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
5 Developing the Nursing Team
The practice based nature of the new GMS contract creates further opportunities to take a team approach to the delivery of primary care services. Practice nurses have already demonstrated that they can take on new roles and develop new skills. Practices wishing to effectively deliver the new GMS Contract, will want to develop and utilise their skills to their full potential. This may mean that practice nursing roles expand to encompass some duties that were formerly part of the GP's remit. It may also mean that for some practices the numbers of practice nurses increase and there is increasing diversity within the skills and responsibilities of the practice nursing team.
In turn this poses new challenges for practices in making the best use of the skills of the practice nursing team, developing sound, reliable professional leadership, supporting safe and effective role development and contributing to planning for the future nursing workforce
This chapter is based on standards 3.1 and 3.2, covering skill mix, role development and leadership. It proposes a skill mix model, which practices can use to inform decisions about the right level of nurse to meet patient needs and explores the potential for nurse partnerships.
The previous funding arrangements for practices reimbursed directly on the basis of the grades of staff employed. There was little opportunity or incentive for practices to consider the mix of skills within the team and it was near impossible (outside of the former PMS arrangements) to consider the skill mix between professional groups and look to replace a doctor with a nurse. The new GMS contract has now changed this and there is both the potential and the incentive for practices to consider the appropriate mix of skills and roles to best deliver a high quality service to patients.
A more varied skill mix will have the positive effect of creating a better career structure and progression for practice nurses, with potential roles from staff nurse to advanced practitioner level, nurse partnerships for those who feel it appropriate. In order to simplify the process for practices, a practice nursing skill mix model has been developed. This model defines four levels of practitioner which are outlined below. The steering group recognised that there are tensions within the profession around job titles and particularly around specialist and advanced practice. The four titles used are purely to help describe levels of practice. Each individual job will inevitably be different and it is not suggested that these will necessarily be the right job titles for any individual post.
Health Care Assistant:
Health care assistants are trained in a particular role, but do not have a professional qualification. The health care assistant undertakes simple clinical procedures that have been taught and delegated, such as venepuncture, ECG recording, weighing, measuring, as well as a range of support functions such as stocking clinical areas or sterilizing instruments. She/he works at all times within defined protocols and procedures and should not be put in the position of having to make a clinical judgment. Health Care Assistants should always be directly accountable to a registered health care professional and should have regular supervision and assessment of competence. Health care assistants may or may not be part of the practice nursing team. While they are not nurses, they are included in the skill mix model to illustrate the progresssion of clinical responsibility and to help inform precctice decisions on skill mix.
A staff nurse is a registered nurse and is capable of undertaking a wide range of nursing procedures. Depending on the length and range of experience he/she may have well developed clinical skills in certain areas that could be deployed within the practice. A staff nurse could see patients self referring for nursing procedures and could participate in the delivery of specialist clinical services for established patients who have already been assessed and have a plan of treatment.
Specialist Practice Nurse:
A specialist level nurse is one who has knowledge, training and experience equivalent to first degree level and considerable evidence of post registration development within her/his chosen field. A nurse at this level would be expected to manage and deliver chronic disease management programmes, deal with direct self referrals from the public, prescribe as an independent and/or supplementary prescriber, undertake triage and deliver specialist clinics, for example family planning or travel medicine. A specialist level nurse could also take a leadership role in the nursing team.
An advanced practitioner is someone with highly developed clinical knowledge and skills achieved through at least a first degree level qualification or the equivalent. The advanced practitioner is able to deal with undifferentiated presenting problems, using advanced skills of physical assessment and examination and clinical judgment to form a diagnosis then initiate appropriate plans of treatment. The advanced practitioner might also have a wider contribution to clinical leadership both within the practice and more widely.
Using the skill mix model
The skill mix model has been developed to support practices in making decisions about the type and level of nurse that they need to fulfil particular role. It can be used by practices seeking to fill a vacant post or develop a new post. The model summarises under each of the four roles the type of duties that a nurse at that level could be responsible for. It is not intended to be any way a comprehensive list of responsibilities, but rather to indicate levels of responsibility appropriate to different posts. It is cumulative, so that a nurse at a higher level can always do all of the things that the levels below can. Nor is it suggested that a nurse at any of the levels would need to undertake all of the duties and responsibilities outlined. They are intended to suggest the types of responsibility that might be appropriate to that level. The actual requirements and responsibilities of any post should be specified and agreed in the job description.
