title: How do clinical nurse specialists influence primary care management of asthma? A qualitative study.
abstract: METHODS
  We carried out a qualitative interview study alongside a randomised controlled trial which tested the effectiveness of asthma nurse specialists in east London. We carried out face-to-face interviews with five asthma nurse specialists, eight general practitioners (GPs) and six practice nurses, and also held a focus group session with six people who had attended hospital with acute asthma.
  
  
  RESULTS
  Four factors were associated with effective specialist nurse liaison: (1) primary care practices which prioritised asthma care; (2) GPs who trusted practice nurses to manage chronic disease autonomously; (3) GPs who recognised specialist nurse expertise and acted on their advice; and (4) practices which had simple systems in place to deal with recommendations. Patients found nurse specialists approachable and informative.
  
  
  CONCLUSIONS
  Asthma specialist nurse influence was greatest in practices that prioritised asthma care and where practice nurses had clinical autonomy. Patients valued specialist nurses but found advice from a multiplicity of clinicians confusing. Ensuring that practices prioritise chronic disease care, and improving the credibility of nurse specialists amongst GPs, may improve the effectiveness of asthma nurse specialists.
authors.affiliation: Centre for General Practice and Primary Care, Institute for Community Health Sciences, Queen Mary's School of Medicine and Dentistry, Barts and the London, Medical Sciences, Mile End Road, London E1 4NS, London, UK.
authors.forename: Gill
authors.initials: G
authors.lastname: Foster
authors.forename: Madeleine
authors.initials: M
authors.lastname: Gantley
authors.forename: Gene
authors.initials: G
authors.lastname: Feder
authors.forename: Chris
authors.initials: C
authors.lastname: Griffiths