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Practice Nursing: picking up the pieces and putting them back together

September 9, 2014

A guest blog by Louise Brady

I am a General Practice Nurse (GPN) in a culturally diverse General Practice on the outskirts of Manchester. We cover a population of approximately 9000 patients. I am often asked by colleagues from other disciplines exactly what my role entails. My usual response is that we care for patients – from public health to palliative care. Despite the government’s drive to reduce health inequalities, hospitalisation and move care closer to home, we are struggling to recruit experienced nurses with the clinical skills and attributes to care for an ageing and frail population.

 
I am about to start a full clinic seeing patients with Coronary Heart Disease when my niece phones. Excited to be setting off for the Far East, she mentions the Japanese art of Kintsukuroi – repairing broken pottery with gold or silver lacquer, with the understanding that the object is more beautiful for having been broken. Intrigued, I inquire further and it turns out this is also a philosophy – or mindset – within Japanese culture. The Japanese believe that when something has suffered damage and has a history, it becomes more beautiful for the care it took to bring it back to life. Perhaps this fascinating concept could be applied to how we view people, patients, families… even primary care. Is there is there opportunity for improvement? Could there be a ‘human kintsukuroi’?

 
Clinic gets under way. One of my patients is a lady attending for routine review. Health promotion in this context would usually consist of a discussion around her diagnosis, how she manages at home and at work including social factors, dietary, exercise and lifestyle choices, routine blood pressure & pulse check, medication review and shared plan of care. Unfortunately this “broken” lady does not want to discuss Coronary Heart Disease, but describes her traumatic journey with cancer.

 
She tells me about her initial diagnosis, her feelings of fear and anxiety, family upheaval, the harrowing side effects of chemotherapy and her eventual remission. She is an inspiring individual; having survived cancer, she now feels invigorated and renewed. Broken no longer, her life has taken on a whole new meaning. She embodies kintsukuroi. I feel very humbled by her story, and very emotionally charged. This is General Practice nursing……

 
General Practice nurses see people from birth to old age. Today I counselled a patient with diabetes who is struggling to mitigate the weight gain he is experiencing with his insulin therapy. Together we review test results, discuss medications and side effects, review his insulin regime, and negotiate a shared plan of care. Next, a family who are grieving for a relative far away require urgent travel assessments – last minute travel advice, eight sets of vaccinations and prescriptions for malaria prophylaxis. Altogether this morning I see fifteen patients, all of whom have complex health needs, and require intensive support and education. No wonder I am running behind!

 
Mid afternoon: I have undertaken cervical cytology, taken blood tests and performed an urgent ECG. For a seven-year-old with brittle asthma I initiate new medication, and agree a care plan with the family. Evening: a distressed elderly patient whose newly diagnosed heart failure has left her struggling to cope with her daily activities, and feeling socially isolated. Her frequent breathless episodes and complex medication regime trigger a comprehensive history, pulse oximetry, blood tests, and check of BP and weight. I listen, offer reassurance and make sure she is seen by our GP today for immediate advice & support. Later, at Respiratory Clinic, I see a gentleman who is struggling with frequent exacerbations of COPD. I prescribe anticipatory antibiotics and steroids and we discuss the benefits of exercise, pulmonary rehabilitation programme, and referral to a local peer support group.

 
The history and development of practice nursing is instructive. According to the Royal College of General Practitioners (RCGP) in 1984 there were fewer than 2,000 full time practice nurses in the UK. By 2001 numbers had risen significantly, with about 18,500 practice nurses employed by GPs.

 
But in contrast with our GP colleagues, nurses opting for a career in General Practice have never had a standardised job description or training. As an example, in the 10 years that I have been nursing in the community, many educational institutions have offered a range of courses to try to meet the developmental role of practice nurses, but there has been very little targeted provision aimed at new or experienced practice nurses. Additionally, access education has depended upon the the good will of GP employers and local commissioning arrangements.

 
Fast forward a few years and the introduction of the Quality and Outcomes Framework has seen the role of the General Practice nurse grow and expand as a cost effective way of meeting the needs of the population. But at the same time we are in the midst of workforce crisis; at my own practice we are two nurses down. The WIPP snapshot survey (2008) and RCN (2009) suggest that retirements mean that in future there will be 30% or 33% reduction in GPNs numbers compared to 2008. There is a need to attract new nurses into general practice and primary care – but they must be equipped with appropriate clinical skills and knowledge. It’s hard to know how this can happen when pre-registration exposure is so variable on so dependent on local commissioning agreements. Without an understanding of our role, few nursing students will consider General Practice as career.

 
I am fortunate to be supported and encouraged to develop my clinical skills; however many of my practice nurse colleagues paint an altogether different picture. One colleague actually described herself as ‘broken’. She worked in an unsupportive stressful environment permeated by financial incentives, tick boxes, and a target driven culture. No access to Continuing Professional Development opportunities, coupled with the pressures of primary care eventually forced the decision to leave general practice nursing altogether. Within some General Practice teams, partnership working still requires a cohesive approach, and there is much work to do on building relationships and alliances between health care teams.

 
The nursing workforce is such a vital part of the planned shift in healthcare delivery. Nurses can improve outcomes. At my practice, we have recently introduced access to patient records to support patients with health literacy, self care and management. To drive up quality standards and improve morbidity and mortality levels, we need to invest in the development of our practice nurses. For the new General practice framework to be successful, we need the combined efforts of national bodies, leaders and policy makers. NHS England, the RCGP, the RCN, the NMC, Clinical Commissioning Groups.

 
Locally, our practices are identifying appropriate high quality education and training to meet the needs of patient groups. We are developing learning environments, so patients nurses and GPs and Allied Health care professionals can network, and share experiences. Nationally, work is being developed towards a new General Practice Educational Framework. It is anticipated that it will provide a coherent system to allow for core clinical competencies to be achieved, and support the continued professional development of GPN’s.

 

Japanese philosophy teaches us that an everyday item like a broken cup can be fixed and made into something more beautiful and valuable than it was before; so surely a uniquely precious and worthwhile human life can also be changed from ‘broken person’ to ‘individual with limitless possibilities’. I’m pragmatic: I recognise it will take more than lacquer to ‘solve’ the problems of General Practice: the underinvestment has gone on for far too long. But though we can’t paper over the cracks of primary care with gold or silver, General Practice can strive for value-based care. We can foster a cross-disciplinary desire to support each other, and balance the rewards against the huge challenges that we face. Our patients and our staff are our biggest investments. Taking these pieces and putting them together in a new way will help us face the challenges ahead: ‘the Japanese craftsman repairs… and in doing so elevates to a new level of singular distinction. It is now not broken, but radiates more beauty than before’.

 
BMA, Practice nursing. Discussion paper by the GPC’s practice nursing working group (2001)

http://www.england.nhs.uk/wp-content/uploads/2012/12/compassion-in-practice.pdf

http://www.wipp.nhs.uk/uploads/GPN/Final%20Report%20SNAPshot%20Survey.pdf
http://en.wikipedia.org/wiki/Kintsugi
Rivett G, National Health Service History: Chapter 5 1988–1997
Royal College of Nursing (2009) Practice Nurses Employment survey

http://www.rcn.org.uk/__data/assets/pdf_file/0005/305969/003583.pdf [accessed 4/9/14)

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