Practice nurses and clinical guidelines in a changing primary care context: an empirical study
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Transcript of Practice nurses and clinical guidelines in a changing primary care context: an empirical study
HEALTH AND NURSING POLICY ISSUES
Practice nurses and clinical guidelines in a changing primary care
context: an empirical study
Stephen Harrison PhD
Professor of Social Policy, Department of Applied Social Science, University of Manchester, Manchester, UK
George Dowswell PhD
Hallsworth Research Fellow, Department of Applied Social Science, University of Manchester, Manchester, UK
and John Wright FFPHM
Consultant in Clinical Epidemiology and Public Health, Bradford Hospitals NHS Trust, Bradford, UK
Submitted for publication 9 November 2001
Accepted for publication 24 April 2002
� 2002 Blackwell Science Ltd 299
Correspondence:
Stephen Harrison,
Department of Applied Social Science,
University of Manchester,
Williamson Building,
Oxford Road,
Manchester M13 9PL,
UK.
E-mail: [email protected]
HARRISON S DOWSWELL G & WRIGHT J (2002)HARRISON S., DOWSWELL G. & WRIGHT J. (2002) Journal of Advanced
Nursing 39(3), 299–307
Practice nurses and clinical guidelines in a changing primary care context: an
empirical study
Background. Practice Nurses form an increasingly large proportion of the English
National Health Service primary care workforce and the delegation to them of
clinical work from General Practitioners has attracted some academic attention.
Central to this process are clinical guidelines, which provide the interface between
the movement towards �evidence-based practice� and a range of government-driven
policy developments in primary care.
Aims. To identify the attitudes of practice nurses to clinical guidelines; to investi-
gate the impact of guidelines on nurse/physician relationships; and to describe the
impact of the changing primary care context on nurses.
Methods. We interviewed a sample of 29 Practice Nurses three times during a
16-month period to clarify their attitudes towards guidelines, their use of guidelines
in practice and their assessment of guidelines’ importance. We gathered further data
on organizational culture and perceptions of national reforms of primary care
structures.
Results. We found that practice nurses are generally supportive of clinical guide-
lines. Moreover, nurses’ role and influence within primary care is in a process of
transition to one in which they may undertake responsibility for influencing General
Practitioners’ clinical behaviour so as to adhere to guidelines. Practice nurses
themselves recognize and welcome this, though with some reservations.
Conclusions. Our findings support the proposal that explicit codification of the
scientific basis of the work of lower paid groups may enhance their relative pro-
fessional status.
Keywords: clinical practice guidelines, primary care, practice nurses, general
practitioners, interprofessional relationships, English National Health Service
Introduction
The ratio of nurses to physicians in the English National
Health Service (NHS) primary health care workforce has
undergone a substantial change in the last decade. Although
the total number of general medical practitioners (GPs) has
risen steadily so has the proportion working part-time, so
that the number of whole time equivalent (WTE) GP
Principals has remained fairly stable. In contrast, the number
of practice nurses has roughly trebled since 1988 (Depart-
ment of Health 2001). The GPs, as owners of their practices,
have been instrumental in this increasing employment of
nurses and hold positive views about it. Thus in the early
1990s, over 90% of GPs expressed positive views on the
extension of the practice nurse’s role (Robinson et al. 1993).
GPs perceive four main advantages to employing practice
nurses, namely saving the physician’s time, meeting targets,
extending services and improving access for patients. This has
resulted in considerable diversity, complexity and autonomy
in the work carried out by practice nurses (Atkin & Lunt
1996). Most GPs have by now delegated some aspects of
chronic disease management, vaccination and immunization,
minor operative procedures, and administrative or technical
activities to practice nurses. A recent study suggests that all
GPs are willing to delegate further tasks to practice nurses (or
other members of the primary care team), although wide
variations were reported; on average, GPs estimated that
17% (range 6–28%) of all patients currently seen by a doctor
could be entirely dealt with by another member of staff
(Jenkins-Clarke & Carr-Hill 2001). These positive percep-
tions are broadly complemented by the findings of studies of
the acceptability, effectiveness and cost effectiveness of
substituting nurses for GPs (Lattimer et al. 1998, Reveley
1998, Bond et al. 1999, Venning et al. 2000), though it
should be noted that most of this work has focused on
additionally qualified nurse practitioners rather than practice
nurses generally.
