Practice nurse Louise Brady discusses how appraisal can be a valuable process for all
Practice nurses and their teams throughout the UK are working flat out to both recruit and retain. One area that is given little attention, both at practice and population level and indeed in the wider nursing literature, is the impact and benefits of an effective appraisal scheme in primary care. With the introduction of revalidation as a requirement by the Nursing and Midwifery Council in 2015, the annual appraisal needs a revival in clinical practice.Appraisal is an annual requirement for all NHS staff, but there is currently no standardised appraisal guidance or process for nurses employed by independent contractors. The Care Quality Commission illustrates:1 ‘GP practices are responsible as employers for ensuring staff are supported to deliver effective care and treatment, including through effective appraisal. Staff should have an appraisal in the last 12 months and be able to describe the impact of this.’From review of the literature, there is an understanding that there is wide variation in the range of skills and knowledge among individuals carrying out practice nurse appraisals and indeed the format the appraiser takes.
The Queen’s Nursing Institute highlighted this as an area for both concern and development in 2016.2 It was encouraging to note that the large UK survey of over 3,000 nurses revealed that 80% of practice nurses did indeed have access to an annual appraisal. However, there was a lack of engagement with any annual appraisal process for 20% of respondents. Moreover, the appraisal process did not always reflect high quality experience at practice level, which was highlighted in comments from respondents:
‘Although these are performed by the lead nurse, appraisal feels like a paper exercise that needs to be completed for QOF. There is no guidance as to performance, service gaps or requirements.’
‘Contractually, I’m supposed to have an appraisal annually, but in my experience I find I have one when it’s a QOF indicator the practice will be remunerated for. I am just preparing for the first one.’
What should a good appraisal in general practice encompass?
In Greater Manchester, we have been working with our local nurses to understand how appraisal should develop and clarify what constitutes a ‘good appraisal’ as well as how this can develop locally. For our localities, the main purpose of any appraisal is to allow the appraisee the opportunity to reflect on their work and learning in order to support and improve care.
From a personal perspective, this can be achieved through discussing individual development and feedback on job performance in a way that is constructive and motivational.
It should result in an effective personal development plan. So, lesson one is not to spend 95% of the time available purely reviewing past performance, and lesson two is to involve nurses fully in the discussion so that they can get the maximum benefit. From local learning and experience, ideally an appraisal should be:
- A piece of ‘two-way’ rather than ‘one-way’ communication.
- A continuous process rather than a one-off event.
- An enabler for continuous professional development as well as for assessing performance.
It is important to clarify that appraisals are not disciplinary processes or a disciplinary discussion. There are other, separate processes for addressing serious issues of conduct or capability, which should be followed and used appropriately. In addition, appraisal is not a discussion you ‘save things up for’. We have found anecdotally that some nurses wait all year to approach employers with concerns or ask for support. An open-door culture in general practices creates the environment that is vital to safe and effective care. Whether feedback contains praise or constructive criticism, it only has value if it is given in a timely manner. Essentially there should be no surprises in any appraisal discussion.
Who should appraise practice nurses?
The appraiser will vary depending on the individual practice. In a larger nursing team, it is likely there will be a lead nurse or nurse manager who can fulfil this role, but in many GP practices this will not be possible and nurses’ appraisals will be carried out by a GP, a practice manager or both. A GP colleague once posited that a ‘great practice manager helps clinicians to excel’. From personal experience, this is indeed the case. But it is rare for practice managers to shadow practice nurses or nurse clinicians in order to understand the depth, complexity and workload challenges faced in day-to-day practice. Clinically, educationally and from an employment perspective, nurses value and appreciate input from their GP colleagues, alongside their practice managers who are well versed in aspects of clinical appraisal and development.
Local intelligence has suggested that it is important to focus on nurses’ strengths as these can motivate the further development and application of skills. The perspective of a GP appraiser can be very useful in enhancing the quality of the appraisee’s work. This is particularly true within training practices where GP appraisers are trained to give a good balance of support and challenge. A GP employer may be able to offer helpful insights into areas of clinical practice where the appraisee has blind spots and development needs, as well as being able to acknowledge their achievements.
Whoever undertakes the appraisal process should have skilful questioning and active listening skills. From my own experience in clinical practice, this is integral to a successful and meaningful experience. So, listening on both parts requires effort combined with a real and honest desire to understand.
In recent years, peer to peer (nurse to nurse) appraisals are becoming a recognised form of reflecting on present practice and the professional development needs that are required for safe and effective service delivery. Evidence points to the positive outcomes of appraisal being given by those who have had support, training or preparation for the role, resulting in enhanced learning and constructive reflection. Using prepared appraisers for the process in practice nursing identifies learning development and gives a structured learning plan as a basis for discussion with the employer.3
Links with pay and achievement
The primary aim of an appraisal is to identify personal and professional development and educational needs, with the ultimate aim of improving clinical performance and patient care. Many nurses locally have asked for their annual meeting to include a pay performance review as part of their CPD.
Historically, this has been a bone of contention for employers who often wish to separate appraisal from discussions about pay, terms and conditions. Charles Handy wrote in the 1990s4 that it was not psychologically compatible to try to combine managerial demands, performance review (especially if linked to pay or reward assessments), feedback on performance, and helping to plan personal and job objectives in one appraisal. However, from a personal and clinical safety perspective, and given the gravity of registered nurse shortages across general practice, it is time to have these important conversations, and annual appraisal is as good an opportunity as any in a pressurised general practice setting.
Practice nurses should ideally be given an appraisal form to complete three months before the discussion due date, and can map their experiences, responsibilities and achievements in this framework. Each locality in collaboration with employers should ensure an appraisal standard. This will support integral CPD discussions and will, as standard, include pay increments aligned to current and future roles and responsibilities. Each nurse should ask what their appraisal form consists of and should keep a date for their annual appraisals and encourage employers to set aside time for the discussion.
What if you are not receiving an appraisal
You should request that the requirement to hold an annual appraisal is written into your employment contract. This way, both employee and employer can benefit from the process. As a quality standard, pay, terms and conditions, and CPD development should be integral to the annual appraisal. If you are not receiving an annual appraisal this should be addressed at practice level in the first instance. Then seek support from localities and primary care networks to ensure a quality practice standard across areas.
Benefits of appraisals for GP employers
Appraisals are an opportunity for GPs to gain insight into the contributions and examples brought by a range of nursing roles across primary care. These may include primary care nurses working both in practice and in communities in very different contexts, and may challenge the appraiser’s skills, both as a clinician and an employer. Hearing about how nursing colleagues manage a broad range of clinical, educational and interpersonal issues may further support team and practice development. These benefits can be further developed in multidisciplinary learning sets or peer groups.
Appraisal offers the opportunity for primary care networks to support the development of whole primary care teams. When we learn together, we value each other’s role significantly. Appraisal then becomes effective and meaningful rather than a burden. Taking a positive, formative approach to appraisals can help to promote the creation of a learning organisation where people feel motivated to develop and to support each other.
Louise Brady is a practice nurse and primary care and community nurse lead in Greater Manchester
1 Care Quality Commission. Nigel’s Surgery 26: practice nurses 2017. cqc.org.uk/guidance-providers/gps/nigels-surgery-26-practice-nurses
2 Queens Nursing Institute. General practice Nursing in the 21st Century, a time of opportunity 2016. qni.org.uk/wp-content/uploads/2016/09/gpn_c21_report.pdf
3 Aird R, Kennedy S, McIntosh P. Benefits of peer appraisal for general practice nurses. Practice Nursing 2016;27:140-2
4 Handy C. Age of Unreason. Harvard Business School 1990 pp57-70, 225-35