Framework for Nursing in General Practice

Guidance and support materials fro general practices on the employment and development of nurses

Framework for Nursing in General Practice

Annex A: Summary of Findings from Practice Nurse Workshops

This annex summarises some of the main findings from a programme of local workshops with practice nurses held across Scotland to inform the development of the framework. These in turn were used to underpin discussion at a consensus workshop on 25th March 2004 attended by a wide range of interested stakeholders. The summary is based on eight broad themes that formed the basis of morning workshops at the event.

Learning and development

Participants in local workshops identified a range of issues in relation to their learning and development needs. Access to study leave, protected learning time and funding for education were commonly reported as problematic. Some nurses reported using significant amounts of their own time and money to undertake education and training. Many reported that their development needs where neglected by GPs. Support for the development of Practice Nurse Banks and structured protected learning time were identified as priority issues by many nurses.

Concerns were expressed regarding the quality and educational level of some of the education that was available. Some nurses who took part in discussions had undertaken the Specialist Practitioner Qualification, recordable with the Nursing and Midwifery Council. While the qualification was highly valued amongst practice nurses, some gaps where identified with the appropriateness of the content of the programme. Nurses valued the methods applied in GP registrar training and expressed a desire for the development of similar models of learning for nurses working in general practice.

The need for good quality induction training that would prepare nurses new to the field of practice was emphasised strongly. Most nurses expressed the need to develop more advanced clinical skills to facilitate their growing range of roles and responsibilities. Some nurses called for more access to work based learning opportunities and better skills based training.

Increasing the exposure of student nurses to nursing in general practice through structured practice placements feature highly as a means to support education and raise the status of practice nursing. Some participants suggested a more coordinated approach to students nurse placements supported by local primary care organisations.

Leadership and professional support

During workshop discussions, many practice nurses expressed high levels of job satisfaction. This was largely associated with the autonomous nature of the role and opportunities to progress clinically rather than managerially. However, nurses recognised the potential drawbacks and reported working in professional isolation. Many nurses wanted access to sound professional leadership to support themselves and their practice.

Access to professional nursing advice when planning new ways of working was seen as increasingly important. Many nurses are needing to develop leadership skills as they assume responsibility for increasingly diverse nursing teams and bring a nursing dimension to the leadership of the overall practice team.

Some areas have developed nurse facilitator roles working across LHCCs and Primary Care Organisations to provide support and advice to frontline nurses. Many nurses felt that leadership needs to be recognised and valued amongst GPs and NHS Boards.

Profile and perceptions

Practice nursing is a relatively new community nursing profession and evolving rapidly. Participants at workshops discussed the issue of how practice nursing is perceived and the relatively low profile within the nursing workforce. It was generally reported that practice nursing was not well promoted as a career option.

Some nurses reported that they had little influence within the practice and that they where often not engaged in making key decisions that affected their working lives. These issues were compounded by the employment status of practice nurses which can make it difficult for nurses to say no or to challenge decisions. Many reported that GPs needed a better understanding of the skills and potential contribution of nurses to service delivery. Whilst the new GMS contract offers the potential of nurse partnerships, few nurses were aware of the possibility. Many nurses regarded the new contract as creating extra workload without any additional reward.

Raising the profile and perceptions of the practice nurse workforce is likely to become an increasingly important issue. Many practices report that the new GMS contract is likely to increase the numbers of practice nurses they employ. In addition, as many as 60% of the current practice nursing workforce will reach retirement age in the next 5 years. Practices will therefore be attempting to recruit more nurses in an increasingly competitive market. Practice nursing therefore needs to have a higher profile and be seen as an attractive career option for nurses. High profile ambassadors for practice nursing were felt to be needed as were improved access to, and quality of, education and better quality evidence of the contribution of practice nurses.

Networking, communication and peer support

Professional isolation featured frequently in comments received through local and national workshops. Practice nurses who work as one of a team of practice nurses reported some peer support within the practice, but communication with nurses in other practices was often limited, reducing the opportunities to share good practice, discuss complex problems and be challenged in their own practice. Many spoke of the lack of opportunities to have structured clinical supervision, although some felt well supported. For those nurses working as a single nurse in a practice, support networks were even more difficult to sustain.

