Clustered randomised trial of an intervention to improve the management of asthma: Greenwich asthma study.
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OBJECTIVES: To evaluate the effectiveness of an asthma resource centre in improving treatment and quality of life for asthmatic patients. DESIGN: Community based randomised controlled trial. SETTING: 41 general practices in Greenwich with a practice nurse. SUBJECTS: All registered patients aged 15-50 years. INTERVENTION: Nurse specialists in asthma who educated and supported practice nurses, who in turn educated patients in the management of asthma according to the British Thoracic Society's guidelines. MAIN OUTCOME MEASURES: Quality of life of asthmatic patients, attendance at accident and emergency departments, admissions to local hospitals, and steroid prescribing by general practitioners. RESULTS: Of 24 400 patients randomly selected and surveyed in 1993, 12 238 replied; 1621 were asthmatic of whom 1291 were sent a repeat questionnaire in 1996 and 780 replied. Of 24 400 patients newly surveyed in 1996, 10 783 (1616 asthmatic) replied. No evidence was found for an improvement in asthma related quality of life among newly surveyed patients in intervention practices compared with control practices. Neither was there evidence of an improvement in other measures of the quality of asthma care. Weak evidence was found for an improvement in quality of life in intervention practices among asthmatics registered with study practices in 1993 and followed up in 1996. Neither attendances at accident and emergency departments nor admissions for asthma showed any tendency to diverge in intervention and control practices over the study period. Steroid prescribing rates rose steadily during the study period. The average annual increase in steroid prescribing was 3% per year higher in intervention than control practices (95% confidence interval -1% to 6%, P=0.10). CONCLUSIONS: This model of service delivery is not effective in improving the outcome of asthma in the community. Further development is required if cost effective management of asthma is to be introduced. (+info)
Trained nurses can obtain satisfactory bone marrow aspirates and trephine biopsies.
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AIMS: To assess the feasibility of training nurse practitioners to perform bone marrow aspiration and trephine biopsy, and to compare the quality of these samples with those obtained by medical staff. METHODS: A retrospective audit was undertaken of nurse practitioner and medical staff performance in bone marrow procedures in a busy haematology day unit. RESULTS: Nurse practitioners fared favourably in comparison with medical staff in performing bone marrow trephine biopsies, with mean biopsy lengths of 11 mm and 10.7 mm respectively. However, only 78% of the smears obtained by the nurses were judged technically satisfactory, compared with 91% prepared by doctors. This discrepancy was thought to be due largely to the quality of slide spreading. CONCLUSIONS: With motivated staff and a structured educational and training programme it is possible for nurse practitioners to perform the techniques of bone marrow aspiration and biopsy, and obtain specimens of satisfactory quality, thus improving efficiency of the haematology day unit and increasing quality of patient care. (+info)
Training nurse practitioners for general practice. The EROS Project Team.
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BACKGROUND: For nurse practitioners (NPs) in general practice to substitute for general practitioners (GPs) in consultations, their educational needs require specification, and their effectiveness and acceptability to patients must be determined. There is limited evidence in the United Kingdom about training requirements or how NPs compare with GPs. AIM: To describe the education provided to trainee NPs (TNPs), describe their work, compare their practise with GPs, and determine their acceptability to patients. METHOD: Four TNPs were provided with a mainly practice-based education. After one year, TNP diagnoses and management decisions were compared with those of GPs for 586 patients. After being judged competent, TNPs conducted independent consultations. After two years, 400 independent consultations were analysed to describe TNPs' work and reasons for patients contacting the practice again. Opinions of a further 400 patients about their consultation with a TNP or GP, and willingness to consult a TNP in the future, were obtained. RESULTS: General practitioners and TNPs agreed on 94% of diagnoses and 96% of management decisions made. Early in training, TNPs transferred 38% of patients to the GP, of whom 34% were without a diagnosis and 40% without a management decision. In independent practice, 69% of patients consulting TNPs were female and fewer than 10% were aged over 65 years. TNPs were dealing with a wide range of diagnoses. Immediate referrals to GPs had decreased to 13%. In one-third of consultations, over-the-counter (OTC) medications were suggested and, in 63%, formulary medications were recommended, with prescriptions signed by GPs. Health education featured in 84% of consultations. After two weeks, 29% of patients had returned to the surgery, of whom 72% had been asked to return and 60% consulted about the original condition or its treatment. Eighty per cent of patients completed an opinion questionnaire. While 38% of TNP consulters would have preferred a GP consultation, they rated TNP consultations as good as or better than GPs' consultations. Patients with experience of previous TNP consultations gave the most positive ratings, were more likely to consult a TNP again, and about a wider range of conditions. TNPs' listening skills and explanations were particularly valued. CONCLUSIONS: Early in their training, TNPs made good diagnostic and treatment decisions, while their high level of patient transfers to GPs indicated residual uncertainty. In independent practice, their GP mentors judged them to be offering an effective service, with acceptable transfer and patient return rates. They were liked by patients and more so by patients with previous TNP experience. TNPs are a valuable substitute for GPs for patients wishing for a same-day consultation, and for younger and female patients who prefer a female TNP over a male GP. Limited authority to prescribe and refer to secondary care reduces NP efficiency. (+info)
Experiences of general practitioners and practice nurses of training courses in evidence-based health care: a qualitative study.
