Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Nurse practitioners in primary care setting
- Susan Thoms (17 April 2004)
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Nurse practitioners: time we came of age.
- ghislaine c young, on behalf of Bradford NP Collaborative (18 April 2004)
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Nurses and Doctors in Brazil
- Elson Romeu Farias (19 April 2004)
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NP impact on GP workload
- Elizabeth J. Anderson (19 April 2004)
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Please use your otoscope properly.
- Andrew P Coatesworth (19 April 2004)
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Nurse Practitioners in Primary Care
- 'Benny' harston (19 April 2004)
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Re: Nurse Practitioners in Primary Care
- Melanie Rogers (20 April 2004)
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Nurse Practitioners in Primary Care
- Penny Louch (20 April 2004)
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Poor standard of peer review?
- Gary Parkes (21 April 2004)
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Editorial Responsibility
- Heather J Griffith (21 April 2004)
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Our Nurse Practitioner is not like your "Nurse Practitioner"
- Rupert Gude (22 April 2004)
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The real Dutch Nurse Practitioner is not a Community Nurse
- Carla JM Broers, Inge Kemper, Eric de Roode, Victor Umans (23 April 2004)
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Nurse Practitioners: Still a way to go!
- Denise P Edwins (24 April 2004)
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Real Teamwork
- Tony Fitchett, Sally O'Connor, Nurse Development Manager, Mornington Health Centre, 169 Eglinton Road, Dunedin, new Zealand, 9001, email: oconn@actrix.co.nz (25 April 2004)
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Rapid Response: Threats to internal and external validity
- Joanne C. Opsteen, Denise Bryant-Lukosius, Alba DiCenso (27 April 2004)
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A nurse practitioner is not a community nurse in the Netherlands
- Wietie Lolkema (27 April 2004)
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Training of nurse practitioners in general practice
- Tony Wright, Sanjeev Silva, Otolarygology SHO, Royal National Throat, Nose and Throat Hospital. London WC1X 8EE, creative_source@yahoo.com (26 May 2004)
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Authors response to the rapid responses
- Miranda GH Laurant, Bonnie Sibbald, Rosella P.M.G. Hermens, Jozé C.C. Braspenning, Richard P.T.M. Grol (15 June 2004)
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Susan Thoms, nurse practitioner Port Clarence Health Centre- Clarences Community Centre, Middlesbrough
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I agree with the author of this research the results should not be generalised without further work internationally. Although these results may have been valid in the Netherlands, they do not represent the current situation in Britain. Nurse prescribing and triage must have reduced the number of minor ailments seen by GPs - leaving them with more time for complex cases. Nurses who use supplementary prescribing can also reduce the work load in straight forward chronic diseases like asthma for example. This has the added bonus of scoring points for the GMS contract and extra funds for the practice. I dont think nurse practitioners have ever been considered substitute GPs, however they do improve patient access and compliment the primary care team, helping to shoulder the ever increasing work load. Competing interests: None declared |
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ghislaine c young, nurse practitioner/partner Westcliffe M/C BD183EE, on behalf of Bradford NP Collaborative
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The conclusion reached in this article is a reflection of the lack of clarity of the role nurse practitioner. The term it seems can mean any type of nurse, and for the purposes of this article it was a BSc community nurse who had then undergone a two week training period in general practice! Is it surprising therefore, that after such a meagre (not to say,non-existent) nurse practitioner (NP) training that the intervention team was found to have no bearing on GP workload? In the UK most NPs are already highly qualified and experienced nurses who then go on to study at a Baccalaureate or Master's degree programmes for a specific NP qualification and this involves modules in patho-pysiology, pharmacology, clinical and communication skills, and assessment is by written examinations and often by OSCE. How can this be compared with a two-week course? It is high time that the Nursing and Midwifery Council recognised and regulated the title Nurse Practitioner so that in future doctors and nurses will share the same understanding of the term, and more importantly so that the public will be protected! Maybe then we will be able to properly assess the impact of trained NPs on GP workload! Competing interests: None declared |
