Background
Train people well enough so they can leave… treat them well enough so they don’t want to.
Attributed to Sir Richard Branson.
In recent years there has been a worldwide shift in healthcare policy from a hospital-based secondary care focus, towards a greater emphasis upon primary care and public health. In the United Kingdom (UK), two government documents, the ‘Five Year Forward View’ [
1] and ‘Long-Term Plan’ [
2] outlined a concerted shift from a secondary to primary care focus in the management of older adults with LTCs. Mirrored worldwide, it is estimated that in the UK 58% of people over the age of 60 are living with at least one long-term condition (LTC), with the majority of these individuals being managed in primary care by General Practice Nurses (GPNs) [
3]. As people live longer, but not necessarily better, there is an ever-increasing demand for primary care services worldwide [
4]. Post-COVID 19, the provision of primary care worldwide is continually under the spotlight [
5].
There is however a worldwide recruitment and retention crisis in general practice nursing (GPN) [
6‐
10]. The Queen’s Nursing Institute (QNI) in the UK identified that approximately 33% of GPNs were likely to have retired by 2021 [
11]. Exacerbated by the COVID-19 pandemic, a significant proportion of this critical mass of experienced GPNs have now disappeared from the general practice workforce [
12].
The increased emphasis upon the management of LTCs in primary care means that since there is no clear recruitment and retention strategy in place to increase the numbers of GPNs ‘at scale’, post-COVID there is a ‘perfect workforce storm’ brewing. This will consist of an acute shortage of GPNs at the very time when the workload in primary care is increasing exponentially [
11,
13,
14].
Literature review
In recent years, there have been various attempts to address the GPN workforce crisis, however attracting nurses into primary care has always been a challenge. General practice has not been considered a suitable ‘first post’ destination for new graduate nurses [
15‐
18]. It has been argued [
15] that at least part of this antipathy has been caused by the continued focus upon secondary and acute care in the undergraduate (UG) nursing curriculum. The absence of much primary care content, together with a shortage of general practice placements for student nurses has meant that many student nurses still do not know what general practice nursing is, or what it has to offer [
19]. It may be argued that Higher Education Institutions (HEIs) worldwide are still slow to reflect the increased emphasis upon primary care in terms of developing both clinical placements and curriculum content [
20].
Unlike medicine, there has been no culture of student nurses spending time on placement in general practice, and consequently there has been a perceived lack of understanding amongst GPs regarding the nature of the undergraduate nursing curriculum and what it has to offer [
16]. There have been a number of initiatives over the years designed to address these issues and increase student nurse access to general practice placements [
21,
22]. In a number of areas within the United Kingdom (UK), GPs were commissioned to provide placements for student nurses. These schemes, funded by Health Education England (HEE) were known as Community Education Provider Networks (CPENs) [
23] or Advanced Training Practices (ATPs) [
24].
General practices in the UK are usually owned by either a single General Practitioner (GP) or a group of GPs, and as with other countries such as Australia and New Zealand they operate within an independent ‘small business’ model or as part of a larger corporate chain. Income is primarily generated through a combination of payment models with variable ‘fees-for-service’ arrangements [
22,
24]. As Bauer & Bodenheimer [
22] note, health care reformers have highlighted the need to move away from ‘fees for service’ towards a system of payment which rewards quality of care rather than simply the volume of activity. The reform of payment for primary care service, whether through private medical insurance, publicly funded insurance, or direct taxation is vital to the future of general practice. Indeed, the way in which primary care is funded plays a significant role in the recruitment and retention issues identified in general practice nursing staff.
In the UK, GPs are subcontracted to provide a range of services to the National Health Service (NHS). GPNs in the UK are employed by the ‘business’ and not the NHS, and as a result, GPs have been reluctant to invest in education and training for new GPNs, much preferring to recruit experienced nurses who can ‘hit the ground running’ [
16,
24]. In the UK, GPN recruitment has been predicated upon access to a (rapidly diminishing) pool of older, experienced GPNs who may be simply ‘poached’ from other practices as required [
24]. In the long term, this had the effect of dissuading younger, new graduates from applying for GPN posts.
It became clear that whilst they have made a difference, the CPEN/ATP schemes were not going to be able to deliver the numbers of new GPNs that were required to address the predicted shortfall [
25]. Evidence has suggested that preceptorship type programmes were required to support the transition of new to general practice nurses (NTGPNs) into the role, and in doing so, address GPs reservations [
25‐
31].
