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A day in the life of ... a nurse practitioner in a nurse-led PMS

My day starts at 6.30am, when my husband brings me a cup of tea in bed. I pretend it is a luxury, but it is really a prompt to get my children up for school while he walks the dogs. At 7.40am I rush out the door.

I am the first to arrive at the practice at 8am. As I fumble for keys I am acutely aware of the threat of mugging and I ensure that I lock the door behind me. Tuesday is my long day and already it is not looking great. Today's staff will comprise myself, a student nurse practitioner (NP), a practice nurse (we are one NP short as they are attending a study day) and, as our fulltime GP has a day off, he will be replaced by two locum GPs who will be unfamiliar with the practice routine and probably unfamiliar with the role of the nurse practitioner. We serve a population of around 5,000 and have one fulltime GP, which is inadequate for the needs of the patients and staff.

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The surgery doors are opened promptly at 8.30am. Patients often turn up early hoping to be seen without an appointment, and we try to see them where we can. As I view the queue, I brace myself for the long day ahead.

Initially this practice was developed to cater for asylum seekers, refugees and people with no fixed address. However, three years ago we inherited a "traditional" population from a retiring GP and this had a huge impact on our service development and provision. We have a high proportion of consultations using interpreting services. The area has a high social and economic deprivation, so we have high levels of repeat consultations because of social issues, and these social issues impact on health and the perception of health.

Due to the high consultation rates and complex needs of the practice population, we frequently run over time. My first appointment is for 8.45 but she is here just after 8.30, so I decide to see her early. She is looking for a repeat contraception prescription. I have a 30-minute slot, which gives us time to discuss issues such as smoking and family history. I record baseline observations. She remarks that she is unhappy with her weight and we discuss the options.

Because our computer system is relatively new, quite a bit of data is missing, so I ask about the date of her last smear, which she thinks was over three years ago. We determine she is midcycle and I offer the test at this visit. She agrees and we proceed. This will make me run over our allotted time, but we try to avoid people having to make repeat appointments where we can. Unfortunately by 9.10am we still have no sign of a doctor to sign the prescription, and she cannot wait any longer. I offer to take it across to the chemist later once it has been signed, where she can collect it at a convenient time.

My next patient has a cough, which, despite his taking various OTC remedies, has continued for more than three days. I begin by taking a history - when the symptoms began, how they first presented, whether they have changed in any way, is there anyone else in his circle of friends and family with the same symptoms. He tells me he is the only one, and as he has no significant past medical or surgical history or trauma, I am unable to identify a positive link. All the time I am gathering my information I am formulating differential diagnoses and eliminating them as new information comes to light.

His other symptoms include a dull frontal headache and stuffy nose. He has no temperature but I notice he looks tired and assume he is not sleeping too well, which he confirms. I examine his eyes - mucous membranes are pink, sclerae are normal. He works as a computer operator and had his eyes checked about a year ago and was issued with new-prescription glasses. I gently press on his sinuses and ask him to lean forward. He complains of discomfort. I palpate and find no head and neck nodes, his ear exam is normal, and so too is his buccal cavity. However, when I inspect the nose, I find the inferior turbinates are red and swollen. I suspect that this is the cause of his cough, but I continue to inspect, palpate and auscultate the chest, which is clear. I explain that I suspect the cause of his cough is from a postnasal drip caused by allergic rhinitis. I recommend a prescription and demonstrate how to administer the nasal drops. I explain that once the nose begins to settle, so too will the sinus discomfort. In the meantime he may continue with simple analgesia for the headaches. I make an appointment to review him at the end of the week and then go in search of the GP to discuss the prescription and to get it signed.

By 9.30am it is clear that one of the locum GPs is not going to turn up, leaving one locum GP, a practice nurse and myself.  I absorb some of the absent locum's list, with the rest going to the locum who is here. Unfortunately using locum cover means they can and do dictate the amount and type of work they will carry out. This isn't as bad as it seems because some of my clinic appointments are kept free to enable patients to "book on the day" or arrive as emergencies. One of our early initiatives was to allocate 15 minutes to all appointments, to enable the practitioner to catch up on outstanding monitoring and make referrals while the patient is present.
 
Our student NP is doing home visits this morning - he is a qualified district nurse, so we try to combine the skills of a district nurse with those of an NP. We do more visits than other surgeries in the area, with a view to identifying problems that if left may result in home visit requests. By doing so we have cut home visit requests by half.

By 10.30am I am 20 minutes behind. The young woman I saw first was given a 15-minute appointment. However, I needed to spend time with her as she is having some vaginal problems, and has a history of risky behaviour. If I did not complete the necessary examination and counselling she may not have come back - her notes indicate sporadic attendance and poor compliance. She appreciated the extra time I took, but the patients in the waiting room do not. I work through my 15-minute coffee break and manage to make up some ground.

At 11.30am the receptionist asks if I can see an extra patient, a 30-year-old woman who has just been mugged outside the surgery. As she was trying to put her purse away, her bag was wrenched off her shoulder. Apart from shock, she complains of general ache and pain in her shoulder. She has no significant past medical history and is taking no current medications other than an oral contraceptive. She describes her health as good. She is able to move the limb in all directions, both passively and actively, colour is good to the fingers, as is sensitivity to touch. The limb exam proves normal. She requires analgesia, and I explain how she may develop ­stiffness over the next 24 hours. I give her a sheet of exercises for her shoulder and, as she is not registered with our practice, advise her to seek further advice from her own GP.

Our trainee NP arrives and is immediately asked to start a clinic, which removes some of the pressure. By 1.15pm the waiting room is quiet. The doors are closed between 1pm and 2pm for lunch. The practice manager hands me a basket full of repeat medication requests, which I wade through while eating my sandwich.

Between 2pm and 4pm I catch up on ordering, make phone calls, chase results and write letters inviting people for their health and medication reviews. We also use this time to attend primary healthcare meetings, catch up with clinical supervision, prepare lectures and have informal clinical meetings where we discuss particular difficulties, interesting patient presentations, home visit outcomes and so on.

Before long my first patient for the evening is waiting. The evening clinics tend to be quite different from the morning ones. I see children who need their asthma reviewed, travellers requesting immunisations and advice, and workers who have developed symptoms during the day. All is fine until 5.45pm. There is a patient requiring a methadone prescription and the locum has refused to see him. This is not a new problem. The doctor who did not show was to see him and it is unfortunate that this appointment was not picked up earlier. Unfortunately it is late in the day, but I eventually find a doctor who will see him. The receptionist writes directions and the young man is happy with this. However, there have been times when such patients are not happy and have caused a scene.

My last patient leaves by 6.50pm, and by the time I have returned my patient notes to the filing room and cleared my room for the next day it is just after 7pm. We make a point of all leaving together for personal safety.

I head home for tea and to see my children and husband. After supper the kids go to bed and I begin on my own homework for the MSc I am doing! It has taken a lot of further study to achieve the level of skill required to be an NP, but it is the best job I have ever had, even if it is frustrating at times.