Avaliação da qualidade da atenção primária à saúde na perspectiva dos enfermeiros da estratégia saúde da família do município do Rio de Janeiro

A Atenção Primária à Saúde (APS) pode ser medida por meio de atributos, ou seja, características. Os atributos essenciais da APS são: acesso de primeiro contato, integralidade, longitudinal idade e coordenação, sendo complementados pelos atributos derivados, a orientação familiar e comunitária e a competência cultural. No Brasil o modelo de APS adotado é a Estratégia Saúde da Família (ESF). O Rio de Janeiro é a capital brasileira com maior número de Equipes de Saúde da Família implantadas nos últimos 6 anos. No ano de 2008 havia pouco mais de 3% de cobertura de Saúde da Família e em 2015 a cobertura alcança 46,92% da população com 876 equipes implantadas. Considerando o cenário de expansão da APS no Rio de Janeiro e a atuação do Enfermeiro na equipe de saúde da família, fez-se necessário avaliar a qualidade da atenção ofertada à população. Tratou-se de uma pesquisa epidemiológica transversal analítica e teve como objetivos: Avaliar a qualidade da atenção primária à saúde a partir da experiência dos enfermeiros atuantes nas equipes de Saúde da Família da Cidade do Rio de Janeiro; Mensurar a presença e extensão dos atributos da Atenção Primária à Saúde nos serviços de saúde de Atenção Primária da Cidade do Rio de Janeiro por região de saúde; e, Identificar a associação da qualidade da APS em relação ao perfil dos enfermeiros. Foi realizada por meio da aplicação do Instrumento de Avaliação da Atenção Primária (PCATool) aos enfermeiros resultando num escore geral de APS de 7,85 indicando forte orientação e presença dos atributos da APS nos serviços de saúde avaliados. Sobre o perfil dos enfermeiros o tempo de atuação na ESF foi a variável que influenciou na avaliação da qualidade da atenção.

The Primary Health Care can be measured by means of attributes, ie characteristics.The essential attributes of Primary Health Care are: Access to First Contact,completeness, longitudinality and coordination, being complemented by derivedattributes, family and community orientation and cultural competence. In Brazil theAPS model adopted is the Family Health Strategy. The Rio de Janeiro is the Braziliancapital with the highest number of Family Health Teams deployed in the last 6 years.In 2008 there were just over 3% of family health coverage and in 2015 the coveragereaches 46.92% of the population with 876 teams implemented. Considering the APSexpansion scenario in Rio de Janeiro and the role of the nurse in the family healthteam, it was necessary to evaluate the quality of care offered to the population. Thiswas an analytical cross and epidemiological research aimed to evaluate the quality ofprimary health care from the experience of nurses working in the Family Healthteams of the City of Rio de Janeiro; Measure the presence and extent of the HealthPrimary attributes in Primary Care Health Services of the City of Rio de Janeiro byhealth region; and identify the APS quality of association in relation to the profile ofnurses. Was performed by applying the Primary Care Assessment Tool (PCATool) tonurses resulting in an overall score of Primary Health Care of 7.85 indicating strongguidance and presence of Primary Health Care attributes in health servicesevaluated. Profile of nurses the playing time in the Family Health Strategy was thevariable that influenced the assessment of quality of care.

La Atención Primaria de Salud se puede medir por medio de atributos,características decir. Los atributos esenciales de la atención primaria de salud son:Acceso al Primer Contacto, la integridad, la longitudinalidad y la coordinación, que secomplementa con atributos derivados, orientación familiar y comunitaria y lacompetencia cultural. En Brasil el modelo APS adoptada es la Estrategia de Saludde la Familia. El Río de Janeiro es la capital brasileña con el mayor número deequipos de salud familiar desplegado en los últimos 6 años. En 2008 había pocomás de 3% de la cobertura de salud de la familia y en el 2015 la cobertura alcanza46.92% de la población con 876 equipos implementados. Teniendo en cuenta elescenario de expansión APS en Río de Janeiro y el papel de la enfermera en elequipo de salud de la familia, era necesario evaluar la calidad de la atención que seofrece a la población. Esta era una cruz de análisis e investigación epidemiológicatuvo como objetivo evaluar la calidad de la atención primaria de la salud a partir de laexperiencia de las enfermeras que trabajan en los equipos de Salud Familiar de laCiudad de Río de Janeiro; Medir la presencia y extensión de la Primaria de Saludatributos en Atención Primaria de Salud de Servicios de la Ciudad de Río de Janeiropor región sanitaria; e identificar la calidad de APS de asociación en relación con elperfil de las enfermeras. Se realizó mediante la aplicación de la Herramienta deEvaluación de la Atención Primaria (PCATool) a las enfermeras que resulta en unapuntuación total de Atención Primaria de Saludde 7,85 indican una orientación fuerte y presencia de la Atención Primaria de Saludatributos en los servicios de salud evaluados. Perfil de las enfermeras el tiempo dejuego en la Estrategia Salud de la Familia fue la variable que influyó en la evaluaciónde la calidad de la atención.

