The best part of being a GPN, is it’s an absolute privilege to be part of patients’ lives, their journeys through health, ill health and well health, being part of their family, it’s absolutely a privilege.
By Fatima Sharifee, GPN SNN Ambassador (London)
Q: How long have you been working in primary care?
A: I started working in primary care in 1997.
Q: What inspired you to enter primary care?
A: The main reason I came into primary care, I was working on an acute admissions ward for a long while and also worked on a medical assessment unit and it was the same patients coming back time and time again. We had a lot of patients having their second myocardial infarction, we had a lot of patients with COPD, we had an acute assessment unit and had a lot of patients overdosing frequently and coming back and it just made me sit and think, this is such a shame we do everything we can whilst they’re in the hospital with us and I used to think for many years that hospital nursing was the only true nursing. So I was thinking, we do everything we can while they’re here and then we send them on their way with no real health promotion, no understanding or discussion about what they are going to do when they get home, no care plans, nothing to support their choices when they get home and what support network they have when their at home and we wonder why they are coming back to us. A bit like a revolving door. So that’s when I first wanted to come out to primary care to see exactly what happened out here and what can we do to stop that first admission? What can we do support the patient?
Q: Do you think primary care does that now?
A: It’s getting there. Absolutely.
Q: Did you face any barriers when entering primary care and if so how did you overcome them?
A: Huge barriers. I couldn’t give up the hospital, so what I did, I used to work during the week in general practice and I still worked weekends in the hospital on night duty because I thought couldn’t leave the hospital straight away. I think the biggest barrier I came across was the lack of leadership, the lack of training, the lack of support and I remember my first patient that I saw, with horrendous blood pressure I think it was about 200/120,I was like, oh my god! I want to admit them right now. The GP was like no, you do this, this and this. And I was thinking gosh where’s the guidelines to this and where’s the research to support this, so that made me want to go off and start to inquire about doing courses for general practice nurses, which was very few and far between in 1997, but there was a course running, a 5 day course which I put myself on and from there I didn’t stop.
Q: What kind of patients do you work with the most?
A: I think in the role I’ve got now, its predominantly patients with long term conditions, so in my ordinary pre-booked clinic, it’s absolutely long term conditions and out of that long term condition, its primarily diabetes, with a little bit of respiratory and little bit of cardiac. In triage obviously I see on the day appointments.
Q: What size team do you have and what is the skill mix now?
A: So I’ve got a fantastic team! I’ve got 3 team members, a HCA who is complimenting the team perfectly at the moment, we have a GPN nurse who leads in respiratory, that’s her portfolio but she also does ears, smears and travel and wound care along with the HCA. We’ve also got a specialist nurse practitioner, she’s just doing her training now, because we want her to work in a more advanced role. At the moment she’s doing all our same day appointments and telephone consultations. That’s been a fantastic help but not just for myself but also for the GPs. And myself as an advanced nurse practitioner.
A lot of my work is around the holistic, absolutely person-centred care for that patient at that time. It’s really about understanding that particular person and what’s happening with them.
Q: Could you describe a typical work day for you?
A: Typical work day starts at 7 o’clock in the morning, and those 7 o’clock appointments can be pre-bookable or they can be same day appointments for triage. At 7-8 I’ll have a 15 minute break, which I usually sit having my breakfast and look at blood results, blood results that have come in overnight. Then patients start coming in at 8:15 till about 12-12:30 depending on how many extras we see on the day. During that time I also do have a few telephone consultations that at times I cannot leave, so I do take them. Never in front of the other patients, obviously for confidentially. The day can be as varied as the first patient can walk in because they had a cough that only started yesterday or a sore throat, to somebody coming in that’s acutely unwell and that could have congestive cardiac failure with fluid overload and they need to have hospital treatment today. That can be somebody coming with some vague symptom especially if they are non-English speaking and very difficult to articulate the symptoms and the wording can be slightly different, and then to find that they had an acute coronary episode which means transfer straight to hospital to somebody coming with a rash, to somebody coming in because actually they don’t need to be here but there’s nowhere else to go, so they are coming for a request of blood pressure check but there’s depression, there’s loneliness, there’s isolation and a whole load of social factors that go along with that. So a lot of my work is around the holistic, absolutely person centred care for that patient at that time. So a patient may come for 4 different co-morbidities, but what is it that’s really bothering them in that day, it may not be any of those co-morbidities, it may be the fact that their dog died yesterday, it may be the fact that the lift broke in their flat for 2 days and they couldn’t get out. So it’s really about understanding that particular person and what’s happening with them. And that day carries on, have lunch, come back, look at the blood results again, do any clinical letters, so I look at the letters that have come through, referrals that I’ve made, if I need to make any referrals I do those, usually after I’ve had my lunch. If I don’t get time then I have surgery again in the afternoon, which finishes 4.30-5, then I sit till 7.30 usually doing the rest of my referrals, looking at all the bloods before I go home. Then obviously meeting with the GP’s to see what’s been going on for the day.
