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Practice comment

'A plethora of job titles just serve to confuse our patients'

The burgeoning number of titles and roles for nurses and others in primary care may encourage choice and uphold the principles of skill mix, but can spell confusion for patients.

Imagine you are feeling unwell. You crawl out of bed and ring your surgery, probably because NHS Direct suggested you should.

There is the ringing tone followed by a minute of “muzak”, then you hear:

“You’d like an appointment for today, certainly, no problem. Would that be for the GP, GP registrar, practice nurse, nurse practitioner, advanced nurse practitioner, assistant practitioner, community nurse, clinical nurse specialist, phlebotomist, level 2 healthcare assistant, level 3 healthcare assistant, or would you just like someone to read your aura?”

You groan. From feeling under the weather, you are now lurching towards the distinctly moribund.

“If it helps at all, one of our PNs and both the NP and ANP are prescribers, and if you think you may need to be referred to hospital, I suggest you see the GP, GP registrar, NP or ANP, unless we are talking about tissue viability, in which case the PN is allowed to refer you on. Is that OK?”

You make your decision, deeply relieved you are not an embarrassed teenager who’d plucked up the courage to call the surgery, someone whose first language is not English or a client with learning difficulties.

With so many primary care job titles out there, can patients deduce what level of service we are capable of providing from our name badges and what we wear?

In the 1970s, the annual addition of an extra stripe on our cap or epaulettes denoted level of seniority. Patients seemed to understand this. So, in our wisdom, what do we do now? We make it more difficult – the higher up the ladder we are, the more likely we are to dress like receptionists.

Are we sure that patients realise they no longer necessarily have to see a GP for family planning, or for asthma or diabetes reviews, because the nurse may have expertise? How can we convey the nature of our roles to patients with absolute clarity?

There are possible solutions, the first of which will be deeply controversial and unpalatable to anyone, like me, who is proud to be a nurse. It is to rebrand ourselves as some kind of generic health professional, distinct from a healthcare support worker. If this is, hopefully, a non-starter, we must start blowing our own trumpets instead of making the professional equivalent of a tentative squeak on a kazoo.

Critically appraise the websites of primary care providers. Are they up to date? Do they include the professional and educational qualifications of the nurses who work there, or just those of their employers? Do they clearly identify which members of staff are equipped to offer specific services? And is this information backed up with written material?

And if all else fails, there is always that reliable old chestnut: greet your patient, and say who you are and what you do. NT

Jane Warner is a locum practice nurse in Somerset, and associate lecturer, general practice nursing foundation programme, University of Plymouth

Readers' comments (8)

  • michael stone

    'And if all else fails, there is always that reliable old chestnut: greet your patient, and say who you are and what you do. NT'

    I think that one would probably work for me.
    The points you raise do seem to have some validity - passim !

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  • I am going to be a little contradictory on this, I do agree with many of the 'titles' that are emerging in our profession, particularly at the higher levels of clinical practice. However, I know this creates confusion amongst staff and patients because quite frankly the role and identity of our profession as a whole has not kept up with the way we have developed, and a lot of this boils down to image.

    There is nothing wrong with a range of titles and roles in and of themselves, but there must be a very distinct and robust career pathway set up for Nurses from newly qualified straight through to highly advanced clinical practitioner, not the fluid and ever changing pathways that are in place now, this works for other professions, Police, Military, Medicine, etc. And more importantly, the public NEEDS to know exactly what our profession does and what we can do for them, and this needs education and time. The 'rebranding' isn't a bad idea, and it does not have to take away from our identity as Nurses, as I believe there are many wrong preconceptions about our profession. But it should make a very clear distinction between Nurses and HCA's, and make it very clear what we can do, because ''greeting our patient and telling them who we are' will never work if the patient does not know to come to us for our help in the first place!

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  • michael stone

    mike | 8-Jul-2011 4:38 pm

    This has been covered 'passim' at length - I'm with you, there needs to a proper definition and demarcation of roles and titles, within a sensible career structure, and also clear explanations for patients about the meaning and qualification levels of particular titles. And you should not downplay the role of HCAs, it only needs to be properly explained.
    As for the 'comming to in the first place' point, patients would normally encounter nurses at a GP Surgery (a clear explanation of the roles and competence of its practice nurses could be on the wall, for patients to read) or in hospitals (again - why not stick the info, on the wall ?).

