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• To be aware of the barriers to recruitment of newly qualified nurses to general practice nursing roles
• To understand nursing students’ perceptions of entering general practice as a first post
• To learn about approaches to improving recruitment of newly qualified nurses to general practice nursing roles
Background There is a widespread nursing shortage within the UK, with trends suggesting that vacancies will continue to rise. The challenge is particularly acute in primary care, where unclear recruitment and career pathways mean that only a small proportion of nurses enter general practice within five years of qualifying.
Aim To explore pre-registrant nursing students’ perceptions of entering general practice as a first-post employment destination.
Method A qualitative interpretive description study was undertaken, recruiting final year pre-registrant nursing students. Semi-structured interviews were analysed through a thematic analysis framework.
Findings Three key themes were identified: myths and perceptions of the general practice nurse (GPN) role, the requirement for secondary care experience and a perceived lack of career advice on entering general practice.
Conclusion Visibility and awareness of the GPN role have still not been realised and further work in this area is required.
Primary Health Care. 32, 5, 26-33. doi: 10.7748/phc.2022.e1758
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Lythgoe C, Galdas P, Hardy B (2022) Pre-registrant nurses’ perceptions of general practice as a first-post destination. Primary Health Care. doi: 10.7748/phc.2022.e1758
Published: 03 October 2022
Published online: 27 April 2022
There is a widespread nursing shortage within the UK. In 2019, national nursing vacancies stood at 38,785 (Macdonald and Baker 2020), with trends in recruitment, retention and attrition suggesting that this number would continue to rise (Murray 2017). The challenge is particularly acute in primary care, where there are unclear recruitment and career pathways (NHS England 2018). Research by Ipsos Mori (2016) and The Queen’s Nursing Institute (QNI) (2016) identified this lack of clarity in primary care recruitment as a particular issue for newly qualified nurses, with only a small proportion entering general practice within five years of qualifying.
As a branch of nursing, general practice primarily recruits mature and experienced nurses aged over 40 years (NHS Digital 2021). Thirty-three percent of general practice nurses (GPNs) were due to retire by 2020 (QNI 2016) and various strategies have been introduced to support the rapidly dwindling workforce, including the NHS England (2018) ‘ten-point action plan for general practice nursing’. The action plan aimed to achieve tangible outcomes in recruitment and retention by raising the profile of GPNs, increasing post-registration education and continuing professional development, increasing the number of pre-registrant placements and providing career support and pathways from preceptorship to advanced clinical roles in primary care.
Many factors can affect GPN recruitment negatively, including a lack of role visibility, with pre-registrant nursing students having minimal placement opportunities in general practice, predominantly hospital-based portrayals of nurses in the media and a lack of primary care content in the pre-registration curriculum (Lane 2015, Lewis and Kelly 2018). Other factors include negative perceptions of the GPN role (Ipsos Mori 2016) and the fact that GPNs’ benefits including salary are not comparable to those of their NHS peers (Ashwood et al 2018). However, little is known about nursing students’ perceptions of the GPN role, not only as a career but also as a first-post destination following registration.
• General practice nursing is an under-discussed and poorly understood clinical discipline
• Unless the limited availability of general practice placements for nursing students is addressed, it will continue to hinder their awareness of the GPN role
• A greater focus on primary care is required in pre-registrant nurse career support
• Nursing students require more information about entering general practice following registration, in particular that secondary care experience is not required
To explore pre-registrant nursing students’ perceptions of entering general practice as a first-post employment destination.
This qualitative study followed an interpretive description design methodology (Thorne 2016), which provides a pragmatic approach to generating qualitative insights relevant to healthcare practice (Hunt 2009). Interpretive description acknowledges nurses’ personal epistemological stance, providing flexibility in the methods used to provide relevant clinical knowledge.
A purposive convenience sampling strategy was used to recruit final-year undergraduate nursing students based at three universities in the North of England. Universities were sent an email outlining the study details to disseminate to all eligible participants and the lead researcher (the lead author, CL) attended lectures to promote participation. Once recruited, all participants were encouraged to discuss the study with their peers, using snowball sampling.
Twenty-one nursing students expressed an interest in participating in the study and were provided with a participant information sheet and consent form. Participants were followed up after two weeks with a total of three ‘chasing’ emails. Five participants who had expressed initial interest chose not to proceed to interview.
