Despite practice nursing being a favoured career choice for many experienced nurses, newly qualified nurses still appear reluctant to enter the primary care workforce. General practice in the UK has seen an increase in patient demand with an estimated 340 million consultations occurring annually, which will continue to increase (Mueller, 2020). In addition to the growing demand for consultations from GPs, there is also an increasing workload for general practice nurses. Due to an ageing population, there has been a substantial increase in the number of complex long-term conditions, with the management of these conditions often falling within the remit of practice nurses (Carrier and Newbury, 2016). It is imperative that as these numbers continue to rise, nurses are encouraged to consider practice nurse roles as a primary career choice after qualifying (Imison et al, 2016).
Nurse numbers in primary care
Despite the need for practice nurses, the number of nurses working in primary care remains significantly lower in comparison to secondary care as shown in Figure 1. It is worth noting that NHS Digital (2018) includes health visitor (HV) numbers in their total of NHS hospital workers. Although HVs work in the community, they are not employed by general practices and are often employed by NHS trusts or local authorities and are linked to the secondary care workforce numbers.
The ‘Five Year Forward View’ described a substantial move for healthcare services into primary care and because of this, the opportunity for nurses working in general practice has never been greater, as they have the capability and opportunity to make a major contribution to the transformation agenda (NHS, 2014; Queen's Nursing Institute (QNI), 2015). Following this, the ‘General Practice Nursing Workforce Development Plan’ was introduced, which supported and highlighted the need to keep practice nursing at the core (Health Education England (HEE), 2017). Despite this scheme and the opportunities created by it, the total number of practice nurses is considerably lower than in 2015 (NHS Digital, 2019). Figure 2 highlights that practice nurse numbers have increased since September 2015, but the most recent data show a plateau or even slight decline in practice nurse numbers (NHS Digital, 2022). Such statistics are concerning, as the demand on primary care continues to increase and does not appear to match the intention of the ‘Five Year Forward View’ or the ‘General Practice Nursing Workforce Development Plan’ (NHS, 2014; HEE, 2017).
There is a known gap between capacity and demand, which can be caused by the aging workforce in primary care, a shortage of newly qualified nurses and an increase in the workload of practice nursing staff. In 2015, a survey conducted by the QNI highlighted that by 2020 33% of existing practice nurses were due to retire, which HEE (2017) indicated was approximately 8000 nurses. While this number seems significant, the greater concern is that 43.1% of respondents expressed concern that their teams did not have properly qualified and trained staff to meet nursing requirements.
Concerns exist throughout the NHS about the current workforce shortage, with almost 40 000 nurse vacancies (NHS Digital, 2021). Although there are no available workforce figures for practice nurses, the pressure identified by secondary care is also extended to general practice and an inability to recruit and retain staff (Lewis and Kelly, 2017). Significant differences remain among the number of nurses working in secondary care compared to primary care in December 2019 (Figure 3). Figure 3 shows how significant the number of nurses working in secondary care compared to primary care is.
Practice nurse myths
There are several falsehoods that surround newly qualified nurses being unable to work in primary care at the start of their career (Gilroy, 2020). With regards to searching and applying for jobs once qualified, student nurses are often told by other qualified nurses that they need to work in secondary care first to gain experience and should only consider a career as a practice nurse when they are wanting their career to slow down. This fits with student nurses' perceptions of practice nursing, in which they believe practice nursing is a slower paced career, which essentially will deskill them (Cunliffe, 2019). However, with the increasing complexity of patients and workload in primary care, the role of the practice nurse has continued to develop into one of autonomy and skill, with many practice nurses leading on the management of chronic diseases and increasing their capabilities. Despite this level of skill and autonomy, newly qualified nurses are still favouring working in secondary care first.
Ageing workforce
To help manage the workload transition from secondary to primary care, an emphasis on encouraging newly qualified nurses to choose to work in primary care is a priority (Mitchell, 2019). As well as the reduced number of nurses opting to work in primary care compared to secondary care, the current primary care workforce is that of an ageing workforce (Launder, 2019). Data released by NHS Digital (2019) for December 2019 show 52.4% of practice nurses are aged 50 or older in comparison to 44.8% under 50, the remaining 2.8% (478) are unknown as illustrated in Figure 4.
