Historically, nurses entering general practice have undertaken their formative careers as a registered nurse working in secondary care. Increasingly however demand for GPNs is outstripping this traditional route of supply, thus alternative options for attracting nurses to general practice have had to be considered. This paper describes one such initiative, the hosting of student nurses undertaking a pre-registration adult nursing programme within primary care, their placement pattern re-orientated to take account of the multiplicity of learning opportunities that primary care offers.
Background
In 2014, the publication of the Five Year Forward View (NHSE 2014) presented a significant policy shift; the main point of delivery for patient’ care and services moved from secondary to community and primary care. While there was agreement on the principle of the policy, it was recognised then, that to meet this changing and future demand, additional resources would be needed (Lewis & Kelly 2017). However workforce shortages in primary care persist, with a best case scenario of a shortfall of around 8,800 FTE GPs in 2030/31 and 6,400 FTE nurses (Health Foundation 2022). Increasing both GP and primary care nursing roles has therefore been recognised as a priority within the NHS Long Term Workforce plan (NHSE 2023).
The general practice nursing (GPN) workforce is an ageing one. In 2015 general practice nurses aged over 55 represented 27% of the workforce, by 2023 this had increased to a third (NHS Digital 2024). In a survey conducted by the QNI (2016) two thirds of practice nurses expressed that they were likely to retire within the next ten years.
An ageing workforce is not the only contributor to the GPN workforce shortages. The business model of primary care means that, unlike their peers in secondary care, GPNs are employed by individual GP practices, at a ‘cost’ to the business (Lewis & Kelly 2017). GPNs are therefore outside of the NHS pay framework (Agenda for Change), with variations in employment terms and conditions apparent. This has caused considerable dissatisfaction (Crossman, Pfeil and Moore 2015, QNI 2016; QNI 2016; Ashwood, Macrae and Marsden 2017; Lewis & Kelly 2017), potentially disincentivising nurses, including younger newly qualified nurses, from joining primary care (Lewis and Kelly 2017).
There is however evidence of considerable churn within primary care, suggesting that GPNs are moving around practices rather than leaving primary care. The QNI's (2016) survey of GPNs while drawing attention to challenges impacting GPN retention, also highlighted the benefits of working in primary care including, caring for people in their home environment, patient’ satisfaction, more sociable/family friendly hours with no on call, nights or weekend working; better continuity of care especially for patients with long term conditions, and working with patients to avoid admissions.
Raising awareness of the benefits of working in primary care is essential to encourage nurses to enter the workforce. One way in which this can be achieved is exposing student nurses to primary care nursing through placements.
Student nurse placements in primary care
Currently nursing students across the UK undertake 2300 hours of practice-based learning across a range of placements. Student nurses studying adult nursing undertake placements primarily in secondary and community care settings. However over the past decade numbers undertaking nursing courses have risen, whilst simultaneously the number of ‘traditional’ hospital-based placements has decreased due to the shift from secondary to community and primary care service delivery. As a consequence significant challenges around placement capacity have emerged. A response to this challenge has been a shift to community and primary care placement for adult nursing students (Gale et al 2016).
Primary care placements are difficult to source, largely due to funding. All learning environments placing pre-registration medical, nursing, midwifery and allied health profession (AHP) students receive a placement tariff. There is however significant discrepancy in the amount of tariff paid for medical students when compared with nursing, midwifery and AHP students. The business model in which primary care operates has meant that the low level of tariff for nursing students is a disincentive to GP partners, who are also reluctant to sanction GPNs to make time for student supervision and assessment as this results in fewer patient consultations with its attendant impact on patient care and [GP] practice income. The historic dearth of nursing students in primary care has also resulted in lack of suitably qualified practice assessors and supervisors impacting on learner numbers.
The establishment of primary care training hubs, and in 2022 ICS aligned workforce development hubs, has raised the profile of clinical placements in primary care. One of the core functions of the hubs, supported by Health Education England (now NHSE WFT), is the development and expansion of capacity of high-quality learning placements at undergraduate and postgraduate levels (HEE 2016).
The increased emphasis on placement capacity in primary care has perhaps influenced GPs attitudes towards hosting student nurses. For example, Lewis and Kelly's (2018 a & b) found that GP's recognised the need for change including, the culture of general practice, the need for succession planning, and the poaching of experienced staff from other practices. To achieve this it was recognised that practices needed to ‘grow their own’ and invest in the GPN workforce.
Lewis and Kelly report on the Advanced Training Practice Scheme In Yorkshire and Humber where student nurse numbers were commissioned by HEE. Preliminary results from the scheme have indicated that GPs now have a better understanding of nurse education and student nurses, and are beginning to recruit newly qualified graduate nurses (Lewis and Kelly 2017, 2018 a & b).
Heath, Wilcox and Leonelli (2021) report on a Capital Nurse funded initiative in South East London. A hub and spoke placement pilot to support student nurses across two primary care networks (PCNs) was implemented. The outcomes were extremely positive, the student nurses benefitting from learning about different patterns of work, differing methods of delivering care and exploring the varied work of GPNs. Importantly for recruiting graduate nurses, the students in this pilot felt welcomed by the participating GP practices.