Desarrollo e implementación de una vía clínica a los pacientes que inician la hemodiálisis de forma programada / Development and implementation of a clinical pathway for patients starting programmed haemodialysis

Una vía clínica pretende ser un instrumento institucionalizado, donde todos los profesionales del servicio sepan en todo momento todas las actividades y acciones que tienen que llevar a cabo el tiempo que dura esta actividad asistencial y los usuarios/familiares conozcan desde el primer momento toda la información de la asistencia que se les va a prestar. Con el fin de diseñar una vía clínica se formó un grupo de trabajo interdisciplinar que elaboró un instrumento compuesto por: • Una matriz temporal, donde se detallan por día las actividades de todos los profesionales implicados en la vía clínica, y se especifican otros aspectos importantes como son las pruebas complementarias, dieta y medicación. • Hoja de variaciones. Donde se detallan tanto las desviaciones de la vía como las acciones realizadas o su justificación. • Hoja de información al paciente y/o familiar. Incluye una serie de ilustraciones que informan al paciente sobre la evolución más frecuente del proceso. Es una versión gráfica simplificada de la matriz para una fácil comprensión del paciente. • Encuesta de satisfacción del paciente y/o familiar. Se entrega al paciente para que exprese de forma anónima su opinión sobre la atención y cuidados prestados. Engloba preguntas respecto a la información recibida, la atención, aspectos de hostelería, etcétera. Hemos considerado todo el equipo, como periodo de reevaluación de la misma cuando alcancemos los 10 pacientes, para poder realizar modificaciones o áreas de mejoras de la misma (AU)

A clinical pathway aims to be an institutionalized instrument, where all the professionals of the service know at all times the activities and actions they have to carry out, the time this care activity lasts, and users and relatives know right from the start all the information on the care they will be given. In order to design a clinical pathway, a multidisciplinary working group was formed which drew up an instrument made up of: • A time chart detailing by day the activities of all the professionals involved in the clinical pathway, and specifying other important aspects such as complementary tests, diet and medication. • Variance sheet. Where both deviations from the pathway and the actions realized or their justification are detailed. • Information sheet for the patient and/or relative. It includes a series of illustrations that inform the patient of the most common evolution of the process. It is a simplified graphic version of the time chart so that it can be easily understood by the patient. • Patient and/or relative satisfaction survey. This is given to the patient so that he or she can give his or her opinion anonymously on the care received. It includes questions on the information received, care, catering aspects, etc. We have considered the entire team, and reassessed the pathway when we reached 10 patients, in order to make modifications or determine areas for improvement (AU)

Quemaduras. Nuevos retos que plantearse / Burns, new challenges to take on

Estudio descriptivo transversal que muestra las características de las quemaduras atendidas en un Centro de Atención Primaria (CAP) de ámbito urbano en Barcelona durante el periodo comprendido desde 19/7/2005 hasta 11/8/2007 (N=93). Los pacientes menores de 15 años fueron excluidos. El 88% (82; IC del 95% 81,41-94,59) de las quemaduras se debió a un agente térmico. El aceite de cocina es el primer elemento causal (24; 27%; IC del 95% 17,99-36,01). El 70% de las heridas señaló dérmicas superficiales (65; IC del 95% 60,70-79,30). El 61% (57; IC del 95% 51,70-70,30) se localizó en EESS (extremidades superiores). La superficie corporal quemada media registrada indicó 0,0076% (mediana=0,005%; rango=0,0001-0,5000%). El mayor número de heridas se observó en los varones de 31 a 45 años (17%; 16; IC del 95% 9,38-24,62). Se precisan programas de educación para la salud centrados en la prevención y actuación ante una quemadura. Estudios como éste pueden resultar útiles a la hora de iniciar estrategias preventivas o educativas (AU)