The roles described match with current nursing grades and with draft job profiles for the proposed new salary bands under Agenda for Change.
Responsibilities at each of the four levels are described under six dimensions:
Management of Health and Illness
Learning & Personal Development
Clinical Leadership & Teamwork
Accountability for Practice
To use the model it is first helpful to know the duties required of the vacant post. These can then be checked against the model to inform a decision about the appropriate role.
Health Care Assistant
Specialist Practice Nurse
Management of Health and Illness
Undertakes specified clinical activities and tests for named patients, within the scope of established clinical protocols, policies and procedures.
Assesses patients health needs and develops plans of care to meet their needs.
Assesses, plans, implements and evaluates specialist clinical nursing care to meet the care needs of individuals and groups
Effectively assesses, diagnoses and treats or refers patients presenting with undifferentiated health problems.
Communicates effectively with patients, carers and the multi disciplinary team.
Communicates clearly within the primary health care team and with other agencies.
Sets and maintains
Develops and sustains professional relationships with other members of the multi-disciplinary team to influence and improve service delivery.
Adheres to agreed policies, standards and guidelines within own practice.
Contributes to clinical governance activities within the team including audit and evaluation.
Initiates & leads evidence based nursing practice developments.
Plays a leading role in the practice's clinical governance arrangements.
Learning & Personal Development
Participates in annual appraisal and regular supervision.
Uses appraisal and supervision to identify development needs and maintains and develops competence in line with NMC requirements.
Participates in and supports staff appraisal, personal development planning and peer review.
Participates in and leads staff appraisal, personal development planning and peer review.
Clinical Leadership & Teamwork
Works as member of the practice clinical team within the limitations of knowledge and skills.
Actively participates as a member of the primary health care team.
Provides professional leadership to the practice nursing team.
Acts as a source of expert advice in clinical nursing practice at CHP and regional level.
Accountability for Practice
Undertakes clearly defined work with patients without direct supervision.
Accountable as a registered nurse for all areas of personal practice.
Acts independently within the practice team.
Exercises accountability associated with a high degree of personal and professional autonomy operating within broadly accepted parameters of practice, acknowledging own limitations and when to seek advice or to refer.
Employing Health Care Assistants in general practice
There has been a rapid growth in the number of health care assistants working in general practice over the last year, fuelled in part by the work of the Primary Care Collaborative. Whilst health care assistants roles are well developed in the NHS, they are a new role for most practices. The following checklist should help practices to ensure that they make effective and safe use of the skills of health care assistants:
Careful consideration should be given to the education programme for staff new to the role. Health care assistants who have worked elsewhere in the NHS are unlikely to have the full range of skills necessary to be effective in the role. In addition to the necessary skills associated with clinical duties, the initial preparation will need to include:
Communication including dealing with upset or aggressive patients
Record keeping and IT systems
Practices should keep full records of training provided and assessment of competence.
Clear and simple written protocols should be developed
for the clinical duties that the health care assistant will undertake. These should avoid any expectation that she/he would make a clinical judgement and should set out arrangements for referring back to a health care professional any patient that fall outside the scope of the protocol.
As health care assistants do not have a professional registration, the professional (whether that be a nurse or doctor) who delegates a duty retains professional accountability for that duty. It is important that practices as employers of health care assistants establish clear lines of accountability which are understood by other team members. This is particularly important where health care assistants also have another role within the practice, such as receptionist, and may have different accountability for each role. RCN guidance for health care assistants and nurse cadets provides further useful information. It is available at http://www.rcn.org.uk/members/downloads/hca-handbook/pdf
There should be a formal arrangement for a health care professional to supervise the health care assistant on a regular basis. Supervision arrangements, including observing practice, should be agreed on appointment and time built into schedules to undertake supervision.
Education and Development
The health care assistant will have development needs like other members of the team and should be included in practice appraisal and personal development planning arrangements. Most health care assistants in the NHS have SVQ level qualifications at either level 2 or 3. Some universities are now offering health care assistant SVQ programmes suitable for practice employed staff. Practices planning to employ health care assistants should access their local SVQ assessment centre or contact with the SVQ co-ordinator employed by the local NHS Board for advice.
