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INNOVATION

A scheme to increase practice nurse numbers

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The Advanced Training Practice Scheme is boosting the number of nurses pursuing a career in practice nursing in the Yorkshire and Humberside region

Abstract

A shortage of practice nurses is adding to the workforce crisis in general practice. This crisis has been caused by there being problems recruiting and retaining enough GPs to cope with rising demand for health services. Health Education Yorkshire and the Humber set up the Advanced Training Practice Scheme to ease workforce pressure. The scheme focuses on creating high-quality, undergraduate nurse placements in GP practices to promote the recruitment of practice nurses. In just over six years, it has created capacity for 350 student placements in more than 130 practices in the region. From November 2012 until March 2014 the number of student nurses considering general practice as a first career rose from 31% to 73%.

Citation: Lane P, Peake C (2015) A scheme to increase practice nurse numbers. Nursing Times; 111: 13, 22-25.

Authors: Peter Lane is clinical lead; Christine Peake is programme lead; both at the Advanced Training Practice Scheme, Health Education Yorkshire and the Humber.

Introduction

General practice faces an unprecedented workforce crisis, triggered by difficulties recruiting and retaining GPs and practice nurses in the face of rising demand for health services. GP recruitment has remained static over the last four years, at around 2,700 trainees per year (Health Education England, 2014) - well below the Department of Health target of the 3,250 trainees needed to meet rising demand (HEE, 2014). At the same time, rising numbers of GPs and practice nurses retiring early, and female GPs leaving the profession in their 30s, has put the GP workforce in decline (HEE, 2014).

The timing of this downturn in the workforce coincides with a growth in demand for health services due to an ageing population. As many as half of all people reaching the age of 75 have three or more chronic diseases, and the number of people aged 65 years and over is forecast to rise by 23% between 2010 and 2035. This will certainly increase pressure on general practice (HEE, 2014).

The funding challenge the NHS faces, along with the government policy of shifting more health services into primary care outlined in the Five Year Forward View (NHS England, 2014), adds to the intense and growing pressure on general practice. Proposed new models of service delivery require practice and district nurses to take a central role. HEE is currently drawing up the first national training framework for district and practice nurses and is expected to publish this in the autumn, alongside recommendations to address staffing levels for these groups (Merrifield, 2015).

In 2009, Health Education Yorkshire and the Humber (HEYH) funded the Advanced Training Practice Scheme (ATPS), to ease workforce pressure on general practice in the region. It aimed to:

  • Ease a local shortfall of GPs by training other professionals in a GP setting;
  • Set up a network of practices accredited to provide undergraduate and postgraduate multiprofessional training placements;
  • Offer high-quality training placements to non-medical health professionals that promote integrated learning;
  • Change the career intentions of student nurses so more would choose a nursing career in general practice.

To date the ATPS has mainly focused on promoting the entry of nurses into general practice. Last year the scheme won the Workforce category in the Health Service Journal Awards 2014.

Local drivers

In line with national trends, HEYH faces increasing demand for health services from an ageing population. The region has approximately 800 GP practices and is experiencing shortfalls in GP recruitment, along with high retirement levels for both GPs and practice nurses. The workforce is also ageing, with 70% of practice nurses and 45% of GPs aged 45 years and over, and more than a quarter of practice nurses and 15% of GPs aged 55 years and over. This is threatening the future workforce supply (HEYH, 2015).

At the start of the scheme the region had no clear training route for practice nurses and a lack of capacity to support training in primary and community care. Only a handful of student nurses gained any exposure to general practice nursing, and then only for short periods, attached to community staff such as district nurses in a largely observational role. Few student nurses saw practice nursing as a viable or desirable first career. HEYH set a target of generating 700 general practice student nurse placements a year by 2016, to give 40% of all student nurses general practice experience and make them more likely to consider general practice nursing as a first career.

The ATPS network

The ATPS provides undergraduate student nurses with accredited, high-quality training placements of six to 14 weeks’ duration during years one to three of their training, with the opportunity to develop their practice skills alongside other professional groups. It initially used GP training practices to develop the model and provide a structured and high-quality learning environment.