These changes in the primary care workforce have taken
place against the background of two major policy trends.
First, the reorganization of general practice into compulsory
geographically based federations of general practices [initially
Primary Care Groups (PCGs), subsequently Primary Care
Trusts (PCTs)], subjects it to new elements of bureaucracy, in
particular to �performance management� by the NHS man-
agement hierarchy, especially in terms of the implementation
of National Service Frameworks (NSFs) for specific patient
conditions and patient groups. Second, the notion of
�evidence-based� practice in the human service occupations
has risen to political and professional prominence in the last
decade. From an intellectual base largely in hospital medicine
(Harrison 1998) it has spread into primary medical care
(Harrison & Dowswell 2002), other health professions
(Thomas et al. 1999), and other policy sectors, including
education, social care, probation, and other criminal justice
interventions. In the English NHS, it has become formally
institutionalized through the activities of the National Insti-
tute for Clinical Excellence (NICE) and the Commission for
Health Improvement (CHI). The former makes recommen-
dations about the clinical and cost effectiveness of health
technologies and commissions specific evidence-based clinical
guidelines for implementation within the NHS, whilst the
latter inspects uptake and implementation of clinical guide-
lines as part of �clinical governance� review (Secretary of State
for Health 1997, NHS Executive 1998, NHS Executive 1999,
Secretary of State for Health 2000).
Clinical guidelines provide an interface between the ele-
ments of changing context that we have described above and
need therefore to be at the centre of any analysis of changing
professional roles in primary care. They are essentially
algorithmic formulations that guide their users to courses of
(diagnostic or therapeutic) action, dependent upon stated
prior conditions, though they do not necessarily claim to
determine clinical action completely. United Kingdom (UK)
studies agree that nurses in primary care, hospitals and mental
health trusts tend to report positive attitudes towards
research-based practice (Veeramah 1995, Hicks et al. 1996,
Parahoo 2000). The consequences of these positive espousals
are, however, unclear. Nurses may report the existence of
various contextual, social and resource �obstacles� or �barriers�
to the utilization of research (Parahoo 2000). On the other
hand, opaque methods of data collection (repertory grid)
suggest that primary care teams (and especially their various
nurse members) actually regard research as peripheral to their
jobs (Hicks et al. 1996), implying that espoused attitudes may
be merely rhetorical. It is not clear how far these attitudes
relate specifically to clinical guidelines, as opposed to research
more generally, though one study found that nurses may see
the provision of clinical guidelines as a means of overcoming
some of the barriers to research-based practice (Parahoo
2000). More generally, the extent to which guidelines impinge
on autonomous practice has been questioned. Though GPs
may characterize guidelines as �flexible tools�, concern has
been expressed that the clinical judgement of nurses may be
constrained by imposed guidelines (Mead 2000), though an
alternative perspective is that the explicit codification of the
scientific basis of the work of relatively low status groups may
enhance their relative status (Berg 1997).
In this paper we focus on the relationship to these
developments of Practice Nurses employed in general medical
practices. In particular, we consider the impact of the
S. Harrison et al.
300 � 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(3), 299–307
changing clinical context on the �negotiated order� between
practice nurses and GPs. To do so, we draw on data collected
from and about practice nurses in a subsample taken from a
larger study of clinical guideline implementation in primary
care (Dowswell et al. 2001, Dowswell et al. 2002, Harrison
& Dowswell 2002). We explore their reported attitudes to and
use of clinical guidelines, their perceptions of mechanisms
within their practice for information transmission about
desirable clinical practice, and their perceptions of the clinical
governance agenda of the PCG within which their practice
was located. In order to situate our data in context, we make
occasional reference to data about the GPs in our study.
The study
Methods
Sample
In our empirical study of clinical practice guideline uptake,
we selected a stratified random sample of 49 GPs from dif-
ferent practices in eight contiguous PCGs in northern Eng-
land (for details of the full sample of practices, see Harrison
& Dowswell 2002). Although GPs were selected randomly,
nurses could only be recruited where (a) the practice
employed at least one (b) the nurse was known by the GP to
use at least one guideline and (c) the GP, as employer,
consented to the involvement of the nurse in our research.
