Journal of Research in Nursing

This paper reviews the current rhetoric on changing professional role boundaries and mixing skills in general practice, particularly in relation to the general practice nurse. The issues relating to the effectiveness and efficiency of the general practice nurse role and to the professional development of general practice nurses, can be placed in a matrix, represented by parameters which relate to teamworking and to the 'doctoring/nursing relationship'. The question is asked: 'How can the reality of current nursing roles within general practice meet the rhetoric of the current NHS (Primary Care) Bill?' By providing conceptual matrices which place the key issues of general practice nursing in contingent relation, questions which relate to, for example, changing professional roles and the appropriateness of a general medical services infrastructure for primary health care can be explored — a process of contingent quality improvement.

Health service reforms emphasise the central place of the general practitioner in a primary care-led NHS, as at the same time aspects of primary care have been deregulated. Simultaneously, there is emphasis within nursing on individual accountability and professional judgement to allow responsiveness to demands for nurses to extend and develop their roles. This paper reviews the range and complexity of primary care nursing, to suggest that the profession needs to take account of the complex and heterogeneous nature of primary care nursing to develop regulatory frameworks which address the problems faced by primary care nurses at the grassroots.

Withdrawing and withholding treatment is an emotive issue, especially when it comes to infant patients who cannot reveal their own preferences. The Institute of Medical Ethics carried out a study exploring the perceptions of doctors and nurses involved in such decisions and found that nurses are reluctant to articulate their opinions. This results in practices taking place and decisions being made with which they are not always totally in agreement. Recommendations have been made for better preparation in ethical reasoning, improved communication and team effort.

The concept of managed care is emerging as a multidisciplinary approach to health care in the United Kingdom. It is implemented through an integrated care pathway (ICP) or care map which is created by the multidisciplinary team around a specific diagnostic group. The ICP consists of key interventions which can be evidence-based, incorporating clinical guidelines where appropriate. The aim of managed care is to improve quality of care while reducing length of stay, thus reducing costs. A pilot project was carried out in the neurosciences unit of a London teaching hospital over a six-month period. Lumbar disc surgery was chosen as the diagnostic group. Outcomes were better coordination of care and less variation in length of stay as well as improved communication and collaboration between the multi-professionals involved. Drawbacks were poor compliance by some clinicians and the time-consuming nature of creating the care map. Recommendations are that where ICPs are used this should be a single record replacing all other documentation.

The aims of this study, which is still in progress, are to assess the value that nursing development units add to nursing and health care and to describe the essence of an NDU. The areas investigated cover: resources and costs, research and audit activities, networking activities, staff morale, staff development and supervision, and clinical leadership. The research took a staged approach with four phases: consultation, profiling the NDUs, comparing NDUs with units without NDU status and case studies of five high-performing NDUs. This paper provides an overview of the study and findings from Phases 1-3. It was important for clinical leaders to be clinically credible, to have authority and to be free from day-to-day care provision and management. Quantitative differences between NDUs and comparison units emerged for research and dissemination activity (NDUs were more active), and sickness absence (more long-term sickness in NDUs) but not for audit and staff development activity, nor for the financial context. Data from the final phase will give a more detailed understanding of the significance of these differences and the different pathways that can be taken to achieving success as an NDU.

Marie Roberts-Davis highlights issues arising from a study she undertook into the roles of 'specialist' and 'adrarrced' practitioners in Canada. The text is based on a paper given at the Florence Nightingale Foundation annual symposium held in London in May this year.