Time to give nurses a greater share of responsibility

Coronavirus has put the Irish healthcare system under strain. Yet, for a long time before the Covid-19 pandemic, shortages in general practice were taking their toll. UCD academic and former nurse, Mary Casey, believes part of the solution lies in giving nurses more responsibility.

Specifically, she wants to see formal training to enable advanced nurse practitioners – nurses trained to master’s level – to support GPs when it comes to routine medical care.

Having worked for decades on the coalface of nursing in the UK, St Vincent's in Dublin and as director of nursing in Our Lady of Lourdes Hospital in Drogheda, Casey believes appropriately-trained nurses could undertake many services offered by GPs – eg, management of chronic illnesses such as diabetes, heart failure and health education to have many positive knock-on effects on the wider healthcare system.

The proportion of these advanced nurse practitioners has increased in many developed countries, running as high as 5.6 per cent in the US, yet the most recent figures show this type of nurse makes up just 0.2 per cent of the nursing population in Ireland with most working in acute hospital care.

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Patients will sometimes confide more readily with the nurse

Next Tuesday (May 12th) is International Nurses Day 2020, the anniversary of Florence Nightingale’s birth, and perhaps never more than today has the crucial role of nurses been more celebrated and in the limelight.

Under proposals that Casey has drawn up she would like to significantly increase the number of registered nurses trained to advanced practice with the up-skilling of many of the practice nurses working in GP services a big part of the plan.

“I would like to set an immediate target of having 2 per cent of the nursing/midwifery registered nurses to be trained up to this level to bring this number up to 700 and if plans expressed in the recent Sláintecare report are to be taken seriously then the enhancement of GP services through the provision of advanced nurse practitioners is essential,” she says.

Casey, an associate professor at the UCD School of Nursing, referenced previous research on highly trained nurses in primary and emergency care that has shown multiple and immediate benefits to healthcare systems.

“Primary care services led by nurses in advanced practice have demonstrated to be as safe and effective as those led by physicians. Previous reviews that examined the effectiveness of nurse-led clinics in primary care and acute and emergency settings found that such models of care delivery improved patient satisfaction, reduced hospital admission, mortality and reduced costs,” she says.

“Arguably, the GP setting where patients across all ages can voluntarily present themselves with any medical condition represents the closest context to emergency settings in the acute care sector so we can presume that the same benefits will apply in GP practices.”

Casey says the benefits would extend to patients and families in terms of encouraging home care and help nursing staff and medical staff working in general practice, public health nursing, and in emergency practice due to a reduction in referrals to acute care and possible admissions.

In addition advanced nursing practice roles have the potential to be time savers in that they lead to reduced workloads for GPs and allow more appropriate use of GPs expertise in diagnoses. She added that down the line serious consideration should be given to enable advanced nurse practitioners to set up nurse-led clinics within general practice along with supporting practice nurses.

Most nurses working in GP practice who take on further training do so under their own steam and the nurses Casey teaches at postgraduate level often come in straight from night shift. Under her proposals she is recommending some provision for time off to study and says it would be important to offer training in a flexible way.

“I would envision blended learning – some online, some class based – and not just the domain of UCD but with all the regional universities and institutes of technology/technological universities a part of this, and also to involve GPs in designing the course,” she says.

Casey points out that patients may not want to bother a GP, with what they consider minor complaints, and in her experience many consider the nurse to be more on the same level as themselves.

“Patients will sometimes confide more readily with the nurse. I think this would help with compliance with taking medicines and adequately trained nurses could help with mental health issues to prevent them getting to crisis level, an area which is increasingly taking up inappropriate admissions to emergency departments.”

Her plans could also make going into general practice a more attractive proposition. “This plan will enhance primary and community care and will enable a more focused and economical GP service in the community. The addition of this advanced nursing resource to GP practice would attract more GPs and help retention in an environment that was less stressful and more patient centred,” she says.

The GP scheme is private and current practice nurses are employed by GPs despite attracting State financial support to fund practice nurses. Casey foresees that GPs will need some support to enable transparency of any nursing activities within their service or be supportive of a nursing activity-based costing model.

Another possible challenge is that many practice nurses choose this career path as it is often part time and blends in with other life commitments. She points out the experience of such nurses should be valued and recognition of their prior learning is important to assist them in taking on additional roles if appropriate.

To date most nurses have self-financed themselves to do postgraduate courses while also taking their own holidays to undertake these programmes

New ideas cost money but while there would be an initial requirement for increased funding to support the education of the practice nurses in GP services and fund better pay, Casey believes these positions would be funded through savings from reduced hospital admissions and enhancement of the primary care model.

She suggested, alternatively, that the current Primary Care Reimbursement Service, which uses taxpayers’ money to help fund practice nurses in GP clinics, could be re-examined and future funding could be obtained through a more affordable charging structure if a patient were to see a nurse instead of the GP.

At the moment there is little consistency between the activities of practice nurses in GP practices as they largely do what is expected of them by their GP, who is their employer. According to Casey, some GPs are enlightened and send their nurses on courses but there is no recognised accredited education path for these nurses. Under her proposals she would like to see this project initially rolled out in up to 10 GP offices.

There has been widespread gratitude for healthcare workers during the coronavirus crisis and perhaps a new conversation can be started once the pandemic has passed on how our nurses are trained. “Acknowledgement of our appreciation of those nurses after the Covid-19 crisis is over can take many forms – it is not about money – perhaps we could consider provision of some additional study leave and/or some financial support as part of every nurse’s contract.

“To date most nurses have self-financed themselves to do postgraduate courses in areas such as intensive care and emergency care and care of older people, while also taking their own holidays to undertake these programmes – where would we be now without the vision and the motivation of these nurses?”