There are also meetings in between that can be MDT, clinical meetings that we have weekly, that can be out big MDT. We do meet with pharmaceutical companies, but we are not swayed by what pharmaceuticals come and tell us, as you have been aware, it is a form of resource that we utilise, but we are not swayed to provide or promote any one company’s product.
Q: What nursing skill do you personally use the most?
A: The most important skill that I use predominantly, is listening and looking. So before I touch a patient, or before I want to do any type of examination, I want to listen, I want to get the history from them and get their story from them, from their perspective which sometimes includes other members of the family if it’s a child or it may be that the person needs an interpreter, so I’m listening. The biggest skill I use is listening, looking not just looking but really seeing and understanding and then being able to paraphrase back. So the absolute use of effective communication skills both verbal and non-verbal is absolutely key, that’s the most important skill to start with. Then obviously, as an advanced nurse practitioner, I can see anybody from birth to death and anything in between and know the different metrics for each of those age groups and then understand the pathology, understand anatomy and physiology and to be able to undertake a full assessment of that patient and then either make recommendations, take bloods, prescribe or not as the case may be, order tests from the hospital, interpret those results and then a management plan.
Q: What surprised you about working in primary care?
A: What surprised me? So if we go back to when I first started, the first surprise was, this was completely autonomous, I hadn’t anticipated or I hadn’t fully appreciated the role of the practice nurse.
It shocked me then and it still shocks me now, that we are still not employed by the NHS. And when I first came into practice nursing, in the very first beginning, I wasn’t allowed to join the NHS pension, that only came later in 1997, so we are still employed by independent contractors so none of us are on the agenda for a change, so our pay can be as variant as the weather. There is no set standard, so most GP practices will not pay as Health Education England suggest and try to match it to the skill. What happens is you get paid, depends how good of a negotiator the practice nurse is. So we’ve got practice nurses that can be paid £15 an hour and we’ve got practice nurses paid £25 an hour, it doesn’t mean to say that the one being paid £25 an hour has got better skills. They may have or may not to the one that’s on less. So the thing that still surprises me is the lack and the unwanted variation, across the patch in terms of pay terms and conditions.
It’s quiet sad to think that other nursing colleagues in other nursing disciples don’t fully appreciate our role, they don’t appreciate the autonomy we have and the don’t really appreciate the work that goes in general practice and some colleagues still think it’s an opt out option, that you only come here when you are due retirement and that you have nice cups of tea, have nice conversations with patients and do a few leg ulcers and blood pressure. So that still upsets me and saddens me that the role of the practice nurse still isn’t where it should be. It’s getting there, it’s much better than when I first started.
I think that, the one thing that is fantastic about practice nursing, that we are all so ready to adapt and to change because in general practice nursing, there has been nothing but change. We have had change right the way through even before I first started but from 1997 till now, it has gone through so many changes, and each change we have been receptive, we’ve been ready, we are proactive and that is our strength I think, absolutely our strength. And how we work in our particular area of Lewisham is that we have collated, we have ensure all our practice nurses and all our health care assistance and all our healthcare team, all have an opportunity to meet in our forums and have links, no nurse should ever feel alone in general practice.
Q: What has been the best part of being a GPN?