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Elson Romeu Farias, Family and Community Doctor Secretariat of the Health/RS, Av Borges de Medeiros, 1501, Porto Alegre - RS/ Brazil 90110-150
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The study of Miranda Laurant and collaborators strengthens the Brazilian strategy of placing doctors and nurses working in sets in teams of primary care. In Brazil, in the strategy for health of the family, initiated in 1994, each health team counts on a family doctor and a nurse to take care of on average 3150 people, working in sets, in the logic of the primary care. Currently 19000 health teams exist. In the center of Health Murialdo School, of the Secretariat of the Health of the Rio Grande Do Sul, the formation in service in primary care(residence) occurs, jointly, with family doctors and community doctors and nurses psychologists, surgeon-dentist, social assistants and nutritionists. Competing interests: None declared |
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Elizabeth J. Anderson, Research Fellow in Psychiatric Medical Education University of Bristol, BS6 6JL
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Whilst I value papers that add to the debate on how nurses contribute to the workload in general practice, this paper muddies the waters because the role of a “nurse practitioner” is not defined in relation to what is by now, widely accepted criteria. A nurse practitioner is a registered nurse who has received extra training (usually as an undergraduate) so that patients with undifferentiated problems can be independently managed [1;2]. Nurse Practitioners may also manage patients with chronic disease, though in the UK for example, the practice nurse usually undertakes this role. In particular, many of the studies comparing nurses with doctors have examined the care given to patients presenting with acute not chronic illness. This was the rationale we used in our systematic review comparing NPs with GPs and therefore we excluded chronic disease management. The aim of this study therefore lacks some credibility, if what it is trying to achieve is to examine the impact of NPs on GP workload. The choice of the intervention, i.e. nurses from the community working to protocols for COPD, asthma, dementia or cancer, does not fit neatly with how NPs would define their role. Unless the nurses in the intervention arm are working independently, it is hard to see how they would reduce the workload of the GPs in any way and because it is not clear how the nurses in the intervention are working, it made it difficult for me to extrapolate the findings to a UK setting. 1. Horrocks S. Anderson E. Salisbury C. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ. 324(7341):819-23, 2002 Apr 6. 2. Kinnersley PK, Anderson EJ, Rogers C, Parry K, Clement MJ (2000).Who should see the extras? A randomised controlled trial of Nurse Practitioner Care versus General Practitioner care for patients requesting “same day” consultations in primary care. BMJ 320 : 1043-48 Competing interests: None declared |
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Andrew P Coatesworth, Consultant ENT surgeon York Hospital, Wigginton Rd, York. YO31 8HE
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Dear Sir/Madam. The illustration in 'This week in the BMJ' for Laurant and colleagues' paper on the impact of nurse practitioners on workload of general practitioners (1)has got it all wrong! The lady illustrated is not only holding the otoscope incorrectly, she is also pulling the ear in the wrong direction. The external auditory canal is not straight. To straighten it prior to otoscopy it needs to be pulled posteriorly in a child, and postero- superiorly in an adult, not inferiorly as illustrated. When examining the left ear, the ear should be straightened with with the right hand. The otoscope should be held in the left hand with the barrel horizontal, and the operative's little finger on the patient's cheek. This prevents inadvertent injury should the patient suddenly move. In their discussion Laurant and colleagues acknowledge that the level of training may be an important factor. I would suggest that this is vital. My department has reported on the usefulness of well trained nursing staff in an ENT setting (2-4). The level of training may well be a significant factor in this paper (1) showing no advantage to having a nurse practitioner. Andrew P Coatesworth References: 1. Laurant MGH, Hermens RPMG, Braspenning JCC, Sibbald B, Grol RPTM. Impact of nurse practitioners on workload of general practitioners: randomised controlled trial. BMJ 2004;328:927-930. 2. Uppal S, Nadig S, Mielcarek MW, Smith L, Jose J, Coatesworth AP. Patient satisfaction with conventional and nurse-led telephone follow-up after nasal septal surgery. Int J Clin Pract 2003;57(9):835-839. 3. Uppal S, Jose J, Banks P, Mackay E, Coatesworth AP. Cost effective analysis of conventional and nurse-led clinics for common otological problems. J Laryngol Otol 2004;118(3):189-192 4. Uppal S, Lee C, Mielcarek M, Banks P, Mackay E, Coatesworth AP. A comparison of patient satisfaction with conventional and nurse-led follow- up after grommet insertion. Auris Nasus Larynx 2004;31(1):23-28 Competing interests: None declared |
