Practice nurses and general practitioners: perspectives on the role and future development of...

NURSING WORKFORCE ISSUES

Practice nurses and general practitioners: perspectives on the role and

future development of practice nursing in Ireland

Geraldine McCarthy, Nicola Cornally, Joe Moran and Marie Courtney

Aims and objectives. To explore the role dimensions, competence and professional development needs of practice nurses in

Ireland from both the general practitioner’s and practice nurse’s perspective and highlight any agreement/disagreement between

the professions.

Background. Economic pressure on healthcare delivery is promoting a re-evaluation of professional roles and boundaries. This

coupled with a primary care sector that is evolving prompted an investigation into the role dimensions and competence of the

practice nurse. There is a lack of empirical data comparing the general practitioner’s and practice nurse’s perspective on the

current role of the nurse, clinical competence (existing and required), strategic direction for the role and continuing professional

development.

Design. A descriptive cross-sectional survey design was used.

Methods. A random sample of general practitioners (n = 414) and a purposeful sample of practice nurses (n = 451) partici-

pated. Data from each profession were analysed and comparisons drawn.

Results. General practitioners and practice nurses agree (±5%) that the nursing role is centred on immunisation, direct clinical

care and elements of chronic disease management. However, in some areas such as preconceptual advice, family planning,

advice on menopause, continence promotion and research, there was a 30% difference between the general practitioners

perceptions of the nurse’s involvement and the practice nurse’s actual involvement in the role. Perceived competency differed in

a number of areas with nurses more likely to indicate competency in health promotion activities. Both disciplines acknowledged

that only a minority of practice nurses were competent in audit, research and dealing with ‘problems with living’ (relationship

breakdown, addiction and parenting).

Conclusion. There is some congruence of opinion among practice nurses and general practitioners in Ireland regarding the current

role of the practice nurse. Divergent opinions on the nurses’ involvement in a particular aspect of the role may be due to the general

practitioners underestimating the nurse’s involvement in the role. Training is required in the areas of audit, research and ‘problems

with living’.

Relevance to clinical practice. This research provides data for role clarity and evidence-based role development for practice

nurses within the context of evolving primary care services. It also indicates how general practitioners perceive the nursing role.

Key words: competence, general practitioners, practice nurse, primary care, professional development, roles

Accepted for publication: 26 February 2012

Authors: Geraldine McCarthy, PhD, RGN, RNT, Dean and Head,

Catherine McAuley School of Nursing and Midwifery, University

College Cork, Cork; Nicola Cornally, MSc, BSc, RGN, Lecturer and

PhD Student, Catherine McAuley School of Nursing and Midwifery,

University College Cork, Cork; Joe Moran, MB, BCh, BAO, MCLSC,

MRCGP, MICGP Lecturer in General Practice, Department of

General Practice, College of Medicine and Health, University

College Cork, Cork; Marie Courtney, BSc, MSc, RGN, Professional

Development Coordinator (Practice Nurses), Nursing and Midwifery

Planning and Development Unit, Cork, Ireland

Correspondence: Nicola Cornally, Lecturer and PhD Student,

Catherine McAuley School of Nursing and Midwifery, University

College Cork, Cork, Ireland. Telephone: +353 21 4901478.

E-mail: [email protected]

� 2012 Blackwell Publishing Ltd

2286 Journal of Clinical Nursing, 21, 2286–2295, doi: 10.1111/j.1365-2702.2012.04148.x

Introduction

Primary health care has changed and is changing at a

significant rate both in Ireland and at an international level

(World Health Organisation 2008). There has been a shift in

focus in the past decade from care centred on diagnosis and

treatment to disease prevention and chronic illness manage-

ment. Healthcare reform in Ireland has meant that primary

care is a priority area for service development (Department of

Health and Children 2001). In China, primary care develop-

ment has been highlighted as a key area requiring restruc-

turing and improvement (Liu et al. 2011). Australia, in 2010,

launched their first primary care strategy aimed at developing

‘a strong, responsive and cost-effective primary healthcare

system’; central to the proposed transition is a skilled

workforce (Australian Government Department of Health

and Ageing 2010, p. 10). In 2008, the Department of Health

in the United Kingdom (UK) published a document delineat-

ing their progress to date on primary healthcare reform,

emphasising the ever-growing need to continue to advance

changes in primary care and the community that promote

choice, quality, equality and healthier lives (Department of

Health 2008).

