Palliative care patients' perceptions of the work involved in understanding and managing the network of care provision surrounding them.

OBJECTIVE: To explore the work carried out for cancer palliative care patients in understanding and dealing with the often large network of care provision surrounding them. METHOD: Qualitative thematic analysis of interviews with 24 patients (aged 48-85 years) with 15 different types/sites of cancer and palliative care needs. RESULTS: The main theme of 'patient work-their strategies and project management' is presented. Subthemes included: being organised and keeping records; planning ahead and coordinating care; information gathering; understanding the hierarchy and knowing who the key people are; strategies to remember names and roles; understanding and 'working the system'. Insights are given into the work carried out on patients' behalf by family, although it was unclear who would do this work if no family was available. Some of the challenges faced by patients and families are identified. These included limited information; uncertainty when care is transferred between different teams or locations; deciding who to contact and how; and negotiating through gatekeepers. CONCLUSIONS: The number and variety of people contributing to the care of a cancer palliative care patient can be difficult for patients and family to comprehend. Work is required by patients or family on their behalf to achieve the level of understanding required to become accomplished at navigating the system and project managing their care organisation, and is probably influenced by role expectations and previous experience. Much of this additional, often hidden, workload for patients and family could probably be reduced with clear, timely information provision by health professionals.

Enemies with benefits: parasitic endoliths protect mussels against heat stress.

Positive and negative aspects of species interactions can be context dependant and strongly affected by environmental conditions. We tested the hypothesis that, during periods of intense heat stress, parasitic phototrophic endoliths that fatally degrade mollusc shells can benefit their mussel hosts. Endolithic infestation significantly reduced body temperatures of sun-exposed mussels and, during unusually extreme heat stress, parasitised individuals suffered lower mortality rates than non-parasitised hosts. This beneficial effect was related to the white discolouration caused by the excavation activity of endoliths. Under climate warming, species relationships may be drastically realigned and conditional benefits of phototrophic endolithic parasites may become more important than the costs of infestation.

Mothers' decision-making during times of stress as a lone parent: a qualitative study.

INTRODUCTION: Little empirical evidence exists to identify the impact that a partner's absence or presence has on the mother's decision-making and her consequential help-seeking behaviour when her child is unwell. METHODS: This study used a qualitative design in three phases using focus groups and interviews to explore Army mothers' help-seeking behaviour as a lone parent when their child was unwell during the out-of-hours period. Thirty-one parents from a British Army garrison were interviewed. RESULTS: The findings demonstrated that Army life created a combination of stressors for Army mothers, which altered their help-seeking behaviour when their child was unwell. When their partner was available, mothers contacted health services as a last resort, once all other avenues had been exhausted. However, in contrast, in their partners' absence, they were contacted as a first resort. CONCLUSION: An algorithm was generated from the findings, which illustrates the importance of ascertaining whether the mother is alone at the time of the consultation. Increased emotional vulnerability intensified the need for reassurance and affected a mother's decision-making ability. Primary healthcare staff should ascertain whether mothers are currently lone parents at an early stage of their assessment, as this may influence the entire consultation.

The networks of care surrounding cancer palliative care patients.

OBJECTIVES: This paper explicates the nature and extent of the networks of care surrounding patients with cancer palliative care needs. METHOD: Twenty-four patients with 15 different types/sites of cancer were recruited in one city in England, UK. During one in-depth interview patients identified who was 'involved in their care' and any known pathways of communication between them. One hundred of these people (35 doctors, 32 nurses, 17 professions allied to medicine, 8 family members and 8 others) were also interviewed. Maps of people/teams and the connections between them for each patient were then reconstructed using social networking software (PAJEK). RESULTS: The 24 patients identified a total of 619 people or teams (mean 26, median 22, range 9-45 per patient) contributing to their care. Selected care network maps are displayed, illustrating the extent and nature of the care networks supporting palliative care patients. Common members of care networks for patients with palliative care needs are revealed, but their individual and unique nature is also apparent. CONCLUSIONS: The possible clinical utility and challenges of mapping care networks are discussed. Exploring the care networks surrounding individual patients can be useful for illuminating the extent and complexity of individual patient's care networks; clarifying who is involved and who they communicate with; providing opportunities to see interaction routes that may otherwise be hidden, revealing potentially missing or weak connections; and highlighting overlaps or gaps in provision.

