Effects of payment for performance in primary care: qualitative interview study.

OBJECTIVES: To understand the effects of a large scale 'payment for performance' scheme (the Quality and Outcomes Framework [QOF]) on professional roles and the delivery of primary care in the English National Health Service. METHODS: Qualitative semi-structured interview study. Twenty-four clinicians were interviewed during 2006: one general practitioner and one practice nurse in 12 general practices in eastern England with a broad range of sociodemographic and organizational characteristics. RESULTS: Participants reported substantial improvements in teamwork and in the organization, consistency and recording of care for conditions incentivized in the scheme, but not for non-incentivized conditions. The need to carry out and record specific clinical activities was felt to have changed the emphasis from 'patient led' consultations and listening to patients' concerns. Loss of continuity of care and of patient choice were described. Nurses experienced increased workload but enjoyed more autonomy and job satisfaction. Doctors acknowledged improved disease management and teamwork but expressed unease about 'box-ticking' and increased demands of team supervision, despite better terms and conditions. Doctors were less motivated to achieve performance indicators where they disputed the evidence on which they were based. Participants expressed little engagement with results of patient surveys or patient involvement initiatives. Some participants described data manipulation to maximize practice income. Many felt overwhelmed by the flow of policy initiatives. CONCLUSIONS: Payment for performance is driving major changes in the roles and organization of English primary health care teams. Non-incentivized activities and patients' concerns may receive less clinical attention. Practitioners would benefit from improved dissemination of the evidence justifying the inclusion of new performance indicators in the QOF.

Hospital nurse productivity enhancement.

Nurse staffing patterns have come under increased scrutiny as hospital managers attempt to control costs without harming service quality or staff morale. This study presents production function results from a study of nurse output from 2002 to 2005. The results suggest that productivity varies widely among the 39 hospitals as a function of staffing patterns, methods of organization, and the degree of reliance on nurse extender technicians. Nurse extenders can enhance the marginal value product of the most educated nurses as the RNs concentrate their workday around patient care activities. The results suggest that nurse extenders free RNs from the burden of nonnursing tasks. Incentive pay for nurses based on productivity gains is associated with enhanced productivity. One should get the greatest output for the least input effort, better balancing all factors of service delivery to achieve the most with the smallest resource effort.

Experiences of primary health care nurses regarding the provision of free health care services in the northern region of the Limpopo Province.

The purpose of the study was to explore the experiences of primary health care nurses working in the clinics and health centres involved in the provision of free health care services. The research design followed was exploratory, descriptive and qualitative. The population of the study included all primary health care nurses working at the clinics and health centres in the Vhembe (northern) region of the Limpopo Province. The sampling method used was purposive for the samples of both the clinics and the nurses. The inclusion criteria for the nurses included experience of two or more years in providing primary health care. The inclusion criteria for the selection of clinics included being a busy clinic (a minimum of 2000 patients per month) with a staff establishment of four or more primary health care nurses. In conducting this research, ethical principles were taken into account. Data was collected from 23 participants in the Northern Region. The research question read as follows: What are your experiences regarding the provision of free health care services? An open coding method consisting of eight steps provided by Tesch's (1990:140-145) eight-step method of analysing data was used. The research findings revealed that the primary health care nurses working in the clinics experience feelings of failure to provide adequate primary health care services due to the increased workload, misuse of the service, and fear associated with lack of security in the clinics and health centres. The conclusions drawn from this research are that on the one hand a poor mechanism exists for the monitoring of the implementation of free health services, and on another hand, there has been misuse of the facilities by the community. The concept "free health care service" has been misinterpreted.

'We are bitter but we are satisfied': nurses as street-level bureaucrats in South Africa.

This study investigates how a group of nurses based in busy urban primary care health clinics experienced the implementation of the free care (the removal of fees) and other South African national health policies introduced after 1996. The study aimed to capture the perceptions and perspectives of front-line providers (street-level bureaucrats) concerning the process of policy implementation. Using qualitative and quantitative research methods, the study paid particular attention to the personal and professional consequences of the free care policy; the factors which influence nurses' responses to policy changes such as free care; and what they perceive to be barriers to effective policy implementation. The research reveals firstly that nurses' views and values inform their implementation of health policy; secondly that nurses feel excluded from the process of policy change; and finally that social, financial and human resources are insufficiently incorporated into the policy implementation process. The study recommends that the practice of policy change be viewed through the lens of the 'street-level bureaucrat' and highlights three sets of related managerial actions.

