Recognition and management of critical illness by midwives: implications for service provision

AIM: The aim of this study was to explore midwives' recognition and management of critical illness in obstetric women in order to inform service provision. BACKGROUND: Critical illness is not confined to Intensive Care. Limited published work was located examining factors affecting critical care provision by midwives. METHODS: A multi-method design incorporating a paper and pencil simulation (n = 11) and in-depth interviewing (n = 5) was conducted with midwives from a large London National Health Service Trust. This study details and discusses the findings. RESULTS: Findings indicated that frequency and type of critical illness experience impact upon midwives' critical care knowledge and skills. Midwives, especially those who were more junior, expressed anxiety regarding this aspect of practice, and considered the support of senior midwives, medical and nursing staff as crucial to effective client management. CONCLUSION: This study has yielded important insights into midwives' management of critical illness. Possible mechanisms to enhance the quality of service provision, and midwife support in this area are highlighted.     

Role of the accident and emergency review clinic in UK service provision

Objectives: Selected patients attending accident and emergency (A&E) are seen again in the A&E review clinic for planned follow up. Despite the large number of patients being seen in these clinics, this area of A&E service provision has rarely been studied. The aim of this study was to determine the current provision of review clinic services in UK A&E departments, their organisation, and their perceived role in current practice.

Methods: Postal survey of all major UK adult and paediatric A&E units.

Results: Almost all major UK A&E departments have a review clinic service and almost three quarters see less than 10% as reviews in line with current guidance. Many departments feel their clinics are well run and fulfil their objectives. Others are under pressure from external sources to see more patients. Over a third of departments have no written policies or protocols guiding referral to these clinics.

Conclusion: Review clinics are an important part of the A&E service in the UK and minimum standards need to be set in the provision of these services. Further audit and research needs to be carried out on the review clinic service to guide its future development.

     

Methodological limitations of cost-effectiveness analysis in health care: implications for decision making and service provision

This article reviews the methodological limitations identified in a recent authoritative US report by the Public Health Service, which provides the theoretical background to several other guidelines on cost effectiveness, such as those of the British Medical Journal. It places each limitation in context and discusses the implications of each individually and collectively. It concludes that while the report's interim solution by consensus agreement offers a way forward in the short term, the complexities identified reveal a range of limitations to the more heroic uses of cost effectiveness analysis in healthcare. More modest approaches, it is suggested, may have greater practical relevance.     

Developing service provision for patients in primary care

This article outlines the government's changes to the way that primary and community health services will be commissioned and provided. It also discusses the opportunities that exist for nurses to lead and develop services for the benefit of patients in the implementation of changes.     

Sowing the seeds of public health nursing–1920–39

The Florence Nightingale International Foundation and the Florence Nightingale International Courses played an important role in the development of public health nursing leadership in Europe and remain an outstanding example of international collaboration. Through the International Courses 203 nurses from 40 countries were prepared to organize and implement systems of public health nursing where none had previously existed; another 97 nurses were prepared for leadership as administrators and teachers. Below, how the courses started and their impact as viewed by nursing leaders of that era.     

Cardiac service provision in the United Kingdom

Cardiac conditions account for at least half of acute medical admissions. The provision of a comprehensive and responsive cardiological service in the UK is therefore pivotal to the manner in which the NHS continues to modernise. This article reviews recent developments in cardiology, describes the current provision of cardiac services for the more commonly encountered conditions, and explores future developments that will impact on the care patients presenting with heart disease receive.     

Ethics and assistive technology service provision

A review of ethical issues that arise in assistive technology service provision suggests that in order to provide effective assistive technology-related services, rehabilitation professionals need to take into account a variety of ethical considerations inherent in consumer-responsive service provision.     