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  • michael stone

    mike, going back to my ‘display it on the wall’ suggestion, and your ‘nurses are equal to doctors but different’ gripe, I have a comment or two, followed by a suggestion and a question for you.
    My comment, is that we are NOT starting from ‘nurses are regarded as being equal to doctors’ – and, as a ‘patient’, I would always want a doctor, not a nurse, to do the ‘working out what is wrong with me’ bit, if I had anything serious or complicated. But, even doctors are not very good at that – and GPs cannot be specialised in everything.
    So, suppose a GP Practice has 3 GPs, none of whom have any particular specialist knowledge of something: let us assume, depression. If a Practice Nurse happens to have some specialist knowledge in depression, then I can see no reason why that nurse, would not be able to provide better treatment for depressed patients, than any of the GPs could. So, I can see no reason why ‘The notice on the wall’ might not include on it ‘Practice Nurse Edwards, has a specialist background in the treatment of depression, and is more experienced in this than any other person who works at this Surgery. So, if you suspect you are suffering from depression, and wish to discuss this, please book an appointment with Practice Nurse Edwards, and not with your normal GP’.
    This, to my mind, would improve the standing of nurses ‘in the public eye’, without turning nurses into doctors – what do you think ? It also allows ‘high-level niches’ for nurses to slot into, because it simply isn’t possible, for GPs to be expert at everything – and people do usually get better with practice, so if a nurse did ‘do the depressions’ that nurse would become expert, in that particular niche. Provided you keep away from differential diagnosis, which I suspect nurses will never be allowed to become very involved with, I’m sure that the public would buy the idea of specialist nurses who were more expert than GPs, within tightly-defined areas of treatment.
    However, even here this is STILL complicated, by the ‘underlaying assumption that doctors know ‘more in the round’ than nurses do’: even if this nurse understands more about both depression and the drug-interactions which involve anti-depressant drugs, those interactions can sometimes be so serious, that I suspect (? – am I right ?) that many of the drugs used to treat depression, cannot be prescribed by any nurse, however highly qualified. So, in practice my very expert nurse, would still need to get a GP to actually write a prescription for such a drug, even if the nurse knew ‘that is what we should try’ better than the GP.
    And ‘at some level’ there will never be a GENERAL ‘freedom of decision-making in critical areas’ for nurses, which is equal to that given to doctors, unless the academic requirements for training as a nurse, become equal to those for training as a doctor – until that happens, there will always be an assumption that ‘on average doctors are cleverer than nurses, and should understand the ‘hard stuff’ better’. Clearly, some nurses, are actually ‘cleverer’ than some doctors – but I suspect it will take a lot of changes to both job titles, and training/qualifications, before anyone (except, perhaps, nurses) will actually BELIEVE that ‘nurses are equal to doctors’. This is, in fact, where the ‘perception’ issue comes from – the assumption that on average doctors need to be ‘cleverer’ than nurses, so if each ‘tries equally hard’ a doctor should tend to make ‘better’ decisions: re-stating ‘we have different paradigms’ isn’t the point, because the issue is who makes what decisions (and if different paradigms clearly assigned who made what decisions, with no overlap, the above problems would not exist).

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  • Michael, you are right on some things and absolutely wrong on others. There is a lot here, so I will attempt to wade through it.

    As for explaining which job role is best for each particular condition, posters on the wall are all well and good, and yes that would help. However, that assumes one is already within a clinical envioronment. It would take a national ad campaign (as in the recent 'where to go in the NHS' one) to understand that they don't have to go to A&E for anything serious and the GP for everything else. It is a matter of developing and advertising the plethora of Nurse led services. As a 'patient', I'm sure you can understand the benefits of knowing who is best there to help instead of going to the GP simply to get refered on. Also, as you amply demonstrate, there is still a perception that GPs are the pinnacle of help and people would rather get their opinion over anyone elses. That needs to change.

