Public safety is clearly crucial to the concept of advanced practice but it is not the only aspect of these NP roles affected by the absence of a regulatory framework. A lack of clear definition of the role itself affected how it developed and was enacted in
practice. The impact of this lack of role clarity formed a clear thread throughout the narratives, touching their professional relationships with patients, employers and professional colleagues. Even though these nurses were working at different levels of advanced practice they all felt the same frustration when their roles were
misunderstood or abused. For Gaynor it translated into irritation that any nurse, whatever her training, could call herself a nurse practitioner. For others it related more to their individual roles with in practice. These and more potential areas of conflict could be resolved if there was a clearly defined scope of practice understood by the public and professional colleagues.
It is so much more difficult to establish clarity in the current miscellany of roles and responsibilities than if a strong governance or regulatory framework had been established when advanced practice was in its early development. Using Plager, Conger a d C aig s odel fo diffe e tiatio of ad a ed u si g oles, he discussed dispassionately advanced nursing may seem the same, but when viewed through a prism, the role splinters and separates into different roles with some shared functions. This then is the role dissonance which any governance framework must now incorporate. It should still be possible for these roles or levels to have clear and
coherent boundaries of practice which define scope, but they do not.
Lack of role clarity impacted upon patients who did not fully understood who they were o sulti g ith a d hat the NPs abilities or responsibilities were. Indeed Ma d , Nao i a d othe s epo ted that patie ts ofte alled the do to ,
suggesting that patients were confused perhaps by nurses not in uniform, adopting the language, tools and routines of the medical professional.
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Lack of role clarity also affected professional relationships within teams and there was much discussion in the interviews about the resentment and difficulties these nurses had experienced from both medical and nursing colleagues. Barbara felt this keenly when secondary care consultants would not accept referrals from her unless
countersigned by a GP. Xyrichis and Lowton (2008) in their review of enablers and barriers to interprofessional teamworking recognised a lack of clear understanding of p ofessio al oles as a ajo fa to i o fli t ithi tea s. Ma hi et al s (2012) study supported this view, and it has resonance also amongst other roles and teams across primary and secondary care. B ault, Kilpat i k, D A ou , Co ta d iopolous, Chouinard, Dubois, Perroux and Beaulieu (2014) suggest that clearly defining roles and professional boundaries is an effective approach to mitigating power struggles and facilitating the integration of new roles in teams.
Lack of clarity impacted upon the professional standing of and respect for the NP role in general practice. These nurses reported feeling valued by their GP employers, Jane felt that she was valued at least as much as a salaried GP in her practice, Gaynor that her role was even more important when her practice lost a GP partner. Yet their narratives do not suggest GP employers valued them for the role they could deliver but for the role they were prepared to deliver within practice. For Sandra it was evident in the expectation that she would complete monthly prescription claims despite wanting to use her newly acquired clinical skills, for Jane it was being prepared to perform routine nursing duties, just to e a u se , he the p a ti e eeded this. These nurses wanted professional legitimacy and credibility amongst the public and their peers. They wanted wider recognition of the important role they felt they were fulfilling. But the obvious difficulty here is that no two nurses interviewed conformed to the same role; ten interviews, ten constructs determined by factors other than regulation, governance or scope of practice. It is this which makes the advanced role in general practice vulnerable. This inability to claim a unique professional role and territory, to define who they are and what they do opens the professional arena to other professional groups who can clearly define where they fit into the service, professional groups such as Physician Associates.
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Lack of regulation or clear governance structures creates a barrier for nurses wishing to progress their roles within general practice to the detriment of the practice population. Nurses working at advanced, autonomous levels have the potential to improve health a e fo o u ities Lo e, Plu e , O B ie a d Bo d . Too much of the debate has focused on nurse substitution, on shifting tasks from medical to nursing professional groups, rather than considering what diversification of the workforce could really contribute. Substitution merely replaces one type of
professional with another to increase efficiency and reduce costs (Sibbald, Shen and McBride 2004). It is subject to the imposed hierarchy of expertise which has its parallel in the hierarchy of appropriateness (Charles-Jones et al 2003). It remains within the confines of that hierarchy, having tasks and responsibilities delegated by the GP, permanently practising within the shadow of medical colleagues. Rather than substitution, nurse practitioners should be proposing a process of diversification; introducing advanced level nursing roles which widen the range of skills which can be accessed by the public (Sibbald et al 2004). Diversification maintains a unique identity as a nurse, working autonomously and collaboratively within general practice. The broader range of roles seen in this study could then really begin to really benefit general practice.