The risks of practice nursing

Medical Protection has seen a steady rise in the number of claims involving practice nurses. Kate Taylor and Diane Baylis, Clinical Risk and Education Managers, examine what areas of practice nursing carry the most risk.

Read this article to:

• Understand the key risks facing practice nurses
• Discover risk management strategies to deal with those risks
• Learn about indemnity arrangements for practice nurses

The role of nurses working within general practice is everchanging, with an expectation that they take on additional responsibilities and increased autonomy. Their responsibilities can include chronic disease management clinics, nurse triage, family planning and immunisation clinics. Other changes include the introduction of the advanced nurse practitioner role, healthcare assistant and nurse prescribing. The expansion of the nursing role, alongside pressures on services and increasing workloads, can lead to increased risk to patient safety and clinical negligence claims from patients. As nurse autonomy increases so does the risk of litigation, therefore it is imperative that nurses ensure they have received the appropriate training and skills to undertake their role. Nursing and Midwifery Council (NMC) professional standards for nurses and midwives states that nurses must recognise and work within the limits of their competence.1 Understanding the common risks facing nurses in general practice can help them to ensure that they employ risk management strategies and efforts to reduce risks. Using data from Medical Protection Clinical Risk Self Assessments (CRSA), which identify and address potential risks in practices that may have an impact on patient and staff safety, we have identified some common risk areas for nurses. 

Childhood immunisation

While administering vaccinations and immunisations is considered to be a routine nurse task, the below risks are examples, encountered in CRSAs, of where issues can arise:

• The practice nurses have not received immunisation training updates.
• The practice is not clear regarding guidance relating to administration of childhood immunisations for children from abroad on different immunisation schedules.
• The practice nurses are not aware of changes to the Green Book regarding consent to immunisation.
• The baby immunisation clinic is run single-handedly by one nurse. 

Administering childhood immunisations is a huge workload for a practice. It is important to ensure that nurses are suitably trained, work within their competence and keep up-to-date with current guidelines, such as the UK Immunisation Schedule. Changes to the Green Book mean that the person with parental responsibility does not necessarily need to be present at the time the immunisation is actually administered.2 This means that children may now be brought in for immunisation by a person without parental responsibility, such as a grandparent or child-minder. There is no requirement for such arrangements to be made in writing; however, you must be satisfied that the person with parental responsibility has consented in advance to the immunisation.

Communication

Practice nurse teams have become more diverse, and communication and team working has becoming more challenging, especially where the teams have grown in size and now many nurses have very different roles within the team. The below risks are examples, encountered in the CRSA, of where issues can arise:

• There are no regular nurse team meetings and the practice rarely holds meetings for all staff.
• The nursing staff do not have the opportunity to attend clinical supervision. 

Practice nursing roles have evolved over recent years with the introduction of new roles and responsibilities, therefore team working and communication is essential. In 2012, the GMC and the NMC jointly outlined how high quality, safe patient care not only involves teamwork, but good communication, leadership and adopting a culture where healthcare professionals can discuss patient safety openly with each other.3

Nurses in general practice need to feel supported in order to undertake their role safely. Clinical supervision is an important part of good clinical practice and can be seen as a strategy for professional development. It also facilitates reflective practice and clinical decision making.  

Protocols

Clinical protocols represent the framework for the management of a specific disorder or clinical situation and define areas of responsibility. They reduce variation and maintain the quality of patient care, as well as serving as evidence of the standard of care to be provided. The use of written clinical protocols and agreed standards ensure that the nurses have a consistent approach to the management of common acute/chronic illness and outcomes. The below risks are examples of where issues can arise:

• There are no practice clinical guidelines/protocols for chronic disease management.
• The nurse undertakes telephone triage without the use of protocols. 

Nursing roles are increasingly being developed to undertake triage of appointments; this way of prioritising patients helps to identify the patient’s problems and directs them to the most appropriate care pathway. Nurse triage tends to be provided over the telephone and should be supported by practice protocols.

Nurse triage is also not without risk; Medical Protection has seen a number of cases whereby assessment of the patient’s needs has been inadequate, resulting in an adverse outcome. Nurses undertaking triage need to be supported by guidelines and protocols and ensure that they work within their own sphere of competency. It is also vital that the reception staff, who are responsible for referring patients for nurse triage, are supported with guidelines. This will help to reduce the risk of nurses seeing patients inappropriately and will also ensure that the patient sees the most appropriate clinician.

Infection control

It is expected that all healthcare providers should meet good hygiene standards; however some practices are still running into difficulties. Infection control and prevention is an area that often falls under the remit of the practice nurse. The below risks are examples of where issues can arise:

• The practice does not have a designated lead clinician for infection control.
• The practice has not produced an infection control annual statement. 

General practice teams are required to produce an annual statement with regard to infection prevention and cleanliness compliance.4 Such a statement should begin with a summary of any action taken in the previous 12 months. It is then important to include comprehensive information on any significant events that have occurred at the practice relating to infection control. 

Indemnity arrangements

It is a legal requirement for practising nurses to have an appropriate insurance or indemnity arrangement in place to register with the NMC.5 Nurses will be asked to provide evidence of this as part of the revalidation process. It is the professional responsibility of each nurse to ensure they have protection that is appropriate to their role and scope of practice. Nurses working in general practice can arrange their own individual membership with Medical Protection, or may receive it free as part of a Practice Xtra group scheme.

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Top risk management tips

• Ensure practice clinical guidelines/protocols are up-to-date and evidence based.
• Ensure nurses are supported in maintaining and developing their clinical skills and knowledge. Nurses should have access to an appropriate level of support and mentorship.
• Ensure nurses working within general practice have suitable indemnity arrangements in place.
• Nurses must always consider the need to maintain confidentiality, gain appropriate consent and maintain complete contemporaneous records of all patient consultations.
• Ensure effective communication within the practice/nurse team.

References

• Nursing and Midwifery Council. The Code. London: NMC 2015.
• Public Health England. UK immunisation schedule: The Green Book, chapter 11. 2017.
• General Medical Council & Nursing and Midwifery Council. Joint Statement of Professional Values. 2012.
• Public and International Health Directorate, Health Protection and Emergency Response Division, Infectious Diseases Branch 10200. The Health and Social Care Act 2008: code of practice on the prevention and control of infections and related guidance. London: Department of Health 2015.
• Professional indemnity arrangement. nmc.org.uk. 2016.