This article concerns a transversal descriptive study which shows the characteristics of burns treated in a Primary Health Care Center in an urban environment in Barcelona from 19 July 2005 until 11 August 2007 (N=93). Patients younger than 15 were excluded from this study. 88% (82; IC of 95% 81,41-94,59) of the burns treated were caused by a thermal agent. Kitchen cooking oil ranks first as the cause of burns (24; 27%; IC of 95% 17,99-36,01). 70% of the burns studied had signs of superficial skin damage (65; IC of 95% 60,70-79,30). 61% (57; IC of 95% 51,70-70,30) of these burns were located on upper extremities. The average recorded body surface burned was 0.0076% (median=0,005%; range=0,0001-0,5000%). The greatest number of wounds were observed among men aged 31 to 45 (17%; 16; IC of 95% 9,38-24,62). Educational health programs which focus on prevention of, and first aid care for, burns are needed. Studies like this one may prove useful when starting preventive or educational strategies (AU)

Improving health status of homeless patients at a nurse-managed clinic in the Midwest USA.

Homeless adults have a higher rate of morbidity and mortality than their housed counterparts. Improving the health of homeless adults is a complex problem because of the overlay of individual risk factors, social issues and lack of economic resources. Due to the increased morbidity and mortality rate in homeless adults, it is imperative to develop interventions with demonstrated efficacy that result in improved health outcomes. The purpose of this pre-post pilot study was to compare pre- and post-test scores on specific health outcomes in a group of homeless adults receiving a nurse intervention when utilising a nurse-managed clinic located in the urban core of a Midwestern city in the USA. Between September of 2004 and January 2006, 43 homeless adults completed a health survey at baseline and 2 months later that included measures of health-related quality of life (HRQOL), substance use and health resource use. There was a significant improvement on the post-test scores including substance use, perceived quality and availability of health care, and on two domains of HRQOL: mental health and vitality. This study provides evidence that a nursing intervention can result in improved health outcomes for adult homeless persons.

Patients' decision-making strategies for managing postoperative pain.

UNLABELLED: Despite technological advances, many postoperative patients continue to suffer unrelieved pain. The aim of this study was to identify the strategies used by postoperative patients to bring about pain management decisions. A single-group noncomparative study design was chosen using observations as the means of examining pain activities in 2 surgical units of a metropolitan teaching hospital in Melbourne, Australia. A total of 52 nurses and 312 patients participated in the study, and 316 pain activities were observed. The most common strategy used was patients acting as a passive recipient for pain relief (60%), whereas problem solving (23%) and active negotiation (17%) were less commonly used. Patients in this study were admitted for surgical treatment of a particular condition, and their subsequent pain was specifically related to this acute event. Therefore, the lack of familiarity of the situation and the severity of pain experienced may have encouraged passivity. Patients may have also felt uncertain about how to approach the pain decision, preferring to defer to nurses. Because increased pain levels can be associated with fear, patients could have been unwilling to speak with nurses to discuss their need for pain relief. PERSPECTIVE: This paper shows that patient decision making for postoperative pain relief largely involves the use of passive requests, compared with problem solving and active negotiation. Effective communication must be supported between health professionals and patients if shared understandings about treatment options are to become a reality.

Grado de satisfacción del cuidado de enfermería en pacientes sometidos a angioplastia coronaria transluminal percutanea (ACTP) con stent / Satisfaction level in nursing care among patients with the experience of percutaneous transluminal Coronary Angioplasty (ACTP) with Stent

El objetivo del presente estudio fue valorar la evolución en el logro de resultados, medir el grado de logro de los mismos y determinar el grado de satisfacción con el cuidado de enfermería en personas que viven la experiencia de angioplastia coronaria. El diseño del estudio fue descriptivo, de casos. La muestra la constituyeron 18 pacientes programados para angioplastia, por enfermedad coronaria, hospitalizados en el Hospital Militar Central de Bogotá durante los meses de octubre-diciembre de 2003 y enero-abril de 2004. De los resultados preliminares se concluye que existe un grado medio, con tendencia a alto, de resultados positivos del cuidado de enfermería ofrecido a los pacientes sometidos al procedimiento de angioplastia coronaria con Stent. Cuidados planifica dos según diagnósticos de enfermería evidencian que las enfermeras poseen los conocimientos técnico-científicos y las habilidades de cuidadoras de pacientes con angioplastia coronaria. El grado de satisfacción con el cuidado varió entre poco y medianamente satisfecho; posiblemente hay algún problema en la comunicación enfermera/paciente, tal vez por la cantidad de tareas que debe cumplir la enfermera en estos servicios.

