Here you will find a selection of themes which an Advanced Nurse Practitioner, General Practice Nurse, Nursing Associate or Healthcare Assistant might face during their working day.
“To be “in charge” is certainly not only to carry out the proper measures yourself but to see that every one else does so too; to see that no one either willfully or ignorantly thwarts or prevents such measures. It is neither to do everything yourself nor to appoint a number of people to each duty, but to ensure that each does that duty to which he is appointed.” – Florence Nightingale, Notes on Nursing: What It Is, and What It Is Not
During a busy morning in the treatment room the GPN calls the next patient in for ear irrigation. She is running 15 mins late. The nurse asks the patient if she has been oiling her ear ready for irrigation and the patient says ‘no’ she hadn’t been told to do so. The nurse examines the patients ears which are dry and impacted with hard wax. She informs the patient that she can’t perform the ear irrigation and they must rebook for the procedure. The patient is very upset as she had waited for 30 mins and was desperate for her ears to be irrigated. The nurse tries to explain the reasoning for her decision and the patient leaves her room very tearful.
A couple of days later the nurse receives a letter of complaint from the patient. The practice manager is informed and asks the nurse to write a letter of apology to the patient. The nurse does this and believes the complaint has been dealt with however a few months later the patient writes again to the nurse complaining about her treatment.
This complaint needs to be dealt with by the Practice Manager. The nurse has already made an apology and the patient is obviously not satisfied. The Practice Manager may discuss the complaint with the Practice Partners. There may be more to this than just the nurse appointment and it may be about care she has received or not from the practice. This needs to be explored and all issues discussed with the patient and Practice Manager.
It may be worth reviewing protocols/procedures involving ear irrigation and preparation for appointments as this may have helped prevent the complaint in the first instance.
Written guidance prior to tests/procedures is useful as patients do not always remember instructions. These can be given out by clinicians, reception staff or put on the surgery website.
An HCA is performing some basic wound care as per protocol. Her elderly patient has a wound on her leg which appears more inflamed than usual and she decides to ask one of the practice nurses to look at the leg. The nurse is busy and quickly comes to assess the wound but feels that there is no infection.
The HCA feels that the wound does show signs of infection but doesn’t feel she can argue with the nurse. The patient is not concerned and in no pain. The HCA dresses the wound and arranges a follow up appointment.
Two days later the patient returns for redressing of the wound. She has an obvious wound infection and is in pain. She calls another practice nurse to assess the wound, it was agreed to take a swab and the duty GP prescribed a course of antibiotics. The patient is sent home with advice and a follow up appointment is made for 2 days.
The HCA feels this could have been prevented or at least reviewed better. She goes to the Lead Nurse to discuss her concerns.
This is always difficult and none of us have a crystal ball. Sometimes we have a ‘gut’ feeling however we need evidence of signs of infection before we can begin to treat it.
No one is at fault and the Lead Nurse needs to support both the HCA and nurse to ensure they understand the situation and take into account personal views and opinions. This would be a good piece of joint learning. Perhaps the nurses could do a ‘lunch and learn’ about managing wounds, dressings and infections.
A practice protocol is useful to ensure everyone follows the same procedures. It may also highlight a need for further training and could be used as a piece of reflective practice for revalidation.
At the end of a busy Friday afternoon clinic the ANP was asked to see a child who was febrile. The child’s parents were very concerned and had arrived at the surgery without phoning first. They refused to accept a call from the GP or ANP and refused to go home without a consultation. They were ‘squeezed’ into the end of the clinic. After examination and discussion with the parents the ANP did not feel that the child needed admission or further review and sent the child and parents home with advice and guidance. They appeared satisfied with the consultation and had some written guidance to take home with them.
On Monday morning the ANP found out that the child had been admitted to the local hospital on Saturday evening. A receptionist made a comment to her that maybe she should have admitted the child on Friday evening as the parents had been very worried.
The ANP felt concerned that she may have made the wrong decision although she was sure she had not ‘missed’ anything significant. She went back to her room and re-read her consultation notes.
We all think about our patients and wonder if we have made the right decisions. Children are even more difficult to assess and can recover or deteriorate very quickly. In these circumstances it would be appropriate to speak with a GP and review the notes together. Talking through consultations helps professionals learn how to become more confident at decision making and supports learning. It was agreed the ANP had made the correct clinical decision at that time and she went on to use it as a piece of reflective practice for revalidation.