Identification and management of prisoners with severe psychiatric illness by specialist mental health services.

BACKGROUND: The prevalence of mental disorders among prisoners is considerably higher than in the general population. This is an important public health issue as the vast majority of prisoners stay in custody for less than 9 months and, when not in prison, offenders' lifestyles are frequently chaotic, characterized by social exclusion, instability and unemployment. Multi-disciplinary mental health inreach services were introduced to target care towards prisoners with severe mental illness (SMI) in a similar way to that provided by Community Mental Health Teams outside prison. The aim was to establish the proportion of prisoners with SMI who were assessed and managed by prison mental health inreach services. Method A two-phase prevalence survey in six prisons in England measured SMI upon reception into custody. Case-note review established the proportion of those with SMI subsequently assessed and treated by inreach services. RESULTS: Of 3492 prisoners screened, 23% had SMI. Inreach teams assessed only 25% of these unwell prisoners, and accepted just 13% onto their caseloads. CONCLUSIONS: Inreach teams identified and managed only a small proportion of prisoners with SMI. Prison-based services need to improve screening procedures and develop effective care pathways to ensure access to appropriate services. Improved identification of mental illness is needed in both the community and the Criminal Justice System to better engage with socially transient individuals who have chaotic lifestyles and complex needs.

Cost-effectiveness of referral for generic care or problem-solving treatment from community mental health nurses, compared with usual general practitioner care for common mental disorders: Randomised controlled trial.

BACKGROUND: UK general practitioners (GPs) refer patients with common mental disorders to community mental health nurses. AIMS: To determine the effectiveness and cost-effectiveness of this practice. METHOD: Randomised trial with three arms: usual GP care, generic mental health nurse care, and care from nurses trained in problem-solving treatment; 98 GPs in 62 practices referred 247 adult patients with new episodes of anxiety, depression and life difficulties, to 37 nurses. RESULTS: There were 212 (86%) and 190 (77%) patients followed up at 8 and 26 weeks respectively. No significant differences between groups were found in effectiveness at either point. Mean differences in Clinical Interview Schedule - Revised scores at 26 weeks compared with GP care were -1.4 (95% CI -5.5 to 2.8) for generic nurse care, and 1.1 (-2.9 to 5.1) for nurse problem-solving. Satisfaction was significantly higher in both nurse-treated groups. Mean extra costs per patient were 283 pound (95% CI154-411) for generic nurse care, and 315 pound (183-481) for nurse problem-solving treatment. CONCLUSIONS: GPs should not refer unselected patients with common mental disorders to specialist nurses. Problem-solving should be reserved for patients who have not responded to initial GP care.

A trial of problem-solving by community mental health nurses for anxiety, depression and life difficulties among general practice patients. The CPN-GP study.

