Managing acute asthma in primary care.

Asthma is a common inflammatory condition affecting the airways. Many people with it fail to achieve a satisfactory level of control and, consequently, have recurrent acute exacerbations. These can occur due to allergen exposure, viral infections or for no identifiable reason. Guidelines categorise exacerbations into three categories, from moderate to life threatening. Prompt assessment and treatment using bronchodilators and corticosteroids are essential, as is follow up to identify and manage factors that may have contributed to the exacerbation. This article discusses guidelines on the management and causes of acute exacerbations, and follow-up care that should be provided.

[Instrument to assess nursing care delivery stystems "IzEP". Making nursing care systematically visible for practice, management and science]. / Instrument zur Erfassung von Pflegesystemen "IzEP". Pflegerische Organisation für Praxis, Management und Wissenschaft sichtbar machen.

Network activities and publications show a rising interest in nursing care delivery systems like primary nursing. There are aspects in quality and outcomes attributed to primary nursing to answer the changes in health care. To assign outcomes in nursing to different kinds of nursing care delivery systems and for systematic developing of primary nursing in a unit one needs a special assessment instrument. IzEP, the instrument to assess nursing care delivery systems, relates the nursing care delivery system of a unit to primary nursing. This article describes the development of the instrument, testing of reliability, validity and possibilities for using.

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.

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.

Physician perspectives of nurse care management located in primary care clinics.

Care management has been suggested as a method to improve management of chronic disease, but its success can depend on the involvement of primary care physicians, especially with referral to care management. Our objective was to identify and characterize physicians' perspectives of care management in order to gain insight into the rationale for referral to care management. The study took place in primary care clinics within an integrated delivery system. Nineteen primary care physicians with varying levels of involvement with care management participated in the study. We performed a qualitative and quantitative analysis ofsemistructured interviews. Four referral patterns emerged that were related to physicians' recognition of care managers' abilities and how care managers were connected to their practice. Results from this study can be used to more effectively implement similar models of chronic disease management, where physician participation is a critical component for successful implementation.

[A study to improve the quality of visiting nursing care at Isehara City].

As for Isehara City Visiting Nursing Liaison Congress, we investigated and analyzed the actual conditions of visiting nursing care development at Isehara city by using the NADA nursing diagnosis. It is desirable that a visiting nurse should have skills in evacuation, suction of the respiratory tract, rehabilitation, prevention of complications and an early detection of a poor condition of the patient. In addition, we found that it is also desirable that a visiting nurse fulfill a leadership function in coordinating to support home-care, have a communication skill to anticipate potential problems of patients and counsel his or her family concerns in a short period of time.

A comparison of GPs and nurses in their approach to psychological disturbance in primary care consultations.

It has frequently been reported that GPs fail to diagnose many of the psychological problems that present to them. It also appears that practice nurses working in primary care also show similar diagnostic 'failings'. This study extends these observations by reporting the psychiatric diagnostic practices of GPs and nurses working in the same settings of six general practices. After each consultation the health professional involved assessed the degree of psychological morbidity and the amount of time they had spent attending to this problem. The health professionals' assessment was compared with the score from a General Health Questionnaire completed by the patient. Analysis of 1646 consultations revealed that GPs saw patients with more psychological problems than nurses. Nurses, however, spent significantly more time dealing with their psychological workload than their GP colleagues, after allowing for the fact that they saw fewer patients in this category. This observation raises the question of whether this use of scarce time resource in the consultation is appropriate.

Effect of a primary-care-based epilepsy specialist nurse service on quality of care from the patients' perspective: quasi-experimental evaluation.