Recruitment concluded when 16 participants had been interviewed and ‘meaning saturation’ was reached (Hennink et al 2016). Code saturation indicates when a full range of thematic issues have been identified, whereas meaning saturation indicates that a full understanding of each code’s nuances has been reached. Table 1 shows the participant demographics.
Data were collected using semi-structured interviews based on an evolving interview guide (Edwards and Holland 2013). Opening questions were based on the participant’s background and experience, for example: ‘Could you tell me a little bit about yourself and how you’ve found your nurse training?’ The interview progressed to exploratory questions, investigating participants’ clinical placement experiences, understanding of the GPN role and plans for and decisions made about their first-post destination (Crabtree and Miller 1999, Braun and Clarke 2013).
The interview concluded with a verbal check of the researcher’s accurate understanding of the participant’s comments and a sense check to ensure that no relevant questions or answers had been missed.
CL undertook all the interviews between November 2019 and January 2021. Ten semi-structured interviews were conducted on-site at participants’ universities and six were undertaken on video-conferencing platforms. Interview times ranged between 18 and 46 minutes. All data were pseudonymised by allocating a unique identifier to each participant.
Data were inductively analysed using Braun and Clarke’s (2013) six-phase thematic analysis process, which is detailed in Table 2. The approach is flexible and iterative and involves short descriptive labels (codes) applied to the data. In this study, code generation continued to evolve following data collection, reflection and data development. The codes were reviewed for their singular value then compared and contrasted with the overall codebook (complete list of the codes and definitions for the entire study). Theme generation was explored, ensuring that the themes worked in a coherent and organised manner and displayed distinct properties that created an overall picture of the data (Braun and Clarke 2013).
Ethical approval was obtained from the University of York Health Sciences Research Governance Committee (HSRGC/2019/352/A) and accepted and adopted by the participant recruitment sites. Informed consent was obtained from all participants who received written and verbal study details, including information on the aims, methods and how the findings would be disseminated. Participants were made aware that they could withdraw their voluntary participation at any time. All data were pseudonymised to limit participant and university subject identification.
The participants’ responses demonstrated commonly held myths and perceptions of working in general practice. These were aligned to three main themes (Table 3): myths and perceptions of the GPN role, presumed requirement for secondary care experience and the availability of career advice for entering general practice.
The GPN role was perceived primarily as suitable only for older nurses who wanted a family-friendly work-life balance. Further, participants believed GPNs did not require the same level of clinical competence as nurses in secondary care. These perceptions appeared to be influenced by participants’ discussions with student peers and family members and their experience of secondary care placements. Negative perceptions were predominant in participants with no experience or previous knowledge of the GPN role. Participants who had experienced a general practice placement reported more favourable views of the GPN role.
Participants noted that the GPN role was not widely discussed in their educational settings, where general practice placements were established alongside community placements. Some participants expressed confusion between the community nurse role and the GPN role. Participants understood the community aspect as nursing within the home but were unsure if the GPN role was a facility-based community role. Participants who had experienced community placements and the GPN role could articulate the nuances of community and GPN roles.
When asked about the GPN role, six participants expressed a lack of knowledge of the role and its responsibilities, capabilities and skills. For example, when questioned about her thoughts on undertaking her first post within general practice, one participant commented:
‘I just wouldn’t really associate that with nursing, but I’ve never had a placement there. Well, I don’t know if that would be for me, I’m more of, hmm, a nurse.’ (Anne)
Anne’s perception of the nursing role was of managing acute events in secondary care. She discussed community and GPN roles interchangeably, which she believed was because her university provided these placements in the same rotation.
Other participants, who had not undertaken a GPN placement, expressed similar concerns about becoming deskilled in general practice, basing their perceptions on community placements, peer group discussions, discussions with secondary care staff while on placement and university feedback. The terminology used by those who had not witnessed the GPN role included ‘deskilled’, ‘not a nurse’ and ‘not a lot of my clinical skills’, which indicated a negative perception of GPNs’ skill levels.
In contrast, participants who discussed the GPN role from a patient’s perspective used words like ‘autonomous’, ‘decision-making’, ‘responsibility’ and ‘prescribing’. Participants who had witnessed the GPN role offered a more positive perception using terms such as ‘enjoyed’, ‘well supported’, ‘tight-knit’ and ‘well organised’.