If NTGPNs are to be successfully recruited and retained therefore, it is argued that there needs to be a significant cultural shift in the way that GPN education and development is organised [
32,
33]. Since they are not employed by the NHS, attempts at addressing the need for GPN continuing professional development in the UK have often been thwarted by the reluctance of GP employers to fund education and training programmes [
34].
Unlike their medical counterparts, there is still no formal, nationally accredited entry qualification and associated training programme for GPNs in the UK [
32]. This situation is mirrored worldwide in other developed countries such as Australia, USA, and New Zealand [
33,
34]. In an attempt to address this situation, a GPN Fellowship scheme was developed in the UK. Arising out of the Long Term Plan [
2], the GPN Fellowship committed to provide a two-year programme of training for NTGPNs. This has begun to address some of the systemic problems within the provision of education for GPNs, and to act as an incentive for new to general practice nurses to actively consider a career in general practice.
The VTS programme
The SY VTS programme is a one-year vocational training scheme for NTGPNs, developed and delivered by the South Yorkshire Primary Care Workforce & Training Hub (SY PCWTH) as the first part of the national GPN Fellowship scheme [
32].
Study aims and objectives
To examine the perspectives of the VTS trainees on a career in general practice regarding:
1)
The culture of general practice in the UK.
2)
‘Readiness to practise’ as GPNs.
3)
The development of a GPN career pathway.
Study design
The study used a longitudinal, qualitative design, following the educational trajectory of a cohort of trainees’ over the 12-months of the programme. It used a constructivist approach, to enable the team to study the trainees’ perceptions of a career in general practice at key points throughout the programme.
Research governance
Ethical approval was obtained from the Sheffield Hallam University (SHU) Research Ethics Committee (Ref: ER27858429), and SHU research governance protocols were adhered to throughout the study. All data were anonymised by the removal of any identifiable information, to maintain confidentiality and to ensure that no individual could be recognised in any subsequent report or publication.
All of the electronic data was held on a password-protected, encrypted network storage system that adheres to Home Office Standards of Data Security. These data will be kept for a minimum of seven years in accordance with SHU guidelines.
Ethical issues and consent
Given that this was a study involving trainees as participants, great care was taken to avoid any perception of coercion. Particular emphasis was given to reassure the participants that (a) they had the right to refuse to take part and (b) they would not be disadvantaged if they chose not to take part.
As Sim & Waterfield [
35] note, there are a number of ethical issues specifically related to focus groups. For example, the unpredictable nature of focus group discourse may give rise to problems with confidentiality, and also limit the extent to which potential problems can be identified during the consent process.
The dynamics within the group may also lead to some individuals dominating the discussion and thereby denying or denigrating other participants’ views. In addition, managing participants’ distress within focus groups is a challenge that needs to be considered.
It is clear that some of these ethical challenges can be addressed through a robust consent process, however efforts may need to be made to reinforce these issues closer to the actual focus group. This may be done in the form of a briefing immediately prior to the discussion, during the discussion itself, or in a debriefing immediately after the focus group has finished.
Recruitment
The participants (n = 17) were recruited from the population of trainees (n = 21) undertaking the September 2020 VTS programme. A preliminary information session regarding the nature and purpose of the study was provided for the participants, with the opportunity to ask questions. Following the information session, interested trainees were invited to contact the nurse lead for the programme giving permission for their contact details to be passed to the study team. The resulting 17 participants were provided with an online information sheet and consent form to complete.
All of the participants identified themselves as female. Ten of the seventeen participants (59%) were new graduates. Of the seven participants (41%) who were not ‘new’ graduates, six came from secondary care and one from primary care. On average, the more experienced participants had been qualified for 4.8 years with a range of between 18 months and 7 years. Approximately half (53%) of the participants were aged between 20 and 29, with an age range of 23 years to 47 years.
Data collection
The data were collected using online focus groups. The membership of each focus group was variable, dictated by the availability of the participants on the day. This meant that not all of the participants attended all of the focus groups, with an average of 12/17 participants in each focus group. With the agreement of the SYPCWTH team, data collection took place during time allocated for personal professional development. The initial question schedules focussed upon the participants’ experiences and were based upon a rapid review of the existing literature undertaken as part of the study.
