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Social Science & Medicine 68 (2009) 1206–1212

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Social Science & Medicine

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Practice nurses and the effects of the new general practitioner contract in theEnglish National Health Service: The extension of a professional project?q

Ruth McDonald*, Stephen Campbell, Helen LesterNational Primary Care Research and Development Centre, University of Manchester, Williamson Building, Oxford Road, Manchester M13 9PL, UK

a r t i c l e i n f o

Article history:Available online 28 February 2009

Keywords:UKProfessional projectNursingPrimary careGenderGeneral practitioner (GP)EnglandRole expansion

q This work was undertaken at the National Primaopment Centre, which receives funding from the Depexpressed are those of the authors and not necessarilHealth.

* Corresponding author. Tel.: þ44 161 275 3535; faE-mail address: ruth.mcdonald@manchester.ac.uk

1 Further more limited changes were implementedebate about the content of the contract is ongoing.

0277-9536/$ – see front matter � 2009 Elsevier Ltd.doi:10.1016/j.socscimed.2009.01.039

a b s t r a c t

This paper reports the impact on nurses working in primary health care settings of changes to thegeneral practitioner (GP) contract in England implemented in 2004. Previous changes to the GP contractin 1990, which gave financial rewards for health promotion activities, were seen as enabling nurses totake on work that GPs did not want and providing an impetus for the development of a professionalproject (Broadbent, J. (1998). Practice nurses and the effects of the new general practitioner contract inthe British NHS: the advent of a professional project? Social Science & Medicine, 47(4), 497–506). Ourstudy, which involved interviews with nurses from 20 practices, finds that nurses are taking on workwhich has previously been the exclusive preserve of medical professionals. An increasing emphasis innurses’ accounts on technical skills and knowledge may help decouple nursing from a narrative of caring,which has been seen as detracting from professional advancement. Our research suggests that practicenurse work is changing to reflect a more medical (and masculine) orientation to service delivery. At thesame time, nursing work is described as routine and template driven, which may limit claims to‘professional’ status. The reaction of some practice nurses to Health Care Assistants encroaching on whatwas previously practice nurse territory suggests a policing of boundaries, rather than an inclusiveapproach to colleagues within the nursing team. This resonates with Davies’ (Davies, C. (1995). Genderand the professional predicament in nursing. Bucks: Open University Press) suggestion that pro-fessionalisation as a process involves compliance with a masculine notion of professionalism (autono-mous, elite, individual, divisive, detached) which marginalises feminine attributes and devalues the workdone by women. The study also raises questions about the role of caring in general practice settingswhere nurses choose to prioritise other concerns.

� 2009 Elsevier Ltd. All rights reserved.

Introduction

The aim of this paper is to examine the effects on practice nursesof a new contract for United Kingdom (UK) primary care doctorsintroduced in April 2004 (Roland, 2004).1 The contract includesfinancial incentives for achieving a series of targets that aim to putquality improvement at the heart of primary care and represents anattempt to more actively manage the work of primary careprofessionals. The policy can be seen as part of a wider trend ofmanagerialism in public sector reform internationally (Flynn,

ry Care Research and Devel-artment of Health. The viewsy those of the Department of

x: þ44 161 275 7600.(R. McDonald).

d in 2006 and 2008 and the

All rights reserved.

2000). This appears to be leading to the blurring of professionalboundaries in health care, as traditional ways of working are beingreordered and reconstituted (Dahl, 2004; Henriksson, Wrede, &Burau, 2006; Lane, 2006).

In the context of the National Health Service (NHS) in England,the contract is part of a programme of health service ‘modernisa-tion’, intended to achieve a transformation from an ‘old’ monolithicservice into a ‘new’ NHS fit for the 21st century (Secretary of Statefor Health, 2000). Nurses are seen as key players in delivering themodernisation agenda. In a context where services are increasinglybeing shifted from hospital to primary care settings (Charles-Jones,Latimer, & May, 2003; Department of Health, 2006), they are to begiven greater freedom to innovate and make decisions about theservices and care they provide (Department of Health, 2002).Agenda for Change (Department of Health, 2004a), a system ofremuneration based on an evaluation of job roles and the skills andknowledge applied to them, sets out new and flexible careerprogression pathways, providing the basis for extensions to nursingroles, such as nurse prescribing (Department of Health, 2006).

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However, policies to ‘empower’ nurses can also be seen asattempting to extract more for less from the nursing workforce, inthe context of managerial reforms of the public sector (Cooke,2006).