Five participants expressed an interest in undertaking advanced practice roles. However, even within this context general practice was regarded as a lower-skilled area compared with secondary acute care, with one participant stating:
‘I think eventually, if I’m confident enough and I feel brave enough, I will go out into A&E and walk-in centres, but I might start out in a GP practice.’ (Belle)
Participants discussed GPNs as an ‘older workforce’, linking this with working patterns perceived as more appropriate for those seeking an enhanced work-life balance. A commonly held perception was that the GPN role was suitable for nurses with childcare responsibilities or who did not want to work secondary care shift patterns, as two participants commented:
‘She wants to go straight into community because she wants to start having children immediately.’ (George)
‘It just felt like it was more for women that didn’t want the lifestyle of a ward – I will be honest with you, it tended to be a lot of older nurses.’ (Jane)
The pace of work in general practice was discussed as ‘easier’, ‘relaxed’ and ‘less stressful’. Several participants linked their perception of this slow pace with the presumed age profile of GPNs and the family-friendly hours.
One participant, Nancy, commented that she believed she would not be interested in a GPN role because it ‘isn’t as intense and fast-paced’, but added that she believed this would benefit patient care as the slower pace meant ‘you could spend more time with patients’.
Belle acknowledged that while the duration of GPN shifts might be comparable to those in secondary care, the pace of work was perceived as more manageable. Eleven of the 16 participants described the pace of work in secondary care in terms such as ‘busy’, ‘stressful’, ‘understaffed’ and ‘burnout’.
Participants who had undertaken a general practice placement used more positive terminology to describe the primary care environment. For example, Jane discussed a transient element to the pace of work, commenting that there were ‘busy days, and not so busy days.’ Conversely, Debbie stated that the pace of work needed ‘time management’ which implied some level of work-related pressure.
There was limited awareness of employment terms and conditions in general practice. Regardless of whether they had general practice experience, ten participants were unaware that these settings were not aligned with NHS employment terms and conditions. Three participants commented on the difference in terms and conditions between secondary care and general practice – for example, lower salaries and a perceived lack of a structured career pathway in general practice – with salary being the primary concern:
‘The pay banding, because it’s not matched to the NHS you will be stuck on the same pay for a few years whereas fellow students in my cohort will go onto wards and go up the pay band quicker.’ (Helen)
‘I’m assuming the terms and conditions will be similar, but I don’t know.’ (Penny)
‘It’s got its differences. Obviously, the environment is different, but I’m not really sure of the differences in terms and conditions.’ (Lynne)
Fourteen participants had been told directly that secondary care experience would be necessary before becoming a GPN. The advice came from multiple sources, including secondary care nurses, universities and peers. Participants’ comments included:
‘They did say it was better that you had [hospital experience].’ (Irene)
‘Probably best to work on a ward for a year or two.’ (Nancy)
‘It was also emphasised at university as well.’ (Penny)
The primary source of advice that secondary care experience was necessary before becoming a GPN came from secondary care colleagues who participants had spoken to while on hospital placements. Those participants who had knowledge of general practice, or who had undertaken a general practice placement, could challenge this perception. Orla acknowledged that her GPN placement had empowered her to challenge the perception appropriately:
‘You don’t need the secondary care experience anymore – possibly before the placement I wouldn’t have known, really.’ (Orla)
However, another participant, Debbie, while acknowledging that secondary care experience before becoming a GPN was not required, did not feel confident in challenging her registered colleagues’ opinions.
Participants believed that secondary care experience was required before becoming a GPN, particularly to consolidate their skills and receive peer support. One commented:
‘So, I want to start off in secondary care because I feel it will get me the opportunity to develop my clinical skills and have a supportive environment with other nurses and sisters and matrons.’ (Fiona)
Various participants expressed a need to ‘build up my skills’, ‘develop a range of skills’ and ‘develop my nursing judgement’, with a perception that these opportunities were not available in primary care. Ten participants stated that secondary care acute clinical areas were the most desirable first-post destinations and linked these settings with the development of nursing skills.
Preceptorship programmes are a recognised model of providing professional support, guidance and clinical education to newly registered staff nurses (Nursing and Midwifery Council (NMC) 2020). Eleven participants stated that preceptorship programmes were only available in secondary care, although those with primary care experience (n=5) were aware they were also available in this setting.