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'Benny' harston, Nurse Practitioner Wroxham Surgery,Norfolk,NR12 8DU
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I do hope that those reading this article will realise that it is a very different scenario in the UK and Nurse Practitioners are not as those described in Holland.In this country a Nurse Practitioner is a nurse with at least 2 years post registration experience who has undergone degree level training in all the skills necessary to enable them to assess treat and/or refer any patient presenting with undifferentiated problems and who also will have skills in many areas of chronic disease management. We offer an alternative choice for the patient, complimenting the existing skill mix in the primary care team. I do not think that this research will reflect the situation in the UK at all. Benny Harston Competing interests: None declared |
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Melanie Rogers, Nurse Practitioner Lecturer Primary Care and Huddersfield UniversityBD18 3EG
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I was dismayed to read the research from the Netherlands claiming Nurse Practitioner's (NP) did not ease the workload in General Practice. Firstly clarity of the NP role is vital, these nurses were clearly not NP's as defined by the International Council of Nurses nor the Royal College of Nursing, 2 weeks training is frankly appalling! There is grave concern that research on NP role development and practice is lacking, especially in the UK, but this article brings further confusion regarding the role and clearly contradicts previous work internationally stating the impact for patients by seeing an NP. In conclusion NP's work closely with there medical colleagues to augment care in general and enhance patient choice. Clarity is needed when research is looking at NP's and the title should only be used by those with the appropriate qualifications. This research is extremely valid but should not have used the term Nurse Practitioner Competing interests: None declared |
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Penny Louch, Nurse Practitioner / Nurse Lead Swanton Morley Nurse-led PMS Practice, Swanton Morley, Dereham, Norfolk NR20 4LT
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I have to say that I read the study by Laurant et al with increasing dismay. It would appear that the authors of this paper have failed to understand the role of the Nurse Practitioner (NP) who works within general practice in the UK. The job description they provide identifies the role of an experienced Practice Nurse not an NP; the outcome measures used to evaluate the impact of the NP on GP workload are also unusual - do COPD, asthma, cancer and dementia make up a large proprotion of day to day workload of the average GP? I would suggest, with respect, that this is not the cas. Accepting this fact therefore, how can this study expect to demonstrate that the 'NP' does reduce the workload of the GP? A NP working in primary care has undertaken an academic course of study at either BSc or MSc level - considerably more than the 2 weeks used within this study. Experience within the area where I work has also demonstrated that skills essential for working in the community are not necessarily transferable to the skills required to work in primary care / general practice in the UK, this may of course be different in the Netherlands. A NP is trained to manage patients presenting with undiagnosed undifferentiated problems; he/she can manage, treat, review and refer these patients as appropriate. Certainly within the busy general practice where I work as a NP I see any patient who presents with a new same day problem - this means I have a very diverse surgery list - varying from self limiting illnesses to acute abdomens, chest pains, chest infections, urinary infections, eczema, ENT problems........ the list is endless. Prior to the introduction of the NP into the general practice these patients would have been seen by the GP, they no longer are. Our GPs very rarely see an ill child, a patient with a sore throat.....etc. Gone are the days when 5+ patients would routinely be added onto each GP list at the end of a session; although their lists might be shorter, they are full of the more complex medical cases which require the skills of the GP to manage. Our objectives when we introduced the NP role 3 years ago were to: 1) Improve access for patients to a healthcare professional 2) To enable the GP to concentrate their skills on the more complex medical cases. Our in-house evaluations consistently prove that we have achieved these objectives. Less than 10% of appropriate NP cases need referral back to the GP - in our view the NP does reduce the workload of the GP and is a substitute for the GP for appropriate patients. The success of the NP role has led to the development of a Nurse-led practice, within this practice GP cover is provided 50% of the time only. Without doubt, the NP is a substitute for the GP. Competing interests: None declared |
