CLINICAL NURSING DEVELOPMENTS professional roles can most easily be sorted out on a day-to-day basis; the change would not lead to any net addition to personnel overall; and there could be local incentives to encou­ rage taking on NPs in inner city and older industrial areas. What kind of initiatives would most en­ courage local experiments? There could be some national finance for a joint course between family doctors and nurse prac­ titioners. A national programme could be established for retraining practice nurses who wished to do so. A number of practices in various parts of the country - perhaps 25 - could take part in a pilot scheme for employment of NPs. They would continue to be employed by practices and there could be reimbursement of 70 per cent of their salaries. On this contentious issue

of employment status it would be better to retain the status quo while leaving time and successful local joint working to bring about solutions more acceptable to all the profes­ sions. In some areas there could also be experiments by health authorities in direct employment. The concept has many merits, but unless there is a clear plan for allowing local initiatives to develop, there is likely to be little progress before 1995. The most helpful types of change may well be in process and training, which give the greatest freedom to local initiative, rather than seeking to resolve national problems of definition and relative role. The future of the nurse practitioner can only be decided through local experiment and development: the current policy issue is how to maximise the opportunity for such development.

Nurse practitioners everybody’s relative but nobody’s baby Jane Salvage describes the progress made by a joint King’s Fund/WHO seminar in identifying key issues in the nurse practitioner debate.

One of the most exciting developments in nursing today is the expanding role of the nurse in primary health care. Many district nurses, health visitors, prac­ tice nurses and other specialist community nurses are exploring a variety of w'ays of improving services and, in particular, making them more responsive to users’ needs. The role of nurse practitioner is just one of these explorations, but is probably the best known.

Assess the need The growing interest in the nurse practitioner led to a joint King's Fund/World Health Organization initiative. The Fund's Nursing Developments Programme hosted a seminar of policymakers and practitioners with an interest in the role, including nursing leaders, doctors, Department of Flealth representa­ tives and voluntary organisations. The objectives were to assess the need for the nurse practitioner in primary health care in the UK; to define the role; to establish whether it should be adopted and developed; to assess support for the development and

spread of the role; and to recommend further areas of work. We made considerable progress in identifying some key issues. Rather than erecting tablets of stone, the group crystallised a series of questions for further consideration. The issue of the nurse practitioner tends to be regarded as everyone's relative but nobody’s baby: the group there­ fore identified a need to clarify what work needs doing on which issues, how, and by whom. Furthermore, it did not ask 'what should nurses do?' but rather 'what are the needs of patients and clients? who can meet those needs most effectively and econom­ ically? in what ways can nurses contribute?’ The following principles were generally agreed to be crucial: • Collaborative work is essential, including multidisciplinary/multi- professional research and education. • Practice is shaped by a variety of factors, some not readily amenable to influence from nurses, but others open to influence through a coherent change strategy. • A bottom-up philosophy is preferred, en­ suring maximum involvement of practitioners and service users.

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i Jane Salvage is Director, Nursing Developments, at the King's Fund Centre for Health Sen ices Development.

Specific skills

developed specific skills such as commu­ nication, decision-making, assertivness, clinical diagnosis, community assessment and epidemiology. Undergraduate nursing courses and the impact of Project 2000 training programmes should also be considered, to evaluate their contribution to the provision of good primary health care. Finally, the part played by lay workers and informal carers - involving the community in meeting its own needs - should be considered. Exploration of the potential of the nurse practitioner role could be successfully tackled through a planned change programme, parti­ cipants felt. This should build on an evolutionary, bottom-up approach while seizing the oppor­ tunities offered by government receptiveness to some of the key issues. The need to develop skills and knowledge was also highlighted, with an emphasis on appropriate training for students and qualified practitioners. Joint education involving both nurses and doctors should play an important role.

These demonstration settings could include group practices of general practitioners, pro­ jects based on total health authority popula­ tions, teams of professionals working with specific client groups, and neighbourhood nursing teams. Other demonstration projects could examine the effectiveness of models where staff have

Further discussion of the nurse practitioner role in primary health care will be contained in a new King's Fund publication. This will incorporate papers given at the King's Fundi WHO seminar. For information on this booklet please write to Jane Salvage. Nursing Developments, King's Fund Centre, 126 Albert Street, London NWl 7NF.

• Ownership of the issue is central to its successful development. The role of the nurse practitioner, it was felt, should be developed through experimen­ tation in the field. Rigid definition of the role was neither feasible or desirable, although a set of underlying principles could be useful, embracing the role within the wider com­ munity as well as in relation to individual clients. There is a need to test whether a new role is required; if so, who should fulfil it, what education and training is required, and how can its effectiveness be assessed? Multidisciplinary action research was seen as an important way forward. These projects should have a multi-professional academic base, and should involve the work of a range of professionals (in education and research as well as practice), in a variety of settings where good practice can be developed and tested. Quality assurance and cost-effectiveness should both be considered.

Nursing Developments at the King’s Fund Centre The aim of the Nursing Developments programme, which was launched in February 1988, is to encourage innovation and promote good practice in nursing, midwifery and health visiting. Good practice within this context encompasses all activities which are proven to be beneficial to the patient or client. The programme also believes that the practitioner's responsibility to give such care must be complemented by due recognition of her or his value, including fair employment policies, appropriate rewards and

attention to individual needs. The programme's core activites are: • Nursing Development Units: Establishing NDUs in hospitals or community to encourage and assess innovation and experiment, and act as a focus for the development of clinical practice. The programme is directed by Jane Salvage and she has been joined by project worker Gill Black who will be working with four Nursing Development Units at Brighton, Southport, Camberwell and West Dorset. Some funds are available for pump-priming such units, and a network

is being launched to encourage shared learning and support. • Primary Nursing Network: A network has been set up, jointly with former primary nurses Steve Ersser and Liz Tutton. to provide a national forum for sharing and spreading information on primary nursing. The emphasis is on critical review and assessment of the approach. If you have a specific interest in one of these schemes, please write with details to Jane Salvage, Director, Nursing Developments, King’s Fund Centre, 126 Albert Street, London NWl 7NF.

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Nurse practitioners--everybody's relative but nobody's baby.

CLINICAL NURSING DEVELOPMENTS professional roles can most easily be sorted out on a day-to-day basis; the change would not lead to any net addition to...
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