While most hospital nurses have developed defined roles as

services evolved, following a review of the literature it is

evident that there is a dearth of research available on the

changing role of practice nurses in Ireland, which appears to

be mostly determined by government funding, the employing

general practitioner (GP) and the desire for change. Accord-

ing to Halcomb et al. (2008), this is also the case interna-

tionally.

No live register exists for practice nursing in Ireland;

however, the Irish Practice Nurse Association (2009) esti-

mates that there are currently over 1500 practice nurses

employed privately by GPs. A recent document on GP

workforce planning for Ireland suggests that a 5% annual

increase in practice nurses is required to meet future primary

care demands (Teljeur et al. 2010).

General practice in Ireland

‘GPs are self-employed professionals who engage in service

commitments, under a range of individual contracts with the

Health Service Executive, for delivery of services to either

exclusively public patients or to a public-private mix…they

also provide services directly to private patients (Department

of Health and Children 2001, p. 52)’. They are often referred

to as the gatekeepers to secondary care (Scottish Intercolle-

giate Guidelines Network 1998). During the early 1970s, GPs

entered into what is known as the General Medical Scheme

with the Heath Service Executive (HSE) (Irish College of

General Practitioners 2007). This scheme allows people with

a medical card (based on income or disability) to have free GP

and practice nurse visits. There are currently over 1Æ5 million

people in Ireland with a medical card (HSE 2010, p. 3). In

2001, the Department of Health and Children published a

Strategy for the development of primary care services in

Ireland, primarily to improve quality and access, reduce the

burden on secondary care and provide a more cohesive

service to patients in the community. Contained within the

strategy were plans to develop primary care teams where

practice nurses, GP, public health nurses and other healthcare

professionals would work jointly to deliver integrated care. It

was envisaged that up to 600 primary care teams, positioned

in specifically designed centres, would be in place by the end

of 2011. To date, only a handful of these primary care centres

have been created throughout the country, by the efforts of

entrepreneurial GPs. Some GPs, in particular those situated

rurally, still work in isolation. Practice nurses are employed

privately by the GP, as is the case internationally, such as

Australia. A subsidised pay agreement for the employment of

a practice nurse has led to the increase in practice nurse

employment nationally. Teljeur et al. (2010) concluded that

there will be a major shortage of GPs in Ireland, and an

increase in the numbers of practice nurses will be required to

deliver care. This raises the issue of extending the role of the

practice nurse into areas previously the GPs domain. How-

ever, before role extension can take place, the current role or

its relationship to that done by practice nurses internationally

must first be established.

The role of the practice nurse in Ireland and

internationally

Only one older study is published, which investigated the

role from the practice nurses’ perspective in Southern

Ireland (Harrington et al. 1994). Results indicated three

areas of practice: basic role [tasks the nurse should be

competent in, e.g. blood pressure (BP) recording], practice

organisation role (i.e. stock control) and extended role

(training required to undertake duties, e.g. cervical smear).

Results also showed that over 90% were undertaking duties

such as stock ordering and receptionist duties (i.e. organ-

isational tasks) despite the presence of a receptionist in most

practices. The Irish College of General Practitioners (2006)

described the clinical duties of the practice nurse as those

relating to direct and indirect clinical care, ranging from

tasks such as phlebotomy to the management of chronic

disease clinics and the development of practice policies.

Educator, manager, communicator, auditor and researcher

Nursing workforce issues Practice nursing in Ireland


Journal of Clinical Nursing, 21, 2286–2295 2287

were also heavily weighted within the scope of the detailed

role description, which was documented without reference

to research.

In the UK, the role of the practice nurse encompasses

clinical health assessments, health promotion and education,

and the clinical management of patients (Longbottom et al.