Following GP recruitment to the study, we identified a
subsample of 29 practices in which to study practice nurses,
all of whom agreed to participate. Two had very recently
become qualified nurse practitioners, but are treated as
practice nurses for the purposes of this paper.
Data collection
We sought to interview each respondent on three occasions
between February 1999 and June 2000, during which period
local clinical practice guidelines in respect of either asthma or
stable angina were developed, agreed and disseminated (see
below and Wright et al. 2000). Interviews were taped and
fully transcribed. Each interview lasted between 30 minutes
and an hour. At the first interview, we collected quantitative
data about respondents’ attitudes to clinical guidelines using
a series of 8-point Likert scales adapted from previous work
(Mansfield 1995). We also discussed participants’ answers,
asking them to explain the reasons for their scores.
At the second interview, we collected further quantitative
data about organizational culture (reported elsewhere;
(Dowswell et al. 2001) and qualitative data about percep-
tions of the impact of PCGs (in existence for 6–8 months at
the time of the interview), opinions about the National
Institute for Clinical Excellence (NICE) (which had just
begun to issue recommendations), and self-reports of clinical
guideline awareness and adherence. The latter focused on
local guidelines based on nationally approved evidence-based
guidelines for asthma (North of England Asthma Guideline
Development Group 1996) and stable angina (North of
England Stable Angina Guideline Development Group 1996).
At the final interview, we discussed preliminary findings
(having provided written feedback to participants), reviewed
the progress of PCGs (in existence for over a year at this time)
with particular attention on clinical governance, asked for
further perceptions of newly emerging national bodies such as
NICE and Commission for Health Improvement (CHI), and
discussed the impact of recent district-wide asthma and
angina audits. We were also able to compare data from
practice nurses with equivalent responses from GPs in the
same practice and with data from a linked audit study
(Wright et al. 2000) about the practice’s adherence to certain
aspects of the above guidelines. We interviewed 26 practice
nurses and 27 of their associated GPs three times as planned.
One nurse was interviewed only twice and one nurse and two
GPs only once. Dropout was caused by long-term sickness
(one GP, one nurse), maternity leave (two nurses) and
pressure of work (one GP). GPs had been in post for slightly
longer than nurses but the range of values was similar (GP
mean, 14Æ0 years, SD 6Æ95, minimum 2, maximum 28; nurse
mean 10Æ1 years, SD 4Æ00, min 2, max 25). Twenty of the
nurses had been in post for exactly 10 years, reflecting the
large increase in the employment of practice nurses in 1990.
All nurses were female, as were 13 of the GPs.
Data analysis
Interview transcripts were checked for completeness and
accuracy. An inductive approach to analysis was adopted and
the entire set of transcripts was read before coding com-
menced. NUD*IST software was employed for data hand-
ling. The quantitative data were entered into SPSS and
descriptive statistics were examined. As most measures were
nominal or ordinal, initial subgroup analysis was carried out
with nonparametric tests (Bryman & Cramer 1999).
Results
Context
In most practices, nurses had considerable autonomy with
certain patients; those with asthma, for example. This was
partly because GPs believed that nurses had more time. It was
also made possible by the development of national, local or
practice guidelines or protocols, each of which could satisfy
Health and nursing policy issues Practice nurses and clinical guidelines
� 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(3), 299–307 301
GPs that there was a shared understanding and sufficient
safeguards to hand over control. In some cases, this amounted
to abdication of interest by GPs. The existence of recognized
nurse training courses, with certification, helped this process.
Nurses were seen by most GPs as more uniform, consistent and
reliable when it came to administering routine tasks, and as
more persuasive with some patients. These perceived assets
were valued, and encouraged GPs to hand over such tasks.
Nurses in most cases decided the treatment and instructed the
GP to write specified prescriptions. Nurses were also seen to be
more interested in audit, reflecting what was perceived as their
thorough, methodical approach. Only two examples were
found of GPs retaining control of their asthma patients. GPs
frequently displayed ambivalent attitudes about their own
clinical behaviour, and that of nurses, in relation to guidelines.
Many were bored by guidelines and routine clinical topics, yet
confessed themselves to be unsystematic and accepted that they
ought to adhere to guidelines more frequently. There was a
corresponding tendency implicitly to denigrate nurses’ will-
ingness to follow guidelines whilst simultaneously recognizing
the value of such behaviour.