Practice nurses, the subject of this paper, are not directlyemployed by the NHS but, in most cases, by the general medicalpractices in which they are based. Whilst these nurses have largelybeen bypassed by national reforms to pay and contracts (Martin &Young, 2006), the general practitioners (GPs) alongside whom theywork have experienced major changes in terms and conditions asa result of a new GP contract. This contract is practice-based (ratherthan with individual GPs as was previously the case) and approx-imately 25% of practice income is currently related to theachievement of the quality targets. Evidence suggests that much ofthe work associated with the new contract is being undertaken bynurses (McDonald, Harrison, Checkland, Campbell, & Roland, 2007;National Audit Office, 2008). Previous contract reforms in primarymedical care introduced in 1990 led to a large increase in thenumber of practice nurses and have been interpreted as providingan impetus for them to develop a professional project (Broadbent,1998) by taking on tasks rejected by GPs. Following Broadbent, andif government policy documents are any indication, we mightexpect the contract to contribute to the development of a practicenursing professional project.

Professional projects and practice nursing

The concept of ‘professional project’, as elaborated by Larson(1977), involves a systematic attempt by a distinct occupationalgroup to secure a monopoly for its services and raise its status,income and prospects for social mobility (for individuals and thecollective). For Witz (1992), professional projects are concrete,historically located and aimed at occupational closure. Importantly,the agents of such projects should be understood as positionedwithin gender relations of dominance and subordination. Locatingfemale professional projects within ‘the structural and historicalparameters of patriarchal-capitalism’ (Witz, 1992: 102). Witz(1992) describes a dual closure strategy involving the exercise ofpower downwards by dominant groups (a form of ‘exclusion’) andupwards, by subordinate groups (a form of ‘usurpation’). Theformer secures ‘privileged access to rewards and opportunities’(Witz, 1990: 679) for an occupational group, by policing andcontrolling its boundaries. The latter is a countervailing strategychallenging (patriarchal) medical definitions and control overnursing work. Demarcationary strategies also play a part inprofessional projects. Whereas exclusionary strategies are con-cerned with intra-occupational control (eligibility to practice asa nurse) gendered demarcationary closure is concerned with thecreation and control of boundaries between gendered occupations(i.e. inter-occupational control). Witz (1990) describes a strategy ofclosure starting in the nineteenth century with the campaign tosecure a state-sponsored system of nurse registration. This wasaimed at securing legal status as a profession, employing cre-dentialist tactics to gain centralised control (by nurses) overa common curriculum and examination process. Whilst Witz(1990) sees the female professional project as liberating nursesfrom the spectre of ‘semi-professions’, others suggest that pro-fessionalisation as a process involves compliance with a masculinenotion of professionalism (autonomous, elite, individual, divisive,detached) marginalising feminine attributes and devaluing thework done by women (Bolton & Muzio, 2008; Davies, 1995). Davies(1995: 152) argues for a ‘new professionalism’ based on a ‘ratio-nality of caring’ rejecting attempts to emulate the masculinetechnically scientific rational model of medical professionalism. Atthe same time she acknowledges that to argue for nursing to focus

on unpaid or low paid carework, which so often falls to women,‘may seem an anathema to many in the nursing profession’ (Davies,1995: 151).

Witz and Annandale (2006) describe the reorganisation of nursetraining in the UK, as part of the Project 2000 initiative, as repre-senting one of the continuities in nursing’s professional project,enabling increased control by nurses over the content and contextof their training and education. Project 2000 succeeded in sepa-rating education and training from the service needs of hospitals. Itwas also underpinned by a view of the trained nurse as a highlyeducated ‘practitioner’ in their own right. The emphasis in Project2000 and subsequent reforms was on professional competencies,individual judgment and accountability in the application of prin-ciples to practice. Rather than seeking to define the set of taskswhich were within or outside the scope of practice, the UKCC’s(1992) Scope of Professional Practice guidance suggested that indi-vidual nurses could extend their role to cover areas where they didnot necessarily hold paper qualifications. Nurses were advised to‘recognise and honour the direct or indirect personal accountabilityborne for all aspects of professional practice’ (UKCC, 1992: 9.5) anduse their judgment when deciding what procedures they shouldundertake and their ability to undertake them. Whilst the absenceof clear guidance on the limits of practice was greeted withenthusiasm by some nurses, it has also resulted in anxiety and‘wide-spread confusion over accountability or the new roles[leading] some nurses to retreat from undertaking them’ (Witz &Annandale, 2006: 27). In the context of previous reforms in primarycare a shift from a ‘rule-focused’ to a judgment-based notion ofpractice, and a lack of clarity about new roles, has been seen tocreate uncertainty and anxiety amongst nurses about the boundarybetween nursing and medical work (Williams & Sibbald, 1999).