2006). A closer examination of the role in the UK, from the

practice nurses’ perspective (n = 1161), by Crossman (2008)

revealed that health promotion, chronic disease management,

immunisation and women’s health defined the role. Eve and

Gerrish (2008) found that management of patients with

hypertension, diabetes and asthma accounted for 60–85% of

the nurses’ role, yet the management of chronic diseases such

as epilepsy, coronary artery disease and chronic obstructive

pulmonary disease (COPD) featured in only 4–10% of

nurses’ activities. Robinson et al. (1993) and Atkin and Lunt

(1996) have explored the role of the practice nurse from the

GP’s perspective both using qualitative methods. Robinson

et al. (1993) investigated GPs attitudes towards practice

nurses and the activities that practice nurses were employed

to undertake. Barriers to role developed, nurse’s attitudes,

lack of opportunity and inability to prescribe were also

investigated. Findings revealed that almost 90% desired role

expansion, and central to role expansion was provision for

education and training. Atkin and Lunt (1996) found that

much of the training involved ‘on-the-job’ instruction, and

GPs supported the continuing professional development of

practice nurses but highlighted that it is very much the

responsibility of the individual nurse.

In Australia, the role of the practice nurse contains four

dimensions: clinical care, clinical organisation, practice

administration and integration of services (Watts et al.

2004, p. 23). A review of the role by Halcomb et al. (2006)

concluded that a substantial amount of practice nurses were

conducting ‘traditional tasks’ and the role lacked defining

boundaries. Subsequent research by Halcomb et al. (2008)

found that the role of the practice nurse was centred on core

clinical skills such as assisting GP with minor surgical

procedures, wound dressings, preparing equipment for GPs,

activities that required minimal further education and train-

ing. Advanced practice skills such as cervical smears/breast

examination were undertaken by <20% of those surveyed

and correlated positively with more clinical experience. Areas

such as health promotion and research were described as

expanded nursing skills, and up to 40% required further

training in these areas to become confident. This work also

showed that roles were shaped by models, GP preferences,

space within the practice and legal implications.

It is evident that there is a dearth of published research

comparing the views of GPs and practice nurses on the role

and competence of practice nurses. This is important as

internationally, in many situations, GPs employ practice

nurses and can impact on their role function, which may lead

to situations where nursing skills are either underused or,

preferably, used to the advantage of the patients requiring

primary care.

Aims and objectives

The aim was to explore the role dimensions, competence and

professional development needs of practice nurses from both

the GP’s and practice nurse’s perspective and highlight any

agreement/disagreement between the professions.

Methods

Research design

A descriptive cross-sectional survey design was used to meet

the aims of this research. The study was conducted in two

phases and took place over a 12-month period. Phase one

examined the role of the practice nurse from the practice

nurse’s perspective, and phase two investigated the role

from the GP’s perspective. Detailed results on the first phase

of the study are published elsewhere (McCarthy et al.

2011).

Study instrument

Similar researcher-developed questionnaires were used for

both phases. Section one of both presented a series of closed

questions regarding demographic and working conditions.

Section two was largely dedicated to questions that related

directly to the role and scope of the practice nurse, as

outlined by the Irish College of General Practitioners (2006)

and Crossman (2008). Forty-nine clinical activities and

specialist skills were presented in a manner that allowed the

respondents to identify areas of clinical practice, compe-

tency and education/training. The practice nurse version

differed slightly from the GP questionnaire when assessing

competency. For example, practice nurses’ perceived com-

petency was measured using Benner’s Competency Frame-

work (1984), and participants were asked to indicate level

of competence from novice to expert (McCarthy et al.

2011). GPs, on the other hand, were asked to indicate

whether they felt the practice nurse was competent or

needed further training to become competent for each of the

49 activities. Section two on both questionnaires also

contained questions and statements regarding barriers to

education.

G McCarthy et al.


2288 Journal of Clinical Nursing, 21, 2286–2295

Four GPs, four practice nurses and a professional devel-

opment coordinator for practice nurses were consulted for

their expert opinion of the questionnaire, and pilot testing

was conducted during the instrument development process.

Minor amendments in formatting and wording of questions

were made as a result.

Sample

Purposeful sampling was used for phase one. The question-

naire together with a letter of invitation, an information

leaflet and a stamped, addressed envelope was distributed to

all 1517 practice nurses registered with the 11 Professional

Development Coordinators for practice nurses in Ireland.

Inclusion criteria specified that practice nurses must be in

current employment. The research pack was distributed

through postal services. A total of 451 questionnaires were

returned (response rate, 30%) following text reminders and

an advertisement on the Irish Practice Nurse Association

(IPNA) website.