Initiatives to improve epilepsy care have emphasized the role of specialist nurses. Formal evaluation of these initiatives are scarce. Further evaluative studies are required to ascertain the optimal means of providing epilepsy care. This study aimed to assess the effect of a primary-care-based epilepsy specialist nurse service on patients' reported health status, perceived quality of life, health care use, attitudes to health care, and provision of information. A quasi-experimental follow-up questionnaire survey was sent to all 574 patients aged 16 years or over and receiving antiepileptic drugs for epilepsy, registered in 14 general practices in north-west Bristol. Patients in seven practices who received the new service (intervention patients) were compared with patients in seven practices who did not (control patients). Follow-up comparisons between intervention and control patients were adjusted for baseline differences. Response rates to the first, second and both surveys were 66.2%, 68.6% and 50.9%, respectively. Intervention patients were more likely than control patients to have discussed most epilepsy topics with general practitioners and/or hospital doctors. and were significantly more likely to have categorized general practitioner care as excellent (odds ratio (OR) 2.30, 95% confidence intervals (CI) 1.12-4.70). Intervention patients were significantly less likely than controls to have reported never missing taking their anti-epileptic drugs (OR 0.48, 95% CI0.24-0.94). There were no significant changes in measures of health status, use of other health care services, and perceived quality of life between intervention and control patients. This study provides evidence of an improvement, after 1 year, in communication and satisfaction but not health status resulting from the introduction of a primary-care-based epilepsy service.

Assessment of process quality in Tanzanian primary care.

Process quality is the commonly used operational definition of health care quality. Its key components are technical and inter-personal skills, but most assessments undertaken in developing countries focus only on technical skills. This study from Tanzania used explicit observation checklists to review the process of providing antenatal, curative and nursing care in primary health units, assessing both technical and inter-personal skills. The study findings emphasize the weaknesses in available care, particularly in the attitudes of health staff but also in aspects of technical care. Differences in performance between health units appear to be influenced by factors such as workloads, structure and staff allocations. Differences between cadres were also identified and may underlie some of the inter-unit differences. The policy actions required to address the problems must reflect the diversity of the underlying influences, seeking to raise both technical and inter-personal quality, as the two are mutually reinforcing.

Community asthma clinics: 1993 survey of primary care by the National Asthma Task Force.

OBJECTIVES: To establish a baseline of work done in primary care asthma clinics in the United Kingdom and to assess the degree of clinical delegation to nurses and the appropriateness of their training. DESIGN: Prospective questionnaire survey of asthma care in general practices and a subsidiary survey of all family health services authorities (FHSAs) of the number of asthma clinics in their area. SETTING: All 14,251 general practices in the United Kingdom and 117 FHSAs or health boards (Scotland and Northern Ireland). RESULTS: Questionnaires were returned by 4327 (30.4%) general practices, 54% being completed by practice nurses and 22% by general practitioners; in 24% profession was not stated. In all, 77.2% (3339/4327) of respondents ran an asthma clinic. 60 FHSAs state the number of asthma clinics at the time of the general practice survey (total 3653 clinics); within responding FHSAs 1702 (46.6%) practices running an asthma clinic replied to the general practice survey. Clinics exclusive for patients with asthma mostly occurred in practices with five or more general practitioners (70.2%), compared with single-handed practices (31.7%). The average number of asthma clinics run per practice was five a month; the average duration was 2 hours and 20 minutes. 1131 (48.8%) nurses ran clinics by themselves, 1180 (47.9%) with the doctor, and 39 (1.7%) had no medical input. Comprehensive questioning occurred other than for nasal (872, 26.1%) or oesophageal (335, 10.0%) symptoms and use of aspirin and non-steroidal drugs (1161, 33.4%). Growth in children was measured by only a third of respondents. Of the 1131 nurses who ran clinics alone, 251 (22.2%) did so without formal training entailing assessment. CONCLUSION: Asthma clinics are now common in general practice and much of their work is done by nurses, a significant minority of whom may not have had sufficient training. IMPLICATIONS: As this survey is probably biased toward the more asthma aware practices, greater deficiencies in training and standards may exist in other practices. Further evaluation of the effectiveness of asthma clinics is needed.