Rather than encouraging nurses to extend their roles bymimicking a medical practice model, advocates of the ‘new nursing’promote role expansion (as opposed to role extension, performingroutine tasks delegated by doctors) and the development of a bodyof knowledge and practice that is distinct from medicine. Whilstthese advocates warn of the dangers of adopting an inappropriate(masculine) model of medical practice (Davies, 1995), they do notdiscourage nurses from taking on new roles involving diagnosisand/or prescribing. However, moves to define nursing in terms ofexpertise and the exercise of judgment, matching the nurse’sknowledge base to the needs of the individual patient have beeninterpreted as taking ‘nursing close – at least– in theory – to theideal-typical core traits of professionalism associated with medi-cine’ (Witz & Annandale, 2006: 28).

The idea that nursing expertise is acquired through professionalexperience over time (Benner, 1984), which has featured promi-nently in nursing discourse during the last 25 years, may be seen asechoing the reflective practice discourse which underpins generalmedical practice. Nursing’s unique holistic approach, combiningphysical care with attention to the patient’s psychosocial needs, isclaimed as a key and distinctive component of professional identity,which distinguishes nurses from other health professionals. Thiscan be interpreted as involving women’s traditional gender rolesand combines ‘caring for’ with ‘caring about’ engaging nurses inholistic emotion work (Hugman, 1991; Smith, 1992). Yet stereo-typical views of care relegate its expressive capacities to women,whilst placing its associated instrumental ability within themasculine domain (Davies, 1995; Gilligan, 1982; Witz, 1992). Criticssuggest that claims about holistic emotion work are based on mythand furthermore, since such work is not a central consideration ofmodern health care, may be an ineffective way of advancingprofessional status (Dingwall & Allen, 2001). The low status of‘caring’, linked to its designation as ‘women’s work’, raises ques-tions about the desirability of such a strategy.

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With regard to the development of a Practice Nursing (asopposed to nursing generally) professional project, until 1998practice nursing had no nationally recognised qualification andsince practice nurses are employed by the GP practices in whichthey work, educational standards and opportunities for profes-sional development vary widely (Crossman, 2006, 2008). The 2004GP contract has been marketed as potentially enhancing the statusof practice nursing, offering opportunities for enterprising nursesto ‘take forward .extended roles and expand on these.bothwithin practices and PCTs on services such as out of hours and otherenhanced services that GPs may choose to opt out of’ (Departmentof Health, 2003). The contract has the potential to exacerbate theuncertainties and tensions surrounding nursing identities by blur-ring professional boundaries and constructing patients as disease(or points and income) bearing objects (Checkland, Harrison,McDonald, Grant, & Guthrie, 2008), in contrast to the holisticnursing narrative. The contract’s most prominent element, theQuality and Outcomes Framework (QOF), comprises a number oflargely evidence-based process indicators of quality of care, mostlyfor chronic diseases. Compliance with each indicator attractsa specific number of points which are converted to practice income.Obtaining a high QOF score is not simply dependent on the deci-sions of individual GPs, but requires organisational effort within thepractice, for instance to construct and maintain registers of patientswith particular diagnoses, call and recall systems for patients toattend surgery, reminder systems to gather information frompatients, and monitoring systems to provide information onperformance against target (McDonald et al., 2007). Some view the2004 contract as encouraging enterprising nurses to innovate(Department of Health, 2004b), although critics have suggested itwill inhibit the ability of nurses to think laterally (Mead, 2005) andthreaten the nurse-patient relationship (Harston, 2005).

A new GP contract introduced in 1990 contained a relativelysmall number of clinical targets compared with the 146 in the 2004contract, and made payments for the provision of health promotionclinics. Broadbent (1998: 497, 498), in her study of the effects of the1990 GP contract, identified the development of a ‘professionalproject on the part of practice nurses.to provide closure arounda particular area of expertise’ as a consequence of the healthpromotion element of the contract, which encouraged nurses toexpand their roles. Broadbent found that was perceived by practicenurses as increasing their autonomy and the contract was associ-ated with a large increase in the numbers of nurses working ingeneral practice. However, the work undertaken by these nurses,although required by the contract, was viewed as unimportant or ofdubious value by GPs (Broadbent, 1998). Despite the depiction ofpractice nurses as ‘absorbing’ mechanisms (Laughlin, Broadbent, &Willig-Atherton, 1994: 117), absorbing unwanted (by GPs) work-load, these nurses appeared willing to accept these tasks and to usethem to provide closure around an area of expertise as part of thedevelopment of a professional project for practice nursing. The factthat the health promotion contract payments were later abolishedraises questions about the subsequent development of a profes-sional project (Larson, 1977) for practice nursing. Other researchexamining the changing roles of practice nurses conducted withina similar time frame (Dent & Burtney, 1997) identifies a process ofsegmentation (Bucher & Stelling, 1961), with some practice nursesactively engaged in extending their role by taking on activitiesdelegated by GPs and others passively accepting the doctors’ defi-nition of their role. However, any redrawing of the boundariesbetween medical and nursing work which was occurring arosefrom the demands placed on practices by agencies of the state, asopposed to initiatives within the nursing profession.

