The role of nurses in general practice: General Practitioners' and Practice Nurses' perceptions is a study that identifies the beliefs of Practice Nurses (PNs) and General Practitioners (GPs) of the PN role and how those roles impact on the general practice. Ethnographic techniquess were used for this study, with data collected through interviews, observation and questionnaires. Interviews were conducted with four PNs and four GPs in practices that employed nurses in an increased role similar to that described in the Nursing in General Practice Fact Sheets (Royal College of Nursing Australia, 2002). Two practices were observed to identify work practices and the nurses' interaction within the practice. The main finding of the study was the importance placed on the general practice team. Both GPs and PNs believed that working as a team was vital. They indicated that working together provided holistic care and enabled the practice to provide quality care. The role of the PN in this study was consistent with other studies in Australia. However, the nurses in this study appeared to have more autonomy in regard to care of people with chronic illness and the aged. Continuing education was considered important for the further development of the PN role. However, participants believed that the PN also needed to have considerable and varied experience together with good people skills. To further develop the PN role innovative ways of providing education to PNs should be investigated to ensure nurses have the necessary skills to undertake their role. Payment issues in general practice should also be examined and addressed to ensure that PNs are able to be employed, and receive remuneration appropriate for their experience and job description.

The overall aim of the thesis is to explore the determinants of General Practitioner (GP) referrals to specialist mental health services, in particular psychological therapy. Paper 1 is intended to contribute to this literature by providing a systematic review of GP and organisational factors identified as impacting on referral in previous research. According to this literature, referral to a mental health specialist was more likely if the GP does not feel that they have the 'capacity to help' and perceives 'time constraints' on how long they can spend with the patient. Referral also appeared more likely if the GP felt they had acceptable 'access to services' and if they had a close 'consultation/liaison' relationship with specialists. The theoretical and clinical implications of these findings are discussed, and gaps in the current literature identified for further research. Paper 2 describes an empirical study aimed at exploring the determinants of GP referral for psychological interventions within Primary Care Mental Health Services (PCMHS). 132 GPs completed questionnaires, including demographic information, attitudes towards mental health and its treatment and responses to short fictional case vignettes indicating their likelihood of referral to the PCMHS. Qualitative results suggested that GPs consider a range of factors in their referral decisions, including patient preference, severity of the problem, access to services and the effectiveness of the service. Alternative options considered included signposting to other services, reviewing, medication and providing advice and support. Quantitative results suggested that younger GPs reported a higher likelihood of referral, and were more likely to refer in line with guidelines. Psychological factors were not associated with referral likelihood or referral in agreement with guidelines. In line with previous research on clinician behaviour, findings of papers 1 and 2 are considered primarily in the context of the Theory of Planned Behaviour, and the utility of this model in predicting referral behaviour is evaluated throughout. A greater understanding of predictors of referral is thought to be valuable in designing clinician and service level interventions to improve the proportion of those in need who are able to access psychological therapy. Paper 3 provides a critical evaluation of the research process as a whole, including the processes involved in the literature review and empirical study. The strengths and weaknesses of both of these elements are discussed, along with an evaluation of the overall approach taken throughout the thesis. The findings of both studies are integrated and discussed in the context of current policy and proposed changes to healthcare provision. Implications for theory, clinical practice and further research are discussed.