Practice Nurse workforce numbers: are we heading towards a problem?

: The number of practice nurses with the United Kingdom is significantly lower than those working as nurses on a ward. Despite many experienced nurses opting to work a practice nurses, the number of newly qualified nurses favouring to work in General Practice and practice nursing as their first post is low. Newly qualified nurses, instead, prefer to gain experience in secondary care first with many not realising, practice nurses do not need to have worked within secondary care prior. Pressures such as increasing workload and ageing workforce will only depleted the number of practice nurses in post already, therefore the need to increase practice nurse numbers is essential.


Introduction
Despite practice nursing being a favoured career choice for many experienced nurses, newly qualified nurses still appear reluctant to enter the primary care workforce. General Practice within the United Kingdom has seen an increase in patient demand with an estimated 340 million consultations occurring annually which will continue to increase (Mueller, 2020). In addition to the growing demand for consultations from GP's there is also an increase workload for general practice nurses. Due to an ageing population, there has been a substantial increase in the number of complex long-term conditions, with the management of these conditions often falling within the remit of practice nurses (Carrier & Newbury, 2016). It is imperative that as these numbers continue to rise, nurses are encouraged to consider practice nurse roles as a primary career choice after qualifying (Imison et al)., 2016).

Nurse numbers in Primary Care
Despite the need for practice nurses, the number of nurses working within primary care remain significantly lower in comparison to secondary care as shown in figure 1. It is worth noting that NHS Digital (2018) includes Health Visitor (HV) numbers within their total of NHS Hospital Workers. Although HV's work within the community, they are not employed by General Practices and are often employed by NHS Trusts or Local Authorities and are linked to the Secondary Care workforce numbers.
'The Five Year Forward View' described a substantial move for health care services into primary care and because of this, the opportunity for nurses working in general practice has never been greater as they have the capability and opportunity to make a major contribution to the transformation agenda (NHS, 2014;QNI 2015). Following this, 'The General Practice Nursing Workforce Development Plan' was introduced which supported and highlighted the need to keep practice nursing at the core (Health Education England, HEE, 2017). Despite this scheme and the opportunities, the total number of practice nurses is considerably lower than 2015 (NHS, Digital 2019). Figure 2, highlights that in March 2016 the number of practice nurses employed was the highest. However, since this peak, the chart shows a decline over two years before an increase in July 2018, but this was not a significant increase. Since then, the number has continued to rise and fall with 778 fewer practice nurses in November 2019 compared to the 2016 peak. Such statistics are concerning as the demand on primary care continues to increase and does not appear to match the intention of  There is a known gap between capacity and demand, which can be caused by the aging workforce in primary care, a shortage of newly qualified nurses and an increase in the workload of a practice nursing staff. In 2015, a survey conducted by the QNI highlighted that by 2020 33% of existing practice nurses are due to retire, which HEE (2017) indicated is approximately 8000. While this number seems significant, the greater concern is that 43.1% of respondents expressed concern that their teams did not have properly qualified and trained staff to meet nursing requirements.

Practice nurse myths
There are several falsehoods that surround newly qualified nurses being unable to work in primary care at the start of their career (Gilroy, 2020). Regards to searching and applying for jobs once qualified, student nurses are often told by other qualified nurses that they need to work in secondary care first to gain experience and should only consider a career as a practice nurse when they are wanting their career to slow down. This fits with student nurses perception of practice nursing, in which they believe practice nursing is of a somewhat a slower paced career, which essentially will deskill them (Cunliffe 2019

Ageing workforce
To help manage the workload transition from secondary to primary emphasis on encouraging newly qualified nurses to choose to work within primary care is a priority (Mitchell, 2009). As well as the reduced number of nurses opting to work in primary care compared to secondary care, the current primary care workforce is that of an ageing workforce (Launder, 2019). Data released by NHS Digital (2019)   However, this is not new, this trend has been clear since 2015 and is shown in Figure 5.
There is a clear trend in the age range of 45 to 55 in the age range, with people over the age of 60 steadily starting to increase again, although these are not significant increases. There is a likelihood that a disparity between knowledge, training and experience could arise. The education and experience of nurses not required to complete a degree during their training may be too different from those more recently qualified nurses. This has the potential to Age of Practice Nurses create a knowledge vacuum in terms of age and experience which can lead to additional gaps (Nelsey and Brownie, 2012).

Practice Nurse student placements
The ability to encourage newly qualified nurses into primary care has not been efficient enough in recent years and still less than one third of GP employers provide student nurse placements (HEE, 2017; The NHS Workforce Review Team 2018). Given the lack of primary care placements available, for many student nurses they do not have the opportunity to experience primary care. As a result of this they can lack an understanding of the role of the practice nurse and this may influence their decision to favour working in secondary care upon qualifying (Ashwood et al., 2018).

Newly qualified vs experienced practice nurses
Despite the need to increase the number of nurses working in primary care, General Practices generally prefer to hire trained and experienced practice nurses, as this reduces the need for time intensive training and enables them to have their own workload quicker (Lewis and Kelly 2018). As mentioned earlier, the practice nurse workforce is already recognised as aging and the continued desire to favour experienced practice nurses over newly qualified will continue to lead to reductions in numbers, especially when those in post reach retirement age in coming years. Now is the time to look forward to the future and to ensure once these nurses retire there is a competent workforce ready to take on the role who have benefited from their knowledge, skills and experience (Imison, 2016).

Encouraging newly qualified nurses to stay in primary care
To encourage newly qualified nurses into primary care, emphasis needs to be placed on providing effective support and development opportunities from the outset, including a mentoring programme. This support and guidance are essential for the transition phase from student to qualified nurse and is designed to improve the skills and confidence level. With the need to keep primary care nurses offering high quality and well-defined advice and can ensure a better start to a nurse's career, which in turn means they are more likely to stay in the profession (Muir et al. 2013). Since there is currently no standard mentoring/supervision program for those who work in primary care, the experience varied greatly with some practice nurses offered structured courses, and some offered a week of induction before working independently. This itself raises concerns. Is it possible within a week to acquire new skills and to become competent in them? There remains also a question of whether the quality of patient care could be compromised.
An autonomous practice nurse can be stressful and hard to adjust to after three years of being a student working directly as part of a team. Despite being part of a team, practice nurses see patients independently, they do not have the opportunities to work alongside colleagues in the same room/environment compared to staff nurses working on the ward. It can feel isolating at times, which is why preceptorship, support and guidance are essential for practice nurses, otherwise there is a strong possibility that nurses will stop practicing as nurses when they are not feeling supported (Edwards et al. 2015).

Conclusion
Practice nursing is a valued career in nursing and provides great opportunities for those wishing to pursue a career in primary care. Newly qualified nurses are able to opt to work in primary care without the need to experience ward work first, and the role will not deskill them. Instead, the role will encourage them to become a skilful autonomous practitioner with a lot of additional skills. Nurses who choose to work as practice nurses in an earlier phase of their professional life will help bridge the vacuum of knowledge that may exist and could turn the tide on the depleting number of practice nurses in the future.