Nursing jeopardy

The Royal College of Nursing has identified an increase in claims against nurses. Julie Price and Dr Richard Stacey explore the risks of nursing in primary care

Between 2009 and 2011 MPS has seen a 25% increase in
its nurse members. This has seen a parallel rise in claims involving practice nurses. According to the Royal College of Nursing (RCN), the costs of claims against nurses each year are high – around £5 million. Common claims relate to failure to diagnose, poor treatment technique and medication error, whilst the highest claims relate to failure to refer on to the GP. It is clear that as the role of the nurse has changed so have the risks associated with their ever-expanding role.

NHS reform – déjà vu

In 1987 the government published a new White Paper called Promoting Better Health, which aimed not only to raise the standards of care provided for patients, promote better health and prevent illness, but also to set clear priorities for family practitioner services. It also proposed giving nurses limited powers to prescribe for patients.1

This was followed by a series of negotiations and reviews between the government and the GP profession and finally culminated in a new GP contract launched in 1990. The new contract set out what was expected of GPs, specifically around quality and financial incentives, eg, targets set for immunisation and cervical cytology. GPs would be paid extra to undertake health promotion, screening and preventative work. Employing a practice nurse was one way of achieving these targets.

The birth of nursing

The development of practice nursing is truly amazing. Back in 1984 there were fewer than 2,000 whole time equivalent practice nurses, but by 1994 the number had risen to more than 9,000 and by 2001 there were 18,500 practice nurses in the UK, which constituted the largest branch of community nursing.2 3

These nurses were experienced nurses, mainly from secondary care moving to primary care for the first time, and were employed by GPs in the practice where they worked, rather than the NHS.

Practice nurse courses sprang up at local institutes of higher education as did courses and diplomas in disease management, eg, asthma, diabetes. The learning curve for practice nurses was steep, but they rose to the challenge, undertaking chronic disease management, new patient checks, over 75 checks, childhood vaccinations, cervical cytology, smoking cessation clinics, ear syringing and treatment room work.

They were allowed autonomy and many were running their own clinics admitting and discharging patients. Nurses became an invaluable workforce for general practice and changed the face of it from an illness-centred approach to one based on public health and health education.4

Changing roles

Over the next decade there were further pressures that impacted on the role of the practice nurse, eg, clinical governance, national service frameworks, the 2004 new GP contract and improved access. In addition new career pathways became open to nurses with the introduction of the nurse practitioner degree course and non-medical prescribing.

From April 2006, practice nurses/nurse practitioners who had undertaken the extended independent prescribing course were able to prescribe from the full British National Formulary for any condition, within their clinical competency. This skill has further developed the role of the nurse – no more waiting outside the GP’s consulting room for a prescription to be signed.

The Royal College of Nursing defines a nurse practitioner as “a registered nurse who has undertaken a specific course of study of at least first degree (honours) level and who makes professional autonomous decisions for which he/she is accountable”.5 These nurses took on increased responsibilities within general practice, including undertaking triage, managing minor illness, monitoring drug therapy and treating illnesses within their individual competencies.

Supporting roles

General practice nurses are now supported by invaluable healthcare assistants (HCA). HCAs are not registered nurses, but many have undertaken extensive training locally at national vocational levels to undertake patient measurements, phlebotomy, ECG records, new patient checks, data collection for Quality and Outcome Framework (QOF) and, in some practices, immunisations.

Challenges

The role of the practice nurse continues to change as nurses prepare to take up the challenges set by the proposed reforms to primary care. As their role has changed so have the risks associated with their ever-expanding role.

Many nurses work in isolation and Jan Goldsmith, assistant director of Standards (Nursing), at the Nursing and Midwifery Council, recently stated that 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.6

MPS is concerned that as nurses’ autonomy increases, so does the risk of litigation. Nurses working at an advanced level manage their own workload and work across professional, organisational, agency and system boundaries to improve services and develop practice.7

These nurses must strive to assess and manage their risks and proactively challenge others about risk, in order to make professional headway and safeguard their role in the future.

References

  1. Government White Paper, Promoting Better Health: the Government’s Programme for Improving Primary Healthcare (1987)
  2. Rivett G, National Health Service History: Chapter 5 1988–1997
  3. BMA, Practice nursing. Discussion paper by the GPC’s practice nursing working group (2001)
  4. Martin J, The Next Generation, Working in Partnership Programme
  5. RCN, Advanced Nurse Practitioners – An RCN Guide to the Advanced Nurse Practitioner
Role, Competences and Programme Accreditation (revised May 2010)

  6. Goldsmith J, Challenges and opportunities, Nursing and Midwifery Council Review Issue 
2 (Summer 2011)
  7. Nursing and Midwifery Council, The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives (2008)

Case flawed protocols


Nurse Owen had been a practice nurse at the Bluebell Surgery for a period of four years – she was popular with the GPs, the practice staff and patients alike. Nurse Owen had individual MPS membership.


