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 investigate 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 guidelines. 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 professional status.