Description and evaluation of a course for practice nurses

There is increasing awareness of the needs of practice nurses for continuing education and both the report of the community nursing review and the government''s white paper Promoting better health have stressed this. A course for practice nurses is described in which the curriculum was based on previous research into their requirements. An evaluation of the course demonstrated changes in the attitude towards the work of the practitioner and an overall increase in confidence of the group. Perceptions of the course and the relevance of the content were also measured. The cost of the course is given and the future direction of training discussed.     

Detection of psychological distress by practice nurses in general practice

BACKGROUND: The general practitioner (GP) has traditionally been the first port of call for people with psychiatric morbidity but increasingly other members of the primary care team see the patients first, particularly practice nurses. The numbers and roles of practice nurses have expanded greatly over the past decade and it is important that practice nurses are able to recognize patients with psychiatric morbidity. This paper reports a study to determine the abilities of 24 practice nurses to detect psychiatric morbidity in patients attending their clinics. METHODS: Twenty-four practices were randomly selected from 41 practices recruited from South London and Kent. One nurse per practice took part in the study. Patients were asked to complete a 12-item General Health Questionnaire (GHQ-12) while waiting for their appointment with the practice nurse. Following their consultation, the practice nurse rated the patients' level of psychological distress on a five-point rating scale. RESULTS: The response rate of patients was 97% (N= 1710). The GHQ case rate was 36%. The mean detection rate by practice nurses when identifying significant distress was 16% (between nurse variation, 0% to 61%). The mean specificity was 96% (variation 77% to 100%). A second analysis, changing the nurse criterion to recognition of distress increased the mean sensitivity rate to 58% (variation 31% to 84%) but the mean specificity rate decreased to 66% (variation 26% to 95%). CONCLUSIONS: These results demonstrate that practice nurses' caseloads include a high proportion of patients with psychiatric morbidity and that agreement with the GHQ classification of psychiatric morbidity is modest. Therefore, training in detection will be crucial for the nurses.     

An evaluation of the hospital component of general practice vocational training.

The contribution of the hospital component of vocational training to the needs of the future general practitioner was investigated by undertaking semi-structured interviews with a representative sample of doctors involved. The findings indicated that, in general, training was failing to address objectives perceived to be important for general practice by the study sample. Problems related to the context and style of hospital training also emerged, which appeared to be limiting the learning potential of this type of experience for general practitioner trainees. It is apparent that there is a need to clarify priority objectives for the hospital component of vocational training, and ensure that it provides the opportunity to achieve them.     

Do patients with sore throat benefit from penicillin? A randomized double-blind placebo-controlled clinical trial with penicillin V in general practice.

BACKGROUND: The effect of antibiotic therapy in sore throat is questionable and this dilemma has been complicated by the emergence of multiple resistant strains of micro-organisms. AIM: A randomized double-blind placebo-controlled clinical trial was undertaken in patients aged 4-60 years to assess the efficacy of penicillin V on the clinical course and bacteriological response in patients with sore throat in general practice. METHOD: Two hundred and thirty-nine patients presenting with an acute sore throat to 37 general practices in the Netherlands who were clinically suspected of group A beta-haemolytic streptococci (GABHS) were randomized for treatment with penicillin V (n = 121) or placebo (n = 118). Resolution of sore throat, fever and return to daily activities were evaluated by the general practitioner 2 days after the start of treatment and by the patients keeping a diary for 7 days. The result of throat culture after 2 days was evaluated. RESULTS: A difference in resolution of sore throat was present after 2 days in all patients, but was a result of GABHS-positive patients (n = 111; 46%) in favour of those randomized for penicillin V (adjusted odds ratio 5.3; 95% CI 1.9-15.1). An effect in the course of fever was also seen in GABHS-positive patients (adjusted odds ratio 5.3; 95% CI 1.02-27.7). A difference of 1-2 days was seen in clinical recovery. No difference was found in daily activities between the treatment groups. After 2 days, 4% of the penicillin-treated patients harboured GABHS compared with 75% of the placebo group. CONCLUSION: Only GABHS-positive patients benefit from penicillin V in their clinical cure in the first few days. Therefore, rapid testing is necessary. Treatment may be beneficial with regard to the clinical course, but it is not necessary.     