Some reported that GPs did not recognise the value of time out for networking and that increasing workload was expected to make this problem worse. Many reported that there was insufficient protected learning time to network effectively. There was some variability in the extent of networking with other community nursing colleagues locally and clearly some potential for CHPs to improve networking opportunities.

It was recognised that practice nurses needed a better understanding of the methods of clinical supervision and that clinical supervision should be a core part of practice nurses' development. Practice nurses felt that they needed a better understanding of the roles of NHS Boards and to be more politically aware if they were to work effectively within wider teams.

Lack of access to, and skills in, IM&T also reduced communication opportunities for some practice nurses. There was a consistent view that practice nurses need to develop their confidence and competence in relation to IM&T and that there needs to be a stronger emphasis on the development of skills and appropriate levels of access.

Career pathways

Practice Nursing has arguably progressed more rapidly than many other spheres of nursing. The Practice Nurse workforce has developed a role which compliments but is distinct from other community nurses. However individual practice nurses' skills have been determined by the organisation and individual perspectives of the practice in which they work. Consequently, one practice nurse can be multi skilled whereas others are specialists in particular aspects of clinical care. This fragmented identity is further compounded by the vast majority of practice nurses being employed part time.

Furthermore, there is little consistency in grading of practice nurses, so nurses with similar roles can have different grades. There is also little skill mix within teams, giving little opportunity for progression within the discipline. Practice nurses in workshops felt that their career progression was hampered by there not being any common understanding of the role and the knowledge and skills that underpin it. Whilst many reported significant opportunities to develop their skills within the practice, this was in most cases not related to pay rewards and skills acquired within one practice would not necessarily be recognised elsewhere.

Agenda for Change is based on the principle of additional reward for taking on additional responsibilities. This will address some of concerns around reward not being linked to responsibility, but as practice nurses are not direct NHS employees, they will not automatically be included in the implementation of Agenda for Change.

Participants in workshops felt that a career pathway within practice nursing was needed that encompasses the role, knowledge and skills required by staff working at all levels. This would support GP employers, give increased status to practice nursing and help with the demands and challenges of implement new GMS.


Practice nurses attending local workshops reported widely differing experiences of teamwork within the practice. Some nurses reported that it was often difficult to make time for multi-disciplinary meetings. In particular, it was felt to be important that GPs value team work and respect the differing contributions of different team members. Although a core member of the practice team, many nurses reported not having an understanding of how the business side of the practice worked and how that related to their own work. Similarly, many were not involved in the development of practice development plans and had little awareness of how their roles related to the overall business of the practice.

Lack of clarity about the roles of different members of the team could hamper effective collaboration and different employment status could often be a barrier to effective collaborative working. There was a consistent view that there needed to be a stronger emphasis on teamwork if practices are to deliver on the challenges posed by the new GMS contract.

Employment conditions

Many nurses reported that their reasons for moving into practice nursing include more flexible working hours and greater professional autonomy. However, this is matched by much greater variability in working conditions. The new GMS contract aims to implement good human resource management practice to improve the working lives of GPs and practice staff, and encourage recruitment and retention. However nurses reported that the focus to date has been around the HR benefits for GPs, most notably the ability to give up a personal commitment to 24 hour care of the practice population with little obvious benefit for practice nurses. Comments from nurses attending local workshops underpin the need for consistent employment conditions. Particular concerns highlighted under current arrangements include inequity in salary and grading compared to other community nurses, lack of reward for taking additional responsibilities, limited access to education, lack of peer support and limited involvement in the practice.

Autonomy and accountability

Practice nurses, like all other nurses, are professionally and legally accountable for the care they give and must ensure patient safety as the role expands. This appears to be a common cause of misunderstanding and conflict in practice nursing. The commonly held myth that it will be OK for nurses to take on new practice because the GP will cover the nurse if something goes wrong is illustrative of the problem. Professional autonomy is clearly valued by practice nurses, but many felt that this must be matched by a clear understanding by GP employers of professional accountability.

In particular, nurses expressed concerns that GP employers where often not aware of the NMC's Code of Professional Conduct and that there needs to be an more explicit understanding by GPs regarding professional accountability.

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