Training and education in practice nursing: the perspectives of the practice nurse, employing general practitioner and Family Health Service Authority

The roles of physician associates and advanced nurse practitioners in the National Health Service in the UK: a scoping review and narrative synthesis

BACKGROUND

Mid-level practitioners (MLPs), including physician associates (PAs) and advanced nurse practitioners (ANPs), have emerged to address workforce shortages in the UK and perform specific roles in relation to population needs. This has resulted in new ways of working and changes to established professional hierarchies. We conducted a study to investigate the career development, competencies, effectiveness, perceptions, and regulation of PAs and ANPs, with the aim of understanding ways to effectively integrate MLPs into the NHS workforce.

METHODS

We conducted a systematic scoping review following PRISMA guidelines. Embase, Medline, the Cochrane database, Pubmed, and CINAHL databases were searched, using terms relating to PAs and ANPs in the UK. A total of 128 studies (60 on PAs and 68 on ANPs) were included in the final analysis. A narrative synthesis, guided by the pre-defined themes and emerging themes, was conducted to bring together the findings.

RESULTS

PAs are educated on a medical model with basic medical skills but lack formal professional regulation and do not have prescribing rights. ANPs are educated on a nurse model with enhanced skills that depend on roles within specific specialities, and their governance is mostly employer-led. PAs are primarily employed in secondary care. ANPs are employed widely in both primary and secondary care. No defined career progression exists for PAs. In contrast, becoming an ANP is a form of career progression within nursing. Both roles were regarded as cost-effective in comparison to doctors performing simple tasks. PAs were less understood compared to ANPs and received a mixed reception from colleagues, which sometimes undermined their professional identity, whereas ANPs were mostly welcomed by colleagues.

CONCLUSIONS

Potential ways to better integrate PAs and ANPs into the NHS workforce include further initiatives by regulatory bodies and the NHS to create more awareness and clearer role definitions for MLPs, outline potential for career progression, offer transparency with regard to remuneration, and introduction of prescribing rights. Future research might include more cadres of MLPs and explore the international literature.

Practice nurses and computing: some evidence on utilization, training, and attitudes to computer use

Seventy-seven practice nurses in the Portsmouth and Worcestershire areas were surveyed by postal questionnaire about their experience with, and attitudes to, using computers in general practice nursing. Almost all (98%) of the respondents worked in a computerized general practice and all reported having a positive attitude towards the clinical and administrative use of computers. Some 84% of practice nurses had a computer terminal where they saw patients and over 70% used the computer to gain access to clinical information. However, over three-quarters (79%) of respondents felt that their training on computers was either missing or inadequate. Some 74% of the nurses surveyed who were in post when the computers were introduced to their practice were either hardly consulted prior to installation, or not at all. Despite positive feelings about computerization, practice nurses appear to be getting insufficient or inadequate training and support to fully utilize the technology.

General practice nursing education in Australia

The quality of care delivered by nurses working in Australian general practices rests on a strong foundation of nursing educatlon and training. A national study of nurses working in general practice was conducted using qualitative and quantitative research techniques to explore their role and educational needs. Results from this research suggest that education for general practice nurses is seen by nurses and General Practitioners to be largely non-formal in nature and is seen by GPs and nurses to be tailored towards general practice nursing needs. Such education is often available locally through general practice support organisations; is strongly focused on National Health Priority Areas and clinical care; and is more appropriate for registered rather than enrolled nurses. The educational opportunities currently available to support nursing in general practice are largely ad hoc and vary in relation to quality, appropriateness and accessibility. Nurses working in general practices in Australia need a system of ongoing training and education to support their responsibilities and foster the development of the position as a viable career option for nurses.

Australian nurses in general practice based heart failure management: implications for innovative collaborative practice

BACKGROUND

The growing global burden of heart failure (HF) necessitates the investigation of alternative methods of providing co-ordinated, integrated and client-focused primary care. Currently, the models of nurse-coordinated care demonstrated to be effective in randomized controlled trials are only available to a relative minority of clients and their families with HF. This current gap in service provision could prove fertile ground for the expansion of practice nursing [The Nurse in Family Practice: Practice Nurses and Nurse Practitioners in primary health care. 1988, Scutari Press, London: Impact of rural living on the experience of chronic illness. Australian Journal of Rural Health, 2001. 9: 235-240].