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Gary Parkes, GP and MSc in Primary Health Care 3rd Year student The Limes Surgery EN11 8EP
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Sir, I agree with most of the responses of NP colleagues. I have to disagree with Penny Louch's assertion that what is described is a Practice nurse. A Nursing degree plus 2 weeks training is not sufficient even for that role which is also highly skilled and needs relevant and adequate training. Nurse practitioners in the UK are right to feel aggrieved by such a poorly designed study. Was the mistake about translation and a difference in terminology? Or was the mistake not getting the proper Peer reviewers who are qualified to comment about Nurse Practitioners. I challenge the editorial board to reveal the status of the reviewers who allowed such nonsense to get into print with the terminolgy Nurse Practitioner intact. Yours G Parkes Competing interests: None declared |
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Heather J Griffith, Course Leader, MSc Nurse Practitioner programme Bournemouth University, Royal London House, Christchurch Road, Bournemouth, BH1 3LT
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The Royal College of Nursing accreditation unit have set robust standards for nurse practitioner education in the UK and have defined domains of clinical competencies. As previous responses have indicated the 'nurse practitioners' in this study bear no resemblance to the majority of those working in the UK, the methodological approach of the study is flawed and the limitations are numerous. I am surprised that a british journal of such calibre agreed to publish it. Does the editorial board not bear ultimate responsibility for the scrutiny of so-called 'research' articles? Yours Heather Griffith Competing interests: None declared |
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Rupert Gude, General Practitioner Abbey Surgery, Tavistock, Devon, PL19 9EL
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The BMJ has done a great disservice to the development of Primary Care by allowing this article to be published describing the work of nurses with an extended role as the work of nurse practitioners. We have 4 Practice Nurses trained within various special interests like asthma or diabetes who have done a huge amount to improve the care of our patients but we have never looked at their work as reducing our workload. However 2 years ago we employed a Nurse Practitioner, a very experienced practice nurse who did a 2 year course based at the local University with one day of learning and one day of supervised practice culminating in an exam at Masters level. She works 3 days a week and sees unselected patients who require an appointment that day. Most are for minor but distressing problems like infections or backpain but being unselected there are occassional more complex problems. She refers patients to the General Practitioner if she feels that they need further assessment or if appropriate refers to consultants or arranges admissions. In the first full year she saw 2700 patients [not 3700 as originally posted], about the same number of patients seen by other General Practitioners working 3 days a week in the practice . Previously these patients would have been seen by a General Practitioner. We have no doubt that our Nurse Practitioner has helped us to share the ever increasing burden on General Practitioners. The BMJ needs to issue a correction to the title so that it is not cited as a reference to the real Nurse Practitioners. Yours sincerely, Rupert Gude Competing interests: I am an ardent supporter of using suitably trained professionals in new roles in primary care |
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Carla JM Broers, Master of Arts in Advanced Nursing Practice Medical Centre Alkmaar, Wilhelminalaan 12, 1815JD, Alkmaar, the Netherlands, Inge Kemper, Eric de Roode, Victor Umans