Phase two was conducted through the Irish College of

General Practitioners. A random sample of 1400 of the

2300 GPs working in Ireland was generated from the 2009

database. The only inclusion criterion was that GPs must be

working in a centre where a practice nurse was employed.

Similar to phase one, the questionnaire together with a letter

of invitation, an information leaflet and a stamped,

addressed envelope was posted to the target sample. A

total of 414 questionnaires were returned (response rate,

29%).

Ethical considerations

Ethical approval to conduct the study was granted from the

Irish College of General Practitioners Ethical Committee and

the Clinical Research Ethics Committee of the Teaching

Hospitals.

Data analysis

Data from the closed questions were analysed using the

Statistical Package for Social Science (SPSS Inc., Chicago, IL,

USA). Descriptive statistics were used to summarise and

interpret the data. Data were collected using different

research instruments for each group, and questions, in part,

were dissimilar, thus restricting statistical analysis across

groups. However, differences between professions in terms of

nurses’ involvement in each activity were calculated using

chi-square test for independence (with Yates continuity

correction).

Results

Demographic details

Practice nurse phase

The demographic characteristics of participating practice

nurses are presented in Table 1. Of the 451 practice nurses

who participated in the study, 79% (n = 356) were employed

in multi-GP practices and over 65% (n = 299) held part-time

positions. Analysis of age profile showed that the majority

were aged between 31 and 50 years (73%, n = 326).

In addition to holding the qualification of registered

general nurse, 33% (n = 153) were registered midwives.

Only 9% (n = 40) had a diploma in nursing, while 15%

(n = 67) had a BSc in nursing. A smaller number of

participants held the qualification of Mental Health Nurse

and Intellectual Disability Nurse (n = 13, 13% each).

Table 1 Demographic details from practice nurse respondents

Characteristics Group Frequency

Percentage

(%)

Age Under 30 38 8Æ4Between 31–40 152 33Æ8Between 41–50 174 38Æ7Between 51–60 76 16Æ9Over 60 10 2Æ2

Number of GPs

working in each

practice

Single GP practice 93 20Æ72 GPs 111 24Æ73 GPs 97 21Æ64 GPs 72 16Æ05 or more GPs 76 17Æ0

Number of

practice

nurses

working in

each practice

1 nurse 188 41Æ82 nurses 134 29Æ83 nurses 66 14Æ74 nurses 37 8Æ25 or more nurses 25 5Æ5

Practice nurse

employment type

Full-time 149 33Æ3Part-time 299 66Æ7

Professional

qualifications

Registered general

nurse

434 96Æ4

Registered midwife 153 34Æ0Registered public

health nurse

31 6Æ9

Registered nurse in

intellectual disabilities

15 3Æ3

Registered nurse in

mental health

13 2Æ9

Diploma nursing 40 8Æ9Degree nursing 67 14Æ9

Specialist

practice

Clinical nurse

specialist

73 16Æ2

Advanced nurse

practitioner

1 0Æ2

GP, general practitioner.




Sixteen per cent (n = 73) of participants reported being

employed as clinical nurse specialists. One participant (0Æ2%)

reported being an advanced nurse practitioner. All others

were employed at staff nurse grade.

GP phase

The practice profile, that is, information on the number of

practice nurses and GPs employed on both part-time and full-

time bases, of GPs who participated in the study showed that

31% (n = 129) worked in a practice where two full-time GPs

were employed. Thirty per cent (n = 125) responded from

single GP practices. Eighteen per cent (n = 74) worked in

practice with three full-time GPs, while 20% (n = 83) worked

in practices that had between 4 and 12 full-time GPs

employed. Forty-two per cent (n = 172) of GPs who partici-

pated in the study indicated that they had one practice nurse

employed full-time. Forty per cent (n = 167) had no full-time

practice nurse only part-time practice nurses employed. Six

per cent (n = 25) had two full-time practice nurses, while the

remaining 4% (n = 15) had between 3 and 8.

Role dimensions

Table 2 illustrates the role activities of practice nurses and the

corresponding percentage of GPs who indicated that their

practice nurses were involved in this activity.

On the whole, congruence (±5%) among both disci-

plines regarding the current role was evident, particularly in

the areas of health promotion, direct clinical care activities,

immunisation and chronic disease management activities.