As part of a process of restructuring in the nursing workforcemore generally aimed at reducing costs, developments such as the

introduction of the health care assistant (HCA) have raised fearsthat nursing is being restructured along the lines of Atkinson’s(1984) flexible firm, with a core of skilled and functionally flexibleworkers and a periphery of insecure, low paid workers. In suchcircumstances, core workers are required to become more func-tionally flexible and evidence suggests that, in hospital settings,policies to ‘empower’ nurses to become more functionally flexiblehave resulted in increased workloads and pressures on nurses(Cooke, 2006), as well as raising fears about deskilling of core staff(Daykin & Clarke, 2000).

In terms of the practice nurse professional project, the foregoingsuggests that expansion of practice nurse roles might involveusurpationary (taking on work previously undertaken by doctors)and exclusionary (downward pressure on HCAs by the skillednursing ‘core’) strategies. It also implies that issues of demarcationare becoming more complex in a changing landscape whichincludes not only doctors and nurses, but a range of lesser skilledhealth workers (Witz & Annandale, 2006). According to Witz andAnnandale (2006: 31), recent reforms in primary care offer the‘potential for (some) nurses to combine extended and expandedroles and thereby draw to a close the long-standing debate withinthe profession about which route nurses should take’. The fore-going raises a number of questions: in what ways have practicenurses responded to opportunities for role expansion and tensionsinherent in the adoption of new roles? To what extent do nurses’responses reflect the shift from ‘certificates for tasks’ to principlesfor practice which underpins the narratives of professionalisationand empowerment in professional guidance and governmentpolicy? What are the implications of these changes for the devel-opment of the practice nursing professional project? We seek toaddress these in what follows.

Participants and methods

Interviews with 1 practice nurse from each of 20 practicesacross England were carried out by the authors betweenFebruary and August 2007. All 20 nurses were female. Thelength of time they had worked as a practice nurse rangedfrom 1 to 25 years, with an average of 12 years. Only five hadworked as a practice nurse for less than 5 years and onlythree had degree level education with a fourth nurse close tocompleting a degree. Eighteen nurses were over 40 years ofage. The practice sample was taken from a nationally repre-sentative (in terms of number of doctors working in thepractice and the socio-economic deprivation of the locality)sample of 42 practices. Interviews were semi-structured, withnurses asked their views on practice nursing and reasons forentering the profession. In addition, participants were askedabout any changes that had occurred following the introduc-tion of the new contract and their views on its impact. Theresearch was part of a larger study involving interviews withGPs and nurses examining the impact of the new contract inEnglish general practice, although in this paper we focus onthe nurse component of the study.

All interviews were digitally recorded and fully transcribed.Themes were compared and contrasted using the constantcomparison method advocated by Glaser and Strauss (1967). Alltranscripts were read by at least two of the research team inde-pendently and a preliminary coding frame constructed. Keyconcepts and categories were identified using an open codingmethod. Main categories were then compared across interviewsand reintegrated into common themes. Disagreements during thisprocess were discussed until a consensus was achieved. Quotationshave been chosen on grounds of representativeness.

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The study had full ethical committee and research governanceapproval.

Findings

Changing roles

Almost all of the nurses reported changes in their roles, whichhad led to them taking on greater responsibility for the manage-ment of chronic disease in primary care. Nurse roles varied widely,with some covering all chronic disease areas (especially in smallerpractices) and others focusing on a small number of conditions.Some nurses described dealing with minor illness or injury, withdelegation of more minor tasks to Health Care Assistants. Therewere differences of opinion, however, with regard to the delegationof tasks previously seen as part of the core work of practice nursing.

you had Health Care Assistants doing a lot of the work thattrained staff did in the past and we’ve resisted that here. Wekept good trained nurses to do it, that’s why [names othernurse] and I can do everything mostly. We haven’t gone downthat route but I think in the future it’s gonna have to come(Practice 10).I hardly take any bloods. I’m much more trusted by the doctorsto carry out checks on our blood pressure patients, diabeticpatients and asthma patients. I take bloods occasionally. I takethem if the girls [HCAs] can’t do it (Practice 16).

