Exploring views on Swedish district nurses' prescribing--a focus group study in primary health care

Since 1994 district nurses (DNs) in Sweden have been permitted to prescribe drugs from a limited list. This reform has met severe resistance from doctors and the opinions of general practitioners (GPs) and DNs have differed in many aspects. The aim of this study was to gain deeper understanding of the different opinions about DNs' prescribing and to explore the impact of the reform on primary care. Six focus group interviews were conducted, four with DNs and two with GPs. Data analysis revealed six categories, which were condensed into two dimensions. The dimensions were individual prerequisites, with the categories responsibility and knowledge, and organizational prerequisites, with the categories distribution of work, climate of co-operation, resistance and economic considerations. District nurses were very positive towards prescribing and had gained new knowledge through the compulsory training course and via discussions with pharmacists. Because of the responsibility required for prescribing, some nurses had introduced systems for self-monitoring. Prescribing was seen as a natural part of the nursing process. All interviewees could describe periods of resistance against the reform, and the head of the health centre was a key person for attitudes at the workplace. The DNs found the nurse prescribing reform very positive. They experienced a strengthening of professionalism and also thought that the reform was a natural development. Negative attitudes and opinions offset the positive feelings. The resistance that had appeared in the beginning had now turned into silent acceptance.     

Expert nurses' use of implicit memory in the care of patients with Alzheimer's disease

AIM: This paper reports a study exploring expert nurses' use of implicit memory in the care of people with Alzheimer's disease. BACKGROUND: Although research has shown the benefits of preserving and using implicit memory in patients with Alzheimer's disease, the literature shows little evidence of how nurses, in particular expert ones, make use of implicit memory with this client group in clinical practice. METHOD: Semi-structured interviews were carried out with a purposive sample of eight nurses (four from Michigan, United States of America and four from Northern Ireland) in 2004. The interviews focused on specific issues, but were deliberately flexible to allow participants to tell their stories as well. A nine-step data analysis process was developed based on a synthesis of methods used by other researchers. FINDINGS: According to the expert nurses interviewed, the effective and meaningful use of the implicit memory of patients with Alzheimer's disease in achieving positive outcomes depended on 'knowing the patient', 'working within the patient's worldview' and 'using sensitive and patient-centred interactional skills'. They explained how their use of implicit memory (drawing from a range of knowledge sources) was underpinned by reflective practice. CONCLUSION: The findings provide a positive profile of expert nurses' use of implicit memory of patients with Alzheimer's disease; however, their use of theoretical and research knowledge could be improved. There is also a need to test interventions based on the use of implicit memories.     

Mentoring for nurses in general practice: an Australian study

This paper presents findings from a project conducted to recommend a national framework for mentoring for general practice nurses in Australia. The first phase identified challenges and key issues; the second and third phases (reported here) engaged practice nurses and general medical practitioners in discussion to advance thinking on the topic. Outcomes revolved around seven core areas: role confusion and diversity of practice nursing; lack of a defined career pathway for practice nurses; professional isolation of practice nurses; need for general practitioner support; expectations of mentoring; importance of resourcing and infrastructure; and roles, skills and qualities of mentors. Implications of these for the development of a systemic approach to supporting nurses in general practice are discussed, taking into account the inter-professional context and special working relationship between nurses and doctors. Findings revealed keen support for the idea of mentoring for nurses in general practice and indicate success will depend on appropriate resourcing and infrastructure through national, state and local coordination processes.     

Patients bringing information to primary care consultations: a cross-sectional (questionnaire) study of doctors' and nurses' views of its impact

Objectives  To explore the perceived frequency and impact of patients bringing health information from the Internet to primary care consultations.
Method  A questionnaire was sent to all general practitioners (GPs) and practice nurses (nurses) in a primary care trust in the North-west of England.
Results  The response was 52.3%, more nurses responding than GPs (61.2% vs 46.8%). A substantial majority (93.9% and 78.0%) had experienced patients bringing such information in the last 6 months, which often lengthened the consultations. Significantly more nurses than GPs felt that the information helped the consultation (87.1% vs 37.7%), but also reported that patients bringing such information was off-putting (21.9% vs 6.3%).
Conclusions  Both GPs and nurses experienced patients bringing health information to consultations and significantly differed in their views about whether it helped or hindered. Primary care staff should anticipate patients' use of the Internet for health information and should actively manage patients introducing it into the consultation.     

Patient safety in primary care has many aspects: an interview study in primary care doctors and nurses

Rationale, aims and objectives Scientific definitions of patient safety may be difficult to apply in routine health care delivery. It is unknown what primary care workers consider patient safety. This study aimed to clarify the concept of patient safety in primary care. Methods We held 29 semi‐structured interviews with a purposeful sample of primary care doctors and nurses regarding their perceptions of patient safety. The answers were analysed in an iterative procedure with respect to common themes. Results A broad range of specific aspects of primary care were named in relation with patient safety. Medication safety was most frequently mentioned. Most items were categorized as organizational, while the remaining aspects were linked to culture or professionalism. Scientific definitions of patient safety were not mentioned, but some primary care workers gave ‘do not harm the patient’ as a short definition for patient safety. Conclusion Patient safety programmes have mostly targeted specific issues, such as incident reporting and medication safety. However, doctors and practice nurses had a broad view of what constitutes patient safety in primary care. This has implications for the measurement and improvement of patient safety in primary care.     

