Improving eye care in the primary health care setting

One of the challenges facing primary health care in South Africa is the delivery of quality eye care to all South Africans. In this regard the role of the primary health care worker, as the first point of contact, is crucial. This paper reports on the problems primary health care workers experience in providing quality eye care in Region B of the Free State. Problems identified by those involved in the study include the cumbersome referral system, the unavailability of appropriate medicine at clinics, the insufficient knowledge of primary health care workers regarding eye conditions and the lack of communication between the various eye care service providers. Suggestions to address the problems identified included more in-service training of primary health care workers regarding eye conditions, liaison with NGO's providing eye care, decentralization of services and the establishment of an eye care committee in the region.     

Patient-Centered Homes and Integrated Behavioral Health Care: Reclaiming the Role of “Consultant” for Psychiatric-Mental Health Nurse Practitioner

The notion of patient-centered care has long been linked with nursing practice since Florence Nightingale. The discipline of nursing is focused on the holistic care of individuals, families, and communities in times of sickness and/or health. However, in psychiatric-mental health nursing, the concepts of mental health and psychiatric illness still remain marginalized in our health care delivery systems, as well as in nursing education, knowledge development, and practice. Even with the concept of patient-centered homes, acute and primary care providers are reluctant to embrace care of those with psychiatric illness in their respective settings. Psychiatric illness was and continues to be in the shadows, hidden and often ignored by the larger community as well as by health care providers. This paper describes a Health Resources Services Administration (HRSA) Advanced Nursing Education (ANE) training grant's objective of reintegrating psychiatric-mental health practice into ALL health care delivery systems using the concept of patient-centered nursing care as a foundation for, and promotion of, the Psychiatric-Mental Health Nurse Practitioner (PMH-NP) as the “navigator” for not only the patients and their families, but also for their acute and primary care colleagues using an Interprofessional Education Model. The major barriers and lessons learned from this project as well as the need for psychiatric-mental health nurses to reclaim their role as a consultant/liaison in acute, primary, and long-term care settings will be discussed. The PMHNP as a consultant/liaison is being revitalized as an innovative advanced practice nursing health care model in North Carolina.     

Improving access--an innovative model

PURPOSE: To present a model of health care delivery in South Africa that made health care services accessible and affordable to members of the community who do not have medical insurance. DATA SOURCES: Statutes and laws governing the practice of health care professionals in South Africa, published professional guidelines, local research data, and the author's experience of the model of health care delivery. CONCLUSIONS: The innovative and visionary approach of a few health care professionals has established a model of health care delivery specifically suited to their community's needs. This model of service delivery has provided an affordable and accessible health service to members of the local community, who have indicated their satisfaction with the service. IMPLICATIONS FOR PRACTICE: Economic and legal barriers to accessible and affordable health care services can be overcome to ensure that health care is available to the whole population. The nurse practitioner has an important role to play in making health care affordable and accessible to the community.     

Learning for heart failure patients (The L‐HF patient study)

Aim and objective. To investigate the learning style and preferences for information delivery of heart failure patients for the purpose of informing the design of educational resources. Background. Patient education is a vital component of heart failure management programmes however the content and delivery of education varies in each programme. Traditionally education programmes for patients have focussed on educational needs as identified by health care providers however research has shown there are discrepancies between patients’ and nurses’ perceptions of the learning needs of heart failure patients. There is no evidence that educational programmes for heart failure patients are based on identification of patients learning needs or their preferred learning style. Design. Qualitative. Method. A purposive sample of 12 participants, diagnosed with heart failure and enrolled in a heart failure management programme, participated in semi‐structured interviews. Results. Four themes emerged: knowledge quest (L‐loading), barriers to learning (L‐inhibitors), facilitators for learning (L‐agonists), and meeting educational needs (L‐titration). Integral to these themes was the participant’s relationship with health care professionals. Conclusion. This study provides unique information regarding the preferred learning modality of heart failure patients and, as such, serves to inform the development of appropriate education resources specifically tailored for this population. Relevance to clinical practice. The development of effective modes of education is likely to further enhance heart failure management programmes service organisation and delivery and improve health outcomes for heart failure patients.     