Eleven participants expressed concern about their ability to develop confidence and competence in their first post and discussed secondary care as the preferred clinical area to support their professional development. Debbie likened registration followed by secondary care experience to ‘passing your driving test and then learning to drive’. Participants actively sought advice and support about being newly qualified from within their peer groups, universities and from colleagues on placements, as one commented:
‘They all kind of gave their opinions and views of nurses and newly qualified nurses, which is something you take on as they have been in the field longer than you have.’ (Belle)
The perceived amount of secondary care experience required before taking on a role in primary care was 12-24 months. Each participant’s perception of the length of the required post-registration secondary care experience correlated with anecdotal discussions with their peers and registered nursing colleagues and recruitment adverts. Three discussed job adverts as affecting their career choices, with one stating:
‘I looked in the application and that said you can’t apply unless you have two years’ postgraduate experience.’ (Mary)
Participants were unclear if the requested timescale for secondary care experience was a requirement of the role or a recruitment preference. Some participants believed these timescales were a recruitment preference, because different geographical areas specified different timescales. One commented:
‘It’s weird that in [one NHS area] you have to have a year’s experience in hospital before they’ll let you work and in [another NHS area] they will take you straight from uni.’ (Irene)
General career planning was discussed in the interviews, with many participants expressing preferences for their first-post destination. Six had already secured a job offer, all within secondary care. Table 4 shows the preferred career fields for all 16 participants.
Overall, participants believed that career guidance and support should be part of their core nursing curriculum, but many obtained this from providers other than their universities, such as careers fairs. Thirteen participants believed it was the university’s responsibility to provide career advice, support and information. All participants knew of or had attended careers fairs in their university or in secondary care settings. Secondary care employers were always represented at careers fairs, as one commented:
‘They [careers fairs] did have the hospitals come in, so they had stands in the foyer, but there were no lectures or anything about how you should construct a CV or anything.’ (Fiona)
Clinical placements enabled participants to assess whether they wanted to work in secondary or primary care when registered, while staff in the practice area could assess students’ suitability for future roles, as one participant commented:
‘If you get a good picture of the placement, you do get a good feel for what you want to do later.’ (Nancy)
Another participant commented that her university had provided a broad range of career options and believed this was a supportive and productive way to provide access to various nursing fields:
‘We had a day where different trusts came into the university and there were a few nurses there and also a trainee practice nurse who had just qualified.’ (Jane)
However, Jane’s views contrasted with those of other participants who attended her university and who believed it had not offered sufficient career support or guidance.
Eight participants expressed a desire to receive increased support with basic career planning such as searching for roles, generating a curriculum vitae (CV), optimal timing for applications and interview techniques. Participants discussed their access to career advice using uncertain terms such as ‘unsure’, ‘don’t know’ and ‘not discussed’. Four acknowledged that career advice was available but with the caveat that they had to search for the information. One commented:
‘There were no initial lectures or anything about how you should construct a CV or anything, interview techniques and stuff like that, which could be quite beneficial.’ (Fiona)
Participants reported a lack of knowledge about how to search and apply for posts in non-secondary care environments, with most unaware of where to obtain general practice recruitment information. Others assumed that these posts would be advertised on the NHS jobs website. Two participants, Debbie and Helen, who cited general practice as their preferred first-post destination, discussed the challenges in sourcing relevant information. Another five stated that GPN posts were frequently discussed within their peer group, with many nursing students expressing an interest but lacking knowledge of how to apply. One of these participants commented:
‘No, not at all. No, we’ve not been given any information about [general practice nursing]; it’s just all about going to work on a ward, going to work in secondary care, you know the hospital and things like that.’ (Lynne)
This study explored pre-registrant nursing students’ perceptions of first-post destinations in general practice. The three main themes offered an insight into myths about and perceptions of the GPN role among this group, which has important implications for the recruitment of the future GPN workforce.
Lack of role visibility appeared to be linked to many of the myths and participants’ presumptions about the GPN role. Previous studies confirmed that poor understanding of the role could be a barrier to nursing students entering general practice (Crossman et al 2015, Lewis and Kelly 2018, Lewis et al 2019).
National and international research has demonstrated that pre-registrant nursing students’ clinical placements affect their awareness of roles and clinical settings, and initial career choices, significantly (McInnes et al 2016, Murray-Parahi et al 2016, NHS England 2018, Lewis et al 2019). This study corroborates this evidence, in that a lack of general practice placements correlated with participants’ negative perceptions of the GPN role. Only five participants had direct knowledge of GPNs’ roles and responsibilities, three of whom had undertaken a formalised placement in this setting. The lack of general practice placements is a known barrier to increasing the visibility of the GPN role, therefore improving the availability of these placements would provide a clearer understanding of GPNs’ roles and responsibilities (NHS England 2016, 2018).
