The impact of primary nursing care pattern: Results from a before-after study.

AIMS AND OBJECTIVES: To explore the effect of "Primary Nursing" on nursing-sensitive patient outcomes, staff-related outcomes and organisation-related outcomes. BACKGROUND: Primary nursing is one example of a care pattern that has recently been implemented in many countries. DESIGN: Before-after study. METHODS: This study was conducted in an Italian hospital. We observed patient-related outcomes (pressure ulcers, falls, urinary tract infection and venous catheter infection) in 2,857 inpatients before the implementation of primary nursing and in 3,169 inpatients after its implementation. Staff-related outcomes (nursing competence and diagnostic thinking) and organisation-related outcomes (empowerment and team climate) were collected from 369 nurses. From a subgroup of inpatients, we collected data regarding their satisfaction with the care provided. RESULTS: After the implementation of primary nursing, some nursing competencies and diagnostic thinking were improved, so were organisation-related outcomes. Our data showed that the number of inpatients with urinary catheter infections (5.5% vs. 4.3%) and venous catheter infections (peripheral: 2.2% vs. 1%; central: 5.6% vs. 1%) was significantly decreased; also, the numbers of falls (2.4% vs. 1.9%) and pressure ulcers (4.8% vs. 4%) decreased, although these decreases were not statistically significant. Overall, the implementation of primary nursing increased patient satisfaction with nursing care (193.57 vs. 210.21). CONCLUSIONS: Primary nursing improved staff-related outcomes, nursing-sensitive patient outcomes and organisation outcomes. RELEVANCE TO CLINICAL PRACTICE: Our results show that primary nursing has the potential to positively impact on inpatients, nurses and organisations. Moreover, the implementation of this care pattern is feasible.

Development of a nursing intervention to facilitate optimal antiretroviral-treatment taking among people living with HIV.

BACKGROUND: Failure by a large portion of PLHIV to take optimally ARV treatment can have serious repercussions on their health. The absence of a systematic treatment-taking promotion program in Quebec prompted stakeholders to develop jointly a theory- and evidence-based nursing intervention to this end. This article describes the results of a collective effort by researchers, clinicians and PLHIV to share their knowledge and create an appropriate intervention. METHODS: Intervention mapping was used as the framework for developing the intervention. First, the target population and environmental conditions were analyzed and a literature review conducted to identify predictors of optimal treatment taking. The predictors to emerge were self-efficacy and attitudes. Performance objectives were subsequently defined and crossed-referenced with the predictors to develop a matrix of change objectives. Then, theories of self-efficacy and persuasion (the predictors to emerge from step 1), together with practical strategies derived from these theories, were used to design the intervention. Finally, the sequence and content of the intervention activities were defined and organized, and the documentary material designed. RESULTS: The intervention involves an intensive, personalized follow-up over four direct-contact sessions, each lasting 45-75 minutes. Individuals are engaged in a learning process that leads to the development of skills to motivate themselves to follow the therapeutic plan properly, to overcome situations that make taking the antiretroviral medication difficult, to cope with side-effects, to relate to people in their social circle, and to deal with health professionals. CONCLUSION: The intervention was validated by various health professionals and pre-tested with four PLHIV. Preliminary results support the suitability and viability of the intervention. A randomized trial is currently underway to verify the effectiveness of the intervention in promoting optimal antiretroviral treatment taking.

Supporting nurse decision making in primary care: exploring use of and attitude to decision tools.

Nurses are increasingly working more autonomously in extended roles, yet we know little about the nature of the decisions they make. Decisions vary in terms of complexity, ambiguity and presentation, and the nature of the decision task impacts on the process of decision making, such as the likelihood of using a decision tool. Thus, knowledge about the nature of nursing decisions is essential for development of effective decision tools. This article presents an analysis of 410 nurse-patient consultations and interviews with 76 primary care nurses, and explores the nature of the decisions that primary care nurses make and the impact of that on their use of and attitudes towards decision tools.

Prevention of type 2 diabetes by lifestyle intervention in an Australian primary health care setting: Greater Green Triangle (GGT) Diabetes Prevention Project.

