Training nurse practitioners for general practice. The EROS Project Team.
BACKGROUND
For nurse practitioners (NPs) in general practice to substitute for general practitioners (GPs) in consultations, their educational needs require specification, and their effectiveness and acceptability to patients must be determined. There is limited evidence in the United Kingdom about training requirements or how NPs compare with GPs.


OBJECTIVE
To describe the education provided to trainee NPs (TNPs), describe their work, compare their practise with GPs, and determine their acceptability to patients.


METHODS
Four TNPs were provided with a mainly practice-based education. After one year, TNP diagnoses and management decisions were compared with those of GPs for 586 patients. After being judged competent, TNPs conducted independent consultations. After two years, 400 independent consultations were analysed to describe TNPs' work and reasons for patients contacting the practice again. Opinions of a further 400 patients about their consultation with a TNP or GP, and willingness to consult a TNP in the future, were obtained.


RESULTS
General practitioners and TNPs agreed on 94% of diagnoses and 96% of management decisions made. Early in training, TNPs transferred 38% of patients to the GP, of whom 34% were without a diagnosis and 40% without a management decision. In independent practice, 69% of patients consulting TNPs were female and fewer than 10% were aged over 65 years. TNPs were dealing with a wide range of diagnoses. Immediate referrals to GPs had decreased to 13%. In one-third of consultations, over-the-counter (OTC) medications were suggested and, in 63%, formulary medications were recommended, with prescriptions signed by GPs. Health education featured in 84% of consultations. After two weeks, 29% of patients had returned to the surgery, of whom 72% had been asked to return and 60% consulted about the original condition or its treatment. Eighty per cent of patients completed an opinion questionnaire. While 38% of TNP consulters would have preferred a GP consultation, they rated TNP consultations as good as or better than GPs' consultations. Patients with experience of previous TNP consultations gave the most positive ratings, were more likely to consult a TNP again, and about a wider range of conditions. TNPs' listening skills and explanations were particularly valued.


CONCLUSIONS
Early in their training, TNPs made good diagnostic and treatment decisions, while their high level of patient transfers to GPs indicated residual uncertainty. In independent practice, their GP mentors judged them to be offering an effective service, with acceptable transfer and patient return rates. They were liked by patients and more so by patients with previous TNP experience. TNPs are a valuable substitute for GPs for patients wishing for a same-day consultation, and for younger and female patients who prefer a female TNP over a male GP. Limited authority to prescribe and refer to secondary care reduces NP efficiency.
D000328:Adult; D000368:Aged; D004509:Education, Nursing, Continuing / Q000379:methods*; D004739:England; D005194:Family Practice / Q000193:education*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009722:Nurse Practitioners / Q000193:education*; D009733:Nursing Diagnosis; D015403:Nursing Evaluation Research; D017060:Patient Satisfaction