As these remarks suggest, there were differing attitudes towardstasks such as taking blood. Some participants viewed these as partof the core nursing identity whilst others appeared to regard themas a distraction from their new roles. Amongst the former,a distinction was made between ‘nursing’, defined in terms of‘hands on’ care often delivered in hospital where nurses undertaketheir initial training, and practice nursing, which reflected ambiv-alence towards new nursing roles.

you still get some dressings, and I do like doing the odddressing. it’s a nursey thing somehow. Whereas a lot of thechronic disease management. It’s just not the hands onnursing that was the in thing when I trained sort of twenty yearsago. So it’s nice to get a bit of hands on.in general practice it’sdifferent [from hospital] because there was never much handson care (Practice 4).

As the quote below highlights, part of the impetus for taking onnew roles and responsibilities may come from the encroachment ofHealth Care Assistants on to what had previously been traditionalpractice nursing territory.

We’ve got a receptionist here that does the blood taking. We’vegot an auxiliary nurse that usually does the blood taking. Idon’t do dressing changes.If they’re now doing the blood tests,and they’re, you know, even doing tests and things, well ‘‘Hangon. What’s my job?’’ you know, what’s my job here? . ‘‘Wellhang on, if you’re gonna do that, I’ve got to do something a bitmore special really, haven’t I?’’ (Practice 8).

The circumstances nurses described involved having ‘freedom’to work hard and engage in self-surveillance, taking responsibilityfor meeting contract targets. Work intensification had accompa-nied these new ‘freedoms’.

running the diabetic clinics, the asthma clinics, all the thingsthat perhaps in the past were done by GPs are now being doneby appropriately trained nurses. And I think that gives me morejob satisfaction, more stress because there’s more that can gowrong. Whereas years ago it was sort of the doctor’s

responsibility if anything went wrong, it was sort of in theirpatch. But now we are more liable for our actions and that’squite scary to be honest (Practice 6).in terms of just the amount of work that we have to do.there’sa lot more pressure on us now. I think nurses are good atprotocols and targets but.there is now much higher demandsthat we get these jobs done in a smaller timeframe [than] we’vebeen given (Practice 3).

From ‘certificates for tasks’ to principles for practice?

Most nurses’ accounts tended to stress the acquisition of newknowledge and viewed the trend towards obtaining high levelqualifications as a positive force for the profession.

I’ve done quite a few on epilepsy. I’ve done diabetes, the War-wick Diploma Course. I’m starting the CHD Diploma Course inMay.and now I’m gonna do the. Asthma Diploma. I’ve.been on loads of study days for the spirometery and the COPD,the Stroke and TIAs and CHD study days.so I’ve done lots ofstudy but I’m working towards achieving and doing a lot more(Practice 20).I did some various basic diabetes course and asthma.then theysent me on the child immunisation course, because they onlycould start doing the child immunisations in September cause Ihadn’t done the course. I’m doing a COPD course at themoment and then I think it’s got to kind of just stop and just tryand put into practice what I’ve learnt now at the minute(Practice 18).

Nurses were dependent on their GP employers to grantpermission and provide financial support to undertake externallyprovided training. Whereas in some cases training was a responseto needs identified by GP partners, nurses were also proactive inidentifying and pursuing training opportunities. The new contractwas seen as facilitating the acquisition of qualifications for nurses,by creating incentives for GPs to enable nurses to take on additionalareas of work.

prior to QOF and the Contract.it was a bit more of a battle to geton to a course. when I asked to do it years ago I was told, ‘‘wellwhy do you need to prescribe cos we’ll prescribe whatever you,you ask us to prescribe?’’ And now it’s, ‘‘Oh yeah, yeah I think it’sa really good idea if you do do a Prescribing Course.’’ So yeahfrom that point of view I think that the QOF’s been a, a goodthing for, in some ways development-wise, yeah, yeah (Practice19).

However, this focus on technical knowledge and the acquisitionof paper qualifications meant that less emphasis was placed onexperiential learning, judgment and holism. Furthermore, theadoption of computerised templates, which guide nurses throughthe consultation, facilitating data collection for the new target-focused culture, was seen by many as changing the consultationprocess in a way which threatened the delivery of patient centredcare.

I try and not look at the screen too much (laughs). I’ve heardother people say it as well, you are inclined to be.looking at thescreen doing this kind of thing. I try and focus on the patient,really. But sometimes.you do get a bit distracted with thescreen (Practice 18).I do have to follow templates all the time.the templates dohelp you and prompt you to do it. There is a danger that whenthe patient’s in, you talk to the template and not to the patient.So I do try and I say to the patient ‘‘I’m looking at the template

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just to see how we’re going. I’m sorry if I’m looking at thetemplate’’ (Practice 16).

These comments also raise questions about the opportunitiesfor nurses to apply judgment in a context where nursing processesinvolve following routines and checklists constructed by others.