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The study of Laurant et al shows that the writers didn’t inform themselves about the development of the role of nurse practitioner in the last 6 years in the Netherlands. The role of nurse practitioner is new in the Netherlands. In 1998 the Hanze Hogeschool in Groningen started with the accredited academic study programme Advanced Nursing Practice. Graduated students receive the Master of Arts degree. In the Netherlands there are about 150 graduated nurse practitioners practicing. Most of them in academic and general hospitals, few of them are working in general practices. Evidence based studies in our hospital have proven the benefit of nurse practitioners for example in cardiac revascularisation, pain management and breast cancer groups. In general practices in the Netherlands we work with so called “doctors assistants” and “practice supporters” and they already have to complete a 2 year training program. It’s a big mistake to confuse these workers and the nurse practitioner with the community nurse as described in the article. The title: “Impact of community nurses on workload of general practitioners: randomised controlled trial” would have been the right title for this article. At this moment we are providing, on behalf of the Dutch Association of Nurse Practitioners (NVNP), title protection for the role of nurse practitioner and the article of Laurant et al shows the need for this. Yours, Carla Broers Competing interests: None declared |
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Denise P Edwins, Trainee Nurse Practitioner The Norwich road surgery. 199 Norwich Road. Ipswich.Suffolk.IP14 5AN
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I was disappointed to read the conclusions drawn by the authors of this paper.The paper shows little understanding of the Nurse practitioner role as it is developing in the UK. The medical conditions chosen for use in the study seem less than appropriate. Many ,if not all Nurse practioners, have a vast knowledge of chronic disease management. This however is not the mainstay of the Nurse practitioner role.The majority of the role involves managing patients with undiagnosed medical conditions and giving health promotion advice or issuing a prescription if appropriate. The use of community nurses with a two week training period to prepare them for the role doesn't seem equitable with the BSc Nurse practioner course i am near to completing. I agree with the authors that Nurse Practitioners should not be considered as substitute doctors ,any more than doctors would be considered substitute Nurse practitioners. The two roles are seperate entities, each with a valuable and mutually complementary role. I feel the objective of the paper misses the ethos of the Nurse Practitioner role completely. The role has not been developed by highly skilled and forward thinking nurses to reduce the workload of GP's. It is being continually developed by Nurse Practitioners in practice to change the way healthcare is delivered, giving patients more choices and improved access to care.We as Nurse Practitioners obviously have a way to go in educating all around us what we are and what we can achieve for our patients. Competing interests: None declared |
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Tony Fitchett, General Practitioner Mornington Health Centre, 169 Eglinton road, Dunedin, New Zealand 9001., Sally O'Connor, Nurse Development Manager, Mornington Health Centre, 169 Eglinton Road, Dunedin, new Zealand, 9001, email: oconn@actrix.co.nz
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As many of the Rapid Responses indicate, the authors use the term 'Nurse Practitioner' loosely. In New Zealand (NZ) a NP has a Master's degree and five years' experience in the specific scope of practice, eg 'NP- Neonatal'. The authors could not be expected to write for the NZ context, but it is clear from Broers' Response that their terminology is wrong in the Netherlands too. But irrespective of definitions of NP, there are some questions about the design and validity of the study. We note a few: 1. The design of the study does not appear to facilitate teamwork between doctor and nurse. The nurse only made contact with patients on referral by a doctor, and working only with three subsets of patients. This suggests a modular style of patient management quite different from real teamwork and real practice nursing. 2. The intervention used in the study was small: one full time equivalent (FTE) nurse for seven FTE doctors may be too small an input to make a measureable difference. 3. The list of tasks undertaken by the nurse excluded treatment, so the patient was obviously going to have to see the doctor for this, limiting the likelihood of a reduction in doctor workload. 4. The work done by nurses in the study excluded those aspects of practice nursing most likely to reduce doctor workload; ie triage of patients presenting acutely. 