Many of the nurses interviewed experienced problems developing new relationships with the wider team structure. This will be explored in terms of relationships with other nursing disciplines, interpreted as professional resentment and with medical colleagues, interpreted as professional threat.
9.2.1. Professional Resentment
Nu ses hose oles de eloped i -house a d ho had ee p a ti es u ses efo e changing roles experienced some initial distrust and resentment from their previous nursing colleagues. Dawn described difficulties she experienced working alongside a practice nurse with whom she had been colleagues for some considerable time.
Dawn: The nurse I worked with when I was a practice nurse was rather difficult for a while.
Researcher: In what way difficult?
Dawn: She seemed distrustful of why I wanted to do it, as if practice u si g as t good e ough i so e a .
Gaynor had worked as a practice nurse whilst studying for her advanced nurse practitioner qualification. This meant that gradually she took on more of the general consulting role of the GP and shed the task-based role of the practice nurse. A
consequence of substituting for the general practitioner was that sometimes she might need to delegate work to the practice nurses; for example therapeutic injections and dressings, and this caused some tension.
It was hard work within the nursing team because there was a nurse who was senior to me, been there a long time, and so suddenly I was taking a step above her and it took a lot of working out. It affected relationships for
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a while. That was quite tough. I think there is often a little bit of envy amongst nurses. Gaynor
I o t ast Nao i s fi st u se p a titio e positio as i a p a ti e hi h had ot had nurses working in the advanced role before. She encountered no problems with the practice nurse there.
The p a ti e u se he e has ee fi e, she s g eat. I thi k she e jo s ha i g an additional resource she can go to.
Naomi suggested that it might be more difficult to upgrade from within an existing nursing team due to personal and professional jealousies. That moving into a practice as a new nurse practitioner might be easier and cause less friction. Mel experienced,
hat she des i ed as ool ess f o a u se ithi he p a ti e.
I never discerned overt resentment but there was coolness from one experienced nurse who was firmly of the mind-set that I a u se, u si g is a e defi ed thi g sepa ate f o edi i e a d ou e t espassi g, ou e ossi g, ou e lu i g ou da ies . It as t for her. And if the conversation went there, always of the opinion that nurses should be nurses and not nurse practitioners.
“o e felt this ea tio , the ool ess o a tago is a e f o u ses ho did ot want to advance their role but were critical and distrustful of those who did. Mel identified this in her relationship with another practice nurse in her practice.
When I joined the practice they were already supporting one practice nurse who specialised in diabetes through her masters so that she could broaden her role. But interestingly, she passed the degree but she never made the transition, she never crossed over to the ANP role. She felt safer in her practice nurse role.
Ellie felt that this was also evident in her practice from a nurse who had tested the ate o pleti g he u se p es i i g ut had hose ot to use those additio al skills and opted instead for a safer role.
We have two nurse prescribers. One has done the minor illness but she eall does t a t to step up to the u se practitioner role.
“tep up e hoes Ga o s des iptio of he ea l elatio ship ith a u se ith ho she had e pe ie ed a tago is . “he talked a out taki g a step a o e as she o ed to the nurse practitioner role. Both reinforce the concept of the hie a h of
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Mandy, who had joined her practice as their first nurse practitioner, had experienced hostility from nurses within the extended nursing team.
I think there was some resentment to start with, but that mainly came f o othe se io le el u ses outside ge e al p a ti e so I thi ki g within the district nursing team, health visiting team, they were a bit sceptical.
Mandy perceived that the hostility was due to uncertainty about where the role would fit i the e isti g u si g o p i a a e f a e o k, pe haps e e ho that ole would relate to theirs in terms of the nursing hierarchy. This suggests some territorial concerns about responsibility and accountability, concerns expanded upon by Dawn.
As for the district nurses, they do seem rather resentful. And yet when it suits them, for example, when they want to report something about one of the patients or when they want an insulin dose adjusting, they ask me to make the decision and fax letters to cover themselves. That really annoys me. Dawn
This may be a simple defensive measure on the part of the district nurse, ensuring that the a e ot held a ou ta le fo de isio s ade a othe li i ia . Da s
interpretation however, is that whilst hostile to the nurse practitioner role in general, they were content to allow her to make and be accountable for decisions they were not prepared to make themselves. It is unclear whether or not the same district nurses would demand a written instruction from the GP.
These narratives have resonance with previous studies of inter-professional
relationships in general practice. These also recounted reported disquiet about the advanced role and its closer association with medicine and highlighted resentment amongst some nurses who perceived nurse practitioners to be elitists who no longer valued nursing (Williams and Sibbald 1999, Charles-Jones et al 2003, Long et al 2004).
9.2.2. Professional threat
As with the extended nursing team, so there were undercurrents of inter-professional disquiet amongst some general practitioners. Of all the professions, GPs are probably the group most affected by the evolving role. Whilst they continue to employ NPs in increasing numbers, some remain concerned about how it affects their status with
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patie ts. The ea tio of GPs i Ja e s p a ti e de o st ated that the e ole remains a perceived threat to traditional medical power.
One of the GPs mentioned the other day, how can we get patients to recognise ou as NPs, a d I sa I a t do a o e, it s o adge, it s o my door and I introduce myself as an NP. Jane
It appeared that whilst her GPs welcomed the role into the practice because of what it could offer, they wanted to be sure that patients appreciated these clinicians were nurses and not doctors.
I thi k the GPs st uggle ith the thought that patie t s thi k olleague and I are doctors, they find this a bit of an affront. Jane
They were concerned about what patients thought. Concerned that they might perceive other less qualified staff could satisfactorily perform some of their usual duties. And this might devalue their traditional dominant position in general practice. This has resonance with other qualitative studies which reported similar concerns from GPs (Wilson et al 2002).
Resentment and threat, different reactions from the team members but both
concerned with roles and disturbance of their own professional equilibrium. Individual professional groups share a common identity (Friedson 1984). But according to Bucher and Strauss, writing in 1961, within each profession there will be divisions defined by specialisation and by intellectual orientation. Nursing is a broad church. Within it there are a variety of nursing disciplines; orthopaedic, general, intensive care and yet more nurses will have diversified to become involved in teaching and management. But the community identify and understanding remains nursing. Part of the resentment felt by nurses, particularly in the practice nursing team, may be due to what Ashforth (2001), des i ed as the effe t of ole e it o those left ehi d. That fo saki g a ursing role and aligning more closely with medicine may be seen as disloyal, as diminishing the integrity and value of their profession. Naomi suggested that resentment might be greater when nurses had transitioned from practice nurse to nurse practitioner within the same practice. Role exit in this situation is real and personal with the potential to disrupt previous professional relationships.
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For the general practitioners role threat may be related more to concerns about retention and control of professional territory and authority. Friedson (1984), in his sociological exploration and explanation of professional power identified control as p o eedi g f o edi i e s ju isdi tio al o opol o e a defi ed a ea of
k o ledge a d a gi e set of tasks p . Nu se p a titio e s halle ge this. The invest in the rituals and symbols of medicine through their training in clinical examination, diagnosis and prescribing. They extend their knowledge base into curative processes as well as caring. But a threat? NPs contesting control over some part of the formal knowledge base and skills that general practitioners have owned for decades may be an attractive notion. But in reality it may be little more than
opportunism, doctors ceding control over these areas to subordinates, relinquishing activities and tasks they see as of less importance. And nurses being prepared to take up that work.