a choice as to whether to accept Jill's resignation or to examine other options with her.

Assuming the latter, then we would discuss in the meeting who was best placed to contact Jill and explore things further. There may be personal or other professional issues here and we would like to do what we could both as responsible employers as well as colleagues. Time off, altering workload, addressing training needs, etc, may all need to be considered where possible – this assumes that Jill is interested in this and that these actions could be arranged without destabilising other members of the team.

I suspect a number of significant events will be generated by today's events (handling complaints, practice protocols, etc) and these will need to be discussed in due course – but not now.

Robin Fox is a GP in Bicester, Oxford

Learning checklist

Coping with sudden absence of key personnel

• Although we don't know when it will happen, the sudden loss of important members of the practice team is an inevitable and predictable event.

• Anticipation of this by discussing who will cover the work of each member of staff in this situation is helpful. Which areas of work can be put on hold and how will patients be informed?

• Experienced receptionists are very good at coping in this type of situation.

• Don't forget to show appreciation of the extra work done by staff.

Work-related stress

• Accounts for one-third of all new incidences of ill-health and results in an average of 31 days absence per person.

• Causes can be considered as:

– interpersonal problems between staff or with bosses

– work quantity or its impingement on personal and family life

– work quality: too difficult or poorly organised with conflicting demands

– working environment:physical conditions, feeling undervalued or insecure in the job.

Preventing work-related stress

• GPs have a legal responsibility to assess the risk of ill-health arising from work-related stress. Fulfilling the QOF organisational criteria goes some way towards this. Implementing policies about sickness, harassment and equal opportunities should also protect staff.

• Using schemes such as Investors in People provides a framework in which staff have more control over their work and more opportunity to discuss issues.

Appraisal of nurses

• Annual appraisal of nurses is particularly important because their responsibilities are changing.

• Appraisal should follow the normal steps of self-assessment, guided discussion, writing a personal development plan and taking actions to help implement this.

• Choosing the person to appraise nurses can be difficult as they must understand both their clinical responsibilities and needs of the practice.

• Tailoring learning needs to the needs of the practice can prove difficult because there are so many courses available.

• Clinical supervision by a nurse adviser can be useful if a practice nurse identifies specific difficulties in her job.

• As GPs it is important that we recognise the conflicting demands placed on nurses. We value their thorough approach to chronic disease, collecting valuable QOF points by ticking each box, but then complain about poor time management and lack of prioritisation.

Meeting an unhappy employee

• This requires the skills of a good consultation – active listening, agreeing on what the problems are and trying to reach a plan acceptable to both parties. Often there are issues outside work and offers of flexible working, training and changes in responsibility can only have a limited impact.

Richard Stokell is a GP trainer in Birkenhead, Merseyside.

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