Nurse Consultant Role in General Practice
The role of Nurse Consultaant has been developed as an expert practitioner who also provides strategic leadership as well as having an education and research remit. These new roles are now developing across a wide range of clinical areas in the NHS. Although there are currently no examples in general practice, there is clearly potential with the new practice based nature of the contract for practices to consider this new role. Similarly, there is the potential to develop roles at CHP or Board level that provide strategic leadership and expert nursing input acrosss practices. Guidance on the development of nurse consultant roles is available in HDL(2001)52 available on the SHOW website ( http://www.show.scot.nhs.uk/sehd).
Career Structure and Progression
To date there has been little opportunity for career progression in practice nursing. Most practice nurses are employed at F or G grade, with little potential to develop beyond that and relatively few posts at a lower level. Career progression is hampered by there not being any common understanding of the role and the knowledge and skills that underpin it. Whilst there are significant opportunities to develop skills within the practice, this is in most cases not related to pay rewards and skills acquired within one practice would not necessarily be recognised elsewhere.
In order to make a reality of career progression in practice nursing, the consensus conference on the framework identified a number of essential steps.
Develop greater skill mix enabling a progression from novice to expert
The skill mix model outlined above provides, for the first time, some structure to skill mix in practice nursing. Using the skill mix model should allow practices to make informed decisions about the requirements of each post and in turn create a more diverse career structure for nurses.
Develop accredited education in order to ensure transferability
Chapter 6 explores current opportunities for learning for practice nurses. One of the outstanding difficulties is that whilst there are currently many and varied options for nurses to develop new knowledge and skills these are not always accredited and do not add up to a recognisable and transferable qualification. The NMC is currently reviewing post registration education and further work on practice nursing will need to be based on the outcome of that review.
Ensure that pay is linked to knowledge, skills and responsibility
Agenda for Change provides a framework to support and enable career progression. Each of the model job descriptions has been mapped against the levels identified in the Knowledge and Skills Framework, so it is possible for nurses to define the knowledge and skills necessary to progress their career, identifying and developing the necessary skills to enable them to apply for jobs at the next level.
Provide professional mentorship for practice nurses
The importance of sound professional leadership is explored further below. CHPs and NHS Boards should play a significant role in supporting the development of practice nurses. In addition, there will be a need to develop a cohort of experienced practice nurses with appropriate mentorship skills to support their peers at all levels in the development of their knowledge and skills. The NMC are consulting on standards for mentorship which should help inform any future development.
Ensure that student nurses have exposure to practice nursing as a career choice
The NMC in it's Code of Professional Conduct states that all nurses "have a duty to facilitate students of nursing, midwifery and health visiting and others to develop their competence." In reality, most practice nurses have little contact with students, which means that students do not have exposure to the unique environment and work of the practice nurse and are therefore less likely to see it as a desirable career choice. It also means that practice nurses lose out on the stimulation and challenge that someone new to the area of practice can bring. Universities and most practice nurses are keen to see student placements in practice nursing. However, the different funding arrangements for medical and nursing education mean that it is not feasible for practices to be paid to take a student nurse.
The potential benefits to the practice of taking student nurses on placement include:
Raising the profile of practice nursing as an attractive career choice. This will become increasingly important as practices have to compete in a challenging recruitment market. (There are examples of practices recruiting staff nurses direct from training who they had come to know as students.)
Access to education materials and updating for practice nurses to fulfil their mentorship roles with students.
Exposure of the practice nurse to the new ideas and challenges that students bring into the practice.
Student nurses near the end of their education can contribute to the delivery of clinical services under supervision.
Taken together, these developments will provide increased structure and provide opportunities for nurses to develop their careers in practice nursing.
Practice nursing has been over the last ten years one of the fastest growing fields of nursing practice, both in terms of numbers and scope of practice. The NMC in it's Code of Professional Conduct: http://www.nmc-uk.org/nmc/main/publications/codeOfProfessionalConduct.pdf
provides the scope for nurses to expand and develop roles to meet patient need, but states that:
"To practise competently, you must possess the knowledge, skills and abilities required for lawful, safe and effective practice without direct supervision. You must acknowledge the limits of your professional competence and only undertake practice and accept responsibilities for those activities in which you are competent."
"If an aspect of practice is beyond your level of competence or outside your area of registration, you must obtain help and supervision from a competent practitioner until you and your employer consider that you have acquired the requisite knowledge and skill."
In order to provide some structure and consistency to the development of nursing roles, the Facing the Future Group on nursing recruitment and retention led a major piece of work on role development, culminating in a consultation on a framework for developing new nursing roles.