A practice nurse professional project?

For Broadbent (1998: 500), the ‘desire for autonomy which maywell have driven practice nurses to this particular sphere of activitymay also be a driver of a move towards strategies to developprofessional closure’. The nurses in our study were keen to stresstheir role in developing new ways of working and to highlight thehigh levels of autonomy they now enjoyed.

I’ve got quite a bit of autonomy in being a practice nurse and thethings that I do. I can examine a patient, check them and seeand then decide that this person may need.antibiotics orwhatever for their condition or, and they may need to bereferred on to someone else. I can generate a prescription but Idon’t actually sign it (Practice 7).you’ve got quite a degree of autonomy, you’re your own boss,really, I mean patients book in every fifteen minutes, you seethem, you tick the boxes, you sort them out, you refer them onto[names GP], or whichever other GP it is, if there’s a problem thatyou feel is outside of your current training (Practice 18).

This suggests a realignment of the boundaries between medicaland nursing work. The demarcationary strategy of GPs in the 1990sresulted in the transfer of what they perceived as low status work tonurses, with no change in the nature of work undertaken by GPs.However, rather than seeing themselves as absorbing mechanisms(cf. Laughlin et al., 1994), nurses in our study described their role astaking on work previously carried out by GPs.

I think we really are more like generally a doctor now.we areexpected to be a lot more multi-skilled than we were, I thinksome nurses would probably see it as exploitation. PersonallyI like being multi-skilled, I enjoy it (Practice 12).when you’re doing your training and you’re updating and you’reable to manage things and advise the GPs in some.capacitysometimes so it’s really good (Practice 20).

Whilst this may be perceived as furthering practice nursing’sprofessional project, nurses are reliant on their GP employers toallow their project to progress. Furthermore, despite claims bymany to be doing work previously undertaken by doctors andsupport for nurses moving into new areas of activity, which hadpreviously been the preserve of doctors, only three of the nurseshad qualified as nurse prescribers.

if you do the prescriber course you’re then expected to diagnoseand prescribe fairly straightforward things, I believe things likebasic antibiotics for chest infections and perhaps for woundinfections, I’m not really certain how far you would take it.tostart diagnosing someone with a chest infection or a throatinfection and perhaps missing something that a doctor would.I don’t know how comfortable I’d feel with doing that (Practice9).we’re taking on a lot of the work that GPs have traditionallydone. Nurses are doing their further qualifications to allowthem to do that.doing a degree if they haven’t got one already.And some people are doing Masters. we’re taking on prescribingas well, nurse prescribing. I suppose I’ve done that for yearsand I have actually prescribed as such, but obviously I don’t putthe signature on the prescription. But I’m not going to do the

nurse prescribing, I’ve actually decided not to do that.takingaway GP work. ’Cos at the end of the day I think the majority ofpeople want, probably want to see a doctor at this moment intime (Practice 5).

Most nurses were reluctant to engage in diagnosis, appearing toview this as a step too far, into medical (as opposed to nursing)territory. Whilst taking on new and extended responsibilitiesaround the management of chronic disease appears to have beena motivating experience for many nurses, the reaction to nurseprescribing suggests that this may be viewed by some nurses asbeyond the sphere of practice nursing. Others described makingprescribing decisions which were then signed off by GPs, enablingnurses to prescribe without having to undertake further training ortake ultimate responsibility for prescribing decisions. Since payrates for nurses have not increased substantially following theintroduction of the contract, despite an increase in practice income,nurses may also be unwilling to take on extra responsibility whichis not rewarded. However, nurses’ reluctance to become prescribersmay serve to limit the development of a professional project and toencourage patients to view nurses as adjuncts to doctors, ratherthan highly skilled professionals in their own right. Theseresponses also suggest a gap between the roles which nursingpublications and professional bodies promote, to which practicenurses may feel obliged to pay lip service, and the local circum-stances which face these nurses in their everyday environment.

Furthermore, a willingness to take on additional work whilstallowing individuals to avail themselves of training and creatinggreater freedom to work independently, rather than working as‘handmaidens’ to doctors, has not translated into greater financialrecognition for the contribution they make to the practices inwhich nurses work. The resentment expressed by a large number ofnurses, regarding what they perceive as unfair treatment, con-cerning financial rewards may discourage them from makingfurther modifications and taking on additional work. However,whilst they express dissatisfaction with their wage levels, there islittle to indicate that these nurses feel able to take action to improvethe situation.