Vertical equity in service provision: a model for the Irish public health nursing service

AIMS: This paper analyses the policy and conceptual basis of public health nursing service provision in the Republic of Ireland and situates it within an international context. It draws on the principles of horizontal and vertical equity in proposing a new model of public health nursing service provision. It gives the reader an understanding of a model of service delivery underpinned by the principle of vertical equity. BACKGROUND ISSUES: The Public Health Nurse in the Republic of Ireland has a wide remit encompassing primary, secondary and tertiary care at the level of the individual, family and community. The changing sociological and demographic nature of society in Ireland has impacted on a service that has largely remained unchanged since 1966. Since 1997 four review bodies have provided recommendations that are incompatible with each other. There remains a need to find a solution to the overwhelming demands placed on the public health nursing service in the Republic of Ireland. KEY ISSUES: The public health nursing service goes beyond the provision of a purely clinical nursing service. Communities differ in demography, epidemiology, environment, history, composition, support and most importantly needs. Using three exemplars a new model for the public health nursing service is explicated. This model has as its main focus the needs of the community it serves. CONCLUSIONS: A service underpinned by the principle of vertical equity can be used to deliver locally based, needs driven public health nursing services. The application of such a model would make the public health nursing service more flexible and responsive to local need. Public health nursing composition and provision must be determined using the principal of vertical equity determined by the needs of the community it serves.     

Clinical reasoning process for service provision in the public school.

This paper outlines the clinical reasoning process used to guide decisions on the provision of occupational therapy services in the Wake County Public School System in North Carolina. The process is based on a theoretical framework derived from occupational therapy theory and public law. Benefits of using the clinical reasoning process include (a) increased consistency of decision making among therapists; (b) increased appropriateness of decisions regarding whether a student needs educationally based occupational therapy services, what type of occupational therapy service would meet the student's need, and how often this service should be provided; and (c) improved ability of therapists to articulate to all those involved with a student the reasoning behind decisions to provide educationally based occupational therapy services. The schematic diagrams that depict this process provide a useful tool for therapists with varied work experiences entering school-based practice.     

Evaluation of CIR-Whirlwind Wheelchair and service provision in Afghanistan

Purpose. The Center for International Rehabilitation (CIR) developed a wheelchair provision strategy that combines central fabrication with regional distribution and local service provision by trained practitioners. A field study was initiated in Kabul, Afghanistan to evaluate this plan.

Method. The CIR-Whirlwind Wheelchair (study wheelchair) is an adult size, manual wheelchair designed to be adjustable to accommodate the individual user and durable to withstand rugged terrain. Manufactured in India, the study wheelchairs, with seat cushions, were packaged as kits and shipped to Afghanistan. Local practitioners in Kabul were trained on user assessment, fitting and training, and wheelchair assembly, maintenance and repair. One hundred subjects with previous experience of independently propelling a manual wheelchair participated in the study. This 4-month study entailed three subject visits for initial wheelchair fitting and training and then follow-up at 3 and 10 weeks. Subject training included wheelchair use and maintenance, and wheelchair skill activities.

Results. The study wheelchair was rated favorably by the subjects in all of five categories. Adjustments made to the wheelchairs during the study were typical for maintaining or improving the fit or function of a manual wheelchair. With the exception of brake handles, the need to repair or replace components on the wheelchairs was minimal. The subjects' proficiency at wheelchair skill activities increased throughout the study.

Conclusions. Data collected indicates that the study wheelchair performed very well. The data also served to identify those aspects of the wheelchair that may require additional development and testing prior to further production. To gain additional information on long term wheelchair use and performance, the CIR plans to extend this study by interviewing the same subjects at nine and fifteen months from the date they originally received the study wheelchair.     

Evaluation of CIR-Whirlwind Wheelchair and service provision in Afghanistan

Purpose. The Center for International Rehabilitation (CIR) developed a wheelchair provision strategy that combines central fabrication with regional distribution and local service provision by trained practitioners. A field study was initiated in Kabul, Afghanistan to evaluate this plan.

Method. The CIR-Whirlwind Wheelchair (study wheelchair) is an adult size, manual wheelchair designed to be adjustable to accommodate the individual user and durable to withstand rugged terrain. Manufactured in India, the study wheelchairs, with seat cushions, were packaged as kits and shipped to Afghanistan. Local practitioners in Kabul were trained on user assessment, fitting and training, and wheelchair assembly, maintenance and repair. One hundred subjects with previous experience of independently propelling a manual wheelchair participated in the study. This 4-month study entailed three subject visits for initial wheelchair fitting and training and then follow-up at 3 and 10 weeks. Subject training included wheelchair use and maintenance, and wheelchair skill activities.