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Patient is a 17-year-old lad who happens to be a friend of your son. He is very high achieving and wants to go into the RAF after 6th form (you suspect his parents are especially keen to get his university expenses paid). His mother phoned you at home on your mobile the previous evening to request that you remove the antihistamine from his medication list, as having hay-fever is a no-no for RAF entry.
Back at the surgery, you check his records: you had already stopped the Loratadine and removed it from his repeat prescriptions the last time you saw him, so thought nothing more of it. However, a few weeks later at the end of afternoon surgery, you are told that his mother had come to see you on a social visit. She wanted to look at her son’s record and find out how the RAF had found out that he has hay-fever. On further inspection, allergic rhinitis is read coded as a diagnosis in 2008, plus he was prescribed Loratadine by a locum in Sept 2009. His mum implied that you should remove the diagnosis from the record. You explain that you are unable to do this, and so she asks you to write a letter saying that he had been symptom free for the past 5 yrs. Unfortunately, you witnessed him having hay-fever when he was at your house a few years ago, and you’d had to go and get him some Loratadine from the chemist.
You feel irritated and manipulated.
What should you do?
The best course of action here is to be truthful. It is unreasonable of the mother to manipulate you like this. Given your personal relationship with the family, you may feel that writing a letter outlining the full details of his condition as you understand it both from the medical record and your personal experience is reasonable. At the end of the day you need to provide factual evidence that enables the RAF to make an informed decision. They have their rules for a reason and you should not attempt to manipulate them, otherwise you are committing the same offence as the boy’s mother.
A 6 year old little girl was brought to see you 4 months ago with a rip- roaring UTI. It recurred after treatment although was not a resistant organism. You re-treated, and referred to paediatrics. Mum has been to see a homeopath (who happens to be a personal friend of hers) and says that the homeopathy treatment ‘worked miracles’ …for a while. They therefore didn’t use the most recent prescription for Trimethoprim and have just got back from holiday. The poor little girl now has such foul-smelling urine that she’s stinking the whole house out apparently. Mum requested a telephone consultation with you yesterday; you suggested that she sends in an MSU and then takes the Trimethoprim. Mum suggested that the antibiotics don’t seem to work as well as the homeopathy and she doesn’t want to give her daughter too many antibiotics. You persuade her to carry out your plan and then come along for a discussion re further management. The girl has a paediatric follow-up in mid October.
Could you have managed this differently?
The parent’s views and ideas might be putting the child at risk so you did the right thing to get her in again – but beware of them not turning up. Luckily, a UTI should be provable one way or the other. You might take the line that, ‘Homeopathy can work, especially on helping you feel well. It may even be that it is stopping her symptoms from the UTI [which may be pretty minor anyway] while the infection is still dragging on’. But you should make them aware that the main risk of an untreated UTI is that it could, long-term, cause kidney damage. This is unlikely, but it is the reason we like to get these things treated with anti-biotics and ensure paediatric follow-up is on place to check on any underlying causes.
One to do with dependency. One of your old ladies- in her late 70s with multiple medical problems, Osteoarthritis, Hypertension, mild Heart Failure – came to see you yesterday although you weren’t expecting her to come back until February. She had several fairly trivial problems bothering her. It dawned on you that the reason she had come in was because you had given her a follow-up appointment which was too far ahead – she literally needs to come and see you at regular intervals, more regular than 6 months, even if she’s actually quite well. You find it very difficult to set the bar correctly with these patients.
How might you manage this situation?
You need to get a really good understanding of why the patient is behaving like this. You need to avoid making suppositions which may in fact be wrong. Ask the patient without being confrontational or brusque. Something like: ‘It’s nice to see you but I wasn’t expecting it until February…’ with an expectant look, should bring an informative reply.
Differences, or perceived differences, in clinician workload provide fertile ground for disputes. The beginnings are always subtle and often go un-noticed.
Different clinicians will have individual work styles, for example:
A practice’s population is likely to have patients needing the full range of medical services and clinician approaches. Does your practice recognise the strengths and different approach of each clinician? Is there a consensus in your practice about where your boundary is set for demands from both patients and the NHS (ICB/Commissioners)? Do your timetabling and other workload arrangements allow good matching of demand (patient needs/wants) and supply (clinician styles and abilities)?