AIM

This paper aims to review the published literature describing the current and potential role of the practice nurse in HF management in Australia.

METHODS

Searches of electronic databases, the reference lists of published materials and the internet were conducted using key words including 'Australia', 'practice nurse', 'office nurse', 'nurs*', 'heart failure', 'cardiac' and 'chronic illness'. Inclusion criteria for this review were English language literature; nursing interventions for heart failure (HF) and the role of practice nurses in primary care.

RESULTS

There is currently a paucity of data evaluating the potential role for practice nurses in a reconfigured, collaborative health care system. Those studies that were identified were, largely, of a descriptive nature. In addition to identifying the practice nurse as a largely unexplored resource, key themes that emerged from the review include: (1) current general practice services face significant barriers to the implementation of evidence-based HF practice; (2) there is considerable variation in the practice nurse role between general practices; (3) there are significant barriers to the expansion of the practice nurse role; (4) multidisciplinary interventions can effectively deliver secondary prevention strategies; (5) practice nurses can potentially facilitate these multidisciplinary interventions; and (6) practice nurses are favorably perceived by consumers although there is some confusion about the nature of their role.

CONCLUSION

On the basis of this literature review, practice nurses represent a potentially useful adjunct to current models of service provision in HF management. Further research needs to comprehensively investigate the role of the practice nurse in the Australian context with a view to developing effective and sustainable frameworks for clinical practice. In particular, high-level evidence is required to evaluate the efficacy of the practice nurse role compared to current disease management strategies.

What we can learn from the British maternal child health system

Infants born in Great Britain have a better chance of living until their first birthdays than do infants born in the United States. Although Great Britain spends less than half what the United States spends on healthcare, its estimated infant mortality rate was 5.5 as compared to 6.8 in the United States in 2001 (Central Intelligence Agency [CIA], 2001). What is different about healthcare in Great Britain? This article details some of the differences, suggesting that there are ways the United States can improve its infant mortality rates.

Continuing professional education and the selection of candidates: the case for a tripartite model

This paper argues the case for a tripartite model involving the manager educator and practitioner in the selection of candidates to programmes of continuing professional education (CPE). Nurse educators are said to play a key link in the education practice chain (Pendleton & Myles 1991), yet with the introduction of a market philosophy for education, the educator appears to have little, if any, influence over the selection of CPE candidates. Empirical studies on the value of an effective system for identifying the educational needs of the individual and the locality are unequivocal in specifying the benefits of a collaborative selection process (Larcombe & Maggs 1991). However, there are few studies that offer a model of collaboration and fewer still on how to operationalize such a model. This paper presents the policy and legislative context of CPE leading to the development of a market philosophy. The tension between educational reforms such as life-long learning and diminishing and finite resources are highlighted. These strategic issues provide the backdrop and rationale for considering the process for identifying CPE needs, and the characteristics of an effective system as suggested in the literature. Finally, this paper outlines recommendations for a partnership between the manager practitioner and educationalist in the selection of CPE candidates.

Nursing's contribution to general practice: general practitioners' and practice nurses' views

This study was instigated by the paucity of knowledge relating to the work of nurses employed by general practitioners in Australia and the phenomenal development of the practice nurse role in the United Kingdom. A mailed survey of general practitioners and practice nurses within one Division of General Practice in South-East Queensland, sought, among other things, their views about the current and potential contribution of nursing to general practice. Eighty-four out of 164 (51%) general practitioners and 37 out of 67 (55%) practice nurses responded to the survey. Results indicated that both general practitioners and practice nurses appreciated the value of nursing services in general practice and would sanction the employment of more nurses especially for the purpose of preventive care. The majority of nurses were agreeable to the notion that the nurse's role could, and should, be expanded to include autonomous functioning while most of the doctors were amenable to some extension of nursing practice but reticent or opposed to any independent interventions.