A network of training practices was established using a “hub and spoke” model. Eight educational “hubs” in general practices across the region recruit surrounding practices - the “spokes” - to offer student nurse placements. The hubs liaise with universities over placements and organise mentorship training, student induction and timetabling materials for practices in the ATPS network. They arrange ongoing student support through mentor workshops and interprofessional learning sessions, and also contribute to an expert steering group.

With the growth of the networks any practice that can demonstrate the right educational ethos and learning environment is encouraged to join as a spoke. ATPS hubs follow standard quality assurance procedures, but are also subject to an annual quality and performance review undertaken by HEYH.

The funding of the placements is based on national non-medical training tariffs, supplemented by a quality premium to account for the small number of placements in any one practice, and delivering the additional quality requirements of the scheme. The model can be developed over time to encourage placements for particular professions. HEYH is the main funder (also funding the hub administration), but increasingly clinical commissioning groups (CCGs) are investing in the scheme.

Putting the scheme in place

The eight hub teams worked extremely hard to convince stressed and busy practice staff to take on student nurse training and become spokes in the network. Following a focused growth strategy the network now has capacity for 350 student nurse placements a year across participating GP practices. This was achieved in just over five years (Table 1 and Fig 1, both attached).

Robust quality assurance monitoring ensures that standards of training and nursing are consistently high. We have strengthened relationships with the universities, increasing collaboration and influence over curriculum and placement requirements. Close collaborative working with CCGs has raised the scheme’s visibility and increased support, as well as promoting cohesive workforce strategies. We have had national interest in the scheme from local education training boards across England.

Outcome measures

Between November 2012 and March 2014 all students and mentors were asked to complete an anonymous online questionnaire before and after the placement.

Students

A total of 116 students were given a questionnaire to complete. As many as 100 respondents had a placement of six weeks or more, with 55 taking eight or nine weeks. Ninety-one respondents were year two and three students, with the remaining 23 from year one.

The survey showed a high level of satisfaction, with 114 respondents agreeing or strongly agreeing that they had gained a better understanding of different professional roles in general practice (Box 1); 109 said the learning opportunities had helped them achieve their competencies. In total, 111 said it had allowed them to develop their practice alongside other professional groups and 112 that interprofessional learning was covered well (HEYH, 2014a). Nearly all respondents said the placement gave them an understanding of patients’ needs (Fig 2, attached); as a result, 111 agreed or strongly agreed that they had learned skills to better care for patients’ needs.

The survey also showed a major shift in career aspirations, with the number of respondents considering general practice as a first career rising from 36 to 84 after they had completed their placement (Fig 3, attached).

Box 1. Student comments on ATPS placements

“My mentor was especially thorough and supportive, as were the other members of the team. I have enjoyed this placement the most and will seriously consider practice nursing as my future career.”

“This has been a fantastic opportunity for me to have a huge insight into caring for patients out in the community. I would highly recommend this placement to other students who are on a nursing degree.”

“Definitely an area of nursing I would look to further develop, consider for a future career and recommend strongly to other student nurses.”

“My placement was very helpful and I was encouraged to make the most of all the opportunities available in general practice to spend time with other disciplines. I would very much like to make a career in general practice and intend to pursue that.”

“I had never considered a career as a practice nurse and was not too sure what it entailed. I never anticipated how varied the role could be and the amount of responsibility and autonomy [practice nurses have], which has changed my opinion and broadened my career opportunities.”

“I really enjoyed my time on placement. I learnt a great deal about long-term conditions and how to manage them. I was able to learn new skills and put them into practice with support and guidance.”

“I really enjoyed this placement. Fantastic learning opportunities and a true picture of what a career in primary care would be like. The one-to-one mentorship was fantastic and I really feel this has helped to develop me as a nurse and really challenged and developed the knowledge I have.”

“This has been a great placement; I have felt well supported by all staff. I have developed a wide range of transferable skills which will help me in the future.”

Mentors and employment

Feedback from nurse mentors was also extremely positive, with 63 out of 67 responding to the survey (HEYH, 2014b). Many practice nurses have a wealth of experience and expertise, but lack confidence when it comes to mentoring. The mentor course, along with close support from the hubs and regular mentor workshops, helps them develop into confident primary care nurse educators.