The purpose of the pre sent study was to evaluate the evolution in achieving results, measuring the achievement level as such and to determine the level of satisfaction in nursing care, among people living with the experience of Coronary Angioplastia. The design of the study was descriptive, on a case by cases basis. The sample was composed by 18 patients programmed for angioplastia, due to coronary illness, hospitalized in the Hospital Militar Central of Bogotá, between October - December 2003, and January - April 2004. From preliminary results we concluded that there is tendency from mid to high level of positive results regarding the nursing care offered to the patients who underwent the procedure of coronary angioplastia with Stent. Care planned according to the Nursing Diagnos...

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.

Primary care nursing of coronary patients and reduction of re-infarction risk: a nested case-control study.

OBJECTIVES: To estimate the risk reduction for re-infarction achieved in primary health care centres. STUDY DESIGN: This was a case-control study nested in a cohort of coronary patients. POPULATION: Nine hundred and eighty-five coronary patients, aged less than 76 years who had survived for more than 6 months after their first acute myocardial infarction (AMI), were recruited from two public hospitals in Navarre, Spain. Cases (repeated myocardial infarction, n = 137) and controls (patients with one AMI who had not had a second infarction, [n = 137) who had not been treated with invasive procedures were extracted from this cohort and matched by gender, age, hospital and the secondary prevention time frame. OUTCOMES MEASURED: Re-infarction. RESULTS: In total, 31.4% of cases and 51.8% of controls attended the primary care nurse clinic regularly. This difference accounted for a significant reduction of the risk of re-infarction, even after adjustment for regular visits to the family physician, life styles (smoking, walking habit and dietary changes) and drug treatments (odds ratio: 0.48; 95% confidence interval: 0.26-0.89). A regular schedule of visits to the family physician showed no association with further coronary risk reduction. CONCLUSIONS: Regular attendance of coronary patients at a primary care nurse clinic is associated with a lower risk for re-infarction. Psychological rehabilitation could be the main reason for this benefit, since protection persists after adjustments for other known risk factors.

Enhancing primary health care services for adults with intellectual disabilities.

BACKGROUND: Primary health care teams have an important part to play in addressing the health inequalities and high levels of unmet health needs experienced by people with intellectual disabilities (ID). Practice nurses have an expanding role within primary health care teams. However, no previous studies have measured their attitudes, knowledge, training needs, and self-efficacy in their work with people with ID. METHODS: All practice nurses working in a defined area were identified. A purpose-designed questionnaire to measure nurse attitudes, knowledge, training needs and self-efficacy was developed and piloted. All practice nurses were then invited to participate. Data from completed questionnaires were entered onto PC and analysed. RESULTS: Of a total of 292 practice nurses 201 (69%) participated. Whilst 89% (n=179) of participants reported having infrequent contact, 25% (n=50) reported a growing workload with people with ID. Only 8% (n=16) had ever received any training in communicating with people with ID. A knowledge gap regarding the health needs of people with ID was identified. Eighty-six per cent reported having experienced specific difficulties during previous appointments, and only 23% thought they had sufficient case note information at appointments, but 68% did not modify the duration of their appointments with people with ID. Conversely, responses demonstrated that practice nurses have a high level of experience and qualification in general nursing, have positive attitudes to working with people with ID, and high self-efficacy scores were identified for work with people with ID. The practice nurses viewed ID to be a high priority area for future training. CONCLUSIONS: Primary health care teams have a key role in tackling the unmet health needs of people with ID. Whilst this project has identified factors that may impact on the accessibility of services, it has also identified practice nurses as having positive attitudes and high self-efficacy scores in their work with people with ID. This indicates that they should be targeted for specific training in this area, which may make an important contribution in enhancing future accessibility of primary health care services for people with ID.

The medical care of patients with primary care home nursing is complex and influenced by non-medical factors: a comprehensive retrospective study from a suburban area in Sweden.