Attitudes to guidelines
All the nurses rated their attitude towards guidelines on the
welcoming half of a eight-point Likert scale. About half
(15/29) scored their colleagues as equally welcoming, none
believed that their colleagues were more welcoming and half
(14/29) believed their colleagues were less welcoming than
they were. All rated guidelines on the useful half of the scale.
Almost all (27/29) the nurses believed that well-developed
guidelines would improve the quality of care within the NHS.
Two-thirds (19/29) would not be reluctant to use a guideline
which was aimed at reducing costs without affecting patient
outcomes. One-third (10/29) agreed that using guidelines
reduced the autonomy of doctors and slightly more (12/29)
agreed that using guidelines denies the individuality of the
patient. GPs’ responses were broadly similar but consistently
less positive on every issue, though in a study of this size,
these differences were not likely to be statistically significant.
A few doctors (5/29) did not believe guidelines were useful, a
few were resentful of guidelines (3/29), and about half (14/
29) thought that their colleagues were resentful (Table 1).
The more subtle qualitative responses to our questions
revealed a broad spectrum of GP views, from enthusiasm,
through caution to reluctance and rejection (Dowswell et al.
2001). Nurses’ views were less disparate, however. They
found guidelines useful for a number of reasons, including
protection for themselves, as a means to consistency of
practice and as a source of expertise and autonomy. Nurses
were also able to link the topic of guidelines with the broader
context of contemporary changes in English primary care
Table 1 Attitudes towards clinical practice guidelines
Extremely useful Totally useless
1. How useful do you believe guidelines
are to you?
1 2 �3 4 5 6 7 8
Extremely welcoming Extremely resentful
2. How would you describe your attitude
towards guidelines?
1 2 �3 4 5 6 7 8
3. How would you describe the attitude of
most of your colleagues towards guidelines?
1 2 �3 4 5 6 7 8
Extremely reluctant Not at all reluctant
4. Would you be reluctant to use guidelines that
were aimed at reducing costs without
affecting patient outcomes?
1 2 3 4 5 �6 7 8
Strongly agree Strongly disagree
5. Do you agree or disagree that using
guidelines reduces the autonomy of doctors?
1 2 3 4 �5 6 7 8
6. Do you agree or disagree that guidelines deny
the individuality of the patient?
1 2 3 4 �5 6 7 8
7. Do you agree or disagree that the
implementation of well developed guidelines
would improve the quality of care
within the NHS?
1 2 �3 4 5 6 7 8
Nurses’ median score is underlined, GPs’ median score is encircled.
S. Harrison et al.
302 � 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(3), 299–307
organization. The quotations that follow are illustrative of
these themes.
Guidelines as protection
Nurses often saw guidelines as offering practical and medico-
legal protection for their own clinical activities, both from the
vagaries of individual GPs’ shifting or inconsistent opinions,
and from the consequences of their own relative lack of
clinical experience:
the nurses…we felt we needed protecting from the GPs really, we
needed to know what they wanted us to do and we wanted to write
down what we wanted to do. (N34)
Probably, as nurses, it’s probably more helpful in our job, than it
is for the doctors. Because when you are working independently,
at times it quite hard to define your role sometimes. If you know
you are following some guidelines, at the end of the day you feel
like, it’s a bit black and white really, but legally, you feel safer, I
suppose, because you can say, look I did what the guidelines say.
and you haven’t got the experience as much of the drugs as the
GPs have. Guidelines are helpful in defining your role really.