All 63 respondents agreed or strongly agreed the placement increased students’ understanding of different professional roles of general practice and enabled students to develop their practice alongside other professional groups (HEYH, 2014b). Of 61 respondents answering the question, 52 thought the placement had given patients the chance to influence students’ learning; 35 out of 61 thought the presence of students had enhanced the quality of the service to patients.

Respondents also agreed the experience of being a mentor had contributed to their own professional development and job satisfaction (HEYH, 2014b). As many as 55 out of 62 people answering the question agreed or strongly agreed that mentoring students had helped further their own professional development, and 52 out of 61 who answered said it had prompted them to review their own clinical practice. All 61 mentors who answered the question on whether they were able to manage their workloads effectively while supporting students agreed or strongly agreed that they were able to do so.

An increasing number of practices offer jobs to their placement students once they qualify; a Facebook page exists for all students and practices on which practices can post vacancies. A growing number of students who have graduated since completing the ATPS are now employed in general practice - either in the practice where they had their placement or another surgery. Some 17% of all practices in Yorkshire and the Humber are now part of the ATPS; this significant growth is embedding the scheme into the general practice culture.

Success factors

The key to success was educating stakeholders at all levels - including universities, higher education institutions and CCGs - on the workforce challenge and the advantages of the scheme. This was used to develop a shared vision. Through our local networks we are empowering local practices to participate and be part of their local workforce solution. We are also supporting and building a group of nurse educationalists with increasing local influence, who are feeding into discussions at regional and national level.

Next steps

We are working with the universities to install a standardised preceptorship programme across the region to support newly qualified nurses in general practice. The programme offers modular day-release training to develop core skills (HEYH, 2014c). Where this is already happening, practices report high levels of satisfaction. We are also developing a training programme for healthcare assistants.

Regional workforce analysis in October to December this year shows a clear career progression for practice nurses in the region, with 22% becoming advanced practitioners, 9% extended role practitioners and 6% specialist practitioners (HEYH, 2015). This seems to dispel the myth of little career progression for nurses in general practice, as is highlighted by the case study in Box 2.

By creating a formal training route for nurses in general practice, with high-quality student placements that promote multi-professional learning, we are giving students the chance to experience general practice nursing. The effect is that more students now see general practice nursing as a viable and desirable first career to help deliver the new primary care led service models outlined in the Five Year Forward View (NHS England, 2014).

Box 2. Case study

I had a training placement before qualifying at the University of Bradford in 2013. As a student nurse I had various hospital placements, but I particularly enjoyed my general practice placement. The nurses had such good working relationships with their patients and I had incredible support from my mentor and the rest of the team.

Near the end of my placement, the practice advertised for a practice nurse. I knew I wanted a general practice job because of the homely feel and continuity of care, but assumed I had to work in a hospital first. However, my mentor told me they would consider a newly qualified nurse, and to my delight they offered me the job.

I had a positive reaction from other students, but most qualified nurses advised me against going straight into the community. I refused to let this deter me and have now been at the practice for 15 months.

I thoroughly enjoy my job and work with a fantastic team of people. I may not be qualified to conduct a medication round or administer intravenous fluids on a hospital ward, but I run a whole variety of clinics a hospital nurse would not be able to do.

Since joining I have been on nine courses, including three distance-learning courses, each earning me 30, degree-level credits. I hope to continue studying and use my credits for further career progression.

Going from student to registered nurse can be daunting, but I have found primary care more relaxed and organised, and felt better supported, than in many other settings. I would encourage any newly qualified nurse who is interested to apply. The shift in care from hospital to general practice is giving nurses an exciting career choice.

Lauren Roberts, 24 years, practice nurse, Bowling Hall Medical Practice, Bradford

Key points

  • A shortage of practice nurses is adding to the current workforce crisis in general practice
  • The lack of a clear training route to give student nurses general practice experience means few see it as a first career option
  • Advanced training can provide high-quality placements in GP practices to encourage student nurses to consider a career in this area
  • A network of accredited GP practices can provide clinical placements
  • The Advanced Training Practice Scheme can be extended to support newly qualified practice nurses and has the potential to help train healthcare assistants 
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