In order to ensure participant safety during the COVID-19 pandemic, the focus groups were conducted online using Zoom© [
36]. This software uses voice over internet protocol (VoIP)-mediated technology. The focus groups were facilitated by RL at 3-monthly intervals. With the participants’ consent the audio-visual content of the Zoom© sessions were digitally recorded and the audio transcribed. The video content was stored securely on the SHU ‘cloud’ and used for reference purposes by the team.
Data analysis
In addition to capturing the video data from the VoIP technology, the audio data from the focus groups were downloaded from the ‘cloud’, and digitally transcribed. The data were cleaned and cross-checked for accuracy by RL and an early career researcher (ECR) colleague to make sure that the participants’ individual contributions were separated, anonymised, and categorised. The cleaned and cross-checked data were then analysed using recognised data analysis software (Quirkos©). Data analysis was carried out using Ritchie & Spencer’s ‘framework analysis’ [
37]. This involves the systematic processing, sifting, charting, and sorting of material of all types. It also allows the integration of existing knowledge from previous research and policy into the analysis of the data [
38].
Discussion
Worldwide, a significant amount of income for individual practices is generated by GPN activity [
24]. In the UK, as elsewhere, this is done through ‘fees-for-service’ payments. In the UK these are known as the Quality Outcomes Framework (QOF) payments. The framework provides targets for LTC surveillance and management [
39]. Consequently, GPs have preferred to recruit already-experienced nurses when there is a vacancy, rather than invest the time and money in the education and training that new GPNs will inevitably need to take up this role [
18].
There is still evidence therefore of a GPN recruitment ‘merry go round’ in the UK, in which GPNs are simply ‘poached’ from other GP practices as required. As a result, there has been little incentive for new graduate nurses to consider applying for a GPN post [
19]. It may be argued that maintaining the status quo has also suited GPs on a hegemonic, patriarchal level. Since this cohort of GPNs has consisted almost exclusively of mature women who were further into their careers and looking for a more ‘family friendly’ work environment, these already-experienced nurses would be less likely to demand promotion and a commensurate increase in salary [
40].
All the evidence internationally [
13,
21,
22,
28‐
33] shows that a continued emphasis upon the recruitment of already-experienced practice nurses has significantly hindered the appointment of new graduate nurses to general practice and as a consequence, the establishment of a career pathway for GPNs. As a consequence of the shift in emphasis from secondary to primary care, the prospects for NTGPNs have slowly begun to improve. Worldwide the need to recruit and retain NTGPNs to address the shortage has driven primary care, as a whole, to explore options for recruiting more NTGPNs [
29‐
31]. However, in spite of this, access to general practice for new graduate nurses still remains an issue [
34].
The expansion of general practice placements for student nurses [
17], together with a belated increase in focus upon primary care within the UG curriculum [
19], have been key in addressing the issue of access to general practice. The ‘world before the VTS’ was characterised by the participants in terms of a lack of exposure to primary care nursing, as students. By increasing both primary care content in the UG curriculum and general practice placement capacity, HEIs provide both student nurses and GPs with the means to make informed judgements regarding the perceived suitability of general practice for NTGPNs [
21]. Whilst the delivery of increased placement capacity has improved the numbers of NTGPNs [
24], it has not provided the numbers of primary care staff required to address the shortfall. As a number of the participants noted, GPs remained reluctant to employ NTGPNs due to the perceived need for previous experience, as outlined above.
There were a number of issues that needed to be addressed. The financial and logistical difficulties inherent in providing cover for staff undertaking training adversely affected the likelihood of the GPNs being released to study [
31,
32]. The need to address the issue of funding was crucial. By funding the programme, the GPs were reimbursed for the trainees’ time and their supervision on placement. It was clear that many previous attempts to provide GPN education had failed as a result of a lack of funding [
32]. Previous attempts at developing a formal programme of GPN education in the UK, linked to a career pathway, had always foundered over various disagreements regarding the funding of that education, amidst the vagaries of the culture in which general practice operates [
25,
26].
Evidence has shown that the ‘transition to primary care’ programmes provide a bridge between increasing access to general practice for UG students and increasing the number of GPNs in post. In Australia, the development of transition to primary care professional programmes have been reported to increase levels of confidence and competence in Australian NTGPNs, within their first year of general practice. Similarly, the VTS programme described here was also adjudged by the trainees, albeit anecdotally, to have provided them with the skills that they needed to ‘hit the ground running’ as a GPN [
32]. The desire to ‘hit the ground running’ was seen as an important aspect of this particular programme.
