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Nurses forced beyond competency levels

Delegating higher levels of responsibility to nurses in out-of-hours practice settings can increase the risk of error, it is claimed.

The warnings come after the Medical Protection Society (MPS) revealed 'catastrophic injury' claims are more likely to occur in out-of-hours practice settings.

Citing anecdotal evidence, Dr Stephanie Bown, MPS Director for Policy and Communication, said both the frequency and severity of claims appears to grow in out-of-hours care in 70% of cases during a working week.

The MPS claims this is due to the skills and experience of staff varying "greatly" out of hours when compared to normal practice.

"Risks are increased by limited patient knowledge, unfamiliar working environment, restricted access to equipment and drugs and the stress and demands of out-of-hours practice," said Dr Bown.

Financial restraints have meant there has been an increasing demand for nurses to work with GPs in out-of-hours services.

The MPS warns that delegating higher levels of responsibility to nurses can cause a pressure to work beyond their competence and thereby increase the risk of error.

It is "imperative" that nurses receive specific training "to be able to make sound clinical judgements."

"For some years, out-of-hours care has been evolving into a differentiated part of general practice, with its own risk profile," said Dr Bown.

"It is vitally important that we continue to study closely emerging risks, learn from past events and make necessary changes to improve the safety and quality of care in this specialised setting."

We asked if you think out-of-hours staff receive sufficient training. Your comments (terms and conditions apply):

"Of course not. As usual it is about saving money in clinical areas. Interesting that in Gloucestershire now a social enterprise unit (but staff consultation did not include a vote on this) the growth area is in Human Resources (25% over a couple of years) presumably to discipline staff if having received minimal support and training they are unfortunate
enough to make an error. Management pour encourager les autres!" - Penny Ballinger, Gypsy1234

"It's is the responsibility of any qualified nurse at any level to ensure that they keep up-to-date with knowledge and skills needed that affect their practice. As a professional it is their responsibility to ensure they get the required training needed" - M Davies, Northeast

"It's good that Dr Bown has raised this issue - I agree with her that 'emerging risks' need to be studied carefully so that lessons can be learned. As a nurse of over 40 yrs I undertook OOH training around 4 years ago. It was a bad experience.
Towards the end of my 3 month training I took a call from a teenager with chest pain, and also the parent. I arranged an appt in less than one hour at the local PC centre but before that time an ambulance was called - the patient died 4 days later in ICU from sepcicaemia. The patient had been seen by the GP and the Primary Care Centre that same morning as my call. I was suspended but was never given any other information. The other nurses had had just one 'clinical' meeting in the past year - an indication of the low priority given to openness in patient safety issues. A respected Professor of GP Practice, Ann McPherson (sadly deceased) has
pointed out that patients requiring urgent care should be seen by the best, not the least qualified" - Catherine Gleeson, West Yorkshire

"I note the comment is 'revealed 'catastrophic injury' claims are more likely to occur in out-of-hours practice settings'.  There is no place for a band 5 nurse in OOH, they will not have the skills nor competency to deal with the situations that arise. Experience and qualifications in first contact (MIU/GP & A&E) settings is essential and should be mandatory. Personally I think that if the title nurse practitioner was regulated as
it should be, then this would help to weed out some less
qualified/suitable candidates. The point about accessible training is valid, in the OOH service where I work, the training is a mixture of day and evening sessions to compensate for the hours worked. Please don't forget though that as a nurse we are required to ensure that we are competent in what we do at all times, as should our medical colleagues be. I would be interested in OOH statistics for medics and nurses and the comparison rate" - Ellen Nicholson, Somerset

"I work at the Out Of Hours service in Gloucestershire as a Bank Nurse Practitioner. All employees in this role  have to attend  and pass The First Contact Care Course, Independent prescribing course, regular updates for prescribing, child protection study days , mandatory study days and more. Our manager keeps a close watch that we are up to date and
fully trained. The PCT is now being taken on by a private enterprise who want to pay Bank Nurse Practitioners and some  experienced OFH community district nurses band 5 point 2 salaries- this is the equivalent of a newly qualified nurse. I have been told nurses are prepared to work for this low salary in positions of responsibility. If the new employer is prepared to employ less qualified staff at a lower rate there will be
mistakes but if they pay qualified staff the correct incentive wage there will be better qualified staff in positions in the Out of Hours. Some of us also have day jobs which we have to take leave from to attend study and update sessions. If the study sessions were also in the unsociable hours this could be a way around the problem. It is a 2 way problem requiring consideration on both sides .We have the Shared Care Record now which has improved information sharing" - Lyndall Mclean, Gloucestershire

"I have worked quite extensively in OOH and urgent care, and the relevance of the experience of the nurses who work in OOH care vary widely. Nurses who see patients, diagnose, treat and discharge should, as a basic requisite, have first contact care experience in either A&E/MIU or GP practice, with at least minor illness and injury qualifications. It has worried me over the last few years that many staff I have seen working in
these areas are not suitably qualified, but are brought in by a desperate management to cover shifts. Many cannot properly document their consultations, cannot prescribe and have no idea how to treat and discharge safely; learning 'on the job' is not an option in these scenarios. Whilst many nurses are expert in their own fields, it does not mean that they can switch without further training to become emergency
nurse practitioners or ANPs in first contact care. The use of emergency care practitioners is also not appropriate in many
cases particularly when they come from an ambulance background; I have known an ECPs dispensing drugs without real knowledge of their legal position under PGDs that have been written for nurses. It is a scary prospect for the patient to continue to employ under qualified people who must diagnose, treat and discharge patients safely" - Name and address supplied

"This article skips over the facts and does appear to demonise nurses working in this area-surely other HCPs make mistakes too-I wonder what the figures are on this?" - Kirsty Armstrong, London

"I agree to a point but then as a nurse we are required to ensure that we are competent in what we do at all times. Therefore if we identify limitations then they need to be addressed immediately by calling in reinforcements eg. doc, more senior colleague and further training. I do though have an issue with private sector employers providing nurses
with inadequate and inappropriate training which does not allow them to meet the regulations of the NMC code of conduct and forcing them to conduct assessments on an extensive range of clients with a variety of medical and psycgological problems. These companies are commercial and have a multitude of ethical issues surrounding the services they provide. These companies need to be investigated and regulated" - Rosina Jones, Wales

"There is an urgent need to ensure that the staff in out-of-hours service receive the same opportunities to improve their knowledge and skills as those staff who work during the day. There is certainly inequity regarding training or updating opportunities as much of the training occurs during
the day. Due to child care and personal circumstances, some staff are not always able to access the training provided during the day. If they access training during the day, this must impact on their available work time if they are on duty later that day. If we are to provide a 24-hour, high-quality service then some staff training should  be provided in the evenings in order to ensure equity. Another important point must be noted. Many staff work full time during the day and also provide additional cover for the out-of-hours service which is often poorly resourced. I would question the safety of this
practice. How can it be safe for some nurses to regularly work over 12 hours a day over several days provide a consistent high-quality service and be safe practitioners?" - Gina Jones, Coventry