Lucy Wood

Standardising protocols in general practice for practice nurses

Background

Every practice nurse will be aware of the on-going task of writing and reviewing protocols.  These are legal requirements and each GP practice will have its own set of up to 100 protocols.

The challenges are:

  • These protocols vary enormously in content and in quality. They are not regulated or checked externally, instead they will be agreed internally
  • The guidance on diagnosis, treatment pathways, evidence and updates will most likely be out of date by the time the protocol is agreed 
  • The protocols are kept on computer and system drives, which are sometimes difficult to access, and once the right protocol is found, the specific information required may be buried in pages of text 

Many nursing hours are wasted annually with individual practice nurses writing and reviewing protocols. By centralising and standardising these clinical protocols, there would be a clear improvement in the quality of these protocols, and thus patient care, as well as saving clinical time and reducing unwanted variations in care between surgeries. This will also ensure protocols are up to date, relevant, accessible and user-friendly. 

 

Many nursing hours are wasted annually with individual practice nurses writing and reviewing protocols

 

Standardising protocols also enable a mobility of workforce across the region. If staff move from one practice or locality to another, they do not have to learn a new set of protocols. They will be familiar with the guidance, how to locate it and where the pertinent information is within each one. This is particularly pertinent where practices are staring to work, and employ staff on a network or federation basis.

Aims and objectives

To standardise and centralise protocols into user-friendly, useful, up to date desktop version.

This will save time for most practice nurses, supporting a workforce that is under immense pressure with current workload and ensure a standard of care and service to patients across the region, improving the overall patient experience of primary health care.

Activity to date

This project started as a personal idea, and I have gained support and engagement in developing it from both Clinical Commissioning Groups (CCGs) in the region; NHS England, Health Education England (HEE), Devon Community Education Provider Network (CEPN), Academic Health Science Network (ASHN) and South West General Practice Sustainability Board (SWGPSN). I did this by attending board meetings and discussing my project with the CCG lead nurse and taking it to the various committees for agreement. Having the backing of these organisations ensures that I have a mandate to continue the project and support for getting it rolled out in GP practices, as well as engagement for clear pathways.

I have been collaborating with Blue Stream Academy, which operate an online training system that is available in all GP practices in Devon, and several hundred practices nationally. The idea is that Blue Stream may serve as the ‘repository’ for the protocols, as all nurses have easy access to the system. With Blue  Stream’s guidance, the project idea has been developed into a word document into a one-page ‘flow chart’ style document, making it much more user-friendly for busy nurses. 

writing on keyboard

To date, a pilot protocol for chronic obstructive pulmonary disease (COPD) and diabetes has been developed, and distributed to the relevant clinical working groups and experts for critique and comment. I run a number of nurse forums across Devon and I am using these opportunities for further feedback and support. 

Following feedback from the working groups and forums, the pilot protocols will be reviewed and adjusted and sent for final approval from the appropriate bodies. 

It has been challenging to find all of the right groups to engage with, and explain the vision of this project. It is somewhat sensitive and each group is sensitive to the needs of their providers and roles held. The feedback for the overall idea has been very positive but it has been a lot of detailed work to make the pilot protocols suitable for stakeholders and this is made slightly more complicated by working across two CCG areas.

Outputs to date

Two pilot protocols have been developed, and a working template for further protocols will follow. There has been detailed engagement with commissioners, providers, clinicians and educational groups. 

Lessons learned

That all areas, federations and Clinical Commissioning Groups have their own formularies and sets of guidelines so any new protocols must be aligned to these.

open book

Reflections on impact

Once quality approved and published, practice nurses across Devon will have free access (via Blue Stream) to up to date, desktop protocols which will help them during consultations to access latest guidelines for disease management, diagnostic criteria, information for patients, patient management plans, as well as information for nurses on gaining appropriate qualifications in the subject area. 

While this project is primarily aimed at saving clinicians’ time in practice in developing each protocol, there are positive benefits that flow from it including:

  • Standardised protocols: all practices do things the same way
  • Improves the patient care and experience – patients know what to expect and how things are done, regardless of practice
  • Improves the portability of staff who are able to work across practices or federations and know what the protocol is regardless of working base
  • Releases the pressure of developing protocols from individual nurses, giving them more time to focus on patient care
  • Standardised templates enable clinicians to know exactly where to look in a document to find the information they seek
  • A central repository for all protocols allows them to be updated easily, by a single person
  • A central repository for protocols enables them to be easily found by clinicians, especially if working away from their home base (e.g. on an out of hours shift)
  • nurses with paper work and computer

    To measure impact, I will utilise nurse forums as focus groups for feedback on the protocols themselves, as well as the implementation of those protocols within practices. 

    Using the Blue Stream platform as the central repository for the protocols will give me access to user statistics such as who is accessing the protocols, from which surgeries, what staff groups and how often. This information will enable me to target those practices who are not accessing them to find out why and what might need to change to help them use it. 

    After the first year of implementation I intend to use a small survey tool, such as survey monkey, and send out to all the nurses across Devon to gauge their level of interest and use of the protocols and also to gather information on any changes needed and what protocols they would like to see developed next.

The way forward

This project has potential to be rolled out nationally. In doing so, these national protocols would be quality assured and updated. Nurses would save time, and practice would be safer as all nurses will follow same protocols and won’t be reliant on writing their own and keeping updated. This creates economies of scale in developing and reviewing protocols across large parts of the country and ensures consistency in the quality and delivery of general practice nursing services. 

Nurse educators and education facilitators from CEPNs across the country can be utilised to implement their project within their area and a national protocols group can be established to ensure consistency. It would assist in reducing unwarranted variation in care. It would need input from CCG colleagues and CEPNs and agreement for these to be taken through the local assurance frameworks. 

 

Nurses would save time, and practice would be safer as all nurses will follow same protocols and won’t be reliant on writing their own and keeping updated

 

Local areas can utilise their expert nurses from that group of nurses who have recently retired, or who are just about to retire, to ensure we keep their expertise and knowledge within the local health community. This encourages retention of the skill base in primary care nursing.

One of the additional benefits of this project is that it makes general practice nursing more attractive to nurses who are newly qualified or new to general practice. They will have a ready-made suite of protocols, reviewed and evidence based from which to learn and base their practice. This makes working in practice a less scary prospect. It does not detract from personalised care but allows a framework upon which to base individual care planning.

nurse typing on laptop

Local areas can utilise their expert nurses from that group of nurses who have recently retired, or who are just about to retire, to ensure we keep their expertise and knowledge within the local health community

Sustaining momentum 

With funding from the RCN and from HEE I intend to utilise a team of experienced nurses to monitor guidelines as they are issued, update the protocols and communicate these updates as they occur to all users. These changes will be communicated via our monthly nurse forums, through our website and newsletter and utilising our stakeholder communications channels.