However, divergent opinions were noted in some areas

such as women’s health and management duties. In these

cases, GPs underestimated the practice nurse’s involvement

in the role, and among some activities, over 20% of

Table 2 Role dimensions

Role dimensions GP Practice nurse

Health promotion

Well baby care 87% (348) 91% (412)

Dietary advice 93% (372) 98% (441)

Exercise 83% (321) 94% (425)

Health screening 93% (371) 95% (430)

Smoking cessation 80% (314) 85% (382)

Men’s health 50% (187) –

Chronic disease management

Asthma 83% (318) 86% (386)

COPD 76% (290) 77% (345)

Diabetes 89% (350) 92% (413)

Hypertension 89% (357) 93% (418)

Secondary prevention

of coronary heart disease

86% (342) 86% (389)

Weight management 85% (335) 89% (400)

Women’s health

Advice on menopause 42% (163) 79% (358)

Antenatal 67% (267) 70% (317)

Breast feeding advice 80% (313) 79% (354)

Cervical screening 92% (373) 92% (415)

Continence promotion 52% (199) 66% (298)

Family planning 62% (248) 87% (391)

Postnatal care 70% (279) 71% (321)

Preconceptual advice 60% (237) 71% (320)

Teach self-breast examination 63% (247) 76% (341)

Nurse prescribing

Nurse prescribing 13% (50) 11% (50)

Management duties

Health and safety 59% (229) 68% (308)

Infection control 83% (325) 81% (363)

Managing other staff 29% (114) 44% (199)

Managing clinic activities 70% (276) 67% (304)

Clinical guidelines/policy

development

62% (237) 66% (297)

Stock control 97% (385) 94% (424)

Vac fridge monitoring 98% (387) –

IT skills 82% (321) 76% (342)

Practice management 37% (143) –

Audit and research

Clinical audit 34% (131) 47% (213)

Implementing change

based on audit results

or best practice

guidelines

41% (155) 57% (259)

Research 22% (85) 45% (202)

Counselling

Problems with living

(relationship breakdown,

addition, parenting)

38% (146) 44% (200)

Crisis pregnancy 41% (155) 52% (235)

Direct clinical care

24-hour BP monitoring 87% (352) 85% (385)

Continence management 43% (164) 53% (240)

Resuscitation 84% (329) 69% (309)

ECG 90% (361) 87% (394)

Table 2 (Continued)

Role dimensions GP Practice nurse

Phlebotomy 98% (396) 95% (427)

Phone triage 79% (317) 80% (362)

Wound care 98% (394) 94% (424)

Management of laboratory results 75% (299) 90% (405)

Assisting with minor surgical

procedures

85% (335) 82% (371)

Ear lavage 77% (302) 76% (341)

Immunisation

Flu/pneumonia vaccination 99% (398) 98% (441)

Child 96% (385) 95% (428)

Travel vaccination 83% (332) 90% (405)

BP, blood pressure; COPD, chronic obstructive pulmonary disease;


G McCarthy et al.



variation was noted (e.g. family planning and advice on

menopause). In almost all elements of the role, a higher

percentage of practice nurses indicated that they were

involved in the role.

More detailed examination of the significance of difference

between GPs perceptions of nurse’s involvement in an activity

and practice nurse’s self-reported involvement was conducted

using chi-square test for independence (with Yates continuity

correction). Result indicated that there was a significant

difference between GPs perception and practice nurses

involvement in 21 areas of practice (Table 3).

However, the effect size was small for all associations,

u < 0Æ3 (exemption: advice on menopause). In most cases,

nurses were more likely to indicate involvement in activities

with the exception of ordering stocks and supplies, IT skills,

resuscitation, phlebotomy and wound care. There was no

difference observed between GPs and practice nurses in all

activities across the domain of chronic disease management.

On examination of Table 4, it can be seen that central to

the role of the practice nurse were activities relating to

immunisation, vaccination, health screening, aspects of

chronic disease management, direct clinical care (cervical

screening and wound care) and health promotion. Despite the

emphasis by the Irish College of General Practitioners (2006)

on clinical audit, management and research, it is evident from

this research that practice nurses or GPs do not view these

areas as currently defining the role.