(N13)
Of course, nurses still had to be aware of the idiosyncrasies of
individual GPs and respond accordingly:
There are four or five fairly academic doctors here. and there are
those who are carried along…It’s quite nice; they give us a free rein,
but we do know individual GPs’ preferences. (N02)
Even if you have a clinical protocol to work within…if there is
something that needs addressing, then depending on which doctor
you go to you will get a different advice or answer… (N12)
We did have a doctor who was lovely but a bit of a dinosaur and it’s
very difficult when you’ve moved on with treatment paths and he still
hasn’t. (N22)
Guidelines as consistency
Guidelines were also seen as a useful means of securing col-
lective agreement to action when clarification was needed, as
a means of securing continuity of care for patients, and as a
natural way of working for nurses:
Our GPs are quite good. At our clinical meetings…what we do if we
have any gripes or if anyone is not sticking to the guidelines or, you
know, if we’ve had a problem with a patient, for instance, �well this
doctor told me this but you�ve told me another thing and what’s
going on?’ We bring it up at the meeting and thrash it out and usually
there is a pretty good explanation. (N34)
But I personally…do find guidelines very helpful and I think…it does
direct the patient through an organized process whereas patients can
be lost in the middle if you don’t have some sort of guidelines to work
to. (N24)
It’s inbuilt, isn’t it, in nurse training…that’s how we are; we just
follow rules. I think that’s the nurse’s thing. (N18)
GPs confirmed that the pressure for guidelines often came
from nurses:
They were requesting guidelines for what they should be doing.
(GP13)
Guidelines, autonomy and expertise
Whilst guidelines, seen in purely logical terms, would be
expected to reduce clinical autonomy, it was clear that many
nurses actually used them in a way that enhanced their au-
tonomy. In particular, the existence of guidelines offered
nurses the explicit foundation on which to develop a spe-
cialized expertise, which might be deployed in several ways.
First, the nurse might have a role in training other nurses and
even GPs:
…a lot of the drug firms, they all kind of jumped on this bandwagon
and were providing a lot of educational opportunities for us. and this
is where we got a lot of our information from and brought it back to
the doctors. (N22)
Second, one nurse regularly used specialized knowledge to
challenge GPs’ clinical decisions:
When a certain doctor says that he thought it was a marvellous idea
these new leukotriene inhibitors �we�ll put them all on them and take
them off the steroids.’ I said that �if you do that then I�ll report you’
(laughs). He said �but that�s my choice’, I said �It isn�t your choice to
do that you know, where does it say it’s safe to do that, where is the
leukotriene inhibitor in the guidelines? Where is the research that
supports your supposition that you can stick somebody on that and
take them off everything else?’. So anyway, but I mean it was all
reasonably light hearted but I had a horrible feeling that was what he
wanted to do. (N12)
It makes my job a lot easier if I can wag my finger at the doctor and
say �It�s all right you saying that but you know if you look at the BTS
(British Thoracic Society) guidelines (for asthma) it does say ‘‘Add in
Seravent blah de blah’’’ you see what I mean? (N12)
Third, specialized knowledge underpinned by guidelines
could become the basis for genuine clinical teamwork:
She doesn’t listen to the chest but she can do everything apart from
that. (GP10)
They tend to sort of leave you to get on with things, this is what we want
you to do and leave you to get on with it…and it’s only when something
doesn’t go well that they sort of say, hey, hang on a minute. (N27)
Health and nursing policy issues Practice nurses and clinical guidelines
� 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(3), 299–307 303
Most nurses expected to be involved in debating, drafting or
modifying at practice level any guidelines they were expected
to use:
We developed some practice guidelines for the management of
coronary disease. They are interdisciplinary. This will make them
acceptable to the GPs and practice nurses. We reviewed the evidence,
looked at the National Service Framework, considered clinical
governance, and chose an area which is one of our local priorities.
(N06)
Thus guidelines were seen as a way of negotiating changes in
care provided by GPs. The relative strength of the nurse’s
position was seen to stem from both the ostensible scientific
basis of guidelines and the implied criticism of GPs’ current
practice, without which the guidelines would be unnecessary.
Guidelines in practice
None of these factors meant that GPs simply assented to
compliance with guidelines. Although most nurses could
identify at least one senior partner who was supportive of
their desire for guidelines, few practices were composed en-
tirely of pro-guideline GPs:
We’re trying to follow guidelines and it’s very difficult, if you’ve got
one person who sits in a meeting and agrees in principle and then
(doesn’t follow). (N22)
You quite often say �right we�re going to try and do this’ and
everybody says �yes we�ll do this’ and when you come to try and put it
into practice you have to say �I thought we were going to do this�. �Oh
well� says the GP, �I�d rather do this’. (N27)
Crucially though, the nurses themselves did not always
adhere to the guidelines either. Most did not see them as �set
in stone�. While nurses were less inclined than GPs to argue
against what they perceived to be the scientific basis of
guidelines, they were also unwilling to argue against the
vagaries of human nature:
Yes, we’re talking about the real world. Frameworks and guide-
lines…protocols aren’t the real world; they are the ideal model, you
know, utopia and all that, and that’s not the real world…the outcome
doesn’t necessarily match what should happen according to that
biomedical model because we are human beings and we’re odd and
we do our own thing. (N12)
We’re very good. We do what we are told; sometimes; when it suits.