When cultures meet in general practice: intercultural differences between GPs and parents of child patients

Although health care professionals in The Netherlands are increasingly confronted with diverse immigrant groups, medical counselling and treatment of these groups has not been the subject of extensive research yet. From other studies it is well known that intercultural differences can have serious consequences for health care, e.g. in terms of risk of incorrect diagnoses or non-compliance. Eighty-seven autochthonous Dutch and immigrant (mainly from Turkey and Surinam) parents of child patients and their general practitioners (GPs) were recruited to investigate the influence of cultural differences on mutual understanding and patient compliance. Analyses of questionnaires and home interviews revealed that there is a relation between the cultural background of the patient and effectiveness of communication. Communication in consultations between GPs and persons from ethnic minorities is less effective than in consultations with Dutch persons: there is more misunderstanding, and also more non-compliance. In general, mutual understanding between GP and patient proves to be a strong predictor for patient compliance. These findings hold especially true for patients living in two worlds, i.e. a mixture of traditional and western cultures. The results are discussed in terms of methodological issues and practical implications for the health care providers.     

Preferences for general practice jobs: a survey of principals and sessional GPs.

BACKGROUND: Many countries are experiencing recruitment and retention problems in general practice, particularly in rural areas. In the United Kingdom (UK), recent contractual changes aim to address general practitioner (GP) recruitment and retention difficulties. However, the evidence base for their impact is limited, and preference differences between principals and sessional GPs (previously called non-principals) are insufficiently explored. AIM: To elicit GP principals' and sessional GPs' preferences for alternative jobs in general practice, and to identify the most important work attributes. Design of study: A discrete choice experiment. SETTING: National Health Service (NHS) general practices throughout Scotland. METHOD: A postal questionnaire was sent to 1862 principals and 712 sessional GPs. The questionnaire contained a discrete choice experiment to quantify GPs' preferences for different job attributes. RESULTS: A response rate of 49% (904/1862) was achieved for principals and 54% (388/712) for sessional GPs. Of responders, most principals were male (60%), and sessional GPs female (75%), with the average age being 42 years. All GPs preferred a job with longer consultations, no increase in working hours, but an increase in earnings. A job with outside commitments (for example, a health board or hospital) was preferable; one with additional out-of-hours work was less preferable. Sessional GPs placed a lower value on consultation length, were less worried about hours of work, and a job offering sufficient continuing professional development was less important. CONCLUSION: The differences in preferences between principals and sessional GPs, and also between different personal characteristics, suggests that a general contract could fail to cater for all GPs. Recruitment and retention of GPs may improve if the least preferred aspects of their jobs are changed. However, the long-term success of contractual reform will require enhancement of the positive aspects of working, such as patient contact.     

Randomized controlled trial of anti-smoking advice by nurses in general practice.

Practice nurses are playing an increasingly prominent role in preventive care, including the provision of anti-smoking advice during routine health checks. A randomized controlled trial was designed to assess the effectiveness of anti-smoking advice provided by nurses in helping smokers to stop smoking. A total of 14,830 patients aged 16-65 years from 11 general practices completed a brief questionnaire on general health, including smoking status, at surgery attendance. The doctor identified 4330 smokers and randomly allocated 4210 to control or intervention groups. The doctor asked those in the intervention group to make an appointment with the practice nurse for a health check. The attendance rate at the health check was 26%. Smokers were sent follow-up questionnaires at one month and one year, and those who did not respond to two reminders were assumed to have continued to smoke. There was no significant difference in reported cessation between the intervention and control groups at one month or one year. However, there was a significant difference in the proportion of patients who reported giving up within one month and who had not lapsed by one year--0.9% in controls and 3.6% in the intervention group (P less than 0.01). Nevertheless, the effect of the nurse intervention itself may be small as the sustained cessation rate in attenders was only 42.4% higher than in non-attenders. The deception rate in reporting cessation, as measured by urinary cotinine, was of the order of 25%.