Results. The study wheelchair was rated favorably by the subjects in all of five categories. Adjustments made to the wheelchairs during the study were typical for maintaining or improving the fit or function of a manual wheelchair. With the exception of brake handles, the need to repair or replace components on the wheelchairs was minimal. The subjects' proficiency at wheelchair skill activities increased throughout the study.

Conclusions. Data collected indicates that the study wheelchair performed very well. The data also served to identify those aspects of the wheelchair that may require additional development and testing prior to further production. To gain additional information on long term wheelchair use and performance, the CIR plans to extend this study by interviewing the same subjects at nine and fifteen months from the date they originally received the study wheelchair.     

Evaluation of CIR-whirlwind wheelchair and service provision in Afghanistan

PURPOSE: The Center for International Rehabilitation (CIR) developed a wheelchair provision strategy that combines central fabrication with regional distribution and local service provision by trained practitioners. A field study was initiated in Kabul, Afghanistan to evaluate this plan. METHOD: The CIR-Whirlwind Wheelchair (study wheelchair) is an adult size, manual wheelchair designed to be adjustable to accommodate the individual user and durable to withstand rugged terrain. Manufactured in India, the study wheelchairs, with seat cushions, were packaged as kits and shipped to Afghanistan. Local practitioners in Kabul were trained on user assessment, fitting and training, and wheelchair assembly, maintenance and repair. One hundred subjects with previous experience of independently propelling a manual wheelchair participated in the study. This 4-month study entailed three subject visits for initial wheelchair fitting and training and then follow-up at 3 and 10 weeks. Subject training included wheelchair use and maintenance, and wheelchair skill activities. RESULTS: The study wheelchair was rated favorably by the subjects in all of five categories. Adjustments made to the wheelchairs during the study were typical for maintaining or improving the fit or function of a manual wheelchair. With the exception of brake handles, the need to repair or replace components on the wheelchairs was minimal. The subjects' proficiency at wheelchair skill activities increased throughout the study. CONCLUSIONS: Data collected indicates that the study wheelchair performed very well. The data also served to identify those aspects of the wheelchair that may require additional development and testing prior to further production. To gain additional information on long term wheelchair use and performance, the CIR plans to extend this study by interviewing the same subjects at nine and fifteen months from the date they originally received the study wheelchair.     

How patient involvement in care is improving service provision

An emphasis on public and service-user involvement runs through the core initiatives of the modernisation agenda as outlined in The NHS Plan (Department of Health, 2000) and related policy documents. This article discusses problems that have prevented the NHS from being responsive to the views of service users and what the implementation of policies can offer in terms of overcoming such problems. In addition, initiatives and other ways of identifying and delivering public or patient needs are considered.     

Role for the nicotinic cholinergic system in movement disorders; therapeutic implications

A large body of evidence using experimental animal models shows that the nicotinic cholinergic system is involved in the control of movement under physiological conditions. This work raised the question whether dysregulation of this system may contribute to motor dysfunction and whether drugs targeting nicotinic acetylcholine receptors (nAChRs) may be of therapeutic benefit in movement disorders. Accumulating preclinical studies now show that drugs acting at nAChRs improve drug-induced dyskinesias. The general nAChR agonist nicotine, as well as several nAChR agonists (varenicline, ABT-089 and ABT-894), reduces l-dopa-induced abnormal involuntary movements or dyskinesias up to 60% in parkinsonian nonhuman primates and rodents. These dyskinesias are potentially debilitating abnormal involuntary movements that arise as a complication of l-dopa therapy for Parkinson's disease. In addition, nicotine and varenicline decrease antipsychotic-induced abnormal involuntary movements in rodent models of tardive dyskinesia. Antipsychotic-induced dyskinesias frequently arise as a side effect of chronic drug treatment for schizophrenia, psychosis and other psychiatric disorders. Preclinical and clinical studies also show that the nAChR agonist varenicline improves balance and coordination in various ataxias. Lastly, nicotine has been reported to attenuate the dyskinetic symptoms of Tourette's disorder. Several nAChR subtypes appear to be involved in these beneficial effects of nicotine and nAChR drugs including α4β2*, α6β2* and α7 nAChRs (the asterisk indicates the possible presence of other subunits in the receptor). Overall, the above findings, coupled with nicotine's neuroprotective effects, suggest that nAChR drugs have potential for future drug development for movement disorders.