One of the positive aspects of the VTS programme was the protected time afforded to the trainees. This provided the trainees with the opportunity to learn and then practise key skills in a timely manner, to manage their own diaries, to reflect, and to organise clinical and peer supervision. Although ad hoc support was provided for the trainees whilst on placement, working ‘solo’ in a largely autonomous setting such as general practice raised some (valid) concerns for the younger, newly graduated participants [
41]. Adjusting to a more isolated working environment in general practice required significant, ongoing support. Inevitably, the new graduate trainees’ need for clinical supervision was greater than some of the more experienced trainees, and there was some concern that this was not always forthcoming [
42]. It may be argued that the increased need for supervision amongst some of the younger trainees was not picked up by the supervisors, who were used to supervising NTGPNs who were already very experienced, albeit in many other clinical contexts [
43].
Looking further ahead, the participants were also concerned that once the funding for the VTS finished, so would their educational opportunities and the supervisory support that went with it [
42]. Over the years there have been various attempts to produce ‘competency frameworks’ for GPNs [
33,
34,
44‐
46]. Worldwide, the use of competency frameworks to ‘map’ GPN activity has been useful in articulating the GPN skillset and setting standards. For example, supported by the Australian government, the Australian Primary Care Nurses Association (APNA) developed a framework for advancing general practice nursing [
33] from UG student to Nurse Practitioner (NP). This framework, supported by the Australian government, is an acknowledgement of the need for a career pathway. Similarly, this need was highlighted by a number of the participants, as they pondered the development of their future career [
25,
32,
44,
45]. Although the majority of participants were under the age of 30, having an identifiable career trajectory was a key concern for all of the trainees. There was a universal agreement that the culture of general practice needed to substantially change in order to facilitate this [
45,
46].
The trainees were also clear that the prevailing attitude(s) towards the provision of continuous professional development for GPNs also needed to change. Unfavourable comparisons were made by a number of the trainees between what they saw as the comprehensive, well-resourced, and properly funded career pathway provided for GP trainees and that currently on offer for GPNs [
45].
The independent ‘small business’ culture of ‘fees for service’ general practice makes the development of any GPN career pathway challenging. In the UK, the QNI paper on standards of education and practice [
47] and the HEE/Skills for Health document ‘Primary Care and General Practice Nursing Career and Core Capabilities Framework’ [
48] have similarly gone some way towards describing a putative GPN career pathway, however there is still a need to sustainably ‘operationalise’ any pathway financially at the local, regional, and national level. The NHSE GPN Fellowship programme [
45], under which umbrella the SY VTS programme operates, was seen by the trainees as an important first step towards developing a nationally funded, sustainable, GPN education and career pathway.
Limitations of the study
The study took place during the COVID-19 pandemic, which clearly had a significant impact upon the trainees’ experiences of the VTS programme. The enforced move from classroom learning to online learning and the use of VoIP technology will have affected the participants’ views of the programme per se, and the author has tried to take this into account. The small sample size, the focus upon one cohort from a single programme are all acknowledged as study limitations. In addition, the pragmatic nature of the study meant that it was not possible to use a ‘neutral’ facilitator. Although the facilitator (RL) was not part of the programme delivery team, it is acknowledged that this may be a potential source of bias.
Conclusion
Changing the workforce culture within general practice nursing was/is never going to be easy. Despite the success of the various access schemes in changing attitudes within undergraduate nursing clinical placements, the number of newly qualified nurses accessing general practice as their first post destination has remained stubbornly low. The reasons for this are multifaceted. The lack of primary care content in UG curricula remains an issue, as does the need for GPNs to need previous experience.
The need to create a sustainable workforce ‘pipeline’ for general practice, however, has never been more critical. If this is to be successful, new, younger, NTGPNs must be able to see general practice as both a suitable ‘first post’ destination and a viable career option in the longer term. Therefore, there must be clearly defined career pathways with the necessary, associated educational infrastructure to support GPNs in their professional and career development. As a successful first step towards the development of a sustainable post-qualification GPN career pathway, transition to general practice programmes such as this must be fully embedded into the infrastructure and culture of general practice, and the necessary funding to ensure their long-term future must be guaranteed.
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