Nurse Owen enjoyed her work, but felt that she wanted to expand her role. After discussion with the senior partner, Dr Duncan, it was decided that she would undertake a course
in the management of minor illnesses.

Nurse Owen completed the course and started to undertake her own minor illness clinics, working in accordance with protocols adopted from a neighbouring practice and nominally under the supervision of Dr Duncan.


One busy Monday morning, Nurse Owen
saw Emily Smith, who was a 21-year-old female patient who presented with a history of vague lower abdominal pain, loose motions and malaise.
Nurse Owen made a diagnosis of gastroenteritis and made the following entry in the notes:

  • 2 day history of diarrhoea (7 episodes in total) no rectal bleeding or vomiting
  • Vague abdominal pains (colicky)
  • No recent foreign travel or meals out
  • Passing urine without difficulty
  • Occupation - accountant
  • On examination - no evidence of dehydration
  • Diagnosis - Gastroenteritis
  • Plan:
    • Advised re fluids
    • Advised re 
analgesia
    • Stool culture

In the early hours of Tuesday morning, 
Emily developed severe abdominal pain and collapsed. An urgent ambulance was called, but despite the efforts of the paramedics, Emily was pronounced dead upon arrival at the emergency department. 
A postmortem examination confirmed the cause of death as haemorrhage from a ruptured right tubal pregnancy. 
Unfortunately the protocol that Nurse Owen was following was deficient in that it did not mandate the following:

  • Assessment of pulse and blood pressure
  • An abdominal examination
  • An exploration of the patient’s menstrual
and contraceptive history together with an exploration of the possibility the patient may be pregnant
  • A pregnancy test.

Naturally, Nurse Owen was devastated at the tragic outcome in this case, and while she was supported by both friends and colleagues, she felt responsible for Emily’s tragic death.







Nurse Owen’s professional confidence was shaken to the extent that she needed to have several weeks off work, and the medicolegal sequelae of the incident were not resolved for a further two years.


Outcomes


MPS took the decision to assist this nurse as not only was she an MPS member with access to indemnity for claims made against her, but also because her employing GPs were MPS members. The GPs were vicariously liable and given that the practice protocols the nurse had followed were brought into question it was deemed appropriate for MPS to assist.


A complaint


Emily’s family pursued a complaint in accordance with the NHS Complaints Procedure. Unfortunately, Emily’s family were not happy at the conclusion
of local resolution and they drew their concerns to the attention of the Parliamentary and Health Service Ombudsman (PHSO). The PHSO upheld the family’s complaint and made recommendations in relation to the minor illness protocols.


Coroner 


Emily’s death was reported to the Coroner by the emergency staff and the Coroner instigated a police investigation into the

 circumstances surrounding Emily’s death. Nurse Owen underwent the harrowing experience of being interviewed under caution by the police and was thankful for the presence of an MPS instructed solicitor.
 Thankfully the police did not pursue any criminal charges in this matter, but Nurse Owen was called
 to give evidence at the Coroner’s Inquest. MPS secured an expert report from a practice nurse (for the purposes of the coroner’s inquest) who was not critical of Nurse Owen on the
basis that she had followed the relevant protocol.
 The Coroner returned a verdict of natural causes and under Rule 43 of the Coroners’ Rules (1984
 – as amended) wrote to the practice asking that they review and amend the managing minor illnesses protocol.


NMC action

The family made a complaint about Nurse Owen to the Nursing and Midwifery Council, in which she was represented by the Royal College of Nursing. The Council did not take any action against Nurse Owen on the basis that she followed the (albeit flawed) minor illness protocol. 


Civil claim


The family pursued a claim in negligence against the practice (all the GPs were MPS members). Given
the concerns about the protocols the claim was settled on behalf of the practice by MPS with no admission of liability.


This case is fictitious, but it is loosely based on MPS’s real experiences.




Useful links


A podcast with Katrina Maclaine, Principal Lecturer in Advanced Nursing at London Southbank University, recorded at the MPS out-of-hours conference, is available to download. In the podcast she discusses the evolving role of nurse practitioners and how to manage them safely. Listen to the podcast at – www.medicalprotection.org/uk/advice-and-publications/podcast.
 






Last updated: October 2011

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