Competency

Specific areas where GPs felt that practice nurses were most

competent included well baby care (n = 280, 82%), dietary

advice (n = 280, 78%), health screening (n = 272, 78%),

cervical screening (n = 338, 96%), 24-hour BP monitoring

(n = 299, 90%), ECG (n = 312, 92%), phlebotomy (n = 359,

98%), phone triage (n = 274, 89%), wound care (n =

350, 96%), assisting with minor surgical procedures

(n = 303, 94%), ear lavage (n = 271, 91%), flu/pneumonia

vaccination (n = 365, 100%), child immunisation (n = 351,

98%), stock control (n = 320, 93%) and travel vaccination

(n = 271, 84%).

When data on competence in practice were examined, the

same elements described by both the practice nurse and GP as

defining the role also emerged as areas where practice nurses

were deemed most competent. Equally, activities undertaken

Table 3 Chi-square test for independence (with Yates continuity

correction)

Role Dimension p-value Percentage

Child health care 0Æ04* 87% GP 91% PN

Dietary advice 0Æ00* 93% GP 98% PN

Exercise 0Æ00* 83% GP 94% PN

Advice on menopause 0Æ00* 42% GP 79% PN

Continence promotion 0Æ00* 52% GP 66% PN

Family planning 0Æ00* 62% GP 87% PN

Preconceptual advice 0Æ00* 60% GP 71% PN

Health and safety 0Æ01* 59% GP 68% PN

Managing other staff 0Æ00* 29% GP 44% PN

Ordering stocks and supplies 0Æ04* 97% GP 94% PN

Auditing of practice 0Æ00* 34% GP 47% PN

Implementing change 0Æ00* 41% GP 57% PN

IT skills 0Æ03* 82% GP 76% PN

Research 0Æ00* 22% GP 45% PN

Crisis pregnancy 0Æ00* 41% GP 52% PN

Continence

management

0Æ01* 43% GP 53% PN

Resuscitation 0Æ00* 84% GP 69% PN

Phlebotomy 0Æ01* 98% GP 95% PN

Wound care 0Æ01* 98% GP 94% PN

Management of

laboratory results

0Æ00* 75% GP 90% PN

Travel vaccination 0Æ00* 83% GP 90% PN


*Significant at p < 0Æ05, n range 832–854, df = 1.

Table 4 Defining elements of the role

Top role activities indicated by GPs Top role activities indicated by practice nurses

Flu/pneumonia vaccination (99%) Flu/pneumonia vaccination AND dietary advice (98%)

Phlebotomy AND wound care (98%) Phlebotomy AND health screening AND child immunisation (95%)

Stock control (97%) Wound care AND stock control AND exercise (94%)

Child immunisations (96%) Hypertension (93%)

Dietary advice AND health screening (93%) Diabetes AND cervical screening (92%)

Cervical screening (92%) Well baby care (91%)

ECG taking (90%) Management of laboratory results AND travel vaccination (90%)

Diabetes AND hypertension (89%) Weight management (89%)

Well baby care AND 24-hour BP monitoring (87%) Family planning AND ECG taking (87%)

Secondary prevention of coronary heart disease (86%) Secondary prevention of coronary heart disease AND asthma (86%)

BP, blood pressure; GP, general practitioner.




less frequently by practice nurses such as research, nurse

prescribing and problems with living were highlighted as least

competent areas of practice.

Overall, count frequencies revealed that GPs perceived

practice nurses to be competent in the domain of immuni-

sation than in counselling activities. This is firmly echoed by

practice nurses’ self-assessed competency (Table 5).

Role development

Over 85% of practice nurses and GPs surveyed appear to

have an agenda in terms of chronic disease management. In

particular, diabetes and respiratory care were at the forefront

of responses regarding further training. GPs also recom-

mended education and training in the following areas:

continence promotion, problems with living and clinical

audit. Conversely, practice nurses cited women’s health,

travel health, wound care and aspects of cardiovascular

disease as high priority.

Ninety-five per cent (n = 387) of participating GPs felt that

practice nurses should extend their role to areas such as

chronic disease management.

Discussion

This study sought to explore the role of the practice nurse

from both the GP’s and practice nurse’s perspective and to

draw comparisons across disciplines. Overall, GPs and

practice nurses agree that the role is centred on immunisa-

tion, health screening, direct clinical care, women’s health

and some aspects of chronic disease management. Practice

nurses were deemed competent by GPs in an array of role

dimensions, encompassing categories such as direct clinical

care and immunisation. Perceived competency differed

slightly in some areas, with nurses more likely to indicate

competency in health promotion activities. Halcomb et al.

