England developing national structure for practice nurses.

A cup of coffee with a colleague in a motorway services stop was the catalyst for a 1 million [pounds sterling] project to develop a national education, pay and career structure for practice nurses in England.

Primary health care expert, Sue Cross, who gave three presentations at conference, has just been appointed as the project manager for the Department of Health's Working in Partnership General Practice Nursing Project, which has an 18-month timeframe to develop the structure. Cross, former associate director of primary care nursing in the Bedfordshire and Hertfordshire Trust, had a chance meeting in a motorway services stop with a colleague in another trust. Over the "appalling coffee", they talked of the need to develop a national career structure for practice nurses because of the real problems of recruiting and retaining practice nurses and general practitioners. "Practice nursing was still seen as a part-time job while the kids were young. It was not seen as a career and primary health care nursing was not seen as a proper profession," Cross said. And the practice nursing workforce was ageing.

From that preliminary discussion, they put together a plan and took it to national leaders in nursing and medicine, including the Royal College of Nursing, the Royal College of GPs and the Royal College of Physicians. "We developed a national policy and when the Department of Health heard about what we were doing, it offered 1 million [pounds sterling] to develop the structure nationally across England. We were just in the right place at the right time, when the money was available."

The project is now under the auspices of the department, with Cross as project manager. "We will be developing a curricula and pay structure that will cover grass roots treatment room nurses in general practice to nurse practitioners (NPs) practising at a high level. Education for practice nurses is very ad hoc. We want to develop training general practices where preregistration nurses can experience working with a GP. Increasingly hospitals are going to be just for acute care and the pre- and post-registration nursing curricula need to fit into that model."

Staffordshire University, which has a department of primary health care, will do a "rapid review of what's happening now, as we don't want to reinvent the wheel", Cross said. As the national structure is developed, there will be five regional road shows and, in September next year, a national conference. Cross is "very excited" about the project which she said was simply what "we saw needed to be done"

There are around 20,000 full-time equivalent practice nurses in England, most employed by GPs, who receive a subsidy to employ nurses, but some are employed by primary care trusts and a growing number are partners in business with GPs, receiving a percentage of practice profits.

In her opening address to conference, giving an international I perspective on education for primary health care nurses, Cross said while there were very different situations in different countries, there were commonalities, including ageing populations and ageing nursing workforces; a shrinking workforce, reducing skill mix and recruitment problems. Differences included education Levels, autonomy and service delivery.

Different education models

She presented a range of different education models from the post-basic NP programme in Botswana, where the curriculum was along the Lines of the United States model and where the development had been driven by the severe shortage of physicians; to the comprehensive NP role in rural Korea, developed in the early '80s and which was subject to ongoing changes in the scope of practice and education, driven both by politics and the needs of patients; to the situation in Pakistan where there were just ten trained specialist PHC nurses and where there were many taboos associated with girls working as nurses.

The aging population--predicted to be 690 million over the age of 65 in 2010, with 460 million of them in developing countries--migration, natural disasters, war, unemployment and technology would all have significant implications for health care.

Improving job satisfaction

In her first concurrent session, on inter-professional collaboration between doctors and nurses in primary care, Cross presented Kanter's theory on work behaviour and attitudes as a way of developing empowering workplace structures, thus enhancing job satisfaction. Canadian research had shown that nurses were attracted to workplaces where there was nurse/ doctor collaboration, autonomy and control over the practice environment.

Self-management is the key

Managing change in patients resistant to change was the title of Cross's second concurrent session. Answers to the questions of why it was difficult to change patients' behaviour and how to change that behaviour included the fact resistance was, to some extent, natural and inevitable, for both patients and health professionals. Many patients were unable to see the benefits of change leg changes to diet to manage diabetes) and others encountered cultural difficulties. The key was helping patients identify that they had a problem, identifying a patient's readiness to change and then allowing people to self-manage their conditions. "Nurses need to be careful not to make a hobby out of a person's disease," she said.

Her case study was of a 57-year-old man with diabetes who was intensively case managed for many years, with little improvement to his condition. Only when he started going to diabetes education classes and self-managing his illness with the support of his peers, did his condition begin to improve. Self management education, combined with routine care delivered by the primary health care team, gave the best results tong-term, said Cross.

"Sometimes we overwhelm patients with information, when it would be far better to drip feed information, checking whether it is really being understood. Self-management education can be delivered in a variety of ways--through classes and groups, individual counselling, videotapes, even text messaging."