I wasn’t very happy about it. I felt it was a bit insulting.alth-ough I feel it’s not fair then I, I feel there’s not a lot I can do aboutit (Practice 7).I might move, if somebody offered to pay me more money. ButI think I probably would regret it. I mean, if my daughter’spoorly and I have to run, I have to run. And it’s dealt with. Sowhat am I gonna do? I’m gonna turn round to him and say ‘‘Iain’t doing this cos you’re not paying me enough money.’’ ‘‘I’llget somebody that will do it.’’. Well I don’t want to go back andwork in a hospital. I think the GPs hold more power. But thenurses just come to work and get on with it, and most of themwill be happy while they’re seeing the patients (Practice 1).

Witz (1990) describes the collective efforts of women who do notacquiesce to the role of handmaiden in the face of patriarchalpractices. The position of practice nurses as individual employees ofmedical practices, with salaries negotiated locally, rather thanbased on the NHS pay structure, make collective action on suchmatters difficult. Whilst professional projects are aimed at securingprivileged access to rewards and opportunities, it appears that thelatter have increased at a greater rate than the former.

Discussion

Our findings suggest that responses to the new GP contractamongst our participants were variable and complex. In terms ofthe first of the questions we raised earlier, concerning the ways in

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which practice nurses have responded to opportunities andtensions inherent in the adoption of new roles, most nurses activelyembraced new ways of working, which increased job satisfactionbut also placed many nurses under increased pressure. The abilityto undertake work which was previously the exclusive preserve ofdoctors was seen by most as a positive development. In addition,the evolution of a hierarchy within practice nursing which washappening prior to 2004 (Charles-Jones et al., 2003), but whichappears to have been accentuated by the new contract, mayencourage nurses to take on additional responsibilities, in order toprotect themselves in a changing environment (White & Begun,1998). The picture which emerged was of a core of skilled nurses, inmany cases supported by HCAs. Although for some nurses, dele-gation to HCAs was resisted in an attempt to preserve what wereseen as key components of the nursing role.

In a context where practice nurse roles are evolving andcontradictory, reflecting a wider tension in nursing generally, thecontract offers a source of clarity, by encouraging nurses to pri-oritise specific (population and disease-based) concerns overothers (caring). This may have a particular appeal in a primary care,chronic disease management environment and where the tradi-tional nursing role, with its requirement for nurses to undertake allaspects of the patient’s care, ranging from ‘hands on’ bodily tendingthrough to specialist technical activities, may be less applicable.

With regard to the second question we raise, which concernsthe shift from ‘certificates for tasks’ to principles for practice, whilstpractice nursing may be viewed as moving towards a moremasculine model of practice, the responses of participants sug-gested that a ‘certificates for tasks’ approach was still very much inevidence, despite the emphasis in nursing professionalisationrhetoric and government policy documents. This may reflect therelative novelty of the contract reforms, with nurses accumulatingexperience over time in new roles. It may also reflect an olderworkforce whose initial training took place, for the most part, priorto the Project 2000 reforms. However, coupled with the checklist,routinised, template driven care processes nurses describe, thepicture which emerges is at odds with that espoused in nurseprofessionalisation discourses.

This is linked to the third question we raise, which concerns theimplications of recent changes for the development of a ‘profes-sional project’ for practice nursing. As we outline, the desirability ofobtaining qualifications and attending courses featured promi-nently in the accounts of many nurses. This might be interpreted asa move to build up a stock of new knowledge as part of a pro-fessionalising strategy. The accumulation of qualifications, ratherthan a reliance on caring with its links to women’s work and,therefore, of low value, might be seen as enhancing the status ofpractice nursing. Whereas Witz (1990, 1992) describes a profes-sional project aimed at securing control by nurses over a commoncurriculum, which freed nurse training from the day to day servicedemands, the picture conveyed by our practice nurses is one inwhich service demands play a large role in determining whatshould be studied and by whom. Training and education appears tobe heavily influenced by the demands of the practice in whichnurses work, rather than derived from the standards of a profes-sional community beyond the practice environment. Some nursesreport using the contract targets as a lever to obtain funding andpermission for training from their GP employers. However, thecontent of nurses’ stock of knowledge is likely to vary according tolocal circumstances since some nurses cover a small number ofdisease areas and others are responsible for a much wider range.Our participants talked of broadening their coverage and engagingin an ongoing process of learning. As new indicators in new areasare incorporated into the QOF, nurses may well be required toaccumulate additional qualifications in those conditions. Accounts

of learning and updating to acquire more ‘paper’ qualifications maycreate the impression of nurses as perpetual novices, rather thanexperts. Additionally, the fact that practice nurses describe theirwork as increasingly governed by standardized templates andprotocols raises questions about the extent to which nurses canconsolidate their new knowledge and combine it with the exerciseof judgment in order to tailor care to individuals, rather thantreating them as disease bearing objects.

