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Practice comment

GPs must take greater care when delegating tasks to practice nurses


The delegation of GPs’ work to nurses is set to increase following the white paper. Nurses must receive ongoing training to take on additional roles, says Claire Rashid

GPs are set to take on additional responsibilities, such as commissioning health care, under the coalition government’s proposed reorganisation of the NHS. Faced with this extra workload, they will be looking to delegate more aspects of their clinical role to practice nurses. However, delegation can result in potential problems for nurses, as I recently discovered when I carried out a literature review (Rashid, 2010).

In the past, the main driver for nurses taking on aspects of a GP’s clinical role has been to make the most use of limited NHS resources. However, there is little evidence to support the assumption that it is more cost effective for nurses to take on such work. Furthermore, any cost savings tend to be cancelled out because nurses tend to spend longer with patients.

The main evidence to support delegation is a literature review published in the Cochrane library, which explores the substitution of GPs by nurses in primary care (Laurant et al, 2004). This study concluded that nurse practitioners can provide similar health outcomes and levels of patient satisfaction as GPs.

However, these days it is actually practice nurses who provide the most nursing care in GP surgeries and they work very differently to nurse practitioners. Practice nurses have shorter patient consultations and often work on predefined tasks, such as checking a patients’ management of their diabetes.

The delegation of work to practice nurses has also been driven by the perceived increase in workload arising from the GP contract .This has resulted in a significant proportion of practice nurses’ days being spent collecting data for the Quality and Outcome Framework (QUOF). They often feel pressurised to perform tasks and meet targets rather than devoting time to understanding the backgrounds of patients and building emotional and personal relationships. This kind of delegation can leave them feeling their work is more about  financial objectives than the traditional nursing values that drew many into the nursing profession in the first place.

Laurant et al’s findings are commonly used to support the premise that nurses should be able to carry out most of the clinical work undertaken by doctors. However, this premise is misleading as many of the nurses in the studies were qualified nurse practitioners, whereas most practice nurses do not have this qualification. The standard of education and training for practice nurses varies considerably with many only receiving task specific training from their GP.  If nurses take on new roles they must receive adequate training and on-going support and supervision.

Delegating work to nurses provides a means of organising workload within a practice without necessarily allowing patient choice, as some patients may prefer to see their GP. The literature I reviewed emphasises the need to provide patients with information on nurses’ roles and competencies to enable them to make informed choices regarding which professional they consult. Rather than operating under triage - a system in which a nurse decides which professional a patient sees - practices could offer patients a choice by consulting a “menu” that provides patients with indications of how to choose the appropriate professional.

There remains a paucity of studies in this key area of health care policy. However, the available literature seems to point to some general recommendations when delegating medical care to practice nurses. They should be adequately trained and supported to take on additional responsibilities.  Patients should be provided with information on nurses’ roles and competencies for them to make informed choices as to which professional they see. Delegation may be inevitable - but it needs to be implemented with care.

CLAIRE RASHID is clinical effectiveness lead, Leicestershire County and Rutland Community Health Services


Readers' comments (7)

  • Nurses must receive ongoing training to take on additional roles???? No, we should recieve additional respect and PAY for taking on increased roles!!!!!!!!!!!!!!!!

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  • I agree taking on more tasks, responsibility and role from the doctors is inevitable and we definitely need the training to do that safely and appropriately. I'm nnot so sure GP's are renowned for encouraging training in general. The GP's I've woked with in the past were exeptions to this but I have now experienced the other side of the coin. I wonder if this will be reflected in our wage, again I'm not so sure based on looking at what practice nurses are given.

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  • Of course it won't be reflected in our wage anonymous, because Nurses are well known for simply getting on with it and not standing up for themselves, it is as simple as that.

    Nurses already have a vastly extended role, our remit runs from managerial to advanced clinical roles, and we have the academic weight to back this up, mostly with degree level, some with Masters and Doctorates. We can very easily expand into a more advanced clinical role (for example making Nurse prescribing more of a norm), especially if we fight to expand Nurse led services such as walk in centres and clinics. Yet should we? Would we get the equivalent pay and status? I don't think so.

    GP's have recently demanded extra pay (on top of their already bloated salary) for taking on the extra admin roles the government is demanding, and they will get it. So why the hell aren't we doing the same as Nurses?

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  • I have been a qualified nurse for over 30 years and it is amazing how our role has extended therefore adding more and more tasks to do in our shift, be it day or night. 30 year ago if we were asked to take blood or insert a canula in someone you would have looked at them in horror! We had phlebotomists who would come to the ward to do that. We used to have women come along and check our stock cupboards and order for us. We never ran out of anything! I could go on about how more and more is expected of us during our shift. I sometimes wonder how we fit looking after patients into our busy days and nights. After all this is what we should be doing isn't it?

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    I was of the understanding that nurses are for nursing and doctors are for doctoring. Very simplistic i realise ,Soon the edges of the role will become so blurred we will not know where one role begins and the other ends.

    I am not too sure about all this patient choice. pre- Salmonisation patients were cared for completely they were unaware of choices.
    should we now place a menu on the wall.

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  • We already take on most of the clinical work originally done by doctors - including helping train the trainee Gp's - our original work is now done by health care assistants! - Obviously this is all a money saving device but we are still expected to see a full quota of patients [ actually we do 8 sessions - the Gp's only 7,] and still there is no sign of any extra pay for us - Many practice nurses in our area are coming up to retirement in the next 5-6 years unless they start to train some new people there will be a rude awakening soon

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  • Yes we will be expected to take on more work, training, well thats a joke.

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