GPNs: Recruiting but not always retaining

NURSE LEADERS IN GENERAL PRACTICE

Nurses are important to general practice, and greater efforts must be made to recruit and to support new to practice nurses  particularly, says Jenny Bowen, RN and Queen’s Nurse. This article is part of the How Nurses Count series.

I have worked as a general practice nurse (GPN) for the last fifteen years, moving from a background in oncology and palliative care within the hospital and community setting.

While some of my skills were transferable, the process of transitioning into the GPN role was a huge learning curve, with very limited support initially. I have worked in a number of surgeries within my geographical area, often moving due to lack of progression or recognition of my skills.

I have recently completed a Master’s programme, undertaking modules such as non-medical prescribing, physical assessment and clinical reasoning and various chronic disease modules.

The lack of a recognised pay scale, poor terms and conditions (particularly around maternity and sick pay) and clear routes for progression often leave GPNs feeling undervalued, at risk of burnout or of leaving the role completely.

The creation of a programme to support new to practice nurses has been a personal passion. In October 2022, thanks to NHS England transformation funding, I had the opportunity to bring this vision to life as a Legacy Nurse, working collaboratively with my colleague, Helen Russell (pictured above) to make it a reality.

Project to support new to practice nurses

In recent years, the recruitment and retention of GPNs have been identified as key areas to develop (NHSE, 2023).¹ A number of factors have been identified, primarily an ageing GPN workforce (Aston, 2018),² in addition to a reduction in the numbers of nurses entering general practice which has been compounded by a growing population of patients with complex needs and comorbidities (Carrier and Newbury, 2016).³

Anderson (2024)⁴ highlighted the ‘growing imbalance’ in the age profile of the GPN workforce, which are further demonstrated in the most recent GP workforce statistics. Those aged 55 and over accounted for 35% of the GPN numbers in England with only 20% aged between 25-34.

Lewis and Kelly (2017)⁵ suggest that historically, new graduates were not deemed suitable candidates for the GPN role due to their lack of experience. Lewis (2024)⁶ suggests that this may partly be due to the small business model used by General Practice; whereby employment of an experienced GPN is more cost effective than a nurse who requires training. However, the limited ‘pool’ of experienced nurses has forced this area to be reconsidered (NHSE, 2017).⁷

GPNs are a valuable part of general practice, undertaking a range of skills including often solely managing patients with chronic disease or requiring sexual healthcare (contraceptive and menopause advice and management).

The need to build firm foundations at the start of a GPNs career has been recognised (NHSE, 2017; QNI, 2020)^7,8 and university modules to teach the fundamentals of the role developed, although Ashley et al (2018)⁹ suggests this alone is not adequate preparation for the role.

The announcement of a general practice fellowship scheme for new GPs and GPNs (NHSE, 2020)¹⁰ in the Long-Term Plan in 2019, which was restated in the February 2020 Update to the GP Contract (BMA, 2020)¹¹ allowed access to funding to enable Integrated Care Boards (ICBs) to deliver local programmes of support, learning and development.

This funding coupled with the provision of Transformation Funding in 2022 allowed a New to Practice and Preceptorship Programme to be developed within the Southwest, in an area which has 73 GP surgeries in 20 PCNs.

Components of the programme

The goal of the programme was to ensure that new GPNs were supported pastorally and professionally during their first two years in practice, but also to assist overstretched practice teams with the induction process and skill development of new nurses.   Initially, research was undertaken to review programmes that had been set up nationally and internationally before designing the local programme.

By offering 1:1 support, the new nurse could gain bespoke support and also take the pressure off the nursing team.  Previously, many practices were reluctant to employ newly qualified nurses or nurses moving from other clinical areas due to the time required to support them while gaining new clinical skills, but the New to Practice Programme has supported this process

Preceptorship was often not considered due to the lack of newly qualified staff within general practice historically and therefore offering this as part of the programme ensured that support at the start of their nursing career could be delivered.

The programme was developed to include the following key components:

• Induction and orientation to the role, the wider system and practice
• A 12-week teaching programme (2-hour sessions) to cover some of the components of the GPN role (e.g. consultation skills).
• Clinical skills development and capability assessment (in practice following core training)
• Mentorship/preceptorship (the National Nursing Preceptorship Interim Quality Mark was gained in 2023)
• Protected learning time (paid CPD time to allow consolidation of skills)
• Peer support.

The New to Practice Programme began as a two-year programme (with CPD time being funded via the national GPN fellowship scheme) until March 2024 when funding ceased, since then it has been  funded locally as a one-year programme.

An essential part of the programme was to collect information about nurses joining the programme, ascertaining how easy they found the transition to general practice, and any elements that they found challenging.

Where are we now?

To date, we have had 108 registered nurses (of these 26 newly qualified, 2 return to practice nurses) and 11 nurse associates (the programme was extended to include nurse associates from April 2024, 9 were newly qualified) on the New to Practice Programme, from 71% of the practices within BNSSG.

The feedback has been resoundingly positive with many participants stating that the programme and the support received being described as a ‘lifeline’, which had ‘eased their transition into the GPN role’. Practice and nurse managers have also found the additional support invaluable.

The teaching sessions are run every other week over a 6-month period and are on a rolling programme, allowing learners to join at any time (sessions can be attended in person, online and are also recorded). Learners are grouped into cohorts enabling them to have a peer support group that they connect with at the teaching sessions and via a WhatsApp group.

