Outnumbered, outvoted and out on a limb - could this be the future of nurses on primary care group boards? The multiprofessional nature of PCGs provides opportunities for board members to learn from one another, but unequal representation is a clear barrier to this, with PCG boards including four to seven GPs compared with only one or two nurses.
Group psychology theory highlights the tendency of group members to fulfil the roles they think are expected of them.1 Applying this to PCGs suggests that interaction, and thus reciprocal learning, may be inhibited.
It is probably still true to say that most GPs consider themselves to be senior to nurses. Such GPs may therefore expect nurses to continue a subordinate role in PCGs rather than taking an active, equal role. Similarly, some GPs are used to performing a teacher or expert role when interacting with nurses.
To maximise the effectiveness of PCGs, GPs must be willing to consider themselves as learners and nurses to adopt a proactive and equal role rather than fulfilling role norms.
Psychologists have found a marked movement to the majority view by those suffering from lack of confidence or a need not to appear different to others.2 This is particularly pertinent to nurse members, given that the GPs forming the majority in PCGs are often likely to hold similar values, views and beliefs.
The self-esteem and confidence of nurse members will be critical in determining their ability to contribute fully to discussions. GP chairs will also have a key role in engendering a culture in which all opinions are valued.
Group members failing to conform are often placed under pressure to do so - explicitly and implicitly.
The well-documented process of 'groupthink', in which a group considers only a limited number of options and does not consider the wider context of its decisions, occurs because groups often come to assume that all members think the same way.
This puts pressure on group members to conform to the majority view and reducing the potential for people to disagree openly, without seeming threatening or disloyal.3
An environment that does not encourage contributions also increases confirmation bias, where the majority seek information consistent with their beliefs and theories.
Belief bias, where people examine evidence only when it conflicts with their beliefs, has also been noted.
These factors reinforce the need for additional perspectives to be offered and discussed. For without debate and critical reflection, the biomedical model of care supported by many GPs is unlikely to be challenged.
Two is better than one
Being exposed alone to the opposition of a majority plays a decisive role in yielding to the group norm. But the presence of just one other individual responding in the same way is sufficient to deplete the power of the majority and, in some cases, destroy it. This strongly supports the value of having two nurse members rather than one.
Where fewer than four GPs are elected, Department of Health guidance allows for each GP board vacancy to be filled by appointing a nurse, lay member or local authority officer.4 A minority of PCGs are operating on this basis, while just two of the 481 PCGs in England are chaired by nurses.
It will be interesting to research the decisions reached by these PCGs over the coming months, compared with those that have the more usual composition. It should be of particular interest to PCGs interested in moving to primary care trust status, as GPs will no longer have the option to form the majority on such boards and will need to find other ways of influencing decisions.
The GP majority on most PCGs has the potential to militate against the DoH's intention that boards will represent a coming together of equals. It is important that these boards include two nurses rather than one. And even then, nurses need support to question others' attitudes to them, challenge norms and be involved in making decisions.
GPs also need to take responsibility for valuing the contribution nurses can make, and recognise the potential for reciprocal learning. Without such willingness on both sides, nurses will become back-seat drivers with little control over the speed or direction of change in health service provision.
REFERENCES
1 Preston-Shoot M. Effective Groupwork. Macmillan, 1987.
2 Asch S. Effects of group pressure upon the modification and distortion of judgements. Readings in Social Anthropology. New York: Henry Holt and Company, 1958.
3 Janis I. Victims of Groupthink. Houghton Mifflin, 1972.
4 HSC1998/230. Governing Arrangements for Primary Care Groups. 1998.
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