Community nurses have reported feeling ‘obliged’ to take on an extended role within palliative care to cover work formerly done by GPs, but without additional pay, consultation or acknowledgement, according to a new study.
Research published in the British Journal of General Practice (BJGP) suggested that an increase in GP remote working and ‘workforce diversification’ within general practice was leaving community nurses feeling inadequately supported when it comes to end-of-life care.
The findings were based on 10 focus group interviews with 35 registered community nurses from across the UK – all of whom had provided end-of-life care for adult patients in the community in the past three months.
The study explored how two changes in primary care – including the shift towards remote working and the diversification of practice teams, by using other staff such as paramedics or physician associates – impacted the community nursing workforce.
Among study participants, researchers identified a ‘common thread’ linking concerns about the two changes, including that the relationship between community nurses and GPs had been damaged and that it was now ‘harder for nurses to get the senior clinical support they want’.
‘Without this support, nurses reported that they had felt obliged to extend their role to cover aspects of care formerly the remit of a GP, taking a lead in building the relationships with patients and their families that enabled shared decision making about complex problems,’ the study concluded.
‘Many expressed a wish for increased GP support with these difficult decisions, alongside a perception that their roles had been extended with inadequate consultation and attracted inadequate acknowledgement and remuneration.’
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How is remote working triggering role-shifting in practices?
The report highlighted an ‘overreliance’ on community nurses and stressed that the profession both wanted and needed more support from GPs when managing the needs of patients who are receiving palliative care.
Although some participants recalled getting this support from palliative care specialists, most emphasised the need for ‘GP back-up’.
Many nurses described pride and satisfaction in taking the lead in providing end-of-life-care, although others shared their resentment at having to take on responsibilities which would otherwise have been taken on by GPs and also raised concerns about the risk to their professional registration as nurses.
‘There’s an overreliance on the community nurses especially to diagnose the problem and then the GPs will just react to whatever we’re telling them without actually seeing the patient face to face,’ one nurse warned.
Many nurses shared their resentment at being asked to take on additional work without receiving pay increases to reflect any new responsibilities.
‘There’s no recognition in our pay that we’re taking on basically the duties of a GP […] we are just so autonomous and with that comes a massive responsibility […] We are putting our registration at risk quite often […] for patient care,’ one nurse added.
Some shared how their workload had increased by taking the lead in person-centred care where community nursing teams saw remote provision of care by GPs to be ‘unsatisfactory’.
The main additional roles highlighted by community nurses were verifying death and prescribing.
Respondents also described how ‘extra things keep being added on’, which participants said used to be done by GPs.
How is remote working straining nurse-GP relationships?
Respondents shared their frustration over a lack of ‘GP back up’, which many saw as essential in community palliative care provision.
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These practical difficulties were seen as worsening the interprofessional relationships between practice staff and community nursing teams.
‘We’ve lost touch with our GPs, the relationships aren’t as strong as they used to be,’ one respondent explained.
There was a large variation in participants’ accounts of their working relationships with GPs, with some nurses able to return to positive face-to-face communication after the pandemic.
Others described more strained relationships, including the struggle to speak with GP directly over the phone and regular interaction with reception teams which added an ‘unwelcome layer of gatekeeping’ to their work.
One nurse shared their ‘frustration’ at being unable to speak with a GP, and said reception teams were being told not to put community nurses in contact with GPs when they call.
‘I’m trying to explain it to you [the receptionist] who doesn’t understand, but they’ve got that pressure from the GP not to put us through to them,’ one nurse said.
‘The GPs seem more remote now and [we] seem very heavily involved, it’s totally switched round really,’ another respondent described.
Of practices who preferred community nursing teams to telephone rather than visit in person, some had set-up ‘professionals-only access’ phone lines which enabled nursing teams to bypass the patients’ line.
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However, not all practices do this, and some nurses described a feeling of ‘professional disrespect’ as even when nurses were given a priority number, they were often linked to a receptionist and not a GP directly.
Some respondents described being routinely offered a paramedic or nurse practitioner to speak with instead of a doctor when they asked for medical input.
When looking at changes to how GPs work, such as an increase in remote working, researchers suggested that policy makers should not only consider the consequences that impact primary care teams, but should also examine the effects across the ‘complex ecosystem’ which teams operate in, including with community nursing teams.
