They say to never start with an apology but here it is. I apologise to all those primary care nurses who I may have looked down my nose at, the nurses and the staff in primary care whose job I thought was easy. I apologise for thinking that you couldn’t ‘hack it’ in secondary care. I see how secondary care nurses look at me sometimes and now think if only you knew that I was you once, I thought the same things you’re thinking about me and now realise I was so wrong. I’m sorry if anything that is written in this offends anyone. It is not intended to.
I graduated from university with my sights firmly set on secondary care. I had no desire to ever step foot in a GP practice unless it was for the sole purpose of my health. Despite having spent time with practice nurses and watching them juggle the many demands of primary care; managing a patient’s diabetes one minute to performing advanced wound care the next, I assumed that GP practices were where nurses who couldn’t cope with secondary healthcare went. The nurses who couldn’t keep up with the pace of having 12+ sick demanding patients, bed managers, discharge planners and then medication rounds and all the paperwork to boot. The nurses who couldn’t hack it on the ward so chose the quiet life of primary care. I had a very snobbish attitude towards primary care nurses, one that I am embarrassed to admit to, but I know it is an opinion that some of my colleagues who worked and still work in secondary care shared, albeit in secret.
Throughout my career, I have worked on busy surgical wards looking after pre and post op patients, I worked in medical wards looking after the patients who didn’t really have a speciality other than ‘Gen Med’. The frail, the septic, the ones whose families couldn’t cope anymore and had no option but to bring them to hospital after their fifth fall. The patients who walked into surgery and walked out again, the ones who were resuscitated in the park by innocent bystanders who undoubtedly and unselfishly saved someone’s life. I participated in multiple cardiac arrests, feeling the rush of adrenaline when the bleep used to go off. I was fortunate enough to secure placements on ambulances, speeding through streets with the sirens wailing and the lights flashing. I worked in ITU, theatres, ophthalmology, ED, AMUs, and spent time on exercises as part of my role in the Royal Navy triaging and treating all sorts of injuries and illnesses.
I have sat alongside patients who took their last breath so they wouldn’t be alone and had the privilege to be in attendance when babies took their first. I worked shifts where I was the only nurse trained to do IVs or PICC lines, I worked shifts where there were not enough staff to even think it was safe. I worked numerous hours overtime; I once did a 16-hour shift because there was not enough oncoming staff for me to feel I could leave the ward safely. I rarely got a lunch break or finished on time. I worked almost every bank holiday known to man, and I lost count of the number of Christmases I worked.
I worked so hard that I damaged the ligaments in my foot so badly I had to be in an immobilising boot for 6 weeks then have electric shock therapy to allow me to walk pain free. I thought I loved the buzz of secondary care. I lived on adrenaline and Pepsi Max. I thought I thrived under the pressure and the stress. I thought I loved it.
In 2020, when COVID19 hit, I was pregnant and had to shield. My planned job post-maternity in secondary care fell through and I didn’t have a job to go back to after my maternity leave ended. I didn’t know what I wanted to do. I searched on NHS Jobs almost daily trying to find something that I thought would be interesting, something where I could apply my many skills that I had honed and developed in secondary care, something that I felt like I would enjoy, but I found nothing.
I changed my search criteria and started looking at primary care job vacancies. I thought maybe I’ll just do a quick stint in primary care, ease me back into nursing after maternity then go back to the medical wards and the job I loved in secondary care. I thought that nurses in primary care had an easy life, I just needed a job that would fit in with a young child and allow me to keep my PIN. I thought I would look for something to keep me occupied whilst I looked elsewhere for the secondary care job I thought I wanted.
I found a job and when I looked at the job spec, I was quite surprised of everything that was being asked for and realised that I had no idea what a practice nurse did. This job spec mentioned advanced wound care, compression therapies, dopplers, cytology competencies, childhood immunisations, vaccines for adults, travel vaccines, reviewing patients with chronic diseases, assisting with Urgent care patients, working within the MDT including making referrals into secondary care, ear checks, blood tests etc. I was shocked at how much was on this job spec and started to wonder would I even be qualified enough to apply for the role? I decided to do a bit of research looking into what primary care nurses do, reaching out to friends who had made the jump from secondary care into primary care and asking their advice. Would this be something I could do? Would I miss secondary care too much? Will I get bored? Am I even qualified enough?
I decided I would apply. I needed something and there was an appeal of the unknown. I was fortunate enough to be offered a position but wasn’t sure if I wanted it. Did I get a good feeling at the interview? Yes. Were there some aspects of primary care I wasn’t sure about? Yes absolutely. I discussed it at length with my husband and decided to accept the job. I was honest with them and explained I wasn’t sure if primary care was ‘my thing’ but was reassured there would be plenty to get my teeth into.
