Contributions from the lifeworld: quality, caring and the general practice nurse.

Introduction: Enhancing quality and safety in primary health systems is of central importance to funders, practitioners, policy makers and consumers. In this paper we explore the roles of general practice nurses in relation to quality and safety.

Method: Cross-sectional multimethod study of 25 Australian general practices. Using rapid appraisal we collected data for each practice from interviews with practice nurses, general practitioners and practice managers; photographs of nurse-identified 'key workspaces'; structured observation of nurses for two one-hour sessions; and floor plans.

Results: Quality was articulated in two domains, reflecting both external and intrinsic determinants. External determinants included a large number of essentially structural, procedural or regulatory processes, the most marked of these being practice accreditation and occupational health and safety; these corresponded to the Habermasian idea of system. Intrinsic determinants related mostly to nurse perception of their own quality behaviour, and consisted of ways and means to improve or optimise patient care; these correspond to Habermas' notion of the lifeworld.

Discussion: Nurses describe a productive tension between the regulatory roles that they play in general practices, and patient-focused care, contrary to Habermas' suggestion that system subsumes lifeworld. Current funding systems often fail to recognise the importance of the particular elements of nurse contributions to quality and safety in primary care.