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We must support the ongoing training and CPD needs of practice nurses

Jane Diggle comments on the lack of opportunity for practice nurses to take part in diabetes training.

I read with interest a recent report published by The Queen’s Nursing Institute (QNI): General Practice Nursing in the 21st Century: A Time of Opportunity. The report summarises the findings of a survey of General Practice Nurses (GPNs) and highlights some of the challenges facing GPNs working in the UK, as well as some of the opportunities. The survey focused on three key areas: workforce, education and employment, and over a 10-week period last year 3405 nurses responded, which represents approximately 15% of the entire GPN workforce in the UK.

The report emphasises the critical role GPNs play in delivering “care closer to home” and in supporting the increasing number of people living with long-term conditions (LTCs), but it also stresses that there is a need for this professional group to acquire more specialist skills than ever before. 

I have been a practice nurse for over 20 years and have seen the GPN role change immeasurably over that time. There has been huge expansion of the role and responsibility, especially in terms of supporting those with often quite complex LTCs and comorbidities. In relation to diabetes care, over the last decade there has been a significant shift of services away from hospital settings into primary care. 

The Quality and Outcomes Framework provided some incentive for practices to achieve certain markers of quality and, more recently, practices in some parts of the country were encouraged to deliver enhanced diabetes services, such as the initiation of insulin. In my experience, however, it is often the practice nurse who is responsible for the day-to-day delivery of diabetes care within a practice, with varying levels of support and supervision from a GP or specialist colleagues.

Other than the basic Registered General Nurse qualification, no additional training is mandatory for a practice nurse to deliver diabetes care. Many nurses will have completed diploma courses or even higher level training in diabetes and some clinical commissioning groups do specify this as a condition for delivering enhanced services, but generally it is not a prerequisite. Neither, of course, is the requirement to attend regular training or specialist updates. The pace of change in diabetes is immense. Keeping up to date is a real challenge and it has never been more relevant. 

Employment terms and conditions vary considerably. Most practice nurses are employed directly by the GP and few are employed under the terms and conditions of the Department of Health’s Agenda for Change. Ultimately, study leave and access to ongoing professional development is negotiated with the employing GP and, with no statutory requirements, is likely to vary between organisations.  

The role boundaries of GPs and practice nurses in managing LTCs have become increasingly blurred. In many practices, including my own, almost all responsibility for the management of diabetes is delegated to the nurses. It is important to remember that nurses are personally accountable for their own practice and will be judged by the professional standards of the function being performed. If a nurse takes on a role typically undertaken by a doctor, the nurse will be judged by the standards expected of a reasonable doctor. So it is critical we understand our level of competency and do not take on roles or responsibilities that are beyond our capability. 

The primary function of the Nursing and Midwifery Council is to protect the public and most nurses will be familiar with the new “Code” and system of revalidation introduced this year. To revalidate, nurses and midwives must have undertaken 35 hours of Continuing Professional Development (CPD) relevant to their scope of practice in the 3-year period prior to their revalidation date and this must include 20 hours of participatory learning. Participatory learning is described as a learning activity undertaken with one or more professionals where you personally interact with other people. The learning activity does not always need to be in a shared physical environment; it could be in a virtual environment, such as an online discussion group.

Worryingly, the QNI results suggests many practice nurses find it difficult to access ongoing education and training, with 47% saying that their employers do not necessarily support additional training. Around half of those surveyed said they have to take annual leave or unpaid leave to access professional development. 

Some GP employers are more generous than others with regard to study leave, but I would argue that considerably more than 35 hours is necessary over three years for a nurse to remain “upskilled” and competent. Inevitably, most of our CPD will have to take place in our own time, outside of office hours and almost certainly unpaid. 

Of course, there are many different formats for education, including e-learning programmes,  which allow participants to study from home. Distance learning courses and e-learning may be more flexible in allowing learners to access education at their own convenience, but you lose the opportunity to meet up with colleagues to share ideas and expertise. Most practice nurses work in small teams and in relative isolation and I believe there is tremendous value in meeting up with colleagues face to face.

For a number of years, annual appraisals and personal development plans have been mandatory for practice nurses under the General Medical Services contract, in order to achieve the management quality indicators. More recently, a series of outcomes and standards developed by the Care Quality Commission cover this domain too. 

There is no statutory requirement to demonstrate an agreed level of clinical competency. Indeed, there are only a few tasks, cervical cytology for example, where there is a requirement to demonstrate competency before being allowed to undertake this task.

An appraisal is an opportunity to reflect on performance and consider developmental needs through setting objectives and identifying learning needs for the coming year. Annual appraisals are part of CPD, a continuous process in order to maintain and further develop competence and performance across all areas of practice. Importantly, it is also a requirement of the Nursing and Midwifery Council. However, the format of appraisals varies considerably between practices. 

In some parts of the country, local guidelines have been developed to support GPN appraisal, and to reduce the disparity and ensure minimum standards. An excellent example of this is Kent & Medway and the forms can be downloaded here: http://bit.ly/1Q8jtpC (accessed 23.02.16).

Practice nurses play an increasingly important role in the delivery of primary care. Levels of decision making and autonomous clinical responsibility vary considerably, but so too do levels of competency. GPNs’ contribution to providing high quality patient-centred diabetes care should not be underestimated or undervalued. I have met many practice nurses who are highly skilled in diabetes management and more than capable of fulfilling the competencies of a “proficient” or “expert” nurse described in An Integrated Career and Competency Framework for Diabetes Nursing (TREND-UK, 2015). Interestingly, the framework makes no distinction between the specialist diabetes nurse and the generalist nurse with a special interest. Arguably GPNs, with their broader range of knowledge and skills, may be better equipped to deal with diabetes in the context of complex comorbidities. It is imperative, however, that we do not take on roles or responsibilities are that our beyond our capability. To practise safely and effectively, we must ensure we are adequately trained, that sufficient time is allowed to perform the role and that appropriate support is available, if required. 

Practice nursing is a rewarding and challenging career and it is of huge concern that the QNI reported that by 2020 more than a third of the current workforce will retire. We need to find ways of attracting more nurses to general practice and this means addressing the huge variation in terms and conditions of employment and access to CPD.

To end on a positive note, it is encouraging that the QNI plan to publish an online resource this year, “Transition to general practice nursing”, to support nurses who are new to the role. 

TREND-UK (2015) An Integrated Career and Competency Framework for Diabetes Nursing. SB Communications Group, London. Available at: http://www.trend-uk.org/documents/TREND_4th%20edn_V9.pdf (accessed 23.02.16)

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