There are essentially three ways in which roles are developed:
Expansion of existing roles: for example practice nurses undertaking independent prescribing
Development of new roles within the existing scope of practice: for example nurse practitioner roles in primary care
Development of completely new roles: Essentially roles that don't necessarily fit within the boundaries of a single profession, for example hybrid health and social care roles.
The first two are particularly relevant to practices. The framework sets out a series of questions that will be helpful to practices in developing or expanding practice nursing roles:
NEEDS ASSESSMENT - What are the drivers for this change?
1. What is the patient/service need this change addresses?
2. What are the intended outcomes this change will deliver? e.g. fewer inappropriate admissions, improved health outcomes
3. What are the options for these outcomes to be delivered? i.e. are there different ways we could do this?
4. Who are the stakeholders who need to be involved in considering these options?
SKILLS/KNOWLEDGE/EXPERIENCE - What kind of role development is this?
1. Is it an expansion of role, a new role for an existing practitioner, a new practitioner, a support worker or administrative support?
2. What knowledge/skills will be required to deliver the desired service/outcome for patients?
3. Which professions already have the required knowledge/skills? e.g. AHPs, health visitors, pharmacists
4. Who is best placed to deliver this change? e.g. experience, capacity, location
5. If there is more than one option, how will a solution be achieved?
GOVERNANCE - What governance arrangements are in place to support this development?
1. How can patient safety be assured within this role? e.g. clinical decision making, treatment delivery, agreed standards/guidelines
2. Has clinical, managerial and professional accountability and supervision been agreed?
3. How have resource and sustainability issues been addressed?
COMPETENCIES/EDUCATION - What are the education and training requirements of this role?
Have key stakeholders been involved in agreeing the educational needs and competencies for this develop-ment? (the professions with a shared interest in the development will have an important role in defining these)
1. How will initial and ongoing education and training needs be met? e.g. induction, shadowing, networks, mentoring, formal education.
INDIVIDUAL ACCOUNTABILITY - What are the parameters of accountability for this role?
1. Have you defined the specific areas of accountability for the individual taking on this role?
2. Do you have team roles and systems that support the individual's accountability? e.g. scheme of delegation.
EVALUATION/FUTURE QUESTIONS - What mechanisms are in place to evaluate the role and plan for the future?
1. How will evaluation and planning for the future, both for individual practitioners and for the service, be achieved before the inception of new roles?
2. How can organisations and professional bodies work together to develop ways in which practitioners can develop their careers?
3. How can new roles be kept under review to ensure they remain relevant?
4. Are there mechanisms for considering implications for the future of other services as new roles develop?
5. What are the arrangements for succession planning?
These questions provide a simple structure for practices to effectively and safely plan new role developments. The framework itself provides further guidance on role development and is available at http://www.scotland.gov.uk/consultations/health/ffnr.pdf. The final version of the framework will be published in the autumn 2004.
Access to professional leadership
Throughout workshops, conference and subsequent discussion around the development of the framework, the issue of leadership has consistently been identified as important for practice nursing. Many practice nurses reported working in professional isolation, which is not helpful in terms of their own development or indeed of effective clinical governance. There seems to be a clear message that both practices and practice nurses see a role for professional leadership outwith the practice. Some NHS Boards have already invested in developing this leadership, using a variety of different models at either LHCC or Board level, with consequent benefits in terms of the development and profile of practice nursing. Models include practice development roles at LHCC level with a particular responsibility for practice nurses and NHS Board wide remits including an Associate Director of Nursing role with responsibility for practice nursing.
The draft statutory guidance on the development of Community Health Partnerships states that "NHS Boards should ensure that effective professional leadership is available to all the clinical and non clinical professionals working within the CHP in order to support the effective delivery of services and promote innovative and safe professional practice". It is perhaps important to differentiate between management and leadership. External professional leadership should not in any way undermine the ability of the practice to manage and deploy their own staff, nor should practice nurses have their practice dictated to them by the NHS Board. Instead, effective professional leadership should enhance practice and enable practice nurses to develop safely and effectively. It should also ensure that the needs of practice nurses as a whole are better understood and addressed by the CHP and NHS Board.
Benefits of professional leadership
There are significant potential benefits to establishing effective professional leadership for practice nurses. These include:
Access for practices to professional advice on recruitment and development of practice nurses.
Access for nurses to professional and career advice
Professional input to appraisal and personal development planning.
Development of networks to share good practice, raising the standard of care delivered.
