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Practice nurses - practise safely

The role of nurses working within general practice is changing. MPS Clinical Risk Programme Manager Julie Price looks at these new responsibilities – and the potential risks they present

The practice nurse’s role is developing in response to the Department of Health and Children’s strategic plans to make primary care the first point of contact for a person needing healthcare.1

Plans to abolish fees for GP care and focus on the prevention of illness and management of chronic diseases will involve the development of the whole primary healthcare team. According to the Irish Practice Nurses Association (IPNA), there are approximately 1,700 practice nurses in Ireland;2 a sizeable number given that there are approximately 3,500 GPs. 211 practice nurses are accredited as clinical nurse specialists (CNS), two have been accredited as advanced nurse practitioners (ANP) in primary care and 11 IPNA members are now registered nurse prescribers.

Practice nurses are privately employed by GPs and must be registered general nurses (ie, on the live active RGN or PHN Register of An Bord Altranais, the nursing board). Practice nurses now represent an important part of healthcare services in general practice: undertaking immunisations, cervical cytology, screening, health promotion, phlebotomy, weight management, smoking cessation, women’s health, men’s health, wound management, travel vaccinations, ear care, and management of chronic conditions such as asthma, COPD, and diabetes.

Challenges

As the role of the practice nurse has expanded, so too have the associated risks. Many nurses work in isolation, managing their own workload, and this in itself presents risks to safe and effective practice, especially when coupled with the inconsistent and variable opportunities for formal education and training to support practice beyond initial registration. MPS has seen a steady rise in the number of claims relating to general practice, some of which involve nurses. Being aware of potential risk areas can help to reduce the likelihood of a complaint or claim being made.

MPS has seen a steady rise in the number of claims relating to general practice, some of which involve nurses

Maintaining competence

Primarily, nurses should only practise within their own competence areas to minimise the potential for error. An Bord Altranais states: “The nurse or midwife must make a judgement as to whether he/she is competent to carry out a particular role or function. The maintenance of competence and ensuring its continuing development is achieved by engaging in continuing professional development.”3

Continuing Professional Development (CPD) enables practice nurses to provide evidence-based, up-to-date, quality care. CPD is essential before undertaking extended nursing roles and is required by An Bord Altranais. Practice nurses should keep a record of all CPD activity they undertake and keep up-to-date with clinical and regulatory guidelines. It is essential that nurses are trained and competent to undertake procedures delegated to them, for example, cervical cytology and ear syringing. It is not enough to “see one, do one”, ie, observe a colleague and then undertake the procedure.

Medication protocols

Of the 92,726 nurses registered with the nursing board in Ireland, only 532 are nurse prescribers.4 Practice nurses who are not nurse prescribers, and who are administering medication without a named prescription, should use medication protocols. These are written directions that allow for the supply and administration of a named medicinal product by a nurse in identified clinical situations. A medication protocol involves the authorisation of the nurse, by the GP, to supply and administer a medication to groups of patients in a defined situation, which meets specific criteria. An individually named prescription is not required for the supply and administration of medication when a medication protocol is in effect.

An Bord Altranais supports the developments of medication protocols using a nationally recognised template based on international evidence and best practice.5The legislative basis for medication protocols for the supply and administration of medication is the Medicinal Products Regulations of 1996 and 2003 (Prescription and Control of Supply). Immunisation and vaccinations Practice nurses are key health professionals involved in providing immunisations to the community in the promotion of public health and prevention of infectious diseases. Examples include childhood immunisation programmes, seasonal vaccinations, occupational health vaccinations and travel vaccinations. Practice nurses should be using medication protocols for the administration of vaccines.

Nurses should ensure that consent is obtained for each vaccine given, from the parent or guardians, at the time of the immunisation
However, in MPS’s experience, very few do so. Parents will normally consent to have their children included in the Health Service Executive national immunisation programme, but this does not mean that they have given their consent to all immunisations.6 Parental consent is required for the administration of vaccinations to children and young people up to the age of 16. There should be a practice policy on whether consent is written. Nurses should ensure that consent is obtained for each vaccine given, from the parent or guardians, at the time of the immunisation.

Nurses should also ensure that they keep up-to-date with current practice in immunisation, including recognition and intervention with sideeffects, treating anaphylaxis,7 adverse events and/or complications post-immunisation. When administering travel injections and other immunisations, the nurse administering the injection should note in the patient’s record: 

  • The name of the injection
  • Batch number
  • Expiry date
  • Mode of injection
  • Site of injection.