Training for transformation: reorientating primary health care nurses for the provision of mental health care in South Africa

Using programme research, this paper reports on the evaluation of a programme designed to orientate primary health care nurses towards the provision of a comprehensive approach to care. In addition to training in psychiatric care, this was deemed necessary in order to facilitate comprehensive integrated primary mental health care in South Africa. Nurse-patient consultations were evaluated on indicators of comprehensive care before and after the programme. Interviews were also conducted with the participants individually and in a group. The results indicate that there are several factors which mediate the provision of comprehensive care by primary health care nurses. These include individual factors as well as contextual factors, inter alia, the structure and organization of the health care system, which historically has been organized to promote biomedical care. Furthermore, biomedicine has dominated training models in South Africa, instilling in nurses a biomedical approach to patient care.     

Assessment of the implementation of the primary health care package at selected sites in South Africa

A major objective of public health policy in South Africa is to develop a district-based health service focused on the delivery of primary health care. The primary health care package has been developed to promote the delivery of a number of services at the primary level. This paper assesses the implementation of the package in eight historically disadvantaged urban renewal nodes singled out for accelerated development through the government's urban renewal strategy. Data were gathered by way of interviews with primary health care facility managers and programme co-ordinators and through physical observations at facilities. The findings show that while some facilities were able to offer clients most of the services specified by the package, many others were unable do so. The urban renewal nodes differed noticeably in this respect.     

Expanding roles of Aboriginal health workers in the primary care setting: seeking recognition

The work of Aboriginal health workers (AHWs) in the primary care setting is discussed, emphasising that partnership with non-Indigenous health providers such as nurses and general practitioners brings complementary skills together to improve the health care available to Aboriginal clients, and to decrease the cultural and communication barriers to delivering such health care.The diverse skills and responsibilities of AHWs, which include clinical, health promotion, education and leadership roles, are illustrated.The current focus on increasing AHW educational opportunities, and the need to recognise AHWs as core health professionals and equal members of the health care team is presented. The increasing recognition of the role of AHWs in providing cultural mentorship for non-Indigenous colleagues is discussed.     

Expanding roles of Aboriginal health workers in the primary care setting: seeking recognition

The work of Aboriginal health workers (AHWs) in the primary care setting is discussed, emphasising that partnership with non-Indigenous health providers such as nurses and general practitioners brings complementary skills together to improve the health care available to Aboriginal clients, and to decrease the cultural and communication barriers to delivering such health care.The diverse skills and responsibilities of AHWs, which include clinical, health promotion, education and leadership roles, are illustrated.The current focus on increasing AHW educational opportunities, and the need to recognise AHWs as core health professionals and equal members of the health care team is presented. The increasing recognition of the role of AHWs in providing cultural mentorship for non-Indigenous colleagues is discussed.     

Introducing human rights and health into a nursing curriculum

AIM: The introduction of a module in Health and Human Rights into a Postgraduate diploma curriculum for registered nurses is described. BACKGROUND: An important component of nursing programmes in South Africa has been teaching of the principles of ethical practice and relevant ethical codes. A number of factors have contributed to the need to include human rights as an integral component of nursing curricula in South Africa. These include the Bill of Rights in the Constitution of South Africa and the implications thereof for health care delivery, the primary health care approach in the delivery of health care in South Africa, the development and acceptance of Patients' Rights Charters, and the recognition of the role that health professionals played--whether through lack of knowledge and awareness or direct involvement--in the human rights violations in the health sector exposed during the hearings of the Truth and Reconciliation Commission. MODULE DESCRIPTION: An outline of themes covered in the course content is described, together with examples of learning activities and teaching materials. Reflections of the course convenor and students are used to highlight the importance of inclusion of health and human rights as foundational to ethical nursing practice, regardless of the health care setting.     

Referral to and discharge from cardiac rehabilitation: key informant views on continuity of care

OBJECTIVES: To assess the system-level barriers and facilitators of continuity of care from acute care to cardiac rehabilitation (CR), and from CR discharge to follow-up with primary health care providers. METHOD: Semi-structured individual interviews with 24 key informants including CR staff, research scientists, policy makers, cardiologists and other doctors from a regional to international level were conducted regarding the processes of referral to and discharge from cardiac rehabilitation. Key informant interviews were audio taped, transcribed, and imported into QSR N6 software for Grounded analysis. RESULTS: Themes that emerged related to communication, referral and discharge processes, health care provider practices, inter- and intra-institutional relationships, and alternative models of delivery to improve continuity. CONCLUSIONS: Ramifications for enhancing referral of patients to beneficial CR services and follow-up by primary care providers to ensure maintenance of functional and health-related gains are discussed.     

