Editor's Choice

Abstract

In this issue of JAN, Osborn et al. (2010, pp. 1452–1458) report an audit they conducted in their hospital in Wales to compare the ability of a nurse practitioner with that of a consultant surgeon in diagnosing breast disease. They explain there are rising numbers of patients being referred to breast clinics in the United Kingdom (UK) while, at the same time, junior doctors’ hours have decreased under the European Working Time Directive. Further pressure, they tell us, arises from the UK government’s requirement that all patients referred by a general practitioner with suspected breast cancer must be seen by a specialist within 2 weeks. Whatever the criticisms of today’s target-driven culture in the National Health Service (NHS), the fact is that the targets – including this one – are intended to benefit patients. What patients with symptoms of breast disease want is to be quickly seen and properly diagnosed. Who does this is of lesser importance. Although Osborn et al.’s paper emphasizes the UK context, the question they ask is of universal interest: can nurses diagnose breast disease as accurately as doctors? Osborn et al. got a positive answer to that question, but emphasize the limitations of their enquiry. It compared only one nurse practitioner and one consultant surgeon over 1 year in one clinic. They ‘advise caution before extrapolating (their) results to other nurses and doctors’ (p. 1456). They plan, they tell us, to continue their investigation, first by comparing the nurse practitioner with other consultants in the unit, and also by applying their method to other clinics. That will take time. Their own audit was modelled on an evaluation in a London hospital well over a decade ago. And will what Osborn et al. plan to do next actually provide definitive, generalizable evidence? No, it almost certainly will not. The next step, if more evidence is needed, is to conduct a robust evaluation able to provide definitive evidence to support (or not) the safety and acceptability of breast disease diagnosis by nurse practitioners. There is now much better understanding of how healthcare evaluations can be designed to be methodologically sound, whether in the form of a conventional parallel group randomized controlled trial or, if not feasible, using an alternative, but rigorous, design. Adding an economic evaluation makes it all the more useful, and Osborn et al. do flag that up (p. 1457). But perhaps there is already enough evidence to promote nurse-led breast clinics, although obviously with the proviso of standardized training, adequate supervision and a robust system of monitoring to ensure that diagnostic reliability is maintained. I do not have the knowledge to judge whether or not this would be prudent, but what I do know is that further small-scale local evaluations, with inherent limitations, will endlessly prolong the process of decision-making. How much more evidence is needed is always a tricky question. Strong evidence is not always picked up in healthcare practice or policy. And new developments are often introduced on the basis of weak evidence, if any at all. It seems to depend on what fits with views about what is urgent and pragmatic, and whether the proposed change is politically acceptable or not. The current political climate, at least in the UK, is highly sympathetic to nurse-led developments, and patients have been found to be generally supportive. The time is ripe for Osborn et al.’s question to be considered. If more evidence is deemed to be necessary, a collective decision with medical and nursing colleagues in the field about what further research is required, also involving research experts to ensure the strongest possible methodology, would ensure that a conclusive answer will be found to the question at stake.