(laughs) (N07)
Thus Practice Nurses perceived that they could have a strong
role in influencing GPs’ practice, and felt that they were in a
better position to design and adhere to guidelines than GPs.
This mechanism, constant indirect influence causing GPs to
adapt to changes occurring around them, has the potential for
considerable impact. It is neither overt nor coercive and
involves no overt confrontation or intellectual challenge.
The changing context of primary care
All nurse respondents were aware of the existence of Primary
Care Groups (PCGs) and most perceived a link between the
activities of these new organizations and the use of clinical
guidelines in primary care, though only one-third (9/27)
thought that the PCG had so far changed their clinical
practice or workload (6–8 months after inception). Some
nurses felt that the development of local clinical governance
arrangements would help them to persuade GPs to practise
more in line with guidelines:
Clinical governance issues within the PCG are going to force their
hands, and at least then we can go along saying �we are following the
clinical guidelines aren�t we’. (N05)
Some nurses commented on specific changes which were
occurring as a result of the PCG. For example, three
mentioned moves to more generic prescribing, two men-
tioned computers and one described increasing paperwork.
Two felt that the existence of PCG targets and possible
incentive payments made an extended nurse-led approach
more important:
…we have agreed targets. We have agreed within the practice that we
are going to look at asthma, ischaemic heart disease and hyper-
tension. All those areas are my areas of interest anyway, so from my
own point of view I have to be aware of what clinical governance is,
what the local Health Improvement Plan is and how we are going to
interpret it locally, but also, because I am the clinical governance
lead, I have to make sure that all of the doctors as well as the other
nurses are all on board as well and that we are all doing the same
thing…There are going to be performance indicators, like the NSF for
cardiology, and at the end of the day, there is that stick. If we don’t
get paid for doing what we said we were going to do, that will
support me a lot. It’s very difficult to get everyone to do the same
thing. You’ve got two choices; you work on the individual practi-
tioner and say �do you realise the guidelines now and maybe we can
work a bit more closely here� and they might say �get lost/so what�, or
�yes� and not do it, which is the trickiest one…I’m a nurse, so I have to
be a bit careful sometimes about what I say. (N06)
Some nurses were already contemplating, or had already been
drawn into a wider PCG role, going beyond the specific
general practice in which they worked:
Not all practice nurses have the same experience or training, so
perhaps those of us who are COPD (chronic obstructive pulmonary
S. Harrison et al.
304 � 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(3), 299–307
disease) trained or diabetes or whatever, have specialist skills, will
perhaps be roaming practice nurses throughout the PCG. So long as
you can provide continuity of care, I don’t think it’s a bad thing,
because if our skills can be passed on to other nurses, that would be
good. We would be raising the standards throughout the PCG so that
all nurses are trained to the same level and delivering the same
standard of care, working to the same protocols. (N07)
Everything will be the same everywhere. We’ll be getting training, but
we don’t know when. Maybe they will have clinics within the (PCG)
and those who are qualified to do them will run them, rather than
having individual clinics at each practice. They do (practice-based
locality) clinics for diabetics now, but I think they will probably do it
for a lot of other things as well. (N19)
Not all the nurses saw the PCG having a positive impact, with
four predicting minimal impact and four identifying negative
impacts. Negative perceptions concerned two main themes,
related, respectively, to patients and to nurses themselves.