A: The best part of being a GPN, is it’s an absolute privilege to be part of patients’ lives, their journeys through health, ill health and well health, being part of their family, it’s absolutely a privilege. I can’t say anything more than that really because the best part is being able to support people to support themselves to make a difference in their own healthcare and that can be very very small changes. Small enough for maybe for someone to get out of their own bed and walk to their bathroom and be able to sit on the toilet without help to the person that was diabetic and has now walked away from diabetes because they have reduced their weight and waist circumference, they’ve become more active. People who have stopped smoking, decreased their medication for COPD, have now got a more active lifestyle and actually go to the corner shop and not have to ask someone else to go for them. Being part of that process is an absolute privilege.
Q: What is the most challenging part of being a GPN?
A: The most challenging? A couple of things. Sometimes you can’t always make it right and we have all the research in front of us, we have all the tools we have to help support people but if that person doesn’t want to be supported, that person doesn’t want to make those changes, it can be very hard, when you’re seeing the same person that has been through all different healthcare support systems and seen different people and yet still have gone on to develop diabetes, COPD, heart failure, still increase their girth and their weight and become obese and have problems with their knees, their back, not working because of the pain, then getting depression and then getting even more obese and unfortunately developing diabetes. The story goes on and that can be very difficult and frustrating at times but you never let a patient know that. It can also be frustrating sometimes trying to implement new ways of working, when you’re constrained by some employers.
Q: What is the career potential like for nurses working in primary care?
A: The career potential for nurses working in primary care is now amazing, thank goodness! It wasn’t when I first started but it is now, you actually can have and we’ve got and have had in Lewisham a receptionist that becomes a health care assistant, can then become a nurse associate, can then go off and do her training. You can get a nurse coming to general practice as a treatment room practice nurse so an equivalent to a band 5 that can start of doing ears, smears, imms and travel and with support from Education England funding, can go through and do their Advanced Nurse Practitioner masters level, they can then do their non-medical prescribing as part of that. They can start looking at becoming a senior practice nurse or specialist practice nurse or an advanced nurse practitioner. From that you can become a lead nurse for a team of nurses and with primary care networks coming in, that’s where we get groups, practices and locality joining together, then you’re going to have a whole team of approach. So we do actually need that leadership structure. I’m not saying hierarchy but leadership structure that allows a team leader, lead nurse, advanced nurse whatever name you’re going to call the nurses, but someone that is going to lead and support the team and there’s your career progression. For myself from 1997, I started off as a treatment room nurse then through the years from completing diploma, degree and then MSc, becoming a nurse consultant in primary care, the first nurse consultant in England. So absolutely there’s career progression in nursing. If they want it.
The career potential for nurses working in primary care is now amazing, thank goodness! Come out and sit with your practice nurse because your views will completely change; career progression is key and it’s there, if the nurse wants it.
Q: They are so many myths in nursing practice…
A: Come out and sit with your practice nurse because your views will completely change and as I’ve just said before, career progression is key and it’s there, if the nurse wants it. Not all nurses want career progression, as I’ve explained before.
The important thing is exposure to what practice nurse do. Absolutely exposure, you don’t see how we work and what we do then you’re going to surmise on what you think we do. So when we have had nurses from intensive care, A&E, district nurses, nurse who work on the wards, they think running around with a stethoscope around your neck, seeing patients with all their high tech equipment is what nursing is all about. When they come into general practice, they are absolutely shocked many of the times, if that is the right word to use, they have completely changed their mind set about how we work and completely changed their mind set around what the role of the practice nurse is. I think one of the other thing that I should have said earlier, the name practice nurse or general practice nurse, the reason it’s very hard to quantify or what a GPN is, is because a GPN can be doing ears smears, imms and travel right up to doing non-medical prescribing and seeing patients with a specialty. So the variation in the role is huge, even though we have guidance from HEE, the role itself can be interpreted into many different guises and that is both a benefit and it’s also a blocker in other cases but no, come sit with us. Come see what we do because we are not what you think.
Q: Any last word, comments or words of wisdom …
A: Words of wisdom. If you want to be part of a patients journey to make a difference in their lives both in their health and wellbeing and in their journey in the health care system. Come and be a practice nurse, come make a difference to people’s lives.
Last little quote, we have been linked to like being a dishwasher.
Q: Why is that?
A: You don’t know you want one till you’ve got one but once you’ve got one you can’t live without them.