Consider using the Dr Chalk vs Dr Cheese assessment below (Download as pdf file):
Where are you on the Chalk-Cheese spectrum? For each pair of statements, simply tick next to the statement which most closely describes you as a GP.
| Dr Chalk | Dr Cheese | |
| Medicine is more a science than an art
Regards patients as clinical problems Respected for being well organised and skilful use of evidence |
Medicine is more an art than a science
Regards patients as needy people Respected for being interested and skilful listening |
|
| Thinks clinicians should not address patients’ non-clinical needs
Does not run late Generally seems on top of the task |
Thinks clinicians should help with anything affecting patients’ health
Often runs late Often seems overloaded |
|
| Scores low on burnout scales
Does not experience work as stressful Complaints taken as part of the job |
May score high on burnout scales
Experiences work as stressful Complaints taken personally |
|
| Minimally engaged with peer appraisal
Comfortable with medical hierarchies Does not dwell on matters that seem insoluble |
Welcomes and values peer appraisal
Uncomfortable when dealing with colleagues Takes on problems others see as insoluble |
|
| Happy to run General Practice as a business
Strives for high earnings Finds lectures ideal for CPD |
Happy to leave running the business to others
Indifferent to high earnings Enjoys group-based education |
|
| Seen as intolerant by some | Seen as a soft touch by some | |
| Sought out by patients who value clarity | Sought out by patients who value support | |
| TOTAL CHALK = | TOTAL CHEESE = |
Add the number of ticks in each column. Was your score greater in the Dr Chalk column? Or the Dr Cheese column?
Adapted from an original idea by Dr Harry Yoxall.
A practice staffed by Dr Chalks will have a proportion of patients whose needs are not met; they may leave and join the surgery down the road and the practice might become uneconomic. But one staffed by Dr Cheeses will eventually have no GPs at all, due to burnout and lack of self-care by the Doctors.
You may not find any quick answers but once again, the debate will forearm you.
Patients, especially those who attend the practice infrequently, often have little idea of whom to approach for their healthcare needs, and are likely to base their behaviour on:
It has always been a part of the administrative support staff job role to educate patients about how to use the service and what is available, and this task frequently spills over into the clinician’s interactions. With such high levels of potential misunderstanding in these contacts, it is important for clinicians and the administrative support staff in the practice to be very explicit about what is being offered and whether it is what the Patient expected. Only by asking about this can it be clear.
In some more deprived areas, it is probably true that Patients come to their GP surgery because they cannot find any other help for their problems. That the GP is cost-free is also clearly an important factor. Each Doctor has to make up their own mind about how they meet these challenges.
Patients are often more reasonable that might be imagined and may not know about your time pressures. It takes a certain level of experience and confidence before a clinician can ask patients what they think about his/her timekeeping and their view of the time set aside for each meeting. These are questions worth asking.
The standard 10 minute GP appointment is of course intrinsically unrealistic. Would you expect to see your Solicitor or Accountant for just 10 minutes, with an important problem? Is health not more important to most of us than legalities or money? Fortunately, many practices are switching to a 15 minute appointments for routine GP appointments, though maintaining shorter consults for acute problems. Nurses generally have a more sensible approach with time apportioned to the task in hand, but even with this approach can get caught out.
Historically, clinicians in primary care have managed this situation by using:
The following may also help:
It often happens that a patient – maybe someone who doesn’t come to the Doctor very often and is essentially unaware of the way GPs work – will initiate the consultation with something like, “I’ve come for you to refer me to a specialist because of my eczema. I’ve tried all the creams I can get from the Chemist. I’ve been told you just have to write a letter for me”. In other words, they are unaware that their problem is usually treated by general practice clinicians and this may be entirely effective and much less inconvenient for the patient.
Your instinct may well be, “Whoa! Hold on a minute!” But it often works well not to be in any way negative at this stage. Your task is to turn around the super-tanker, not to blow it out of the water. Even though you may be thinking “No”, the word “Yes” can be very helpful here: “Yes, we can certainly think about that. But tell me a bit more about the problem first… For example, have you tried using a steroid cream regularly for 2 weeks?”