Impact of nurse prescribing: a qualitative study

AIM: This paper is a report of an investigation of the impact of prescribing on a group of recently qualified nurse prescribers in the United Kingdom. BACKGROUND: The creation of advanced nursing roles, and specific skills such as nurse prescribing, has resulted in nurses taking on roles that have traditionally been associated with doctors. The non-doctor prescribing initiative is continually developing and many nurses are now able to prescribe independently from almost the same range of medicines as doctors. Despite the advantages that appear to stem from nurses prescribing, some nurse researchers have been cautious about the impact that prescribing may have on the nursing profession. METHOD: Interviews were conducted during 2005 and 2006 with 45 nurse prescribers. All nurses had successfully qualified and registered as prescribers. Interviews were analysed thematically in line with the principles of grounded theory. FINDINGS: Prescribing allows nurses to overcome difficulties in the healthcare system that previously delayed patients' access to medicines. Prescribing is viewed as more than an 'add on' to current roles, it complements many aspects of nursing and integrates previously diffuse aspects of the nursing role. This enables nurses to adopt a more holistic approach to patient care and prescribing. Prescribing has the potential to increase job satisfaction and autonomous working, with the result that nurses are more likely to involve patients in decision-making about their care. CONCLUSIONS: Prescribing enhances nurses' knowledge about medication and increases their confidence to engage in prescribing decisions across the healthcare team. Nurse prescribing has the potential to improve service-user care, enhance collaboration and widen discussions about medicines. However, team members need to be prepared for the impact nurse prescribing could have on the dynamics of the multidisciplinary team. Preparatory information about nurse prescribing should be provided to all team members by trainee nurse prescribers. Information could include details about the proposed scope of future prescribing roles, allowing team members to consider how their roles could develop.     

Patients' and nurses' perspectives on oxygen therapy: a qualitative study

Title.  Patients' and nurses' perspectives on oxygen therapy: a qualitative study.
Aim.  This paper is a report of a study to describe patients' and nurses' perspectives on oxygen therapy.
Background.  Failure to correct significant hypoxaemia may result in cardiac arrest, need for mechanical ventilation or death. Nurses frequently make clinical decisions about the selection and management of low-flow oxygen therapy devices. Better understanding of patients' and nurses' experiences of oxygen therapy could inform clinical decisions about oxygen administration using low-flow devices.
Methods.  Face-to-face interviews with a convenience sample of 37 adult patients (17 cardio-thoracic: 20 medical surgical) and 25 intensive care unit nurses were conducted from February 2007 to September 2007. Interviews were audio-taped, transcribed verbatim and then analysed using a thematic analysis approach.
Findings.  The patients identified three key factors that underpinned their compliance with oxygen therapy: (i) device comfort; (ii) ability to maintain activities of daily living; and (iii) therapeutic effect. The nurses identified factors, such as: (i) therapeutic effect, (ii) issues associated with compliance, (iii) strategies to optimize compliance, (iv) familiarity with device, (v) triggers for changing oxygen therapy devices, as being key to the effective management of oxygen therapy.
Conclusion.  Differences between the patients' and nurses' perspective of oxygen therapy illustrate the variety of factors that impact on effective oxygen administration. Further research should seek to provide a further in-depth understanding of the current oxygen administration practices of nurses and the patient factors that enhance or hinder effectiveness of oxygen therapy. Detailed information about nurse and patient factors that influence oxygen therapy will inform a sound evidence base for nurses' oxygen administration decisions.     

Working relationships between practice nurses and general practitioners in Australia: a critical analysis

This research set out to explore shared care between practice nurses and general practitioners in South Australia. Nine practice nurses (PNs), two nurse practitioners and 10 general practitioners (GPs) were interviewed in urban and rural practices in order to build up a picture of how GPs and PNs worked together. The interviews showed that shared care was not a reality, although practice nurses were very busy, enjoyed their work and were no longer performing as receptionists doing a little nursing on the side, but as highly skilled nurses. Questions that emerged included whether or not practice nurses are specialists or generalists; their relationship to nurse practitioners; the extent to which the doctor–nurse game explains the relationship between practice nurses and general practitioners; and the potential for expanding the practice nurse role.     