Potential to link into NHS Board run educational opportunities.
Development of clinical supervision and mentorship schemes to support practice nurses.
The Practice Nurse as Leader
Although employers can influence the quality of patient care, it is the qualities of individual nurses which have a more direct effect on the way patients are looked after. Clinical leadership is about developing nurses who are effective at managing themselves, building effective relationships, focusing on the patient, networking effectively and being politically aware. All practice nurses have a clinical leadership role and can directly effect the quality of their own patient care as well as contributing more effectively to practice's clinical priorities by developing sound leadership skills.
Practice nurses see themselves primarily as clinicians rather than leaders, indeed many entered the field of practice in order to progress clinically rather than managerially. However, increasingly practices will have skill-mixed practice nursing teams. A direct consequence of this will be that more senior nurses take on roles in leading and managing the nursing team. Issues such as development and appraisal of staff, recruitment, management of clinical nursing services, establishing appropriate delegation and supervision of junior staff and leading nursing involvement in practice decision making will inevitably become the remit of some practice nurses. Whilst some nurses will be well experienced in leadership from previous roles, others may need to develop their leadership skills.
The national Facing the Future programme on nursing recruitment and retention has highlighted the importance of clinical leadership. All NHS Boards are investing in clinical leadership development for nurses and opportunities should be sought to link practice nurses into such programmes.
Whilst there are rare existing examples of non medical partners, including both practice managers and practice nurses, the old GMS contract was not designed to support non medical partnerships. The new GMS contract however is held by the practice rather than individual contractors and specifically allows for non medical partners, so long as the partnership includes one GP, offering the practice greater flexibility to practices in partnership arrangements. A number of practices and practice nurses have expressed interest in exploring the potential of nurse partnerships. There is no definitive guidance available on the subject and experience across the UK is limited. However the following is a summary of potential benefits and issues to consider.
Potential benefits of a nurse partnership
Nurse partnership has not historically been seen as a natural career progression for nurses and both nurses and practices will want to consider carefully the potential benefits of a partnership and put in place effective partnership arrangements to ensure that those benefits are realised. Nurse partnership brings the practice the potential to be more creative about skill mix, which may be particularly attractive in areas where recruitment is difficult.
Having a different professional perspective on the clinical management and leadership of the practice brings additional benefits, which could be helpful to practices in meeting some of the requirements of the new contract. It has the potential to breakdown traditional hierarchies and recognise the contribution of different professionals to meeting the practice's professional and business goals.
For most practices the most pressing drive to developing a nurse partnership will be to recognise the contribution of a long standing senior nurse and to secure her/his longer term commitment to the practice.
Issues to consider
There can be little doubt that having greater involvement in the decision making aspects of the practice promotes a sense of ownership and satisfaction. However nurses and GPs will have to consider the issues that may arise from the responsibilities and liabilities associated with becoming a nurse partner.
Most nurses will not have been self employed before and will need to consider and seek advice on the issues associated with a changed status. An alternative is to become a salaried partner, who receives a fixed share of the profits.
In order to effectively contribute to the running of a small business, nurses will need some business management and financial skills.
Nurses will need to understand the financial and professional liability that they are taking on as a partner in the practice.
Nurses will need to ensure that the practice and any personal indemnity insurance provides adequate cover for their new role and responsibilities
Practices will need to consider what type of partnership best meets their needs. Particular issues that need to be resolved include:
What contribution the nurse partner will make to the decision making of the partnership and whether any issues will be specifically reserved. This may be particularly relevant where the nurse is in a salaried partnership.
Should specific areas of accountability be clarified, for example should the nurse partner have a specific accountability for nursing staff and what should her/his role be in respect of any employed medical staff?
What arrangements should there be for profit sharing and how should they reflect any differing responsibilities within the partnership?
What arrangements are there for indemnity insurance and how does the changed employment status of the nurse partner affect them?
How will the nurse partner's remuneration reflect the additional responsibilities of the role?
Establishing a nurse partnership
Nurse partnerships should be considered as a long term commitment and not taken lightly. Successful nurse partnership arrangements work well where the professional contribution of the nurse to the partnership is recognised and valued. There is little established precedent on which to base any definitive guidance to practices considering developing a nurse partnership. Nurses and practices considering a partnership would be well advised to seek professional and legal advice to help inform their decisions. The recently published BMA guidance on partnership agreements provides a sound structure on which to base a written agreement. It is available to members on www.bma.org.uk
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