Clinicians are often asked to do things that they don’t normally do as part of their job description although this sometimes feels almost infinite in scope!
The sense that we are being asked to do something outside our remit can be very subtle at least initially. For example: “Doctor, you have been kindly treating me for my depression. A large part of it is my noisy neighbours. I really need a letter to them pointing out that they are making me ill. I’ve brought something I printed off – all you need to do is sign it. Goodness is that the time? I must be off – can you just put your squiggle here …”
A good tool here is summarisation: “Just to summarise what you have said, you wish me to sign a letter that you have written to a member of the public who you think is making you ill…” This should lead towards an equally clear, “I regret I cannot help you. This is not part of what Doctors do.” Using “Doctors” rather than “I” may help prevent the patient going to each of your colleagues in turn!
In addition, with a broader multi-disciplinary team working in general practice these days, it is also necessary to gently educate patients that the GP is not the only person who is able to help them with their problem. This can be done by extolling the virtues of a more appropriate clinician or service to help.
When you feel uneasy with a patient’s expectation or attitude, it is essential to know where the patient is coming from and thus to understand why you feel uncomfortable. This information can then inform your decision on what kind of boundary to set. What is it about the patient’s behaviour that you feel to be inappropriate? If your discomfort is around perceived unrealistic expectations by patients of you or the processes or services you provide, please see the ‘Managing expectations‘ section.
When it appears that the patient wants to simply hand their problem to you, you are being drawn into a variant of the child-parent consultation model. It is important to always try and maintain an adult-adult interaction. As clinicians we need to help the patient understand that their health is our concern, but their task/responsibility. The aim should be for the patient to accept that their health is the result of their decisions and actions, and that the clinician is there to inform and support this process but not to take it over. Occasionally patients have a deeply ingrained external “locus of control” which can be difficult to change.
It is worth spending some time developing common boundaries for clinicians within the practice to observe in any consultation. What behaviour is appropriate, and what is not? Do we expect patients to call us by our professional names, and do we reciprocate by calling them Mr., Mrs., etc., or do we not? Do we agree that this is how we will all behave on all occasions, or are we willing to allow a degree of deviation? In order to be successful, the agreed ways of working should be observed and upheld, without deviation where possible. Patients are more likely to recognise boundaries if they are consistent across the organisation and, to this end, wider considerations for patient-staff interactions overall should also be set.
You might wish to consider the following:
When we speak of “Time Management” we often mean something more far-reaching than simple timetabling. The advice to “handle each piece of paper only once,” or “cascade tasks that do not require your level of skill” may thus miss the mark. There are few finite solutions here because the model of GP care we use is essentially flawed – there will always be more to do than can be achieved. But in the natural ebb-and-flow of patient care, the more you understand about what is actually going on, the better prepared you will be for problems when they arise.
There was a time when GPs were able to be the one person in the community to whom people could bring almost any problem they were having in their life, and often receive valuable support and advice. Today General Practice is comprised of a number of different health professionals, each with particular skills and supported by experienced administrative staff and the focus has moved towards only providing medical care. But, of course, the boundaries of this are not clear, and certainly not universal.
When considering working styles, happy practices avoid any sense that ‘One size fits all’. They acknowledge the different styles and contributions of their clinicians and make the best use of them. The first step is to identify what these are, then to match them up to the work that is needed to be done. Of course, no single clinician can merely do what comes easiest to them – we all have to rise to the daily challenge. However, if timekeeping is a problem for you here are some suggestions:
On a daily basis, we run into people who behave in all manner of ways. Often these interactions are comfortable and feel easy; when you have developed a good rapport with the other person and all parties are open, honest and respectful. However, sometimes these interactions leave us feeling very uncomfortable, when there is anger, defensiveness, fear, anxiety, demanding behaviour or even hysteria – on behalf of the other person, their family or carer, or even on behalf of ourselves. We all have interactions that challenge us. Those that challenge one person may not challenge another in the same way.
We all have our own lived experience, our own filters that affect our perceptions. Working in healthcare can sometimes lead to a degree of desensitisation or development of a slightly peculiar way of viewing life, that dark sense of humour that you may well recognise. This is a self-protective mechanism, an additional filter if you like, and one that we need to be mindful of. It means that we need to pay careful attention to how we are interacting with others on a human level, regarding our clients as people first and patients second.