5. Doctor workload is an odd outcome to choose to measure. The description of the NPs' work suggests that access, co-ordination of care, and overall quality of care were more likely to be improved. Are these not more important (though perhaps harder to measure) than doctor workload? We work in a practice (see www.mhc.co.nz) of twelve FTE doctors and seven FTE nurses, in a teamwork model which deliberately tries to include all staff (manager, administrator, receptionists, van driver and cleaners as well as nurses and doctors) in the planning and provision of services (we are working on increasing patient and community input). Part of the model means using practice nurses in a much less restricted way than in the study, making use of each nurse's specialised field of expertise, and using the nurses' clinic for self or reception referred triage and, where appropriate, treatment of patients with acute problems, as well as ongoing support of those with chronic illness. This enables us to provide a same-day acute service without grinding the doctors into the ground and is, we believe, a major factor in achieving a manageable workload for all staff. This approach is only possible with good organisation at all levels, intentional on-going postgraduate training for nurses as well as doctors to ensure that an appropriate and increasing range of nursing and doctor specialties exists in the practice alongside our general nursing and medical skills, and a practice environment that actively encourages a team approach. The recent moves of the NZ Government to fund general practice by capitation, rather than fee-for-service plus part nurse subsidy, though initiated (we believe) for financial risk-sharing reasons, fits well with this model. It may be hard to design a prospective study capable of measuring the possible effects of such a practice ethos - and doctor workload is only a small part of primary care. More important are patient outcomes and satisfaction and population health, not to mention cost effectiveness. Subjectively, though, we are convinced that teamwork is what makes the practice successful for us as well as for patients, even on those occasions when the number of doctors able to work has unexpectedly been significantly reduced. Competing interests: Both of us work in the Mornington Health Centre, as doctor and nurse respectively. |
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Joanne C. Opsteen, Primary Health Care Nurse Practitioner East End Community Health Centre, Denise Bryant-Lukosius, Alba DiCenso
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Studies examining the introduction of new services in primary health
care are complex by nature, and with all studies, there are strengths and
limitations. We commend the authors for using matched clusters as the unit
of randomization and for incorporating an 18 month follow-up. However, we
consider the threats to this study's internal and external validity as
fatal flaws. With respect to internal validity, there are 3 serious
concerns:
The threat to external validity, however, is the most central fatal flaw. The NP role as defined in this study (i.e. registered nurse with a BSc. degree, 2 years community nursing experience, and 2 weeks training in general practice) is not generalizable to NP roles in other settings. The internationally accepted definition of the Nurse Practitioner/Advanced Practice Nurse is a registered nurse who has acquired the expert knowledge base, complex decision-making skills, and clinical competencies for expanded practice that is achieved through extensive practice experience and completion of a formal NP education program at graduate (masters degree) level.1 This study does not examine the impact of the NP on GP workload, but rather that of the community nurse and even then, the length of the training program is highly questionable. In the past few years, there has been remarkable progress toward the full integration of NPs into primary health care delivery in North America based on the consistent findings of numerous high quality randomized controlled trials.2 What a disservice the BMJ has done to publish this misleading study fraught with both internal and external validity issues. Our only hope is that policy makers are not equally misled. Joanne Opsteen RN(EC) BScN
Denise Bryant-Lukosius, RN, PhD
Alba DiCenso, RN, PhD
1 International Council of Nurses.Definition and characteristics of the role. International Council of Nurses, 2003. Retrieved April 21, 2004 from http://icn-apnetwork.org. http://www.nursing.health.wa.gov.au/resources/NP%20Information%20Update_Feb%202003.pdf, 2 Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working in primary care provide equal care to doctors. BMJ 2002;324:819-23. Competing interests: None declared |
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Wietie Lolkema, Nurse Practitoner general practice 9751BH Haren The Netherlands