Medical records

It is important that medical records include enough detail to justify the proposed management of the patient’s condition. Maintaining complete contemporaneous records can provide evidence of care and/or treatment given, enable one member of the team to take over where another left off and can prove invaluable in defending a complaint or claim.

In Recording Clinical Practice Guidance to Nurses and Midwives An Bord Altranais states: “The quality of records maintained by nurses and midwives is a reflection of the quality of the care provided by them to patients/clients. Nurses and midwives are professionally and legally accountable for the standard of practice which they deliver and to which they contribute. Good practice in record management is an integral part of quality nursing and midwifery practice.”8

Chronic disease management

Many practice nurses are now taking on responsibility for chronic disease management. It is particularly important that nurses have protocols regarding the management of these patients and set guidelines regarding referral onwards.9 The use of evidence-based clinical protocols and agreed standards helps to ensure that nurses have a consistent approach to the management of chronic disease.

Management of chronic diseases in primary care will increase over the next few years and now is the time to ensure that clinical protocols are in place. The DOHC will work with the HSE to introduce chronic disease management programmes between 2013 and 2015.

Vicarious liability

Vicarious liability is an important legal principle. In the case of a GP practice, it is the liability a GP may have for the acts and omissions of an employee or some other individual for whose conduct they are legally responsible, eg, practice nurses. Although assistance is always at the discretion of MPS Council, it is likely that a GP would be granted assistance with requests related to claims of negligence against any of their employed nurses working at a basic level. Though it is unlikely that GPs would be granted assistance for such claims against nurses working in extended roles and/or at a more autonomous level, eg, nurse practitioners.

For this reason, all practice nurses should ensure that they have their own appropriate indemnity. MPS can provide indemnity for practice nurses. A Guide to MPS Membership provides more information on vicarious liability.

In the case of a GP practice, it is the liability a GP may have for the acts and omissions of an employee or some other individual for whose conduct they are legally responsible, eg, practice nurses

Summary

As a nurse’s clinical responsibility increases, so too does this risk of an adverse event. But by understanding the common pitfalls, ensuring the correct protocols are in place, and continuing professional development, the margin for error can be dramatically reduced.

Above all, practices must ensure that all staff they employ have adequate and appropriate indemnity.

Medication protocols

Protocols define areas of responsibility and are documentary evidence of the standard of care provided. There is a danger that protocols may be developed by one individual in isolation, resulting in a lack of ownership for the rest of the practice team, and protocols that are rarely followed and only occasionally updated. Protocols should:

  • Be discussed and agreed by the relevant practice teams 
  • Involve relevant representatives from different parts of the practice (eg, doctor, nurse) in their development 
  • Be revised regularly, eg, annually, and amendments made if necessary 
  • State the date they came into effect 
  • Be easily accessible to all relevant members of the practice team.
There is a danger that protocols may be developed by one individual in isolation, resulting in a lack of ownership for the rest of the practice team

Out-of-date protocols should:

  • Record the date they are withdrawn 
  • Be stored for at least eight years, because litigation can occur many years after an event.
References
  1. Department of Health and Children, A Strategic Framework for Reform of the Health Service 2012–2015 (2012) www.dohc.ie/publications
  2. Irish Practice Nurses Association, The Role of the Practice Nursewww.irishpracticenurses.ie/roleofthepracticenurse.php (Information correct as of 2012)
  3. An Bord Altranais, Scope of Nursing and Midwifery Practice Framework (2000)www.nursingboard.ie
  4. An Bord Altranais, Register statistics (2012) www.nursingboard.ie
  5. An Bord Altranais, Guidance to Nurses and Midwives on Medication Management (2007) www.nursingboard.ie
  6. Health Service Executive (HSE) National Immunisation Office, Childhood immunisation (updated January 2010) www.immunisation.ie
  7. Royal College of Physicians, Immunisation Guidelines for Ireland (2008, updated August 2010) www.dohc.ie/publications
  8. An Bord Altranais, Recording Clinical Practice Guidance to Nurses and Midwives (2002) www.nursingboard.ie
  9. An Bord Altranais, Guidance to Nurses and Midwives on the Development of Policies, Guidelines and Protocols (2000) www.nursingboard.ie

Julie Price is speaking on medication protocols at this year’s MPS General Practice Conference: Spotlight on Risk, being held at the IMI, Dublin, on Thursday 12 September. More information >>

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