BACKGROUND: Randomised controlled trials demonstrate a 60% reduction in type 2 diabetes incidence through lifestyle modification programmes. The aim of this study is to determine whether such programmes are feasible in primary health care. METHODS: An intervention study including 237 individuals 40-75 years of age with moderate or high risk of developing type 2 diabetes. A structured group programme with six 90 minute sessions delivered during an eight month period by trained nurses in Australian primary health care in 2004-2006. Main outcome measures taken at baseline, three, and 12 months included weight, height, waist circumference, fasting plasma glucose and lipids, plasma glucose two hours after oral glucose challenge, blood pressure, measures of psychological distress and general health outcomes. To test differences between baseline and follow-up, paired t-tests and Wilcoxon rank sum tests were performed. RESULTS: At twelve months participants' mean weight reduced by 2.52 kg (95% confidence interval 1.85 to 3.19) and waist circumference by 4.17 cm (3.48 to 4.87). Mean fasting glucose reduced by 0.14 mmol/l (0.07 to 0.20), plasma glucose two hours after oral glucose challenge by 0.58 mmol/l (0.36 to 0.79), total cholesterol by 0.29 mmol/l (0.18 to 0.40), low density lipoprotein cholesterol by 0.25 mmol/l (0.16 to 0.34), triglycerides by 0.15 mmol/l (0.05 to 0.24) and diastolic blood pressure by 2.14 mmHg (0.94 to 3.33). Significant improvements were also found in most psychological measures. CONCLUSION: This study provides evidence that a type 2 diabetes prevention programme using lifestyle intervention is feasible in primary health care settings, with reductions in risk factors approaching those observed in clinical trials.

Assessment of childhood allergy for the primary care practitioner.

PURPOSE: To update the primary care practitioner on the assessment of common childhood allergic illnesses. DATA SOURCES: Relevant scientific literature and published clinical practice guidelines. CONCLUSIONS: Atopic children often develop symptoms that occur in a predictable progression from atopic dermatitis to gastrointestinal disturbances, chronic serous otitis media, rhinitis, and asthma. Evaluation of allergic symptoms should be based on their chronicity, family history of atopy, and knowledge of how the information will change patient management. Both skin and blood testing are accurate and useful tools in establishing a diagnosis of allergic disease. Management includes avoidance/environmental control, medications, and, when necessary, referral to specialists. IMPLICATIONS FOR PRACTICE: As the incidence of allergic disease increases, the human and monetary costs associated with allergies place a major burden on our healthcare system. Early identification of allergies and appropriate intervention are important to prevent progression to more significant disease. The use of objective diagnostic testing aids in implementing appropriate evidence-based medical management.

Frequent attenders in general practice: problem solving treatment provided by nurses [ISRCTN51021015].

BACKGROUND: There is a need for assistance from primary care mental health workers in general practice in the Netherlands. General practitioners (GPs) experience an overload of frequent attenders suffering from psychological problems. Problem Solving Treatment (PST) is a brief psychological treatment tailored for use in a primary care setting. PST is provided by nurses, and earlier research has shown that it is a treatment at least as effective as usual care. However, research outcomes are not totally satisfying. This protocol describes a randomized clinical trial on the effectiveness of PST provided by nurses for patients in general practice. The results of this study, which currently being carried out, will be presented as soon as they are available. METHODS/DESIGN: This study protocol describes the design of a randomized controlled trial to investigate the effectiveness and cost-effectiveness of PST and usual care compared to usual care only. Patients, 18 years and older, who present psychological problems and are frequent attenders in general practice are recruited by the research assistant. The participants receive questionnaires at baseline, after the intervention, and again after 3 months and 9 months. Primary outcome is the reduction of symptoms, and other outcomes measured are improvement in problem solving skills, psychological and physical well being, daily functioning, social support, coping styles, problem evaluation and health care utilization. DISCUSSION: Our results may either confirm that PST in primary care is an effective way of dealing with emotional disorders and a promising addition to the primary care in the UK and USA, or may question this assumption. This trial will allow an evaluation of the effects of PST in practical circumstances and in a rather heterogeneous group of primary care patients. This study delivers scientific support for this use and therefore indications for optimal treatment and referral.

Recruitment and retention: successful strategies in critical care.

Recruitment and retention of critical care nurses is a major concern for nurse managers. Factors that affect recruitment and retention are management style, perceptions of isolation, stress, and burnout. Decentralization, primary nursing, and clinical advancement programs are strategies that allow nurses to participate in decision making at the unit level and to be recognized for their individual contributions. The application of these strategies to a cardiac surgery intensive care unit is presented.