Broadbent (1998: 503), following Larson (1977), highlights theimportance for the development of a professional project ofcreating links between occupation and education. Following theintroduction of the 1990 GP contract, she identified ‘an impetus fordeveloping educational support’ indicating that ‘the professionalproject is developing relatively strongly’. However, a recent surveyof over 1000 practice nurses (or 6% of the total population ofpractice nurses in the UK) found that ‘education provision ingeneral practice is not universally available and does not alwaysmeet the needs of the nurses’. There is evidence that some nursesare carrying out tasks that they are not formally trained to perform’(Crossman, 2008: 34). Widespread variation in roles, educationalopportunities and working conditions were also highlighted in thereport. It might be tempting to suggest that such variations will bereduced over time, but a large survey of practice nurses publishedin 1993 reported similar findings (Atkins & Lunt, 1993). This raisesquestions about the mechanisms, other than the mere passage oftime, which are intended to address these variations.

Broadbent’s (1998) research identified a sphere of activity(health promotion) which was common to practice nurses anddistinct from the work of GPs. Our study suggests that practicenurses, far from absorbing unwanted (by GPs) low status work, arebecoming first contact providers of care with regard to themanagement of chronic disease. The reports of our practice nursesare supported by other qualitative (Campbell, McDonald, & Lester,2008; McDonald et al., 2007) and quantitative (National AuditOffice, 2008) studies. However, our research identifies a range ofroles being performed by practice nurses and differences in viewsabout what constitutes core tasks and the relevant sphere ofpractice nursing, amongst our participants. Furthermore, changesin the nature of practice nurse work appear to be arising from thedemarcationary strategies of GPs rather than from a usurpatorystrategy on the part of the practice nurse body. Broadbent points tothe power differentials between GPs and nurses arising from thedoctor-nurse divide, the gendered nature of relations and the statusof GPs as nurse employers. She raises the possibility that nurses willchallenge the medical orientation in general practice, replacing itwith their own values. However, our study suggests that practicenurse work is changing to reflect a more medical (and masculine)orientation to service delivery. The introduction of HCAs alsocreates tensions for the practice nurse professional project. On theone hand, the ability to delegate low status work to subordinatesmight be seen as enhancing the status of practice nursing. At thesame, it threatens nurses’ claims to provide a distinct contributionto care (Daykin & Clarke, 2000). Whilst nurses may ‘benefit froma more inclusive discourse of care that addresses power relation-ships within nursing teams’ (Daykin & Clarke, 2000: 351) thecomments of some study nurses suggest a less than inclusiveapproach to HCAs, with respondents either resisting HCAencroachment on what was previously practice nurse territory orpassing on unwanted tasks in a way which emphasises hierarchicalrelationships between ‘skilled’ practice nurses and HCAs. Thisresonates with Davies’ (1995) suggestion that professionalisation asa process involves compliance with a masculine notion of profes-sionalism (autonomous, elite, individual, divisive, detached) whichmarginalises feminine attributes and devalues the work done bywomen.

R. McDonald et al. / Social Science & Medicine 68 (2009) 1206–12121212

Although changes to nursing roles are in part dependent on theviews and actions of GPs, to present this as a professional projectthwarted by medical power would be to wildly overstate the extentof collective action on the part of practice nurses and to ignore thesupport for role expansion by GPs (Campbell et al., 2008). It wouldalso be to ignore the role of the state, which is seeking to makeprimary care more accountable, flexible and cost effective. As partof this process, the new contract seeks to define and shape medicalwork in primary care. The contract has been conceived as threat-ening general medical practice’s disciplinary identity, moving froman ‘internal framework of professionalism that supports it, to anexternal framework that holds it up and embraces a market modelof health care with performance linked bonuses’ (Mangin & Toop,2007: 435). The concerns expressed by nurses about giving up areasof work to HCAs are echoed by GPs who fear deskilling asa consequence of the transfer of chronic disease management topractice nurses. Similarly, worries about the impact of the targetdriven environment, which may mean that more time is spent onlooking at computer screens and treating patients as diseasebearing objects, have been expressed by GPs who fear that the ‘tickbox’ approach to patient consultations threatens the doctor-patientrelationship (Campbell et al., 2008). Whilst the focus of the paperhas been on the practice nurse professional project, it raises issuesabout the nature of general practice more broadly in the context ofan increasingly medicalised approach to service delivery. To para-phrase Broadbent’s (1998: 505) concluding remarks writtena decade ago ‘In the light of continued negotiations about thenature of the GP Contract some time ought perhaps to be taken toreflect and debate more widely the nature of the service which wewish to see and the relative roles of GPs’, practice nurses and HCAswithin it.

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