BACKGROUND: The reduced number of hospital beds and an ageing population have resulted in growing demands for home nursing. We know very little about the comprehensive care of these patients. The objectives were to identify the care, in addition to primary health care, of patients with primary-care home nursing to give a comprehensive view of their care and to investigate how personal, social and functional factors influence the use of specialised medical care. METHODS: One-third (158) of all patients receiving primary-care home nursing in an area were sampled, and 73 % (116) were included. Their care from October 1995 until October 1996 was investigated by sending questionnaires to district nurses and home-help providers and by collecting retrospective data from primary-care records and official statistics. We used non-parametric statistical methods, i.e. medians and minimum - maximum, chi2, and the Mann-Whitney test, since the data were not normally distributed. Conditional logistic regression was used to study whether personal, social or functional factors influenced the chance (expressed as odds ratio) that study patients had made visits to or had received inpatient care from specialised medical care during the study year. RESULTS: 56 % of the patients had been hospitalised. 73 % had made outpatient visits to specialised medical care. The care took place at 14 different hospitals, and more than 22 specialities were involved, but local care predominated. Almost all patients visited doctors, usually in both primary and specialised medical care. Patients who saw doctors in specialised care had more help from all other categories of care. Patients who received help from their families made more visits to specialised medical care and patients with severe ADL dependence made fewer visits. CONCLUSIONS: The care of patients with primary-care home nursing is complex. Apart from home nursing, all patients also made outpatient visits to doctors, usually in both primary and specialised medical care. Many different caregivers and professions were involved. Reduced functional capacity decreased and help from family members increased the chance of having received outpatient specialised medical care. This raises questions concerning the medical care for patients with both medical and functional problems.

Investigación de resultados en enfermería. El camino hacia la efectividad de los cuidados / Outcomes research and nursing. The path to effectiveness in nursing care

Existe un interés máximo sobre los modos en que los distintos Estados pueden dar respuesta a la creciente demanda de servicios de salud por parte de la población. Fenómenos como el envejecimiento poblacional, el aumento de la dependencia, la cronicidad de los procesos y la inflación de expectativas en la ciudadanía, obligan, ante lá presencia de recursos limitados, a dilucidar con mayor precisión qué intervenciones sanitarias realmente producen resultados en la población. Se desprende de ello, toda una corriente de investigación de resultados en Salud que intenta dar respuesta a esta pregunta, no exenta de dificultades metodológicas importantes: ¿cómo medir resultados en salud?, ¿con arreglo a parámetros clínicos?, ¿a través de la perspectiva de los ciudadanos (calidad de vida, satisfacción...)?, ¿en función del coste que conlleva la consecución de los mismos...? A todo ello, hay que añadir la creciente variabilidad de la práctica clínica de los profesionales, que incide directamente en la homogeneidad de los resultados. Para determinar de quiénes dependen los resultados, el enfoque exclusivamente centrado en parámetros biomédicos no tiene suficiente poder explicativo. Una parte importante de éstos, van a estar influenciados por las respuestas humanas a la situación de salud; motivo por el cual, desde hace algunos años se acuña el concepto de resultados sensibles a la práctica enfermera. A lo largo del artículo se exponen los intentos que la ciencia de los cuidados ha intentado ofrecer a este desafío y el estado actual de desarrollo, tras la incorporación de la Nursing Outcomes Classification, así como las vías de crecimiento que este tipo de investigación requiere a corto plazo (AU)

A survey of diabetes care in general practice in England and Wales.

BACKGROUND: The focus of care for people with diabetes has shifted from hospital to general practice. Many practices now offer diabetes care via dedicated mini-clinics, shared care schemes or opportunistically. There has never been a national survey of the organisation of diabetes care in general practice. AIM: To describe some key features of diabetes care in primary care in England and Wales. METHOD: Descriptive postal questionnaire survey to one in five (1873) randomly sampled general practices. RESULTS: Seventy per cent (1320) of practices responded. Of these, 96% had diabetes registers identifying 1.9% of their population as having diabetes; 71% held clinics run by a general practitioner (GP) and a nurse (64%) or a nurse alone (34%); 80% felt adequately supported; and 54% shared patient management protocols with the local secondary care team. Overall, practices provided most of the routine diabetes care for 75% of their diabetic patients. The majority of GPs and practice nurses had received some recent, albeit brief, diabetes education. CONCLUSION: A large proportion of diabetes care now takes place in the community, much of it delivered by practice nurses. The organisational infrastructure necessary for delivering good care is in place. Many practices have a special interest in diabetes with the majority feeling adequately supported by secondary care. However, there are concerns about the educational needs of those providing care. More work needs to be done to ensure seamless care across the primary-secondary care interface.

Adult asthma review in general practice: nurses' perception of their role.

