General practices across the UK are facing a recruitment and retention crisis, with most general practice nurses aged over 45 years (Napier and Clinch, 2019). The blend of patient facing staff is rapidly changing and general practice nurse (GPN) numbers have been declining (Buchan et al 2019). It has therefore been a priority to recruit more nurses to work in general practices, but there are significant gaps in the education available to ensure that GPNs have the competencies they need to work in primary care (Queen's Nursing Institute (QNI), 2016).
Nurses applying to work in general practice come from a wide range of clinical settings, often with little or no primary care experience. The flexibility and autonomy of working in general practice is attractive to some, but this is sometimes offset by isolation and a lack of empowerment to negotiate conditions and professional development opportunities (Aston, 2018). This makes it even more important that the courses available for nurses new to general practice offer everything that nurses need to work in new ways.
There are many courses available to train those commencing roles as GPNs, but their quality, length and content varies greatly across the UK, and even within individual areas. This means that it can be difficult for nurses to access the training they need to equip them to work in general practice. It also makes it difficult for nurses, employers and those selecting and funding courses to know which course to choose.
In 2019, the seven educational institutions providing GPN programmes in London collaborated with nurses, practices, Health Education England, Capital Nurse and other stakeholders to produce Minimum Standards for GPN Education. The Standards cover 8 key areas (Box 1).
Box 1.Areas covered by the minimum standards for GPN education
- Overarching curriculum standard stating the aim and outcomes
- Common core curriculum elements (minimum consistent programme content)
- Specified essential skills and competencies
- Blend of academic and practical components
- Clear assessment processes and academic credits
- Quality monitoring procedures
- Networking and resources for continuing professional development and career progression
- Specific responsibilities for education providers, learners, employers, supervisors/assessors
We detailed the development and content of the Standards in a previous issue of Practice Nursing (Crossman and Rogers, 2020).
We tested whether it would be feasible to use these Standards to review the education available to train new GPNs in one Integrated Care System in London.
Method
Aim
There were five different courses for new GPNs available in the Integrated Care System. Three were offered by universities, one by an arms-length organisation and one by a private organisation. We tested whether it was feasible for local stakeholders to use the Minimum Standards to discuss whether the courses were fit for purpose in educating new GPNs. In the longer term, we hope that this will influence changes to the courses, leading to more consistent education and, ultimately, increased competency to provide good patient care. However, our feasibility test focused on short term outcomes such as whether it was possible to draw a wide range of stakeholders together, whether the Standards could be used to structure discussions about a course and whether stakeholders thought that the process was useful. Figure 1 shows our ‘theory of change’.
Approach
We brought together groups of stakeholders to take part in facilitated discussions about each course, comparing it against the Minimum Standards. We held two meetings about each course, plus a system-wide meeting to review and compare perceptions. Participants included 30 representatives from nursing, education providers, Training Hubs, employers, commissioners and Integrated Care Systems.
At the first meeting about each course, small groups of stakeholders used a structured form based on the Standards to ‘self-assess’ the course. We then held a larger meeting bringing together stakeholders to review commonalities and differences between courses and consider wider system-level issues. At a final small group meeting focused on an individual course, stakeholders rated the extent to which the course was compliant with the Standards on a scale from 1–10 and considered potential changes to address gaps. Education providers and commissioners then agreed on practical next steps and timeframes for change. All meetings were virtual due to COVID-19 restrictions.
We observed discussion sessions and undertook focus groups, interviews and online surveys with 97% of the programme participants (29), including 5 education providers, 5 Integrated Care System representatives and workforce leads, 4 Training Hub representatives, 4 general practice employers, 3 GPNs and 8 representatives from Capital Nurse, Health Education England and the facilitation team. We compiled the feedback using a constant comparative method and a grounded theory approach. We used the Statistical Package for the Social Sciences (IBM SPSS Statistics 28) to compile univariate statistics from an online survey undertaken with participants at the end of the feasibility test.
Results
Feasibility
It was feasible to bring together a wide range of stakeholders and use the Minimum Standards as part of a structured review process. Integrated Care System workforce leads, education providers and organisations such as Health Education England were all highly engaged and saw this as a way to improve the standardisation and value of education.
Stakeholders were overwhelmingly positive about the approach, with 100% saying that they thought it was worthwhile to use the Standards to check the content of courses and that they would use this approach in their area again (Figure 2).
Bringing together diverse stakeholders was key to success, even though this happened online. Many said that this was the first time that nurses, education providers and commissioners in an area had come together to talk about course content and general practice needs. Using a self-assessment form helped to guide the discussion, but stakeholders did not think that individually filling in a form would have the same benefits as discussing educational needs and content collaboratively.
‘We review our courses every year, but this covered much more. All the right people were in the room. We talked about the course, challenges, and how we all had a part to play. The process was feasible, enjoyable and easy to do.’