How do expert labor nurses view their role?

OBJECTIVE: To examine how expert perinatal nurses in a nurse-managed labor model view their role in caring for mothers during labor and birth. DESIGN: Focus group methodology. Data were analyzed using inductive coding methods to gain understanding from the perspective of those providing the care. SETTING: Labor and birth units in four large Midwestern medical centers. PARTICIPANTS: Fifty-four expert labor nurses. INCLUSION CRITERIA: 5 years experience in nursing care during labor and birth in institutions where nurse-managed labor was the predominant practice model. RESULTS: Four common themes related to nursing roles were identified. These included knowing the labor process and the intuitive nature of nursing care provided by expert labor nurses based on years of experience, knowing the woman and letting her body guide labor, advocacy for laboring woman, and the autonomous nature of the nurse-managed labor model. CONCLUSIONS: Expert labor nurses developed a keen sense of intuitive knowledge based on their years of experience. They reported using hands-on high-touch supportive care techniques with the potential to affect labor and birth outcomes. Autonomy is perceived as a key component of practice within the nurse-managed labor model.

Postpartum mothers' preferences for nighttime care of the neonate.

This study, conducted in response to issues raised during implementation of a dyad care delivery system, investigated preferences of postpartum mothers for nighttime care of the neonate. For dyad as well as traditional care subjects, the availability of individual care options emerged as a theme in both personal preference and preference based on available hospital accommodation. Significant differences existed between dyad and traditional care subjects on second choices for nighttime care and on environmental variables.

What psychiatric nurses say about constant care.

As part of a qualitative research project on constant care, 8 psychiatric nurses described their perceptions of the constant care experience and its purposes and values. One of the major domains that emerged from the interviews was "nursing"; it consisted of nine themes, some of which indicated that constant care alters the passage, meaning, and use of time, is a dynamic rather than a static relationship, and enhances a nurse's sense of powerfulness. The findings showed that constant care is a dynamic, and to some, distorting, experience. It demands extra work from the nurses, yet constrains them from doing counseling or other higher-order interventions. Having more nursing experience was seen as an advantage in preparing for constant care, controlling angry feelings, and discriminating for potentially dangerous situations. Also, due to the interactive nature of constant care, a nurse could not merely guard a patient because the nurse is also on constant care. These findings have implications for making patient assignments, teaching novice nurses how to do constant care, affirming current practice even though it is against hospital policies, and illustrating how nurses can be aware of and resourceful when constant care is stressful.

Effectiveness of primary health-care nurses in the promotion of oral rehydration therapy in a rural area of Nigeria.

Using a pre- and post-intervention method, this study evaluates the effects of verbal instructions and demonstration by the primary health-care nurses on knowledge, attitude and practice of home management of childhood diarrhoea by mothers in a rural area of Nigeria. Although the proportion of mothers that knew how to prepare and give oral rehydration therapy (ORT) increased significantly from 6.2 to 47.0%, few (9.5%) were practising it during subsequent episodes of diarrhoea. The use of starvation by the mothers also decreased significantly from 43.0 to 8.2% however the use of traditional medicines and medicines from chemists did not show any significant change. The beliefs that sugar worsens diarrhoea, that home-made ORT was not a medicine, and continued reliance of the mothers on traditional healers and medicine dealers for advice were factors constraining adoption of the ORT by the mothers. For effectiveness, therefore, the educational programmes of the nurses should also be directed at the traditional healers and the medicine dealers.

Case management in long-term care: new directions for professional nursing.

Case management can be a highly successful model to deal with issues of cost effectiveness, accountability, and quality care. Continuity of care is a guaranteed benefit of the case management model. Case management is a centralized or structured system whose standard is not set by those performing less effectively. Case management offers autonomy, empowerment, and positive patient care outcomes. These are magnet issues in the retention of staff nurses. The case management method of primary nursing allows for a reduction in the need for professional nurse staff.

Judgment strategies for coping with ambiguous clinical situations encountered in primary health care [corrected].