OBJECTIVES: To compare the effectiveness of community mental health nurse (CMHN) problem-solving and generic CMHN care, against usual general practitioner (GP) care in reducing symptoms, alleviating problems, and improving social functioning and quality of life for people living in the community with common mental disorders; and to undertake a cost comparison of each CMHN treatment compared with usual GP care. DESIGN: A pragmatic, randomised controlled trial with three arms: CMHN problem-solving, generic CMHN care and usual GP care. SETTING: General practices in two southern English counties were included in the study. CMHNs were employed by local NHS trusts providing community mental health services. PARTICIPANTS: Participants were GP patients aged 18--65 years with a new episode of anxiety, depression or reaction to life difficulties and had to score at least 3 points on the General Health Questionnaire-12 screening tool. Symptoms had to be present for a minimum of 4 weeks but no longer than 6 months. INTERVENTIONS: Patients were randomised to one of three groups: (1) CMHN problem-solving treatment, (2) generic CMHN treatment, or (3) usual GP care. All three groups of patients remained free to consult their GPs throughout the course of the study, and could be prescribed psychotropic drug treatments. MAIN OUTCOME MEASURES: Patients were assessed at baseline, and 8 weeks and 26 weeks after randomisation. The primary outcome measure was psychological symptoms measured on the Clinical Interview Schedule -- Revised. Other measures included social functioning, health-related quality of life, problem severity and satisfaction. The economic outcomes were evaluated with a cost--utility analysis. RESULTS: Twenty-four CMHNs were trained to provide problem-solving under supervision, and another 29 were referred patients for generic support. In total, 247 patients were randomised to the three arms of the study, referred by 98 GPs in 62 practices. All three groups of patients were greatly improved by the 8-week follow-up. No significant differences were found between the groups at 8 weeks or 26 weeks in symptoms, social functioning or quality of life. Greater satisfaction with treatment was found in the CMHN groups. CMHN care represented a significant additional health service cost and there were no savings in sickness absence. CONCLUSIONS: The study found that specialist mental health nurse support is no better than support from GPs for patients with anxiety, depression and reactions to life difficulties. The results suggest that healthcare providers could consider adopting policies of restricting referrals of unselected patients with common mental disorders to specialist CMHNs, although there may be other roles in primary care that CMHNs could play effectively. Further research should address the predictors of chronicity in common mental disorders and target extra treatment. More research is also needed into the effectiveness and cost-effectiveness of problem-solving treatment for other disorders, of facilitated self-help treatments for common mental disorders and of CMHN care for people with severe and enduring mental illnesses, as well as the prevention of mental disorders.

Carers' and Users' Expectations of Services--User version (CUES-U): a new instrument to measure the experience of users of mental health services.

BACKGROUND: No existing instrument measures all or even most of the issues considered important by users of mental health services. AIMS: To develop and test a self-assessment instrument to enable users of mental health services to rate their experience across the range of domains that they consider to be important. METHOD: Relevant domains were identified and a new instrument was drafted and field tested to examine its psychometric properties. RESULTS: The 17-item, self-rated Carers' and Users' Expectations of Services--User version (CUES-U) appears acceptable to most service users. Its items have reasonable test-retest reliability and a 'total CUES-U score' correlates significantly with a total score of the Health of the Nations Outcome Scales (Spearman's rho=0.42; P < 0.01). CONCLUSIONS: The development and testing of CUES-U suggest that it might be feasible to apply a self-rated measure of the expectations and experience of users of mental health services.

The theory/practice "gap': taking issue with the issue.

Theory/practice issues have a long-standing history in nurse education, and are a chronic source of controversy to which there is no easy or perfect solution. We have argued that it is the tension between theory and practice and research which can be usefully exploited in teaching and research. Students need to be introduced to the debates surrounding the genesis and generation of nursing knowledge. They need to gain an appreciation of what counts as nursing knowledge at different points in time and the politics which drive the legitimation of nursing theory and practice. Such an approach has much to offer in helping students deal with reality shock and make sense of their experience as they confront the ambiguities, uncertainties and contradictions that characterize the stock-in-trade of professional life.

An innovative training programme for ward sisters.

The need for the preparation and professional development of ward sisters is now well recognised, and recent actual and proposed changes affecting nursing and nursing education have served to highlight its role and the need further. The London Postgraduate Teaching Hospitals have responded by establishing a training scheme for their sisters. This aims to develop the knowledge and skills of sisters who are relatively new or inexperienced and combines periods of theoretical study with observation of work on wards and/or consolidation of learning in the sister's own clinical setting. The features of the scheme include a course with a comprehensive curriculum related to most, if not all, of the aspects of the sister's role, the extensive use of experimental learning methods, the use of facilitators to create links between the course itself, course members and the workplace, formal and informal evaluation, particularly during the pilot period, and a specifically appointed project director. The evaluation of this innovation has indicated positive outcomes, both in terms of improvements in individuals and beneficial effects in the hospitals. As a result of the relative success of the first 2 years, the scheme has now been incorporated into a programme of provision for trained nursing staff, and has stimulated the development of other initiatives for other grades of staff.