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BACKGROUND: Clinical governance will require general practitioners (GPs) and practice nurses (PNs) to become competent in finding, appraising, and implementing research evidence--the skills of evidence-based health care (EBHC). AIM: To report the experiences of GPs and PNs in training in this area. METHOD: We held 30 in-depth, semi-structured interviews throughout North Thames region with three groups of informants: primary care practitioners recruited from the mailing lists of established EBHC courses; organizers and teachers on these courses; and educational advisers from Royal Colleges, universities, and postgraduate departments. Detailed qualitative analysis was undertaken to identify themes from each of these interview groups. RESULTS: At the time of the fieldwork for this study (late 1997), remarkably few GPs or PNs had attended any formal EBHC courses in our region. Perceived barriers to attendance on courses included inconsistency in marketing terminology, cultural issues (e.g. EBHC being perceived as one aspect of rapid and unwanted change in the workplace), lack of confidence in the subject matter (especially mathematics and statistics), lack of time, and practical and financial constraints. Our interviews suggested, however, that the principles and philosophy of EBHC are beginning to permeate traditional lecture-based continuing medical education courses, and consultant colleagues increasingly seek to make their advice 'evidence based'. CONCLUSION: We offer some preliminary recommendations for the organizers of EBHC courses for primary care. These include offering a range of flexible training, being explicit about course content, recognizing differences in professional culture between primary and secondary care and between doctors and nurses, and addressing issues of funding and accreditation at national level. Introducing EBHC through traditional topic-based postgraduate teaching programmes may be more acceptable and more effective than providing dedicated courses in its theoretical principles. (+info)
General-practice-based nurse specialists-taking a lead in improving the care of people with epilepsy.
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Epilepsy is almost as common as diabetes and some 750 people with epilepsy die suddenly and prematurely each year. Unfortunately, the management of epilepsy has been much neglected and services often remain fragmented and difficult for patients to understand. We employed a nurse specialist in epilepsy to work with practice nurses in a group of general practices to promote better care, to make patients aware of sources of help and support, and to provide information about issues such as driving, employment and pregnancy. Over 70% of patients with epilepsy attended 'clinics' run by the specialist nurse and many previously unidentified problems were successfully resolved-including misdiagnosis, over-medication and lack of awareness of the side-effects of antiepileptic drugs. Nurse specialists in epilepsy, working with groups of general practices but in collaboration with hospital specialists and voluntary organizations, can take a lead role in facilitating joint working between all those involved in service provision, in training practice nurses and others in the special needs of people with epilepsy and in providing support in hospital clinics. (+info)
Preparing currently employed public health nurses for changes in the health system.
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OBJECTIVES: This article describes a core public health nursing curriculum, part of a larger project designed to identify the skills needed by practicing public health workers if they are to successfully fill roles in the current and emerging public health system. METHODS: Two focus groups of key informants, representing state and local public health nursing practice, public health nursing education, organizations interested in public health and nursing education, federal agencies, and academia, synthesized material from multiple sources and outlined the key content for a continuing education curriculum appropriate to the current public health nursing workforce. RESULTS: The skills identified as most needed were those required for analyzing data, practicing epidemiology, measuring health status and organizational change, connecting people to organizations, bringing about change in organizations, building strength in diversity, conducting population-based intervention, building coalitions, strengthening environmental health, developing interdisciplinary teams, developing and advocating policy, evaluating programs, and devising approaches to quality improvement. CONCLUSIONS: Collaboration between public health nursing practice and education and partnerships with other public health agencies will be essential for public health nurses to achieve the required skills to enhance public health infrastructure. (+info)
Pediatric emergency preparedness in the office.
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Pediatric office emergencies occur more commonly than is usually perceived by family physicians, and most offices are not optimally prepared to deal with these situations. Obtaining specific training in pediatric emergencies and performing mock "codes" to check office readiness can improve the proper handling of pediatric emergencies. Common airway emergencies include foreign-body aspiration and croup. Cool mist, racemic epinephrine nebulization and dexamethasone are typical treatment measures for croup. Asthma and bronchiolitis are common causes of respiratory distress. Hypovolemic shock is the most common cause of circulatory failure in children. Intraosseous access is a simple and underutilized route for vascular access in a critically ill child. Status epilepticus is the most common neurologic emergency. Avoidance of iatrogenic respiratory depression and hypotension can be optimized by taking an algorithmic approach to the use of anticonvulsant medications. Transport of patients after initial stabilization of an emergency should always be done in a manner that provides adequate safety and monitoring. (+info)
General practice nurses' knowledge of alcohol use and misuse: a questionnaire survey.
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Nurses in general practice (termed practice nurses) are an under-utilized resource for the detection and management of patients with alcohol misuse. However, little is known about their knowledge and attitudes towards alcohol use and misuse. We therefore conducted a postal questionnaire survey of 132 practice nurses in Liverpool (UK). The results of our survey (response rate 77%) show that a knowledge and skills gap exists in the delivery of effective advice on alcohol-related issues. Indeed, our results suggest that only one in two women and one in three men are receiving correct advice on sensible limits of alcohol consumption, this despite the fact that alcohol histories are taken. Further training was requested by most nurses to develop their screening and health promotion roles, and to become involved in the management of patients with alcohol-related problems in primary care. We suggest practice nurses should be encouraged to become involved in screening for, and management of, alcohol-related problems. However, it is important to ensure that the nurses receive appropriate training and have adequate back-up facilities from doctors and other workers involved in the care of patients with alcohol-related problems. (+info)