This naturalistic study identifies and describes strategies for clinical problem solving in situations of uncertainty, from observations of patient/family visits in a family health center. Judgment strategies were described for four types of uncertainty: information, diagnosis, treatment, and patient response that roughly correspond to the phases of assessment, planning, implementation, and evaluation of the clinical problem-solving process. The study contributes to increased understanding of the practical (experiential) knowledge involved in clinical judgment.

An integrated nursing and telemedicine approach to vascular care.

We have developed a telemedicine approach to vascular care for patients being managed in primary care. District nurses visit patients in their homes. Clinical information and digital photographs can be sent by email to the vascular surgeon for assessment. Where appropriate a preliminary teleconsultation between the patient and a vascular surgeon, with the nurse in attendance, is held at the primary care centre and the management of the patient is agreed. This may include referral to surgery. Over eight months six patients with diabetes and peripheral ulcers participated in the vascular telemedicine clinic. The average consultation time was 12 min (SD 4), which included discussion of the case and negotiation of its management. Important outcomes of the new system were the ability to schedule patients for rapid referral and to have completed the management of the case during the teleconsultation.

Primary care across clinical settings.

This article discusses the role of the Family Nurse Practitioner. It is a personal account of the nurse practitioner role across the clinical spectrum of office, infirmary, hospital, and home care settings. General information is provided on professional liability, prescriptive authority, and other practice issues. An evaluation of the multi-faceted role of the nurse practitioner is provided.

Continuity of care. Balancing care of elders between health care settings.

Continuing care planning and balancing care of elders are crucial components of health care today. The most sweeping change that has come with the advent of prospective pricing for the acute care setting is in the financing of health care for the aged and disabled. Prospective pricing, which uses the diagnosis-related group system, is the method chosen by federal agencies to restrain Medicare costs. For almost two decades, the hospital has been the reservoir for the impaired elderly who could not be returned home or to the community without support services. The system now encourages shortened hospital stays. Continuing care planning is the key to balancing the care of the elder through the process of discharge planning. We must assure patients and families that their needs will be met in the community when the patient is discharged. Balancing care of elders between health care settings through discharge planning is identified in three simple words: A Complex Process. As health care professionals, we must be ready to accept this challenge.

Telephone follow-up program evaluation: application of Orem's self-care model.

The traditional model of nursing, in which patients are discharged with a follow-up medical appointment, is no longer sufficient in the current healthcare environment. Primary nurses working in a 58-bed rehabilitation unit located in a 1,700-bed tertiary care medical center implemented a follow-up telephone call program to support the patient's transition from acute rehabilitation nursing care to community living. Patients discharged to home within a five-state area were called 2 weeks and 6 weeks after discharge. Notes on the telephone conversations were entered on a data collection form and later analyzed using Orem's self-care deficit theory (Orem, 1991). A total of 144 follow-up calls were made. During the first call (n = 105), 157 problems (1.5 per call) were noted, whereas 79 (2.0 per call) were identified during the second call (n = 39). Medication, safety, and bladder problems were most often cited as concerns by patients and caregivers after discharge. The most frequently used helping interventions during both the first and the second telephone calls were guiding and supporting.

Nursing management of patients with brain injury requiring one-on-one care.

Patients with traumatic brain injury currently constitute a major portion of the rehabilitation population. Although agitated, restless, and wandering behavior is an expected stage in the recovery process of these patients, issues involving the patient's and the staff's safety can arise when these behaviors are excessive and hard to control. In addition, patients may have difficulty achieving their rehabilitation goals because of these behaviors. One-on-one supervision, specialized interventions, and a structured approach often are necessary and beneficial if patients are to achieve rehabilitation goals. The facility described in this article has a large population of patients with head injury who require one-on-one supervision. Guidelines for the nursing management of two different patient populations that required two different interdisciplinary approaches were developed and established.

Biopsychosocial nursing assessment: a way to enhance care plans.

1. A psychiatric nursing assessment tool reinforces the primary nursing care model; re-establishes nursing's input at comprehensive treatment plan meeting; reorients the staff to the total nursing needs of the client; and provides a tool for establishing nursing diagnoses. 2. Implementation of the nursing assessment form has educated other staff about professional nursing practice, as well as promoted a greater understanding of the nursing process and reinforced accountability for the nurses. 3. The form enables clients to be viewed from a holistic biopsychosocial nursing context, and nursing care plan recommendations are more individualized and inclusive of the total aspects of patient needs.