BACKGROUND: Asthma clinics have become widespread in general practice with nurses now playing an important role in asthma review. However, little is known about training of nurses carrying out reviews and how this affects the nurse role in patient management. OBJECTIVES: We aimed to discover the level of asthma training of practice nurses carrying out review of adult asthma patients in one Health Authority and to see if this has any effect on their perception of their role. METHOD: All 187 practice nurses in Grampian were sent a postal questionnaire investigating how asthma review is organized in general practice, their role in review and the asthma training they had received. Personal interviews were carried out with 17 nurses, exploring in more depth the topics covered in the questionnaire. RESULTS: A total of 167 nurses from 92% of the practices in Grampian responded, of whom 61% carried out asthma reviews. Among nurses carrying out reviews 71% did so on their own. 49% of nurses had or were training for advanced asthma qualification. Nurses without an asthma qualification were significantly more likely to feel that their training was not sufficient for their asthma related tasks (54% versus 11%, P = 0.0002). Nurses without advanced asthma qualifications were less likely to provide or review a self-management plan (29% versus 49%, P = 0.01), to review patient PEF recording (38% versus 65%, P < 0.01), to discuss patient worries (75% versus 94%, P < 0.05) or to make the initial diagnosis of asthma (24% versus 76%, P < 0.005). Nurses were unlikely to view their role as fully responsible unless they had an asthma qualification (13% versus 49%, P < 0.001). CONCLUSION: Nurses without advanced asthma qualifications do not feel fully confident in responsibility for patient management. Nurses without training are more likely to only carry out routine monitoring at reviews while nurses with asthma training are more likely to actively develop patient self-management skills. This suggests that nurses should be supported to obtain asthma qualifications if they are to give the best possible care to asthma patients.

Satisfaction with ambulatory care of persons with AIDS: predictors of patient ratings of quality.

OBJECTIVE: To examine the relation of patient characteristics and site of care to the perception of ambulatory care quality by persons with AIDS (PWAs). DESIGN: Patient surveys and medical record review were used to determine PWAs' perceptions of their ambulatory care, self-perceived health status, primary care relationships, sociodemographic characteristics, and severity of illness. SETTING: A public-hospital HIV clinic, an academic group practice, and a staff-model health maintenance organization (HMO) that together care for 20% of all Massachusetts PWAs. PATIENTS: All active patients as of February 12, 1990, and all new AIDS patients at each of the three sites during the subsequent 13 months. MEASUREMENTS AND MAIN RESULTS: The primary outcome measure was a six-item scale of patient-rated quality of care (PRQC), a newly developed measure that combined patients' ratings of their physician care, nursing care, involvement in medical decisions, and overall quality of care. Multiple logistic regression was carried out with low PRQC (lowest quartile) as the dependent variable, to identify correlates of patient perceptions of poor quality. Patients who had a primary nurse were significantly less likely to have low PRQC scores (OR = 0.50, 95% CI = 0.26 to 0.97). Black patients and patients who used injection drugs were significantly more likely to rate their care in the lowest quartile (OR = 2.22, 95% CI = 1.04 to 4.78; and OR = 2.43, 95% CI = 1.13 to 5.23, respectively), as were those who had lower self-perceived health status, after controlling for confounders; no association was found by site or severity. CONCLUSIONS: These results show that primary nursing may be an important determinant of how PWAs rate the quality of their ambulatory care. Furthermore, PWAs who are black or who are injection drug users are less satisfied than are others with the quality of their ambulatory AIDS care.

Nursing diagnosis as a framework for college health nursing protocols.

Standardized nursing protocols in college health must facilitate cost-effective student healthcare, allow nurses to function within the legislated scope of practice of their state, and still address the health needs of the patient population. Nursing diagnosis provides the framework for a protocol model that does all of this, as well as providing professional growth opportunities for college health nurses and nursing.

Application of primary nursing within a team setting in the hospice care of cancer patients.

A qualitative study was conducted to obtain a deeper understanding of the hospice care of terminally ill cancer patients, where care was delivered via a primary nursing system combined with a team setting. Relatives of terminally ill cancer patients (n = 20) and the personnel (n = 8) participated in open-ended interviews. Phenomena relating to the philosophy of primary nursing and the hospice movement (continuity; closeness; accountability 24 h/day; individualized care; satisfied physical, psychological, social, and spiritual needs; and support to relatives) were experienced by the relatives, nurses, and physician as "good care." Most of the phenomena defined as important needs by the relatives and personnel were met when the primary nurse was on duty and the team was intact. Needs that were unmet were mainly a result of lack of continuity. Caring for the terminally ill via primary nursing in a team setting was regarded as two-sided by the nurses. It was seen as stimulating and rewarding, as well as demanding and burdensome. Therefore, the need for support to the nurses involved was deeply stressed.