    As for the education of Nurses, " unless the academic requirements for training as a nurse, become equal to those for training as a doctor – until that happens, there will always be an assumption that ‘on average doctors are cleverer than nurses, and should understand the ‘hard stuff’ better’." You are absolutely wrong, and this is the problem with laypeople commenting on what they do not know about, as you demonstrate the problems our profession is having with image. I have said this ad nauseum in other posts so I will refer you onto them (in the perception of Nurses articles) rather than repeat everything. But basically, I am sure you are aware that a medical Doctorate is not in fact a Doctorate, it is an honourary title bestowed on them and in fact their correct title is physician, which many still use too. An academic Doctorate therefore is actually scholastically speaking 'superior' (for lack of a better term, I do not view either profession 'better' or 'worse' than eachother). Now, a newly qualified Staff Nurse is not as qualified as a Doctor, no. However, our post reg quals, leading up to true academic Doctorates in Nursing as well as specific clinical areas, redress that balance. So academically, we ARE equal. I admit there are still problems with the course content, academic requirements to start, etc, but this is changing as we speak, and many of these problems are remnants from the professions past and background. Furthermore, a Nurse prescriber has been prescribing from the FULL BNF, the same as any Doctor, for a long time now, with the exception of controls on very few controlled Drugs, therefore Nurses CAN complete the circle of care in certain envioronments. This will become increasingly commonplace as more Nurses take up those quals and roles.

    However, I do agree that there is still a lot of work to be done on both our qualifications and our professional roles and job titles, as is demonstrated by this article.

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  • michael stone

    mike | 11-Jul-2011 6:33 pm

    Mike, we may well both be wrong about some things - tha tis why people argue the toss.

    My own PCT has got one of those 'you don't need A&E' promotions at the moment. It would make sense, except the guy in the line up with 'a bit of stomach pain' is doubled over - he could very well, need A&E !

    Thanks for the bit about Nurse Prescribers, which removes one complication - I was using a copy of the BNF about 2005ish, which I happened to pick up for 50p a month or two ago in a charity shop.

    But your persistent comments about qualifications, do not seem to match my own experience - and I do have a doctorate. You seem to be assuming, 2 things which are not true. Firstly, that doctors suddenly stop trainign and learning. And secondly, that there isn't an 'inherent ability' aspect to 'qualifying'. It just isn't true, that 'anybody who works hard enough can get any qualification'. I could never have been good at foreign languages, because my memory for anything 'I can't logically check' is bloody awful. And from my experience, the people on degree courses are 'inherently' positioned in terms of outcomes. If you would get a 2.1 by working reasonably hard, you could perhaps get a 1st by working very hard, or a 2.2 if you slacked. But, I've seen people who would 'naturally' get a 2.2, but were working ridiculously hard, to try and get a 1st - almost always, they suffer a break down !

    And, my comment was about the public perception that doctors are PROBABLY 'cleverer' than nurses. Which I still consider, is what most laymen would assume. Were you, somewhere in there, telling me that from your position as a nurse, DOCTORS assume that nurses are 'as clever' as doctors ?

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  • Can I just point out that, when I graduate in November, I will hold two Honour degrees in theory. My first was my basic training and my second is my advanced nurse practitioner. I am a non medical prescriber which involved undergoing rigorous testing (which doctors do not do - they are threw onto a ward with a BNF and told to get on with it). My point it I will hold two degrees when qualified whereas a doctor only holds one. I have coached and encouraged many house officers on the wards during my career and GP will ask my advice from time to time and likewise for me. I don't profess to know as much as a GP but, and this is the funny part a GP looked at my portfolio and said, I couldn't write something like that, thank god we didn't have to do essays. We are all experts in out own way and if I had the finances and came from a middles class background instead of a single parent working class upbringing then perhaps yes, I would be a doctor now

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  • michael stone

    amanda rendall | 24-Jul-2011 12:42 pm

    I agree with you - and people usually get better with practice. Obviously nurses who do something a lot, will be better at it than doctors who do it very infrequently. This is why, if your hip is being replaced, you want not the world's 'best surgeon' who has never performed a hip replacement, but a good surgeon who performs loads of them !

    Your point about middle class people being more likely to become doctors is, I suspect, correct - and 'unfair'. But - and doubtless some people get around this - being middle class and not clever enough to be a doctor, should disqualify someone from being a doctor, as indeed 'not being clever enough to be a nurse should be a barrier'.

    Which does not make someone 'bad' in some way - none of us, can be better than our own best.

    And I think you were saying that newly-qualified doctors would be even more lethal, without experienced nurses keeping an eye on them - well, that has a definite ring of truth to it !

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