However, this is not new, this trend has been clear since 2015 (Figure 5). There is a clear trend in the age range of 45 to 55 years, with people over the age of 60 steadily starting to increase again, although these are not significant increases. There is a likelihood that a disparity between knowledge, training and experience could arise. The education and experience of nurses not required to complete a degree during their training may be too different from those more recently qualified nurses. This has the potential to create a knowledge vacuum in terms of age and experience, which can lead to additional gaps (Nelsey and Brownie, 2012).
Practice nurse student placements
The ability to encourage newly qualified nurses into primary care has not been efficient enough in recent years and less than one-third of GP employers provide student nurse placements (HEE, 2017). Given the lack of primary care placements available, many student nurses do not have the opportunity to experience primary care. As a result of this they can lack an understanding of the role of the practice nurse and this may influence their decision to favour working in secondary care upon qualifying (Ashwood et al, 2018).
Newly qualified vs experienced practice nurses
Despite the need to increase the number of nurses working in primary care, general practices generally prefer to hire trained and experienced practice nurses, as this reduces the need for time intensive training and enables them to have their own workload quicker (Lewis and Kelly, 2017). As mentioned earlier, the practice nurse workforce is already recognised as aging and the continued desire to favour experienced practice nurses over newly qualified will continue to lead to reductions in numbers, especially when those in post reach retirement age in coming years. Now is the time to look forward to the future and to ensure once these nurses retire there is a competent workforce ready to take on the role who have benefited from their knowledge, skills and experience (Imison et al, 2016).
Encouraging newly qualified nurses to stay in primary care
To encourage newly qualified nurses into primary care, emphasis needs to be placed on providing effective support and development opportunities from the outset, including a mentoring programme. This support and guidance are essential for the transition phase from student to qualified nurse and is designed to improve a nurse's skills and confidence level. With the need to keep primary care nurses offering high quality and well-defined advice, a preceptorship programme can ensure a better start to a nurse's career, which in turn means they are more likely to stay in the profession (Muir et al, 2013).
Despite this outlook endorsed by the Nursing and Midwifery Council (NMC), there are views that because of the nature of general practice, practice nurses do not need to undertake this preceptorship period, again highlighting another difference between primary and secondary care. Working as an autonomous practice nurse requires additional training and support even after completing a 3-year degree in nursing from a university. Existing curriculum and skill sets taught do not prepare newly qualified nurses to work in general practice without further training (Macleod Clark and Maben, 1998).
For nurses already working in general practice, in a survey carried out on 3400 general practice nurses by the QNI (2015), only one-fifth reported receiving any form of preceptorship. Since there is currently no standard mentoring/supervision program for those who work in primary care, the experience varied greatly, with some practice nurses offered structured courses, and some offered a week of induction before working independently. This itself raises concerns. Is it possible within a week to acquire new skills and to become competent in them? There remains also a question of whether the quality of patient care could be compromised.
An autonomous practice nurse role can be stressful and hard to adjust to after 3 years of being a student working directly as part of a team. Despite being part of a team, practice nurses see patients independently, they do not have the opportunities to work alongside colleagues in the same room/environment compared to staff nurses working on the ward. It can feel isolating at times, which is why preceptorship, support and guidance are essential for practice nurses, otherwise there is a strong possibility that nurses will stop practicing as nurses when they are not feeling supported (Edwards et al, 2015).
Conclusion
Practice nursing is a valued career in nursing and provides great opportunities for those wishing to pursue a position in primary care. Newly qualified nurses are able to opt to work in primary care without the need to experience ward work first, and the role will not deskill them. Instead, the role will encourage them to become a skilful, autonomous practitioner with a lot of additional skills. Nurses who choose to work as practice nurses in an earlier phase of their professional life will help bridge the vacuum of knowledge that may exist and could turn the tide on the depleting number of practice nurses in the future.
KEY POINTS
- There are significant differences in nurses employed in secondary care compared to primary care
- 33% of existing practice nurses are due to retire, which amounts to approximately 8000 individuals
- There are concerns throughout the NHS about the current workforce shortage with approximately 40 000 nurse vacancies
- Newly qualified nurses are not required to have worked in secondary care before applying to be a practice nurse
CPD reflective practice
- Consider where you work now, how would your organisation cope if the majority of your nursing colleagues retired, what would you need to put into place to ensure no disruption to patient care?
- What myths are you aware of relating to practice nursing and how can you work to dispel these?