First published in 1996: Lorentzon M. & Hooker J.C. (1996) Nurse practitioners, practice nurses and nurse specialists: what's in a name? Journal of Advanced Nursing 24, 649–651
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.