(Education provider)
Holding two structured group discussions a month or two apart helped stakeholders first familiarise themselves with the expectations and then hone-in on the extent to which a course met the Standards and practical next steps.
Short-term impacts
We plan to follow up with education providers to see whether they have made changes to their courses 1 year after the review process. However, stakeholders reported that there were many short-term benefits from using Minimum Standards including building relationships between commissioners and education providers, increasing providers' understanding of the education needed to equip nurses to work in the changing landscape of general practice and empowering Training Hubs and Integrated Care Systems to use commissioning levers to enhance education (Figure 3). Some of the organisations responsible for selecting courses said they had changed the courses they recommended as a result of using the Standards.
‘I felt energised and empowered by these discussions. It showed how much work there is to do to make training more consistent and fit for purpose, but it also showed that people might be willing to work together to sort this out. It's not a quick fix, but I am passionate about building on the links we forged here.’
(System-level planner)
Nine out of ten stakeholders believed that courses would change as a result of applying the Standards (91%). Education providers did not make changes to the courses during our short feasibility test, but four out of the five providers committed to make specific changes to their courses to bring them more in line with the Standards.
Areas for development
We identified areas for development, both in terms of the content and structure of the Standards and in the range of stakeholders engaged. In particular, general practice employers were not well represented at review meetings. Interviews suggested that employers supported the idea of using standards to improve the quality and consistency of education for GPNs, but did not prioritise taking an active role in the review process. They felt that Training Hubs and Integrated Care Systems were better placed to act on behalf of general practices as a whole, particularly as individual small businesses may not feel that they had any power to alter course content or have time to invest in this.
Discussion
Our ‘proof of concept’ test found that it was feasible to use Minimum Standards to review GPN courses collaboratively, assisted by a structured template and local facilitation. Stakeholders were in favour of using the Standards routinely to review courses, both to help improve them and to inform decisions about which courses to place nurses on.
Next steps
A next step is to consider how the Standards could be embedded as part of business as usual. Educational providers review their courses at least yearly, with learner representatives, faculty and others. It may be important to use the Standards in these meetings, as long as the right range of stakeholders were involved in the discussions.
Based on the feasibility test, we are developing a toolkit to help expand use of the Standards. This will refine the Standards into a short practical document focused on ‘high level’ principles that GPNs should learn rather than a long list of tasks. This will future-proof the Standards and account for new ways of working and emerging roles in general practice. The toolkit will also set out how to use the Standards to review courses, such as in collaborative meetings led by Integrated Care Systems or in the regular review meetings already run by educational providers, and detail how to score the extent to which a course achieves the required criteria.
We are also considering a process for deciding whether a course is compliant with the Standards, such as requiring submission of evidence from providers. The discursive process we tested would allow a provider to say that their course is compliant even if this was not the case. Educational providers that took part in our test expressed a willingness to work together to develop London-wide templates and processes to submit evidence, and this could be expanded nationally.
We also need to consider how to use the Standards to review courses run by smaller providers or those that only aim to provide a portion of the content needed to fulfil a nurse's learning needs.
Our test suggests that there is a willingness to use the Standards, but it is unlikely that systems will do so without this being expected or rewarded. Education providers were clear that unless the Standards were linked to funding opportunities or penalties, the Standards would be unlikely to drive improved education. In other words, not achieving the Standards needs to have a consequence.
At present, there are few direct financial or other consequences for education providers whose courses do not meet population and workforce needs. Health Education England (as it was called at the time of this feasibility test) stated that it was responsible for funding places in London, not determining their content or quality. Training Hubs and Integrated Care Systems may be well placed to work alongside educational providers on behalf of employers to make sure course content meets workforce and population health needs. In this ‘market demand’ approach, if systems and employers do not place nurses on substandard courses, education providers would not receive funding for those places. Providers would then need to adapt courses to in order to fill places and gain funding.
Conclusions
There are many systems-level and strategic issues that need to be addressed to continue improving education, but minimum standards are a step in the journey to improving courses for GPNs. In addition to reviewing course content, the process had intangible benefits such as making quality review processes more explicit, building relationships and encouraging systems and education providers to collaborate. However, questions remain about who should take responsibility for embedding the Standards. Integrated Care Systems and Training Hubs have a key role to play on behalf of nurses and employers to make sure that GPN education is appropriate. If commissioners do not send nurses on courses that do not meet minimum standards, then this will drive change.
KEY POINTS:
- There is significant variation in the extent to which courses support nurses new to general practice to develop the competencies they need for working in primary care
- A test in one Integrated Care System in London found that it is feasible to bring together nurses, education providers, commissioners and other stakeholders to review courses against minimum standards and highlight areas for change
- If employers and commissioners continue to send nurses on substandard courses, there is no incentive for education providers to change. Having minimum standards to compare courses against can empower Integrated Care Systems, Training Hubs and employers to chose courses that are fit for purpose