Perceived factors influencing hospital-based primary care clinic referrals to community health medical nutrition therapy: An exploratory study

Primary care clinics provide an array of diagnostic and clinical services that assist patients in preventing the onset or managing acute and chronic conditions. Some chronic conditions such as high blood pressure, high cholesterol, and type 2 diabetes require primary care professionals to seek additional medical intervention from registered dieticians. This study explored beliefs, attitudes, and practices of medical and administrative professionals in primary care clinics encountering patients who are potential candidates for ongoing nutrition education or counselling. Five focus groups with primary care providers and clinical staff (n = 24) were conducted to identify perceived intra-organisational factors influencing initiation of community health medical nutrition therapy (MNT) referrals. Lack of clarity regarding community health dieticians’ role in chronic disease management was the primary finding for the absence of MNT referrals. Insurance-imposed constraints, perceived patient readiness to change, and service inaccessibility were revealed as barriers that influence referrals to both community health and specialty care dieticians. This study underscores the importance of identifying organisational and interpersonal barriers that influence the initiation of community health MNT referrals. Understanding these barriers can create stronger interprofessional collaboration between primary care providers and community health dieticians.     

Barriers to providing diabetes care in community health centers

OBJECTIVE: We aimed to identify barriers to improving care for individuals with diabetes in community health centers. These findings are important because many such patients, as in most other practice settings, receive care that does not meet evidence-based standards. RESEARCH DESIGN AND METHODS: In 42 Midwestern health centers, we surveyed 389 health providers and administrators about the barriers they faced delivering diabetes care. We report on home blood glucose monitoring, HbA1c tests, dilated eye examinations, foot examinations, diet, and exercise, all of which are a subset of the larger clinical practice recommendations of the American Diabetes Association (ADA). RESULTS: Among the 279 (72%) respondents, providers perceived that patients were significantly less likely than providers to believe that key processes of care were important (overall mean on 30-point scale: providers 26.8, patients 18.2, P = 0.0001). Providers were more confident in their ability to instruct patients on diet and exercise than on their ability to help them make changes in these areas. Ratings of the importance of access to care and finances as barriers varied widely; however, >25% of the providers and administrators agreed that significant barriers included affordability of home blood glucose monitoring, HbA1c testing, dilated eye examination, and special diets; nonproximity of ophthalmologist; forgetting to order eye examinations and to examine patients' feet; time required to teach home blood glucose monitoring; and language or cultural barriers. CONCLUSIONS: Providers in health centers indicate a need to enhance behavioral change in diabetic patients. In addition, better health care delivery systems and reforms that improve the affordability, accessibility, and efficiency of care are also likely to help health centers meet ADA standards of care.     

Excessive gestational weight gain: Assessing patients’ and providers’ perceptions

ObjectiveTo assess counseling practices for gestational weight gain (GWG) among primary care providers (PCPs) at 2 clinics to identify barriers and potential health interventions for patients from diverse cultural backgrounds.DesignQualitative interviews with data analyzed for emerging themes using a modified grounded theory method.SettingInterviews at the South East Toronto Family Health Team and Flemingdon Health Centre in Toronto, Ont, from September 2016 to February 2018.ParticipantsFamily practice obstetric providers and pregnant patients.MethodsSemistructured interviews and focus groups were audiorecorded and transcribed. Analysis used a constant comparative approach to identify themes.Main findingsPatients had a limited understanding of risks associated with excessive GWG and reported infrequent weight counseling by PCPs. Patients at the South East Toronto Family Health Team had high health literacy and were proactive in seeking health information but had difficulty navigating reliable resources. Patients at Flemingdon Health Centre had lower health literacy and more passive interactions with PCPs, relying on family advice and cultural practices to inform health behaviour. Barriers for this group included social isolation and limited funds. Both groups desired increased proactive health counseling and resources. Physicians were knowledgeable about excessive GWG and reported counseling their patients, although patient retention and limited time were barriers.ConclusionHealthy lifestyle in pregnancy is an important but underemphasized topic in antenatal care owing to barriers faced by patients and physicians, with unique socioeconomic considerations. This gap provides an opportunity to increase education of patients and providers and to develop patient-centred weight management interventions. By contrasting patient groups, our study reflected the importance of addressing social determinants of health in comprehensive care.     