The former centred on the possible impact on patients of an
over-emphasis on cost and over-specialization of nursing
staff:
You might find that it leads to narrowing of guidelines. You’ll get
fairly strict guidelines about what drugs you can prescribe. These
drugs will be, first and foremost, cheap. After that will be the clinical
aspects – does it work? I am not saying they don’t want to improve
care if they can, but their first priority is to save money. (N12)
I think I look more at costs than I did. Plus we’re going to have to
stop referring patients to certain places because they’re not in our
area, now we’ve got people going to locality clinics, they are going to
have to go back to hospital for certain things. (N17)
The latter centred on the assumption that nurses would be
happy to take on an extended role without additional
remuneration:
I’m not just speaking for myself but for the three nurses in the
practice, the thing that did annoy us, and we were annoyed…there is
no mention whatsoever about the nurses’ grading structure, or pay
structure for taking on all this extra work and it was just, they took it
as read that the nurses were going to do this extra work, not �do you
want to do it? Do you want to take it on? Do you think you can
accommodate it within the hours that you are doing?�. We were
annoyed, I thought it was rather condescending. �You ought to be
damn grateful that we as doctors think that you as nurses can be
allowed to do this for no extra grading, no remuneration�, and I just
thought it wasn’t on, to be honest…Not that I think it hasn’t got it’s
good points. I can see a lot of the reasoning why they say it should be
nurse run, because a lot of patients do talk to the nurses more, and
for one reason or another, they think that we’ve got more time for
them than the doctors, and yes you probably could get quite a bit
more information initially. But I just think it’s shifting work sideways
because of economics – it’s bloody cheaper for the nurses to do it
than the doctors, and I’m sorry, but I consider myself just as much a
professional, and I know, I’ve been in the business long enough, and
I’ve worked for enough GPs, that GPs don’t do anything unless they
are actively remunerated for it, and I don’t think that nurses’ services
should come cheap. (N03)
Discussion
The data reported in this paper are consonant with earlier
findings that nurses are generally supportive of clinical
guidelines and confirm that, where relevant guidelines exist,
GPs have their own pragmatic reasons for delegating a good
deal of clinical work to practice nurses. Most important, it is
evident that the role of these nurses is in a process of
transition and that they themselves recognize and generally
welcome this though with some reservations, mainly on the
part of older nurses who contrasted their willingness to
accept new roles with the reluctance of GPs to make any
changes without remuneration. The restructuring of roles
across the primary care team advocated by commentators
such as Kernick (1999) may well be happening in practice,
enabled in part by the existence of clinical guidelines and of
clinical governance mechanisms in PCGs.
Our findings have some theoretical relevance in the context
of sociological analyses of professional dominance and
autonomy. On the face of it, a clinical guideline constrains
a practitioner’s autonomy (Berg 1997, Harrison & Ahmad
2000, Mead 2000). Within the medical profession, the
increasing enforcement of guidelines can be seen either as
an example of further stratification (Freidson 1985, p. 26) in
which professional elites exert greater control over rank and
file practitioners, or as a means for the proletarianization of
the physician labour process through bureaucratic rules
whose prime intent is managerial (Coburn et al. 1983, p.
423). In either case, the autonomy of rank and file physicians
(GPs in this study) so far as labour process is concerned is
diminished. Yet if the analysis is extended to include the
relationships between the medical and nursing professions, an
apparent paradox emerges. Although guidelines also logically
diminish nursing autonomy, our study shows that substantive
changes in such autonomy will depend on how guidelines are
actually used.
Conclusion
The evidence suggests that the NHS’s policy drive towards
guideline-based clinical care, as manifest in NSFs, target
setting, performance indicators and other clinical governance
Health and nursing policy issues Practice nurses and clinical guidelines
� 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(3), 299–307 305
activities of PCGs, has provided practice nurses with
increased legitimacy in their relationship to both patients
and employers. This has led to nurses perceiving themselves
as more authoritative within general practices, enabling them
to argue with their employing GPs for the adoption of, and
adherence to clinical guidelines. In some areas of clinical
practice, this placed them in a power sharing position, but in
areas with established training opportunities and credible
standards (such as asthma and diabetes), nurses seem to
exercise considerable control. Thus guidelines have implica-
tions for interprofessional power relationships and our
findings lend some support to Berg’s (1997) argument that
explicit codification of the scientific basis of the work of
relatively low status groups may enhance their relative status.
In other words, clinical guidelines may attenuate the dom-
inance of medicine over nursing. However, GPs have their
own reasons for delegating clinical work, and government
has its own reasons for encouraging guideline-based clinical
care, so that elucidation of the full implications for both
medical/managerial and interprofessional power relation-
ships would depend on wider studies of whose agendas are
served by the increasing diffusion of clinical guidelines.
Acknowledgements
Thanks are due to all participants and to NHS Executive
London who funded the study.
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