Transitioning into primary care was a shock. I felt like I was drowning, I felt like I had no idea what I was doing. Surely this wasn’t the right job for me… who even knew there were so many wound dressings and what on earth were they all used for?! I had no idea of the workload the practice nurses were doing. They did absolutely everything, there was nothing that they couldn’t do. I was amazed and very daunted by this new role. I suddenly realised that all my previous assumptions were wrong.
I found that practice nurses are autonomous practitioners, they run their clinics on their own, they work within a practice and may have a GP on site but ultimately the decisions they make are from the knowledge base that they have built up. The buck stops with them. This was so daunting coming from a background where generally you have a doctor on the end of the phone who makes the big decisions and shares some of that responsibility with you.
I know that I have skill fade in certain secondary healthcare skills, however, I have learnt new skills like how to apply compression bandages at the right amount of compression; what wound dressing is best for a 95% sloughy wound that needs antimicrobial cover. I now know what 95% of the dressing we have are used for and what is the best for certain wounds. I have learnt how to take a cytology sample and how to perform contraceptive reviews, I’ve learnt how to do childhood and adult vaccines. I’ve learnt so much about the MDT involved with primary care and how when we use people’s skills efficiently, together we can make a difference in a patient’s life.
I love that I can see a patient and then decide to refer them straight into a secondary care department without having to do 8 sheets of paperwork prior to discussing with a doctor about a referral that only they can make. I love that I can spend time with a patient and actually find out about them and feel like I’m actually making a difference to their lives. It might only be a 10-minute appointment, but I’ve realised you can learn so much about them when you talk to someone on an individual basis. I love that I see patients from cradle to grave.
Children always used to petrify me because of how quickly they can decompensate, but the more experience I gain with them the better I am at recognising the little sick from the big sick, I’ve learnt to trust parents’ instincts and now encourage them to trust their instincts too. I enjoy the responsibility that being a practice nurse brings, instead of spending my evenings worrying if I handed over that Patient X needs a wound dressing done because I ran out of time, I now spend time with my family. Occasionally I might spend an evening going over my NHS emails and doing some CPD training but that is my choice. I enjoy the feeling of satisfaction when you find those pesky DP pulses and realise they’re triphasic and the ABPI result is 1.2 so you can squeeze that wound. I enjoy being able to deliver gold standard of care. Sometimes when I start to miss a busy medical ward, fate gives me a sick patient or someone presenting with ECG changes needing hospitalisation, fulfilling that need for the adrenaline rush of busy medicine, yet also making me grateful I only need to focus on that one patient at a time.
Primary care isn’t all roses and unicorns. Stressful days in primary care are very different to stressful days on the ward. Stress, for example, can be caused by the combination of two clinics because someone is off sick and you have 15 urgent blood tests, 3 smears, a doppler and 4 bilat compression reviews booked into a morning clinic then being asked to fit in an urgent ECG for the patient who gets chest pain whilst seeing a doctor.
There is much more of a zero approach to aggressive behaviour in primary care. Someone shouted at me once and I thought nothing of it until the practice manager told me they were writing the patient a letter reiterating the zero-tolerance policy. I was shocked, I explained that while in secondary care there is a zero-tolerance policy in place, aggressive behaviour is still widely occurring, from patients and relatives alike. It wouldn’t be a night shift without someone using profanities towards the staff.
I think transitioning into primary care was a wake-up call for me. I enjoy it and now can’t imagine returning to secondary care. I enjoy the responsibility and the professional relationships that I have developed with my patients. I love the autonomy I now have in patient care. I find it touching that patients go out of their way to thank us, to show their appreciation. I think I am fortunate enough to have found primary care at a point in my nursing career when I wasn’t sure if I wanted to keep going.
I apologised at the start for my previous thoughts on practice nursing and I stand by that apology. Despite the feeling of deskilling in some areas, I have become a skilled practitioner in others. I have more responsibility for patients than I ever have done before, and I am more of an autonomous practitioner than I ever have been. Practice nursing has changed me as a person and a nurse, I’ve become more aware of social issues, I’m more of a holistic nurse, I feel that I am more empathetic because I am less burnt out. I think everyone should give it a go.
Practice nursing is not for the weak hearted, and perhaps I should’ve learnt that a long time ago.
Written by G.L.T.
Photo by Laura James on Pexels.