'Back to the bedside': graduate level education in critical care

The need for post registration education for nurses practising at specialty level in critical care environments is widely acknowledged in nursing and educational literature. There is also clear consensus that the ultimate aim of educational preparation and practice development is to improve the delivery of nursing care to patients who are critically ill and provide support for their families. Yet the 'right' approach to educational delivery and evaluation is less clear and stimulates considerable debate amongst nursing educators, care providers, learners and regulatory bodies. The need for critical care nurses to apply advanced knowledge and technical skills to complex and dynamic practice situations necessitates the development of critical thinking and a problem-solving approach to clinical practice that can be fostered through education and experience. This paper explores the relationships within teaching, learning and practice development in critical care nursing and questions the popular assumption that 'post graduate (Master's level) education fits all'. Discussion focuses on the successful development and implementation of graduate level education for critical care nurses in the South Island of New Zealand and how this development is challenging existing approaches to the provision and evaluation of formal critical care education in New Zealand.     

A framework for the introduction and evaluation of advanced practice nursing roles

AIM: This paper describes a participatory, evidence-based, patient-focused process for advanced practice nursing (APN) role development, implementation, and evaluation (PEPPA framework). BACKGROUND: Despite the growing demand for advanced practice nurses, there are limited data to guide the successful implementation and optimal utilization of these roles. The participatory, evidence-based, patient-focused process, for guiding the development, implementation, and evaluation of advanced practice nursing (PEPPA) framework is an adaptation of two existing frameworks and is designed to overcome role implementation barriers through knowledge and understanding of APN roles and environments. The principles of participatory action research directed the construction of the new framework. CONCLUSIONS: The process for implementing and evaluating APN roles is as complex and dynamic as the roles themselves. The PEPPA framework is shaped by the underlying principles and values consistent with APN, namely, a focus on addressing patient health needs through the delivery of coordinated care and collaborative relationships among health care providers and systems. Engaging environmental stakeholders as participants in the process provides opportunity to identify the need and shared goals for a clearly defined APN role. The process promotes increased understanding of APN roles and optimal use of the broad range of APN knowledge, skills, and expertise in all role domains and scope of practice. The steps for planning and implementation are designed to create environments to support APN role development and long-term integration within health care systems. The goal-directed and outcome-based process also provides the basis for prospective ongoing evaluation and improvement of both the role and delivery of health care services.     

Contrasting experiences with child health care services by mothers and professional caregivers in transitional housing.

The study examined experiences of mothers and health care providers with preventive child health care services using qualitative methods at a primary care clinic located in transitional housing for homeless families in an urban community with predominantly Black American residents. Participants were 20 mothers and 4 health care professionals. Three major domains emerged: (a). the infrastructure of the clinic and health care delivery poses barriers to mothers' access and use of services for their children; (b). specialized, biomedical-driven care produces fragmented care delivery not responsive to the comprehensive nature of problems of mothers and their children; and (c). organizational strategies for improving access and use of health care services are directed by health care providers' value orientations. Findings support existence of infrastructural characteristics of the health care system that maintains differential value orientations and power structure, and care delivery processes that are non responsive to racially diverse and poor mothers.     

Legal limitations for nurse prescribers in primary health care

The nurse plays an important role in the delivery of primary health care services in South Africa. The primary purpose is to provide the public with access to safe competent basic health care and to achieve this, the nurse should be empowered to practice within legal and ethical boundaries. This paper explores and describes the limitations imposed by legislation on the nurse's ability to prescribe treatment in the primary health care field. The focus is mainly on the Nursing Act, the Pharmacy Act and the Medicines and Related Substances Control Act which highlights a number of limitations. It is concluded that empowerment of the nurse should not only include addressing the legal boundaries for practice, but also education and training opportunities to equip them with the expert knowledge and skills that they need to render a quality health care service.     

Self-Perceived Autism Competency of Primary Care Nurse Practitioners

The incidence of autism spectrum disorder (ASD) is increasing in children. Primary care providers lack training in managing patients with ASD. This study examined the self-perceived autism competency and barriers of 126 nurse practitioners (NPs) who provide primary care to patients under the age of 18. NPs reported a lack of self perceived competency (P < .05) and identified significant barriers to providing care to children with ASD compared to children with neurodevelopmental or medical conditions. Based on study results, education is needed to expand NPs' knowledge that may improve the delivery of care to patients with ASD.