Nurse Practitioners, Practice Nurses and Nurse Specialists: what's in a name?

Abstract

Professionalizing forces in nursing, increasing crisis in medical manpower and extension of primary health care have combined to create new roles for nurses in this sector of the British National Health Service (NHS) in recent years and many similar forces have been at work in other countries. Expansion of the already existing body of practice nurses in the United Kingdom (UK) has also taken place. The traditional distinction between nurses who are mainly employed by NHS Community Health Trusts, such as district nurses, health visitors and community midwives and practice nurses, who are, generally, employees of general practitioners, is becoming blurred. Fundholding general practitioners in the UK are increasingly contemplating direct employment of health visitors and district nurses to work full or part-time within their practices. The shifts in power demonstrated by such arrangements require monitoring in terms of the inter-professional dynamics between doctors and nurses. Similar ‘boundary issues’ have been debated, especially in the American literature, which gave birth to the primary nurse concept so crucial to the development of nurse-led care (Manthey 1992). Nursing development units have provided evidence of effective care in nurse-led units catering for specific groups of patients, e.g. the elderly (Black 1993, Turner-Shaw & Bosanquet 1993). The cost-effectiveness argument is often used: nurses are generally cheaper than doctors. But are they? Anecdotal feedback from personal communication with general practitioners indicates that nurse practitioners spend much longer periods with individual patients than general practitioners, thus cancelling out the comparatively lower unit cost of a nurse compared to a doctor. Many nurse practitioners have argued that they provide ‘something different’ compared to the service given by a general practitioner. But what is this magic ‘something’? Comparative studies of both clinical outcomes and patient satisfaction are needed to explore the difference, if any, between general practitioner and nurse practitioner services provided to matched groups of patients in the same surgery. Smith (1995) points to lack of research documentation regarding the efficacy of nursing care. Cost-effective methods of delivering care in developing countries have included development of medical/nursing cross-over roles on the ‘Feldscher’ model (Russian rural health worker), loosely described as a ‘barefoot doctor’ (Hyde 1974). Another example of such developments is the work undertaken by traditional healers in Swaziland (Moran 1992). These indigenous health workers function alongside family nurse practitioners as a means of ameliorating shortage of doctors. Unconventional health care roles, such as these, need to be explored further in a comparative international setting. Practice nurses have existed in the UK for many years, but their numbers have increased dramatically in recent years (Salisbury 1991, Lorentzon 1993). Their role is traditional in remaining within the confines of a ‘normal’ nursing function, as employees of general practitioners and working as ‘junior partners’ of doctors. However, there is evidence of confusion on the part of both some general practitioners and nurses in primary care about the role boundaries between nurse practitioners and practice nurses, ignoring the important fact that nurse practitioners take on specific diagnostic tasks independent of the doctor, whereas practice nurses generally do not. (But see Marsh & Dawes 1995, in a later section of this guest editorial). British nurse practitioners in primary care are generalists in a similar way to that of general (medical) practitioners. However, because of their ‘extension’ of the traditional role of nurses, these practitioners are often bracketed with the increasing body of nurse specialists, e.g. Macmillan nurses (providing cancer care), continence advisors, HIV/AIDS and diabetic nurses, and Parkinson's disease nurse specialists, currently being developed and evaluated within the Department of General Practice, Imperial College of Science School of Medicine, at St. Mary's Medical School, London. Nurse specialists resemble medical specialists, i.e. hospital consultants, more than they do general practitioners. The function of nurse specialists calls for further cross-national comparative research as initiated by Wilson-Barnett & Beech (1994). A recent research report by the Inner City Task Force of the Royal College of General Practitioners, which was based on a survey of 10% of general practitioners in the UK, concerning suggested improvement to their working conditions in deprived areas (Lorentzon et al. 1994) provided overwhelming evidence that general practitioners wanted more nurses in their teams, both acting in traditional roles and fulfilling the newer ‘extended’ functions. Team-building is clearly the key to making such expansion possible and effective. The primary health care team (PHCT) has been strongly identified as the focus for nursing activity outside acute care. Primary and community care nurses in the UK are being actively encouraged to commit themselves to a PHCT model for service delivery (National Health Service Management Executive 1993). In addition to this the drivers of change in Britain are pushing towards a general practitioner managed PHCT. It is within this context that team building and development become necessities rather than luxuries. Unless growth is organic, new roles such as that of the nurse practitioner, will be grafts onto a weakened root stock and will fail to thrive or even survive. There are many routes to team development. One such avenue is the UK's National Primary Care Facilitation Programme (Hooker 1994) which began as a means of improving anticipatory care, but has embraced team building and development. Other primary health care managers working within the commissioning organizations have similarly adopted a facilitatory approach towards team development. Given the right blend of abilities and personal qualities, together with a high degree of commitment, much can also be achieved from within teams themselves. Measuring the effectiveness of teams is a problematic exercise but innovation is a yard-stick which has been proposed for this purpose (Poulton & West 1993). This argument could be extended by adopting the corollary that the degree to which a primary health care team is able to carve out and develop innovative nursing roles depends largely on its cohesion and effectiveness as a team. Support for this view comes from the recent evaluation of nurse practitioner pilot projects in the South East Thames Region of England. The evaluation team found that the introduction of the role was more likely to be successful where ‘an experienced nurse, already working on the site, is developed into the role’ (National Health Service Executive South Thames 1995). It can certainly be argued that, whatever the primary care setting, team-building is crucial to developing the nursing contribution to its full capacity. A joint King's Fund/World Health Organization seminar in 1988 argued against rigidly defining the nurse practitioner role (Salvage 1991). In the UK, roles which are hybrids between practice nurse, nurse practitioner and nurse specialist are beginning to emerge: for example, practice nurses are extending their roles into dealing with minor illnesses in general practices (Marsh & Dawes 1995). Not surprisingly the United Kingdom Central Council (UKCC) for Nursing, Midwifery and Health Visiting has found it difficult to come to terms with the rapid and needs-led changes and to codify the range of new roles. While supporting the concept of specialist roles, the council came perilously close to offering no support for nurse practitioners (UKCC 1993). However, it is welcome news that the UKCC is now seeking ways of embracing the nurse practitioner role. What is urgently needed is more worldwide research into innovative developments, especially of an action-based type. A projected primary care based nursing development unit in Birtley, County Durham, England, will embrace all community and primary care nurses under the leadership of a senior clinical nurse. Within this exciting demonstration project it is expected that improved teamwork will generate useful role progression for all nurses working in the unit. These are likely to be multidimensional. Research arising from such developments is eagerly awaited. So, what is in a name? Not very much in itself. However, it is important to understand distinctions between roles as discussed above. It does not matter greatly what we call a person fulfilling the role of nurse specialist, nurse practitioner or practice nurse as long as there is a common understanding, within the primary care team and among patients, about the skills and functions of these health workers. Clarification in this area is urgently needed as British health workers move towards closer collaboration with European Union nurses and further extension of the debate about nursing roles is also urgently needed within wider international forums.