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The practice nurse: generalist or specialist?

Marilyn Eveleigh
Consultant Editor

Defining the role of the practice nurse isn't always easy. When does a generalist become a recognised specialist? Marilyn Eveleigh looks at the range of competencies required by nurses working in general practice throughout the UK ...

Ask any general practice nurse (PN) and they will confirm the challenge that being a primary care generalist brings. You need a broad set of competencies to meet a wide range of patient needs. PNs require a little knowledge on a lot of things - and a lot of knowledge in key areas of practice. Just like the GPs they work with. Independent GP practices are contracted by the NHS to deliver a General Medical Services Contract, providing first contact primary care to those who are ill, think they are ill or at risk of becoming ill.

The clinical competencies and skills required to meet patient needs in a general practice setting could range from managing burns, advising on bunions and identifying bulimia to undertaking cervical cells sampling, supplying information on sexual health and contraception, supporting self-management of substance misuse and obesity as well as teaching patients with diabetic/cardiac/respiratory/gastrointestinal conditions how to manage their medication.

Circulatory disease, allergies, anaemia and depression may manifest in the same patient who may also have asthma, COPD and is in need of ear syringing and a seasonal flu vaccination! Public health protection through vaccination programmes for childhood, travel and HPV infections are almost exclusively provided by practice nurses. And IT competencies are crucial to providing evidence for the Quality and Outcomes Framework (QOF) that generates practice income.  

Then there are the competencies required to meet the emotional and social needs of patients. Knowledge on identification and legal responsibilities are required for child protection, safeguarding vulnerable adults and domestic violence disclosures. Understanding benefit entitlement, social services links and respite care options offers holistic care to the disadvantaged, to families and carers; and signposting to other specialist teams and agencies are all key to the generalist primary care role.

Generalists are flexible. PNs provide care across all age groups, to the sick and the well, in response to an acute need or a chronic condition, to all genders and abilities, at the surgery or in the home. They give proactive as well as reactive care, receive and make referrals, undertake diagnostic investigations, eg, spirometry, provide a one-off episode, or a care package depending on the patient needs. PNs undertake screening, initiate care plans and develop patient self-management plans, as well as provide regular reviews of long-term conditions. Ideally for the patient, many aspects would be addressed by one practitioner in a consultation - a one-stop shop.

It's a big job! Having this many generalist clinical competencies feels like a very special role to me. Especially as PNs work alone, behind closed doors, and often with little forewarning of what patients are consulting for.

There is no monitored blueprint for the job; every GP practice creates a practice nursing model that suits their way of working, and is at liberty to develop the competencies to match. A practice nurse in Hackney may not have the same competencies as one in Bognor or Belfast, or in rural Yorkshire.
Nurses within one practice may not share common competencies. This dilutes the identity of the professional role and diminishes the potential for patients. As a consequence, many nurses outside general practice still see working in a surgery as an easy part-time option with training given
in-house as needed.  

Though there is a national practice nursing competency framework developed by nurses and GPs in 2008,1 evidence suggests it is not widely known and is patchily used in general practices across the UK. There have been other random local initiatives by primary care trusts, strategic health authorities or higher educational institutes to set out clearly the role and competencies of a PN, identifying what training GP employers should support and specifying what the public can expect when accessing a PN. Such guidance has been used as a basis for allocating training funds, identifying career progression from novice to expert and offering objective nurse remuneration. Although not universally adopted, they have formally identified a minimum skill set and highlighted the special talents of the practice nursing role.

Should the public have a clear and dependable expectation of the general practice nurse role - as they have of a general medical practitioner? Should commissioners of primary care services require core competencies in nurses employed by independent GP contractors? Would clarity on PN competencies be welcomed by all PNs? Might they encourage GP employers to release nurses for training? 

In my experience, unless we address these points, and PNs, GP employers and nurse leaders embrace a common understanding with agreed and implemented competencies for the role, practice nursing will never achieve the specialist status it deserves. Inequalities will remain for patients receiving care from the practice nursing workforce.

1. Royal College of Nursing (RCN). Available from: practice nursing career framework

Your comments (terms and conditions apply):

"I agree that the guidance produced by WIPP and now held by the RCN should be used more widely in both recruitment of practice nurses and ANPs in general practice. There is no real driver for GPs to use the competencies outlined, especially as the majority of practices are not signed up to using agenda for change or the KSF. I am not advocating the use of agenda
for change in general practice but do feel there should be some pressure on GPs to look at existing and development of competence in the nurses they employ. There is still a culture of 'see one do one teach one' in some practices. There are a reducing number of experienced PNs resulting in newly qualified and hospital nurses being attracted to what they
perceive is an easy job. It is only when they find themselves in post and are not able to deal with the problems the patients present with do they realise that it is a difficult job. The lack of training and often the reluctance of GPs to fund appropriate training opportunities stifles the nurses progression and results in a stressful worker and patients not getting the care they deserve" - Michelle Davidson, Somerset