If we look at ourselves first, we probably recognise that there are some factors that set us up to consult in a less-ideal fashion. You may have come across the acronym HALT – Hungry, Angry, Late, Tired – if any (or all) of these factors are present for us as we interact with others, we are more likely to emit negative vibes. We can take steps to ameliorate all of these to an extent, but just being mindful of how we’re feeling can help.
In addition to this, it can be helpful to remember that we choose our thoughts and behaviours. The vast majority of the time people do not behave in a deliberately malicious or irritating fashion. They are invariably trying to achieve a positive outcome to a situation and choose a behaviour that they think will facilitate that. Unfortunately, sometimes that chosen behaviour can be overdone and can then be perceived by others as something negative.
The following is taken from a very helpful article in Pulse magazine, written by Dr Shaba Nabi, a GP trainer in Bristol:
There are many reasons why a patient may be angry. They may have had access issues, perhaps no one has got to the bottom of their illness or, more commonly, they may just have a life that causes them to feel that way.
Anger doesn’t erupt out of nowhere and the signs are usually there as the patient arrives. If you acknowledge some of these signs early on, patients feel they are being taking seriously and listened to.
And although anger can set off a reflex adrenaline response, it is unlikely that the anger is directed at us personally; we are normally just the outlet for the patient’s expression. It is therefore important to keep some of our own emotional reactions in check and control that ‘inner chimp’.
Pain has always held a fascination for me. There are so many facets to it, and none more fascinating than our psychological appraisal of it. But regardless of the underlying causes or maintaining factors for a patient’s pain, it feels very real for them. It is irrelevant how much of the pain is ‘organic’ and how much is ‘psychological’; it is important to acknowledge their suffering and negotiate a plan to manage it.
Doctors often have a mistaken belief that when patients complain of pain, all they want is stronger analgesia. Often, what they want is empathic listening.
I understand why patients do this; they’ve waited three weeks for an appointment and are unaware you have patients booked at 10-minute intervals. There is no point getting frustrated at them – they need an explanation and negotiation.
There are two types of ‘shopping list’ consultations: overt and covert. For the former, acknowledge the list, explain time constraints and ask the patient to prioritise one or two things, having advised what is achievable in a single appointment.
The covert list is when a patient springs new problems on you after you have been consulting for 15 minutes. You can address all their problems and run late, you can advise them to rebook but risk missing a red flag or something that was important to them, or you can begin the consultation by asking if they have any other issues they want to discuss.
I doubt comorbidity would have been much of an issue 20 years ago, when secondary care followed up all patients with long-term conditions. But these days, patients with complex comorbidities are like unwanted visitors, and hospital managers put enormous pressure on consultants to discharge them. But as patients live longer, and survive long-term conditions, we need strategies for managing complex patients in primary care.
The obvious solution is establishing continuity of care with a named GP. It is also imperative to prioritise clinical problems – you can’t deal with all of their problems at once.
Red flags obviously need to be addressed immediately, followed by what is most important for the patient. You may need to chip away slowly while you get to know the patient.
When patients demand medications or investigations, it is often challenging for GPs to manage this in a patient-centred manner.
But it should be a true partnership approach. There must be a balance between the doctor’s and the patient’s agenda so that the pendulum doesn’t swing between being overly prescriptive and overly submissive. The only management options that should be shared with the patient are those that are also reasonable for the doctor.
It can be hard for patients to understand why their requests are being declined, so we need to emphasise that the reason is based on their best interests.
Human beings self-destruct in all sorts of ways; the person with COPD who continues to smoke and the woman who overeats in spite of being too overweight for the fertility clinic.
What all these patients are likely to have in common is the inability to deal with emotional pain in a healthy and constructive way. Sadly, this cannot be taught in a 10-minute consultation.
It is easy for a GP to become subconsciously paternalistic under these circumstances, which can lead to dysfunctional consultations. Consider using motivational interviewing. It is not just a buzzword, the technique enables a doctor to remain detached while sowing seeds of reflection in the patient’s mind. Motivational interviewing has the added benefit that we will not see it as a personal failure if we are not successful.
