A healthy development for Ireland

GP surgeries are becoming more like one-stop shops these days and practice nurses are part of that development.

They have their own appointment list and are very much part of the primary care team.

While in the past having a nurse like this may have been seen as “freeing up the doctor’s time”, Berna Rackard, practice nurse in the surgery of Dr John Cox in Fethard-on-Sea, Co Wexford, considers this a somewhat outdated view.

“While we don’t diagnose or prescribe, practice nurses have their own role as part of the multi-disciplinary team that’s needed to keep a practice running smoothly and efficiently.”

The tradition of doctors employing nurses in their surgeries developed over time, she says.

“Historically, many nurses were married to GPs and they helped out in the practice. As time went on, chaperones were needed while female patients were being examined but the value of having a nurse in the practice was also realised. Now the practice nurse’s role is a very full one and they are developing their skills all the time.”

Such nurses have their own representative body since 2008 – the Irish Practice Nurses Association. It developed from the 1990s when practice nurses scattered round the country began to meet to share ideas and information.

Berna loves her job, she says, and finds her work varied and interesting. We asked both her and her colleague Anne Numan for a flavour of their working week in the run up to Christmas in this second-generation Cox practice which has 2,700 patients.

“While my appointments are scheduled any kind of emergency can come through the door so you have to be prepared,” says Berna.

“Winter-time is always busy because of the increase in sickness in general but also because of the flu vaccine. We have a new walk-in clinic this year as we have a huge number of patients who need it. Doing it at a set time keeps it focused and frees up surgery hours.”

WELL-WOMAN CLINICS

“I do cervical smears as part of the Cervical Check screening programme and having the well woman clinic also provides a chance to talk to women about any contraceptive or health concerns they have. Child immunisations are a big part of a practice nurse’s week too, as are ante- and post-natal clinics.

“Patients with high blood pressure also need to be kept an eye on,” she says.

“‘White coat syndrome’ is very common. This means that a person’s blood pressure goes through the roof the minute they set foot in the surgery. In that case, we would put them on a twice-a-day monitor or a 24-hour monitor as it’s the most reliable way to distinguish between ‘white coat syndrome’ and clinical hypertension. There is a big demand for the machines, with sometimes as many as six people a week using them.”

Berna also oversees a warfarin clinic one afternoon a week as the practice has more than 60 patients on this blood-thinning drug.

“It’s a drug that fluctuates in its effect for various reasons in each individual patient so regular checks are necessary to ensure the dose is accurate,” she says.

The Heartwatch clinic is also a weekly feature of Berna’s work.

“This is for patients who’ve already had a heart attack or have had cardiac surgery for existing heart disease. We want to prevent further cardiac incidents so it’s important to monitor for all the risk factors like high cholesterol or high blood pressure and focus on diet and exercise.”

On Thursday afternoons, Berna assists Dr Cox with his minor surgery clinic.

“Procedures vary from removal of ingrown toenails to removal of pigmented lesions like moles. It’s a good service to have in place in a rural practice,” she says, “as it means that patients don’t have to travel to hospital for the procedures.”

DIABETES

Diabetes clinics are now a huge part of the weekly schedule too.

“We’ve had one on Friday mornings for the past eight years,” she says.

“My job is to educate and support the patient in getting good control of their condition. That can mean referrals to the dietician and making sure that they are up to date with all appointments relevant to their diabetes, such as the opthalmologist and chiropodist.

“I often think that it would be beneficial if there were a designated community based diabetic specialist nurse available to patients in their own homes. Hopefully in the future ...”

DEPRESSION

One of the most satisfying aspects of Berna’s work is supporting patients who are suffering with depression by making CBT or cognitive behavioural therapy available to them.

“Many practice nurses are training in this area now because we know that being on medication has its limitations.

“CBT is useful training to have as it’s about making people aware of how they think and how they can change their thinking from negative to positive. That can be very empowering,” she says.

Note: Berna recommends a book on meditation for patients coping with depression. It is Meditation for Beginners (book and CD) by Jack Kornfield.

‘Once they get here, I find they chat away’

Local nurse Anne Noonan is a former health promotion officer with the HSE and now works in Dr Cox’s practice part-time. A mother of four she is married to Tom, a dairy farmer and animal nutritionist and they live near Hook Head.

Anne also likes the variety of practice nursing. Her principal task is keeping track of patients’ blood tests and she stands in for Berna in holiday time doing all the required nursing tasks.

“The blood test results come back electronically from the hospital and I look out for any abnormal results and liase with the doctor and the patient. Bloods also go to Waterford Regional by courier two days a week and that has to be looked after.”

Overall, Anne believes that rural GP practices are offering a good service to local people and she is particularly glad to see that rural men are getting better at looking after their health.

“Some elderly men would almost have to be dying before they’d go to the doctor. In my experience it’s often a fear of having to go to hospital but everyone has to go to the doctor ultimately whether it’s for driving licence eye tests or hearing tests. Once they get here, though, I find they chat away and strike up great conversations in the waiting room.

“Younger men are now attending more frequently to have their blood pressure and cholesterol checked, too, which is good. It can happen that a younger person can have a stroke too so it’s important to keep an eye on blood pressure and cholesterol levels.”

CONFIDENTIALITY

Confidentiality is particularly important in a rural practice, she says.

“That’s because, being local, we could see people socially outside the practice and it is awfully important that what happens in the practice stays in the practice.”

Anne and Berna both like the rural community aspect of the practice.

“If anyone in the area dies, for example,” Anne says, “all the staff would be mindful of that when relatives come in, as we’d know the family connections.”

Anne and Berna both see the role of practice nurse continuing to develop in the future – a future they look forward to.