The purpose of this paper is to explore the need for 'new' nursing roles in primay health care (PHC): the nurse practitioner and the public health nurse. This discussion is placed in the context of present changes in PHC and the tension between the individual focus, traditional in British PHC, and the community oriented approach. The concepts of holism, equality and autonomy are discussed in relation to the contribution of dzfferent PHC team members. The roles of nurse practitioner and public health nurse are then described in the context of World Health Organization statements regarding the future of PHC nursing. In conclusion it is suggested that while there may be a need for these new roles there is a prior need to assess the roles of current PHC nurses and the extent to which they are able presently to exercise the full range of their skills (holism), practice in equal partnership and with autonomy, There is a need to question to what extent skill constraint is a feature of PHC nursing practice.
Approaches to primary health careWithin the British system of general practice and PHC there has always been a tension between the individual-focused, medical model approach to PHC and the community based approach (Macdonald, 1993), between the business interests of the practice and the community health needs of the population. This tension has been exacerbated in Britain by the erroneous representation of primary medical care and PHC as synonymous (Fry, 1983; Bryar, 1991a). Rather, primary medical care should be seen as an element in the wide arena of community based activities which contribute to PHC. The identification of PHC as primary medical care within current health care changes, that is perpetuation of the medical model approach to care in the community (as opposed to the hospital setting), may, as North (1993) has argued, reduce the input of the patient or client in decisions about the provision of health services while strengthening the power of health professionals. This may be seen, for example, in restrictions on referrals by practices to specialist services, such as homoeopathic clinics, that they may not have contracted to buy. Present changes indicate that it is timely to consider these two models of PHC and the roles of practitioners within these models.The model of community based PHC seeks to develop a community oriented service (Tollman, 199 1). This approach, which advocates working with the population in genuine, as opposed to token, partnership is closely aligned to the model of PHC advocated in the Correspondence: Rosamund Bryar, 3 Newtown, Eaton Road, Brynhyfryd, Swansea SA5 9JN, UK. J Interprof Care Downloaded from informahealthcare.com by McMaster University on 11/18/14 For personal use only. J Interprof Care Downloaded from informahealthcare.com by McMaster University on 11/18/14 For personal use only. Medicine, 32(6) pp. 633-642. Association).