(2008) describes health promotion activities as expanded

skills that are usually undertaken by advanced nurse prac-

titioners. They suggest that practice nurses engaging in

health promotion activities require education beyond what is

needed to conduct core clinical skills such as taking ECGs.

They found, however, that more nurses were undertaking

tasks such as health promotion as opposed to advanced

practice skills, such as cervical smears. This is in contrast to

the findings in this study where participating practice nurses

indicated that cervical screening was undertaken more

frequently than most other activities, this observation can

be attributed primarily to a government-incentivised scheme

in Ireland.

Despite the congruence of opinion that chronic disease

management is central to the role, in particular care of

individuals with diabetes, hypertension and secondary pre-

vention of coronary heart disease, further training is

required before case management of chronic diseases

becomes an integral part of the role of practice nurses in

Ireland. While respiratory conditions were acknowledged as

part of the role, fewer practice nurses were described as

being involved in the care of patients with asthma and

COPD compared to diabetes and hypertension. A report by

Brennan et al. (2008) highlighted that Ireland has one of the

highest death rates in Europe from respiratory disease.

Further to this, they reveal that the equivalent to over

143,771 hospital bed days per year are occupied by patients

with COPD and pneumonia. The practice nurse has the

potential to run nurse-led clinics including those for respi-

ratory conditions that would manage and monitor patients

in the community, thereby reducing the burden on acute

services. In a report aimed at tackling chronic disease in

Europe, Busse et al. (2010, p. 33) state that ‘in many

countries in which strong primary care teams already exist,

such as the United Kingdom, the Netherlands and Scandi-

navia, the management of many chronic diseases has been

moving progressively to nurse-led clinics’. Although GPs and

practice nurses agree that nurse-led clinics should be

prioritised as part of the future development of the role,

funding has been highlighted as a major obstacle (McCarthy

et al. 2011). Similar concerns were reported by Halcomb

et al. (2008) in terms of role expansion particularly in terms

of chronic disease management. These researchers content

that the skills of the practice nurse are underused and the

potential to become an integral practitioner in the preven-

tion and management of chronic diseases is great; however,

funding presents as a major obstacle.

When the information on the role is compared to that from

the only other Irish study (Harrington et al. 1994), it is evident

that activities in the area of women’s health, immunisations

Table 5 Competence across the domains of practice

Practice domains

GPs Practice nurses

n = responses of competence

Immunisation 329 364

Health promotion 253 356

Direct clinical care activities 277 307

Chronic disease management 235 305

Women’s health 202 245

Management duties 193 246

Audit and research 111 159

Counselling 91 102


G McCarthy et al.



and chronic disease management have increased over the past

15 years. In the UK (Longbottom et al. 2006, Crossman 2008)

and Australia (Halcomb et al. 2006), chronic disease man-

agement, immunisation and women’s health are described as

the defining attributes of the role. The results of this research

suggest that the current role of the practice nurse in Ireland is

comparable in broad terms but may not be in terms of specifics

in chronic disease management.

In 2006, the Irish College of General Practitioners

produced guidelines on the role of the practice nurse stating

that researcher, auditor and manager were central to the

role. This research highlights that practice nurses are not

involved in these areas regularly, and further training is

required for practice nurses to become competent. In this

study, both professions acknowledge the lack of competency

in areas such as audit, research and dealing with problems of

living.

Strengths and limitations of the study

One obvious limitation of this research is the response rate

from the postal survey (29% GPs and 31% practice nurses).

Assumptions cannot be made regarding those who did not

respond. Nonetheless, a heterogeneous sample was still

achieved and generalisability of the findings is possible as

the sample included GPs and practice nurses from both rural

and urban practices, and single and multi-GP centres, and

each county in the Republic of Ireland was represented. With

regard to design, results could have been further enhanced

through mixed methods, where observation of practice may

have strengthened the findings in relation to self-assessed/

perceived competency.