Williamson et al (2023) evaluated the implementation of Collaborative Learning In Practice (CLIP), and its implications for placement learning and patient access in primary care. Peer Support, Interprofessional Learning and the Importance of ‘own clinics’ for students to see patients were found to be important to both students and staff. The audit data indicated that having students leading their own clinics increased the clinic numbers available by approximately 20% compared to when students were not in placement.
There is therefore emerging evidence that attitudes towards student nurse placements in primary care are changing, students nurses becoming a welcome member of practice teams and making a valuable contribution in increasing patient access.
Primary care as hosts for pre-registration nursing students
Placement for students nurses in GP practices do exist, these placements being ad-hoc, founded on good will, and existing networks. They are not though generally the norm. Commonly student nurses are hosted by a NHS Trust in secondary care, where students undertake the majority of placements. The Trust then actively recruits ‘their’ students as newly qualified nurses (NQNs) on completion, by which point the student is familiarised with the Trust polices, practices, geography and culture. Within this mode, primary care has been used as a placement, mainly as an elective placement, or as part of a spoke placement, the hub placement being district nursing. It has not been convention for primary care to host students nurses. Consequently while allocating resource to supporting student nurses, GP practices are unlikely to realise a return on this investment as in the first instance students take up employment in their host Trust. To support opportunities to recruit NQNs directly into general practice, South East London Workforce Development Hub (SELWDH), in partnership with a local HEI (University of Greenwich), implemented a model for hosting adult nursing students across Primary Care Networks in SE London.
Flipping the placement pattern
The premise of the GP hosting model was to ‘flip’ the placement pattern so that 75% of placement hours occur in primary and community care and 25% in secondary care. The students are allocated to a GP practice within a PCN. The first placement occurs in this practice, the practice the student's hub placement (Heath, Wilcox and Leonelli 2021). Throughout their first year students undertake spoke placements across the PCN and its networks. These placements enable the students to familiarise and orientate themselves to the geography of their patients' locality. During year two students rotate out to placements in secondary care to gain experience on medical and surgical wards. These placements allow the students to achieve specific NMC proficiencies pertinent to surgical care and aspects of medicines management. Students hosted by primary care complete their final extended ‘management’ placement in their hosting practice, with a view to a seamless transition to newly qualified general practice nurse.
Support offered to PCNs/practices
To engage and support practices, SELWDH provided placement support from an experienced practice nurse who worked peripatetically across South East London. The nurse lead undertook the following activities:
Project outcomes
To date 24 student nurses have been hosted by Primary Care Networks (PCNs) across South East London, with high levels of retention (92%) evident (See Table 1).
Data and feedback obtained through placement evaluation confirm that being hosted by a PCN has allowed the students to:
Students reported that the practice teams were welcoming. The one to one relationship they form and maintain with their Practice Assessor and Practice Supervisor enabled them to assimilate into the practice team quickly, with an accompanying sense of belonging. Supervisors and assessors provided students with constructive feedback on their overall performance, allowing them to reflect and modify behaviours and practices to better meet patients' needs. A typical example of student feedback is as follows:
‘My practice assessor and supervisor showed such enthusiasm for general practice nursing such that it became infectious. I enjoyed the opportunity GP nursing provides to enable a viable career progression’.
Students were asked to rank on a continuum of 1-10 whether or not placements in general practice met their learning needs; 89% of the students ranked this response at the highest level (10). Likewise 89% reported feeling supported by the practice and the team and the same percentage would recommend general practice placement to their peers. Importantly placement evaluation reveals that all students hosted in primary care to date would consider a career as a practice nurse on qualifying.
Moving forward
The acquisition of transferable skills was reported by students and observed by practice supervisors and assessor in secondary care. However achieving some of the more fundamental proficiencies in the first year, i.e. meeting the hygiene and nutritional needs of patients, was at times a challenge. The feasibility of offering an acute secondary care placement in year one is therefore being explored.
As students begin to emerge as NQNs in general practice, developing their knowledge and clinical skills as a GPN is an imperative. Strong preceptorship will be a core element of the newly qualified GPN strategy. A structured rolling programme of development has been established by the nursing directorate within SELWDH, allowing the NQN to move from newly qualified [novice] GPN to [expert] advanced clinical practitioner.
Conclusion
The aim of the project was to increase exposure of GPs and their practice staff to student nurses, through a ‘hosting model.’ The intended outcome of the project is to recruit and retain hosted nursing students within a PCN/GP Practice, with the longer term goal of GPN expansion in South East London. Preliminary retention data and feedback from students indicates these goals can be met. To date students are highly satisfied with their experience and see their future career being located in Primary care. They are excited about the next steps of their career and the opportunities for career progression that general practice nursing provides. The Practices/PCNs are beginning to reap the reward of the resource invested (GPN times for supervision and assessment) as they begin to ‘grow their own’ nursing workforce.
A key learning point has been the contribution of the placement lead, facilitated through South East London Workforce Development Hub. The support and encouragement offered to practices unused to hosting student nurses through the placement lead role has been a key factor in the success of the project.