Expansion of nursing role in general practice: studies suggest patients think that nurses can manage simple conditions but have some concerns about knowledge and competence in some areas
- Family and Community Health Research Group, University of Western Sydney, Penrith, New South Wales, Australia
- Correspondence to Elizabeth J Halcomb
Building 17, Campbelltown Campus, Locked Bag 1797, Penrith South DC, NSW 1797, Australia;
The increasing burden of chronic disease and an ageing population in the developed world has led to a shift towards primary care to manage chronic and complex disease. This has prompted a growing interest in the nursing role within general practice. Various models of substitution, delegation and supplementation have been proposed in the literature.1 The impact of these models on patient outcomes and service delivery has only recently begun to receive attention. This article sought to review the recent evidence about the benefits and limitations of the role expansion of nurses in UK general practice.
An integrative review method was used to identify and synthesise the literature published since 2004 that investigated the role of nurses in UK general practice. The search of nine electronic databases identified 164 articles, of which 8 met the inclusion criteria and were included in the review.
The outcomes from the included studies could be clustered under three themes namely, the impact on patients, nurse competence and National Health Service policy. From these outcomes, the author also identifies that the nursing role has been driven by the general practitioner contract and that current models of delegation remove consumer choice about the health professional that they see.
The article concludes that there is limited literature about the expanding nursing role in general practice, as well as identifying a need for additional nurse training around consultation and inclusion of patients views.
This study specifically set out to examine the UK literature. Although the article contains brief justification of this limited approach, the varying characteristics and funding of primary health systems internationally may be seen as a potential rationale. However, it must be considered by the reader that this limited approach has contributed to the small number of included articles and the exclusion of international literature that could have informed the discussion and provided information about the experience in other health systems. Although some of this literature is eluded to in the discussion section, the literature that has come from Australia, New Zealand and Europe has not been well explored, and some sentinel literature from these countries has not been cited.2 3 This limits the international relevance and depth of the review.
Although this article sought to explore studies published since the Cochrane review of randomised controlled trials (RCTs) of substitution of doctors by nurses4 in 2004, this criteria meant that the non-RCT literature published prior to 2004 was also not included in either review. This exclusion has also contributed to the narrow focus of the review.
The author reportedly used a quality checklist to evaluate the methodological quality of included studies; however, there is no information in the review about the outcomes of this quality assessment. The evaluation of methodological quality is of particular importance to assist the reader in evaluating the strength of the evidence presented, particularly given the relatively small sample sizes reported in many of the included articles.
The basis for the conclusions made by the author about the need for additional nurse training in consultation skills and increased consumer input was somewhat unclear. Although the findings did raise issues in these areas, it is not clear why these were selected as conclusions of the review. There has been some work previously undertaken around consumer perceptions of practice nurse roles in the international context which may have provided more insight in this area.5,–,7
Limited clinical application
Conclusions drawn from this review cannot be readily generalised because of the focus solely on UK literature and the methodological limitations of the included literature. Findings are applicable to the environment of UK general practice but are likely not directly applicable to international settings. The authors' conclusion is that few studies have been conducted in this area could have been broadened to explicitly identify the need for additional workforce research around models for nurses in general practice internationally.
Given the significant development in primary care workforces internationally, further research is clearly required to evaluate shifting existing and emerging models of care. Such research should, where possible, incorporate the perspectives of nurses, consumers and medical/allied health professionals. Researchers should consider using a range of outcome measures. These should include quantitative measures of health outcomes and cost effectiveness, as well as qualitative measures such as stakeholder satisfaction and preferences. The conduct of studies in this topic area using a mixed methods approach has the potential in to provide detailed insights into the impact of nurses in general practice on health service delivery and the health of the community.