A major strength of this research is that both disciplines

are represented, this is essential for future development of

the role. To exert efforts on enhancing the role based on

data provided by the nurses alone would be imprudent as

the employing GP largely funds further education and

directs the role to meet the needs of their practice. A

strength of this research was also the use of a questionnaire

that was developed and modified based on national guide-

lines and research both in Ireland and in the UK, expert

review and pilot testing.

Conclusion

Practice nurses conduct a wide range of clinical activities,

some of which are determined by Government Policy (e.g.

vaccination) and some, which in other countries such as

Australia, are categorised at advanced practice level (i.e.

cervical screening). However, overall, when the findings

regarding the role dimensions are compared to practice

nurses in Australia, similarities are evident, particularly there

is no denying the broad generic role they play in general

practice (Joyce & Piterman 2011). The unique and significant

contribution that practice nurses make in primary care and

the potential for future development of the role need to be

recognised at both Government level and GP practice level.

There is lack of Government Policy in Ireland on the role of

the practice nurse and its place within primary care, unlike

Australia and the UK, in particular. Policies need to be set

relating to the role and function of the practice nurse within

primary care. It is evident that there is a need for collaborative

strategic planning for the expansion of the role of the practice

nurse in Ireland. The information derived from this research is

vital for the advancement of the role within Government

Policy for primary health care. The research, however, raises

questions whether practice nursing is determined by patient’s

needs or assigned tasks based on allocated work to GPs (such

as vaccination and cervical screening). There is also little

evidence from this research that practice nurses are currently

managing specialist clinics, unlike in the UK where nurse-led

services in the area of chronic disease appear to be well

established (Hoare et al. 2012). In addition to, chronic disease

management is not the main focus of practice nursing in

Ireland and may only become a reality if publically funded.

This research has shown that GP practices are diverse in

nature, with 30% operating with one GP and temporary

part-time practice nurses. Despite the Government agenda to

develop large multi-GP centres, fewer than 38% of respon-

dents worked in practices where more than three GPs were

employed. The conventional profile of a practice nurse (i.e.

employed on a part-time base) is apparent in this research,

with 40% of practices working without a full-time practice

nurse. These findings are comparable with international data

on GP practices (Halcomb et al. 2008).

The education of practice nurses in Ireland is not compa-

rable to those practising in many other areas of clinical care.

Similar concerns are reported in Australia and New Zealand

(Hoare et al. 2011), and consideration needs to be given to

the development of specific programmes of education

together with focused career paths for practice nurses.

The paucity of specific education programs for practice

nurses is evidenced by the education levels of practice nurses

both in Ireland and internationally, with most having basic

general qualifications augmented by short continuing profes-

sional development courses to meet specific clinical activities,

for example cervical screening. With the global health focus

shifting from secondary care to primary care, this research

presents implications for the training and education of

practice nurses internationally.




Relevance to clinical practice

At policy level, the results have been made available to the

National Director of Primary Care Services. The potential for

practice nurses to expand their role in line with future service

developments may now be realised. An implementation plan

needs to be accepted and operationalised to introduce new

roles for practice nurses within the service. These may include

a continuation of the generic nurse as in the research but

development of the role to Clinical nurse specialist/Advanced

nurse practitioner level for some.

Results of this study, in particular those pertinent to areas

highlighted for further training by both disciplines, that is,

diabetes and respiratory care, audit and research, can be used

to form an evidence-based curriculum for practice nurses.

Specific programmes are required to educate practice nurses

to the level hospital nurses now enjoy. This may be achieved

through continuing professional development programmes

and through structured programmes in university depart-

ments. The latter would be favoured as specific modules can

now be developed and offered on a pathway from certificate

to degree level based on credit accumulation if desired.

The results of this study have the potential to strengthen

the relationship between the GP and the practice nurse

through the mutual realisation of the extent of the existing

role. In addition, the study has provided clinically relevant

data to inform the future direction of the role which is not

based solely on government funding initiatives but the

professionals agendas of both nursing and medical disciplines

and the changing needs of the population.

Acknowledgements

The authors would like to thank the GPs and practice nurses

who participating in the research. Our thanks are also

extended to the Irish College of General Practitioners and the

Professional Development Coordinators for practice nurses

for facilitating data collection.

Contributions

Study design: GMc, NC, MC, JM; data collection and

analysis: NC, GMc, JM, MC and manuscript preparation:

NC, GMc.

Conflict of interests

None known.

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