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.


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)



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.


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



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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practice nurses and clinical guidelines in a changing primary care context: an empirical study

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