A cost consequence study of the impact of a dermatology-trained practice nurse on the quality of life of primary care patients with eczema and psoriasis.

BACKGROUND: The practice nurse is central to the development of a primary care-led National Health Service. Skin diseases can have a major impact on patients' lives but general practitioners (GPs) lack many of the skills of practical dermatology care and support. AIM: To determine whether a primary care dermatology liaison nurse should be introduced by our health authority. We identified the resources consumed and the benefits that accrued from a practice nurse who had received training in practical dermatology care. METHOD: A cost consequence study in parallel with a randomised controlled trial was undertaken in a group of nine GPs and 109 patients between the ages of 18 and 65 years who had a diagnosis of psoriasis or eczema. RESULTS: Although there was a significant improvement in our primary outcome measure within group, when compared with the control group significance was not achieved. There was no significant change in the Euroqol measure but the clinical instrument showed a significant change when compared with control. On entry, our qualitative data identified three main themes--the embarrassment caused by these skin conditions, the wish for a cure rather than treatment, and concern over the long-term effects of steroids. On completion, 20% of patients expressed that they had received a positive benefit from the clinic. CONCLUSION: This study demonstrates the difficulties of obtaining relevant information to facilitate decisions on how resources should be allocated in primary care. Not all questions can be answered by large multi-centred trials and studies themselves have an opportunity cost consuming resources that could otherwise be spent on direct health care. Often, local resource decisions will be based on partial evidence-yielding solutions that are satisfactory rather than optimum but which are, nevertheless, better than decisions taken with no evidence at all.

A comparison of primary nursing and team nursing in a geriatric long-term care setting.

The purpose of this study was to evaluate primary and team nursing on two 45-bed geriatric units. A 2 year longitudinal study with a quasi-experimental ABA cross-over design and a staff survey, permitted comparisons of the two nursing systems on indices of patient well-being, nursing practice, staff morale and costs. Differences in nursing practice, in selected measures of patient well-being and in responses to the staff survey were positively associated with primary nursing. No differences emerged in relation to staff morale or costs. The benefits of primary nursing and implications for further research are discussed.

The reorganization of the nursing labor process: from team to primary nursing.

The author presents a labor process analysis of recent changes in nursing work on hospital wards. In the immediate post-World War II decades, hospital nursing was organized to include stratified nurses--registered and auxiliary nurses (licensed practical nurses and nurses' aides)--in a common labor process called "team nursing." Team nursing adapted Taylorist principles to sharply demarcate tasks between registered nurses (RNs) and auxiliaries. In the 1970s and 1980s, team nursing increasingly replaced by "primary nursing" with a majority of RNs. Auxiliaries were displaced as RNs assumed undivided responsibility for complete nursing care. The transition to primary nursing is partly explained through the convergence of managerial interests with the professionalizing interests of nursing's elite. However, primary nursing was not simply imposed from the top down. Team nursing produced divisiveness between RNs and auxiliaries at the same time that it forced these workers to violate the official differentiation of tasks and held RNs responsible for work performed by auxiliaries. Primary nursing eliminates the problems of team nursing as RNs perform reunified tasks in an unmediated RN-patient relationship. However, primary nursing has produced a new set of contradictions, including an intensified labor process.

An interview with Joyce C. Clifford. Interview by Carmella A. Bocchino.

Various professional practice models have been used to advance nursing. The primary nursing model at Boston's Beth Israel Hospital has continued to be successful for over 15 years and has gained the respect of both the nursing community and the hospital industry. Joyce C. Clifford, MSN, RN, FAAN, Vice-President for Nursing and Nurse-in-Chief at Beth Israel, discusses the development and implementation of this practice model and her strategies--continuity and accountability--to advance nursing.

Restructured patient care delivery: evaluation of the ProAct model.

This budget-neutral model uses fewer RNs with increased clinical and nonclinical support and demonstrates potential to improve quality of care, reduce length of stay, and increase revenue.

A longitudinal cost analysis of primary and team nursing.

Cost findings from a 4-year (1984-1989) externally funded, empirical study, comparing primary and team nursing on medical units in a tertiary care teaching hospital, demonstrates that primary nursing is less costly than team nursing. An average savings of 6.5% was realized for the duration of the study. Three factors are identified as being responsible for the difference on a cost per patient per day basis. Overall, cost analysis per DRG from primary nursing suggests cost differences related to high DRG volume and average length-of-stay. An administrative review of the study's implications highlights the relevancy of these findings in relationship to nurse retention and cost savings.