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This paper discusses the impact of community nurses, and not nurse practitioners on the workload of general practitioners. In the Netherlands a nurse practitioner is a registered nurse with an Advanced Nursing Practice education at the Master level. In general practice teams in the Netherlands a nurse practitioner sees patients with undifferentiated problems that are managed independently. In some cases, nurse practitioners in a general practice may also manage patients with a chronic disease. A community nurse is not a nurse practitioner; they have a different level of education level and play a different role. A nurse practitioner works in the nursing- and medical domain, a community nurse in the nursing domain. Therefore, the aim of this study to examine the impact of nurse practitioners on general practitioners is not in agreement with the content of the study which is about the impact of community nurses on general practitioners. Therefore, the conclusions of the study on the impact of nurse practitioners on general practitioners are not covered by the content of the study that is about the impact of community nurses on general practitioners. Wietie Lolkema
Competing interests: None declared |
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Tony Wright, Professor of Otolaryngology Royal National Throat, Nose and Throat Hospital, London WC1X 8EE, Sanjeev Silva, Otolarygology SHO, Royal National Throat, Nose and Throat Hospital. London WC1X 8EE, creative_source@yahoo.com
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EDITOR—In the ‘This week in the BMJ’ section referring to the study conducted by Miranda et al which evaluated the impact on general practioners’workload of adding nurse practitioners to the general practice team, it was perhaps quite apt to include a picture of a nurse using an otoscope1. The nurse is holding the instrument with the wrong hand and pulling the pinna in completely the wrong direction. She would have found it impossible to see the ear drum and any associated pathology. A general practitioner would have been required to repeat the examination and having the nurse practioner would not have reduced the workload. As the study concludes, the nurse practioner supplements rather than substitutes for care given by a general practitioner. Nurse specialists can have a very useful role in the routine management of chronic disease. However, without correct training patient care may be compromised and there may be no reduction in the GP’s workload. References 1. Miranda G H Laurant, Rosella P M G Hermens, Jozé C C Braspenning, Bonnie Sibbald, and Richard P T M Grol. Impact of nurse practitioners on workload of general practitioners: randomised controlled trial BMJ;328: 927-32. (6th Apr 2004) Competing interests: None declared |
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Miranda GH Laurant, health scientist, researcher Centre for Quality of Care Research (WOK), UMCN, PO box 9101, 6500 HB Nijmegen, the Netherlands, Bonnie Sibbald, Rosella P.M.G. Hermens, Jozé C.C. Braspenning, Richard P.T.M. Grol
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Criticism centres on the definition and role of nurse practitioners. Specifically it is has been said that the nurse practitioners in our trial were not as highly trained as nurse practitioners in the UK, USA, or New Zealand, and that the role undertaken by our nurse practitioners was not typical of the role they played in other countries. There is, however, considerable variation between, and sometimes within, countries regarding the training and role of nurses who use the title nurse practitioner. We gave a clear job description within our paper which enables readers to generalise the findings, if appropriate, to their own setting. The important question is whether these differences in definition and role could account for the largely negative effect of nurse practitioners on general practitioner workload. We think not. The nurse practitioners in our trial were adequately well trained to undertake a number of key tasks that the general practitioners would otherwise have had to perform. Our data (only some of which has been reported) suggest that the nurse practitioners did carry out these tasks to a high standard and were much appreciated by their general practitioner colleagues. The fact that we found no impact on doctors’ workload is, in our opinion, not a reflection on the capability of the nurses. Rather, it reflects an inability on the part of the doctors to stop doing the type of work which should have been delegated to the nurses. The reasons why this might have happened are outlined in the paper. The ‘solution’ is to introduce better management systems to ensure doctors stop doing the work which nurses have been deputed to take over. We share the view of our critics that, in a properly managed general practice, the doctors’ workload could be reduced through the addition of nurse practitioners to the team. However, there is no good research evidence to prove this point (observational studies and anecdote are not good enough). Futher research into teamworking between doctors and nurses should focus on the factors which facilitate delegation of tasks from doctors to nurses and how doctors invest their time savings. Competing interests: None declared |
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