When I first qualified as a GP, patients who had multiple somatic symptoms were called somatisers. This was a little unfair as we couldn’t be 100 percent certain that their physical symptoms were not indicative of an illness that was yet to be diagnosed.
Medically unexplained symptoms is a better term because it is not labelling the patient as ‘having it all in the mind’ and opens up the possibility of underlying illness. It is also a term that can be openly shared with the patient in order to decide on a management plan.
I am usually very honest about my appraisal of unexplained symptoms, advising that I cannot fit their symptoms into any kind of disease category that requires investigation. But l also explain that I will remain open minded about exploring new symptoms that arise.
I usually find these patients the most frustrating, probably because their behaviour comes across as irrational at times.
It may be a patient demanding treatment that is not available on the NHS and saying you are doing nothing to help them. Or it could be a patient requesting an urgent appointment for their own convenience rather than an urgent clinical need.
I find it is useful to encourage the patient to draw up their own list of management options for their problems, which I will write down and perhaps add to. Once a list has been drawn up, we assess which options are achievable and the patient is empowered to choose one of those.
This approach takes time but it is worth it if you want to continue having a good long-term relationship with the patient.
These patients may be either new to the practice or new to you. Either way, when they present with a long history of a complicated neurological condition, for example, and want ‘something’ to be done about it, you may find it difficult to keep your cool.
If the patient is new to the practice, take a step-wise approach to information gathering and use the first consultation purely to listen to the patient’s concerns.
It is then important to book a follow-up appointment after reviewing the patient’s medical records in order to complete the assessment and consider the management option. In total, this may take three to four appointments.
If the patient is known to another GP, simply address any priority issues during the appointment and then direct the patient back to their usual GP (see also point 4).
Your first decision is whether to call an interpreter. This is not as easy as it sounds as the patient may speak some English and not feel an interpreter is required, or they may attend with English-speaking relatives.
But it is vital not to compromise the quality of your consultation. If you feel the patient’s English is not adequate or the family are not translating verbatim what you are saying, you need to either terminate the consultation or insist on an interpreter.
However, even with professional interpretation services, you cannot always be certain of their quality assurance.
Cultural differences within a consultation are equally important. Patients from many cultures often expect a far more paternalistic approach from their doctors than they get with British GPs. That is not to say a variety of management options shouldn’t be offered, but you must also respect a patient’s wishes for you to become prescriptive if that is expressed.
We could add a couple of patients to this list that you might recognise:
Some patients do not follow advice or comply with process or treatment. They may not turn up or routinely turn up late for booked appointments, they may return again and again as they are not improving (as a result of their non-compliance) or they might disengage completely with treatment. All manifestations are frustrating in their own respect.
Taking some time to explore the reasons behind this behaviour is likely to be more productive than simply applying sanctions; treating a person with compassion is more likely to engender respect and adherence. There may be very good reasons (real or imagined) why compliance is difficult. However, a firm discussion around the individual responsibilities of each party in the clinician-client contract may be necessary.
This may simply be related to someone’s personality, but occasionally it can be an indication that a patient is becoming more dependent on you than is healthy. It may show itself as a patient being overly familiar, being flirtatious, repeatedly booking appointments ‘for a chat’ or delivering small, yet unsolicited gifts.
This situation can be difficult to manage, particularly if you (as many clinicians do) derive pleasure and purpose from helping others. Consider the drama triangle (Stephen Karpman) , made up of victim-rescuer-persecutor. When you find yourself troubled by a patient being over-friendly it is likely that you are being pulled into this dysfunctional scenario which rarely ends well. Safeguard yourself against this by maintaining a professional relationship with clear boundaries, staying within the empowerment dynamic (Dave Emerald) made up of the corresponding roles of creator-challenger-coach. Remember you are their clinician, not their friend.
Be clear about your objectives.
Take 2 minutes’ thought to complete this sentence. You will discover what you are aiming to achieve:
“By the end of the meeting, participants will….”
Now think about how this can be done, bearing in mind the individuals in your group:
On the day of the meeting, remember that you as Facilitator are at the helm. However clever, learned and articulate the Consultant, only you know what the group needs to learn. If in doubt, be like John Humphries. (OK maybe Evan Davis.)
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