Unfortunately, 21 of participants have left prior completing the New to Practice Programme.  The reasons included relocation, workplaces issues, lack of a clear progression structure, lack of pay increase, lack of maternity and sick pay.  In fact, 71% of leavers cited the terms, conditions and pay as their reason for leaving with many returning to jobs within secondary or community care for Agenda for Change terms and conditions.

Nurses starting in GPN roles are expected to negotiate their salary, a concept that is alien to most, with others not realising that this is necessary and presuming that practices would follow Agenda for Change conditions of employment.

The data from nurses joining the New to Practice Programme revealed that:

• 57% took a drop in pay to come into primary care
• 37% negotiated their salary
• 43% were made aware of the pay structure at the practice prior to their employment
• 56% were made aware of specific terms and conditions at the practice (e.g. maternity and sick pay).

The top four reasons for becoming a GPN were given as better working hours, greater autonomy, better opportunities for career progression and being ready for a change in specialism. Almost half (49%) of nurses recruited on to the New to Practice Programme and into GPN roles were between 25-34 years of age, at the start of their careers and many keen to progress. However, as the data suggests, if dedicated ringfenced government funding to provide fair terms, condition and pay structures are not in place, nurses will leave the role or in some cases seek employment at an alternative practice with better employment conditions (6 nurses moved to an alternative practice while on the programme).

What are the takeaways and what’s needed next?

Nurses on the programme are encouraged to advocate for themselves requesting pay increases when specific skills are gained and are supported with career progression.  Through the data collected as part of the programme we have demonstrated in our local area that newly qualified nurses are being employed within general practice but, sadly, nurses are still leaving primary care.

To increase the levels of retention and decrease the burnout experienced by GPNs, it is vital that:

• We seek national legislation to address the inconsistences within pay, terms and conditions.
• We ensure that GPNs stand together to highlight the challenges they are facing and are represented on local and national decision-making boards.

The ‘How Nurses Count’ campaign can play a huge role in highlighting the importance of GPNs within general practice and also drawing attention to the inequalities in employment conditions for nurses within different sectors and between staff groups in general practice (generally it is only GPs who are afforded benefits such as maternity pay).

I have spoken to GP colleagues who are unaware that GPNs are in many cases given only entitled to statutory maternity and sick pay, the general public also assume that nurses are paid the same in every sector that they may work.

The difference in pay between GPNs within my local area is staggering, it is not surprising that they leave to seek an improvement.

To make the role sustainable, we need to be focusing on standardising pay, terms and conditions and valuing GPNs for the huge impact that they have on providing high quality patient care.

References

1. NHS England (2023) Delivery plan for recovering access to primary care [online]. Available from https://www.england.nhs.uk/long-read/delivery-plan-for-recovering-access-to-primary-care-2/
2. Aston J. (2018) The Future of Primary Care Nursing. British Journal of General Practice [online]. 68 (672): 312-313
3. Carrier J and Newbury N. (2016) Managing long-term conditions in primary and community care. British Journal of Community Nursing [online]. 21(10): 504-508.
4. Anderson M. (2024) ‘Growing imbalance’ in age profile of GPN workforce. Nursing in Practice [online]. 30 May.
5. Lewis R and Kelly S. (2017) Evaluation of the Yorkshire & the Humber Advanced Training Practice Scheme. (ATPS). Sheffield Hallam University. Report for Health Education England. HEE/NHSE WTE. Available from https://www.shu.ac.uk/research/specialisms/health-and-social-care-research/reports/an-evaluation-of-the-yh-advanced-training-practice-scheme
6. Lewis R. (2024) Developing a ‘national module’ for nurses considering a career in general practice: addressing the workforce crisis in primary care, Practice Nursing [online]. 35(4).
7. NHS England (2017) General Practice – Developing Confidence, Capability and Capacity: A Ten Point Action Plan for General Practice Nursing [online]. Available from https://www.england.nhs.uk/wp-content/uploads/2018/01/general-practice-nursing-ten-point-plan-v17.pdf
8. Queen’s Nursing Institute (2020) The QNI Standards of Education and Practice for Nurses New to General Practice Nursing [online]. Available from https://www.qni.org.uk/wp-content/uploads/2020/05/Standards-of-Education-and-Practice-for-Nurses-New-to-General-Practice-Nursing-1.pdf
9. Ashley C, Halcom E, Brown A, Peters K. (2018) Experiences of registered nurses transitioning from employment in acute care to primary health care-quantitative findings from a mixed-methods study. Journal of Clinical Nursing [online]. John Wiley & Sons, Inc, vol. 27, no. 1–2, pp. 355–362
10. NHS England (2020) General practice fellowship scheme of newly-qualified GPs and Nurses and new to practice nurses [online]. Available from https://www.england.nhs.uk/long-read/general-practice-fellowship-scheme-for-newly-qualified-gps-and-nurses-and-new-to-practice-nurses-guidance/#annex-1-fellowship-framework
11. BMA/NHSE (2020) Update to the GP contract agreement 2020/21-2023/24 [online]. Available from https://www.england.nhs.uk/wp-content/uploads/2020/03/update-to-the-gp-contract-agreement-v2-updated.pdf