The recent Department of Health announcement that nurses and other non-medical groups (with the ap-propriate advanced level skills and knowledge) could be granted full prescribing rights evoked strong reaction particularly amongst the medical community. Given the current pace of change in primary care organ-isations one could be forgiven for thinking this is a step too far, too quickly, until one reflects that the Cumberledge report first recommended nurse pre-scribing in the interests of improving patient care over two decades ago. Familiar concerns have arisen about nurses’ preparedness for this role and some view this decision as a dilution of the skills of general prac-titioners and an ‘attack on [doctors’] professional status’.[1] However, there is much rejoicing among the many experienced primary care nurses who have long felt that the care they provide for their patients has been compromised unnecessarily by the limits im-posed on their prescribing.

As policy makers and managers try to balance cost containment and work force shortages, alongside the need to improve the quality of services, the introduc-tion of different contracting mechanisms is creating greater diversification of models of primary care, in-cluding general practice and further redistribution of some medical work to nurses. The competing require-ments to increase access for patients and manage patient demand more effectively have served to accel-erate these nursing developments, for example, ‘first contact’ care, although the cost-effectiveness of nurse substitution, and it’s subsequent impact on the work of general practitioners and other health professionals (both volume and nature of workload) has yet to be established. Nurse-led first contact care, defined as seeing patients at the first point of contact with un-differentiated problems and managing episodes of care by diagnosing, treating or referring is now be-coming increasingly common place in general practice in areas such as acute/minor illness, the on-going management of long-term conditions and health promotion/preventative care.[2] These activities require nurses working at the front line of clinical practice to consult with patients autonomously in a similar way to doctors.

While many nurses have embraced these oppor-tunities with enormous enthusiasm other nurses, in common with some in the medical profession, have voiced concerns that by introducing advanced nursing roles in the delivery of an ever greater range of services, the ‘essence’ of nursing may be lost, diminishing the core nursing workforce.[3–5] Similar sentiments about the potential loss of professional identity through the erosion of the values of traditional family practice have also been voiced by some doctors. But what do patients’ think about receiving care from a nurse rather than a general practitioner, what is their per-ception of the quality of care they receive and what aspects of the consultation do they value?

Systematic reviews of nurse–general practitioner substitution in primary care have found that appro-priately trained nurses can produce as high-quality care as general practitioners and achieve good health outcomes for patients.[6–8] Patient satisfaction assessed using standard patient questionnaires has been found to be higher following nurse consultations for chronic disease and minor illness conditions.[6–8] Patients tend to be more satisfied with the amount of information they receive during consultations with nurses than with doctors and they adhere more readily to treatment recommendations from nurses.[6–8] However, the results of these studies need to be interpreted cautiously as they have been criticised for their narrowly conceived definitions of and measures of patient satisfaction and their failure to take into account previous experience and expectations.[9]

To date few studies have explored patient defined perceptions of quality within nursing consultations. Most of these are small scale, qualitative studies but a few key points have emerged. Most patients find con-sulting with a nurse rather than a general practitioner acceptable for minor illness and some long-term con-ditions[7,10,11] but general practitioners are preferred

when they perceive themselves to be seriously ill. Patients are uncertain about the scope of nurses’ first contact roles and their knowledge and competence to diagnose and treat serious illness.[10] However, patients are frustrated at the lack of settlement regarding nurses’ and general practitioners’ roles and dislike nurses being unable to prescribe appropriately with-out deferring to a general practitioner.[10] Patients’ trust general practitioners because they believe they have had good education and training; they place trust in nurses both as employees of the practice and because believe they have gained experience ‘on the job’.[10]

So what do we know about what happens during nurses’ consultations with patients that might explain why patients tend to rate them so favourably? There is a small amount of evidence to suggest that nurses’ communication behaviours and interactions with patients may differ from general practitioners’ con-sultations. Interview-based studies suggest that patients perceive nurses as more communicative, they are made to feel more at ease and are provided with more information[9,11–13] during consultations with nurses than doctors. Patients also tend to be more forth-coming with nurses than doctors.[13] A comparison of nurses’ and doctors’ consultations in primary care diabetes clinics found that nurses used more expla-nations, were more inclusive of patient opinions and patients and nurses appeared to be on a more ‘equal footing’ whereas doctors and patients tended to be more distant from one another.[13]

Patients have clear views about the different con-sultation approaches of nurses and doctors. They value doctors for their skills and knowledge in diagnosing serious illness and nurses for their rapport-building and communication skills; these qualities are recog-nised as different but complementary. Should we there-fore conclude that nursing and medical roles are distinct, and that one cannot substitute for another? But where does nurse prescribing fit within this model? The evidence is beginning to suggest that patients’ do not just want a nurse to make them feel better; and would like nurses to work in an auton-omous way and to be able to prescribe appropriately. And so we need to consider another model whereby nurses’ and doctors’ roles are complementary, some tasks are distinct and others interchangeable. But we need to remember that whilst the professional delib-erations and lack of clarity about nursing roles are confusing for ourselves, patients’ lack of understand-ing is even greater. Sometime soon we ought to tell them what they can expect from a nurse working in an advanced role.

References

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2. Bradbury P. Get ready for the front line. Nursing Standard 2003;18:58–9.
3. Ball J. Advanced and Specialist Nursing Roles: results from a survey of RCN members in advanced and specialist roles. Royal College of Nursing and Department of Health, 2005.
4. Castelden G. Nurse prescribing: the sensible way for-ward? British Journal of Nursing 2000;9:454.
5. While A. In defence of nursing and the generic nurse. International Journal of Nursing Studies 2005;42:715–16.
6. Laurant M, Reeves D, Hermens R, Braspenning J, Grol R and Sibbald B. Substitution of doctors by nurses in primary care. The Cochrane Database of Systematic Reviews, 2005 (Issue 4. Art. No.: CD001271.pub2. DOI: 10.1002/14651858.CD001271.pub2.).
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