Many of this study’s findings have been reported in previous research (Ipsos Mori 2016, NHS England 2018, NHS England 2019); for example, that the complexity of the GPN role might be clarified by improving its visibility and increasing career pathways in primary care (Calma et al 2021). The findings also demonstrated that clinical experience, peers, families and educators influenced participants’ perceptions of the GPN role. Participants were in broad agreement that to enhance understanding of the role would require increased placement activity and university-supported teaching.
Participants often spoke of the need to gain secondary care experience before entering general practice, despite this being unnecessary. Preceptorship is designed to provide newly qualified nurses with support from registered nurses when learning new skills. However, if preceptorship in general practice is perceived by nursing students as unavailable, they may be less inclined to consider this setting for their first post-registration role (Cathala and Moorley 2020).
The mentorship model of providing support and advice to nursing students while on clinical placement could be viewed as a form of career counselling (Foster and Hill 2019), providing nursing students with experiential learning and the opportunity to consider the opinions of registered nurse colleagues (Pellatt 2006). The five participants who had experience of the GPN role were confident that they could consolidate their skills and become professionally socialised in general practice. Three of these participants had undergone a general practice placement, one had worked for two days with a practice nurse, and one had worked in general practice as a healthcare assistant and these experiences, combined with the mentorship they received while on placement, improved their confidence.
Participants perceived a lack of support in obtaining career advice on primary care nursing roles. All three universities had designated departments offering career support, with support also available through careers fairs and placements, although participants were expected to locate these themselves. Further, careers fairs that focused on jobs in secondary care were often held in educational and work-based settings, allowing secondary care employers to recruit from a ‘captive audience’ of nursing students (Ngune et al 2012, McNeil et al 2020). For participants, this offered easy access to information about secondary care posts. Conversely, primary care employers did not employ the same strategies, with Ipsos Mori (2016) acknowledging that many GPN posts are recruited through word of mouth or by already-registered GPNs headhunted for specific positions. Recruitment by these methods does not contribute to long-term sustainability in the GPN workforce (QNI 2017) and represents further recruitment obstacles for new nursing registrants.
Participants who were aware of the GPN role had a clearer understanding of who to contact for information, but even they did not feel supported in the job application process. A lack of placement availability exacerbated the suboptimal career advice and support for nursing students wanting to work in general practice (NHS England 2016).
In 2016, Health Education England launched the GPN Ready scheme, a nationally supported pilot programme that provided financial and educational support to employing general practices and newly registered nurses for two years. The scheme provided the educational and professional socialisation required by the NMC for new registrants (NMC 2020). Aston (2018) noted that general practices that were embedded in the GPN Ready scheme experienced an improvement in recruitment and retention of GPNs, but that such national strategies are sparse and fragmented. Funding for the GPN Ready scheme was discontinued by HEE in 2018/2019 and although other training schemes such as the National Association of Primary Care CARE programme (Further resources)have been initiated, they do not target or support newly qualified nurses entering general practice. Conversely, there is a clearly defined training and recruitment strategy for GPs (Health Education England 2021) which is not available to GPNs.
In the UK, general practices are primarily private-run businesses that commission work from the NHS and many do not adopt NHS working terms and conditions. This may be an additional challenge to the recruitment of GPNs, deterring applicants who could not transfer their NHS benefits package (Crossman et al 2015, Ashwood et al 2018, Aston 2018). Participants in this study demonstrated minimal knowledge of GPNs’ salaries and associated terms and conditions and perceived a disparity between these and the salaries, terms and conditions of their secondary care colleagues.
The study was undertaken from November 2019 to January 2021. Because of the coronavirus disease 2019 pandemic, the study was paused for six months between March 2020 and September 2020. The pandemic may also have affected nursing students’ placement availability and quality and their reported experiences.
Research suggests that many pre-registrant nursing students may not have a clear understanding of the GPN role. In this study there was an assumption among participants that secondary care experience was required before undertaking a GPN role. Further, participants stated that career guidance and support was not readily available. Participants perceived that compared with secondary care nursing roles, the GPN role involved a slower pace of working and lower skill levels and had an older demographic and predominantly family-friendly working practices.
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