Dying well: nurses' experiences of 'good and bad' deaths in hospital

Aim: This paper reports a study investigating hospital nurses' experiences of death and dying. BACKGROUND: Despite advances in medical science and health care, together with the push towards individualizing approaches to patient care in the developed world, significant variation in the care of dying patients still exists. The international issues relating to differing types of death reveal both its complexity and diversity, with evidence of 'good death' experiences largely focused on hospice experiences, and a lack of research on death in general hospitals. METHOD: In-depth interviews were conducted in 1999 with a convenience sample of 29 Registered Nurses in the United Kingdom based on their hospital death experiences. Semiotic analysis was used to identify the 'deep structures' that underlie and form part of cultural communication as a way of understanding how nurses made sense of death. Data interpretation was enhanced through the use of a typology of 'good and bad deaths'. FINDINGS: The findings suggest that different experiences of death are based on the extent to which nurses were able to exert control over the dying process. The management of death in hospital is a major source of conflict for nurses. Good and bad death experiences were constructed according to their impact on the sentimental order of the ward, the intangible, but real patterns of mood that influenced nurses' feelings. Moreover, good and bad deaths focused less on patients' needs and the dying process and more on the death event and nurses' abilities to manage organizational demands. CONCLUSION: There is a need to improve communication with patients and families about diagnosis and prognosis to ensure that effective communication takes place and 'blocking behaviour' is avoided. The findings also challenge practitioners to focus attention on death as a process, and to prioritize patients' needs above those of the organization. Moreover, there is the need for guidelines to be developed enabling patients to have a role in shaping events at the end of their lives.     

Practice nurses and the facilitation of self-management in primary care

Title. Practice nurses and the facilitation of self‐management in primary care. Aim. This paper is a report of a study to explore practice nurse involvement in facilitation of self‐management for long‐term conditions. Background. In the United Kingdom chronic disease services have shifted from secondary care to general practice and from general practitioners to practice nurses. A new United Kingdom General Practice contract requires adherence to chronic disease management protocols, and facilitating self‐management is recognized as an important component. However, improving self‐management is a relatively new focus and little is known about the ways in which nurses engage with patient self‐management and how they view work with patients in chronic disease clinics. Method. Semi‐structured interviews with 25 practice nurses were carried out in 2004–2005. Interviews were audio‐taped and transcribed verbatim. Analysis was informed by the ‘trajectory model’ and ‘personal construct’ theories. Findings. Main themes in the early stages of work with patients were: categorization of patients, diagnosis, and patient education. First impressions appeared to determine expectations of self‐management abilities, although these were amenable to change. Intermediate stages were ‘ways of working’ (breaking the task down, cognitive restructuring and addressing dissonance, modelling ‘good’ behaviour, encouragement, listening, involving carers and referral) and maintaining relationships with patients. However, in the longer‐term nurses seemed to lack resources beyond personal experience and intuitive ways of working for encouraging effective self‐care. Conclusion. The ways of working identified are unlikely to be sufficient to support patients’ self‐management, pointing to a need for education to equip nurses with techniques to work effectively with patients dealing with longer‐term effects of chronic illness.     

Predictors of hospital-based registered nurses' engagement in on-the-job policy activities

Nurses have been urged to participate in public policy-formulation processes as an integral part of their professional role through collective and personal policy activities. However, there is only limited empirical data on this participation. This cross-sectional study examined the level and the predictors of the personal policy activities of 200 Israeli hospital-based registered nurses undertaken in their work setting and aimed at furthering hospital, local or national policies. The nurses completed questionnaires that examined policy activities, policy skills, political interest, political efficacy, political and professional network involvement, and organizational support for policy activities. The overall engagement of nurses in on-the-job policy activities was limited and focused primarily on their immediate surroundings, their departments and their hospitals, and much less on local or national policies. The most common policy activities were internal and indirect and included receiving feedback from patients to improve nursing care policy and calling colleagues' attention to policy issues. Positive significant correlations emerged between motivational and organizational factors and personal policy activities, and these contributed 55% to the explained variance. The findings enhance the relevance of integrating motivational and organizational factors in understanding the policy activity of nurses. As such, increasing personal involvement of hospital nurses in policy formulation processes requires professional training that seeks to improve nurses' policy skills, to enhance their political interest and efficacy, and to encourage their involvement in political and professional networks. In addition, hospitals need to cultivate an organizational culture that supports personal policy activities by nurses.     

Management of obesity in primary care: nurses' practices, beliefs and attitudes

AIM: This paper is a report of a study to investigate patterns of clinical practice, beliefs and attitudes of primary care nurses with respect to obesity management. BACKGROUND: Nurses in primary care potentially play a key role in managing obesity, which has become a priority issue. There have been few studies of either the extent of clinical practice of nurses, or their attitudes and beliefs in this setting. METHODS: A correlational survey design was employed. Structured questionnaires were posted to 564 nurses and health visitors in primary care organizations in England. The response rate was 72.3%. The survey was conducted in April and May 2006. FINDINGS: Very few respondents reported training in obesity management, and most did not believe that organizational support was in place. Only practice nurses reported substantial clinical activity in obesity management, accounting for almost 5% of their contracted hours. This activity, comprised of assessment, lifestyle change support and referral, occurred in one-to-one consultations. Other nurses and health visitors reported much less activity, although they believed obesity to be an important health issue and its management an appropriate part of their role. Whilst outright negative stereotypes were rare, there were nevertheless a range of potentially negative beliefs and attitudes relating to obesity and obese patients. These views were related to the respondent's own body mass index but not to gender, age, experience and occupation. CONCLUSION: Training and organizational support for obesity management are required by primary care nurses. Training should also address beliefs and attitudes about obesity and obese persons.