Collaborative practice and patient satisfaction: impact and selected outcomes.

The Collaborative Practice was a demonstration project sponsored by the Hartford Hospital Administration, and the Departments of Medicine and Nursing. A prospective evaluative study was established to measure the impact of collaborative practice on increased patient and family satisfaction with health care, as well as the impact on selected outcome variables. A specific 27-bed medical unit and a comparison unit with identical structural characteristics were chosen for study from March 31, 1982, to March 31, 1983. Results of the study indicate that significant differences in patients' perceptions of care existed between the Collaborative Practice Unit (CPU) and the comparison unit under a traditional team nursing system. More positive ratings from patients on the CPU were found for all selected dimensions: patient-provider interaction; quality of care; health education; knowledge of practitioners; and the environment. In order to assess the impact of collaborative practice on outcome variables, a retrospective audit of randomly selected patient records was done. No significant differences for selected variables were found except for the number of health teaching plans. More documented health teaching was recorded on the Team Nursing Unit.

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.

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.

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.

Abused women's concerns about safety and the therapeutic environment during psychiatric hospitalization.

The purposes of this study were to identify the concerns of women who have a history of abuse regarding safety and the inpatient environment during psychiatric hospitalization, and to identify environmental changes they would like to see. A qualitative design was used to explore the women's concerns through semi-structured interviews. Instruments measuring sexual and physical abuse were administered. Of the 20 women recruited from 3 hospitals, 18 reported a history of sexual and/or physical abuse. One investigator interviewed the participants and one acted as recorder. After each interview, a list of identified concerns was generated; these concerns were raised in the next interview if not spontaneously brought up by the participant. Seventeen women reported feeling unsafe in mixed-gender units and said they would prefer segregated areas for programming and meals; 16 expressed concerns about nighttime routines and the traditional practices of restricting medications and contact with staff at night; 15 considered primary nursing extremely important to feeling understood and safe. The participants said they wanted to be heard and to be included in decision-making.

Outcomes of nursing care: the case of primary nursing.

Using primary nursing as a 'case study', this paper reviews research literature which attempts to measure the effectiveness of a mode of nursing using outcome measures. Previous research, it is argued, is hampered by a lack of conceptualization of structure and process and inadequate research design, with consequent uncertain findings. A shift in emphasis is suggested from an evaluation of global concepts, such as primary nursing, to an identification of the features of structures and processes of nursing care which interrelate with patient and nurse outcomes. For this purpose, multivariate research design and investment in methodological research are recommended.

An approach to evaluating the introduction of primary nursing in an acute medical unit for the elderly--II. Operationalizing the principles.

The first paper set out the 10 principles which formed the basis on which primary nursing has been introduced in an acute elderly care ward. This paper explores the problems of expressing these principles in terms which make it possible to demonstrate that changes in the way nurses approach their patients and their work have really taken place and suggest some of the research strategies which might be appropriate.

An approach to evaluating the introduction of primary nursing in an acute medical unit for the elderly--I. Principles and practice.

The paper reviews the research literature on primary nursing and some of the problems in research methodology which have been identified. It sets out the 10 principles which are the basis on which primary nursing will be introduced in an acute elderly care ward. The problem of outcome measures is discussed and a research design proposed.

Can feedback be individualised, useful, and economical?

An important, but often neglected, part of any research or audit exercise is the reporting back to participants of the results of that exercise. When feedback is made, it is often of a general, aggregated nature. Considerations of cost and psychological factors usually preclude feedback to individuals. As part of a larger study we have developed a prototype mechanism for providing such individual feedback. This was done by writing a computer program which automatically generated the report, using rules on how to interpret different patterns of responses to a questionnaire. Previous qualitative evaluation had shown a positive response from participating nurses. The current small-scale study reports a more formal evaluation. Participants who received reports on the degree to which their ward was practising primary nursing overwhelmingly found the reports readable, informative, encouraging, accurate and useful.