Patient-sensitive treatment decision- making? Preferences and perceptions in a sample of renal patients

Patient participation in various aspects of healthcare is rapidly expanding. However, patients' preferences with regard to participation in treatment decision-making remain relatively under-explored, as does the congruence between such preferences and patients' perceptions of their actual role in decision-making. The aims of this study were to identify and to compare treatment decision-making role preferences and perceptions of the actual decisional role in a sample of renal patients.

A cross-sectional survey was conducted at a single regional renal unit in the North of England. A convenience sample of 405 patients was obtained (pre-dialysis N=155; dialysis N=103; transplant N=147). Preferred and perceived role were identified using a card sort technique (choice of five options, active to passive). Rationales for role preference were recorded verbatim.

Most patients were found to prefer passive (N=186, 45.9%; 95% Cl 41.2- 50.9) or collaborative (N=147; 36.3%; 95% Cl 31.3-40.7) decisional roles; perceived role was typically passive (N=319; 78.8%; 95% Cl 74.8-82.8). Trust in health professionals, perceived lack of knowledge and severity of condition were the most frequently cited determinants of role preference. Patients' decisional role preferences were often at variance with their perceived roles. Taking a highly active role in treatment decision-making was undesirable to most patients. Trust in healthcare professionals was an important contributor to desire to defer or retain control over treatment decisions.

A poststructural rethinking of the ethics of technology in relation to the provision of palliative home care by district nurses

Technology and its interfaces with nursing care, patients and carers, and the home are many and varied. To date, healthcare services research has generally focussed on pragmatic issues such access to and the optimization of technology, while philosophical inquiry has tended to focus on the ethics of how technology makes the home more hospital like. However, the ethical implications of the ways in which technology shapes the subjectivities of patients and carers have not been explored. In order to explore this, poststructural theory, in particular the work of Butler, Foucault, and Deleuze, is used to theorize the relationship between subjectivity and materiality as ethically mandated on producing rather than precluding the development of subjectivities in novel ways. This theoretical understanding is then utilized through a process of 'plugged in' as described by Jackson and Massie that aims to link empirical data, research, and philosophical inquiry. Through this process, it is suggested that power, which the empirical data demonstrate, is frequently exercised through medical discourses and restricts patients' and carers' ability to shape the material environment of the home as a place to live and be cared for in palliative stages of illness. Alternative discourses are suggested both from the empirical data as well as other research, which may offer patients and carers the possibility of reclaiming power over the home and their subjectivities. Finally, the dichotomy between the home and hospital, mediated via technology, is posited as being problematic. It is argued the dichotomy is false and should be moved away from in order to allow an ethical embrace of technology in palliative care.

Quality care as ethical care: a poststructural analysis of palliative and supportive district nursing care

Quality of care is a prominent discourse in modern health‐care and has previously been conceptualised in terms of ethics. In addition, the role of knowledge has been suggested as being particularly influential with regard to the nurse–patient–carer relationship. However, to date, no analyses have examined how knowledge (as an ethical concept) impinges on quality of care. Qualitative semi‐structured interviews were conducted with 26 patients with palliative and supportive care needs receiving district nursing care and thirteen of their lay carers. Poststructural discourse analysis techniques were utilised to take an ethical perspective on the current way in which quality of care is assessed and produced in health‐care. It is argued that if quality of care is to be achieved, patients and carers need to be able to redistribute and redevelop the knowledge of their services in a collaborative way that goes beyond the current ways of working. Theoretical works and extant research are then used to produce tentative suggestions about how this may be achieved.

Referral and management options for patients with chronic kidney disease: perspectives of patients, generalists and specialists

BACKGROUND

Chronic Kidney Disease (CKD) is increasing in prevalence and significance as a global public health issue. Appropriate management of CKD stages 3-4 in either generalist or specialist care is essential in order to slow disease progression. As various consulting options between services may be used, it is important to understand how patients and practitioners view these options.

OBJECTIVE

To elicit patient and practitioner views and preferences on the acceptability and appropriateness of referral practices and consulting options for CKD stage 3-4.

DESIGN

A mixed methods approach involving a semi-structured interview and structured rating exercise administered by telephone.

SETTING & PARTICIPANTS

Adult (18+) patients with CKD stage 3-4 were recruited via their General Practitioner (GP). Practitioners were recruited from both general and specialist services.

RESULTS

Sixteen patients and twenty-two practitioners participated in the study between July and September, 2011. Both patients and practitioners preferred 'GP with access to a specialist' and least preferred 'Specialist Review'. Computer review and telephone review were acceptable to participants under certain conditions. Practitioners favoured generalist management of patients with CKD 3. Specialists recommended active discharge of patients with stabilised stage 4 back to generalist care. Both generalists and specialists strongly supported sharing patients' medical records via electronic consultation systems.

CONCLUSION

Participants tended to prefer the current model of CKD management. Suggested improvements included; increasing the involvement of patients in referral and discharge decisions; improving the adequacy of information given to specialists on referral and encouraging further use of clinical guidelines in practice.

Predictors of outcomes of recovery following total hip replacement surgery: A prospective study

Objectives

To investigate psychosocial and biomedical outcomes following total hip replacement (THR) and to identify predictors of recovery from THR.

Methods

Patients with osteoarthritis (OA) on the waiting list for primary THR in North West England were assessed pre-operatively and at six and 12 months post-operatively to investigate psychosocial and biomedical outcomes. Psychosocial outcomes were anxiety and depression, social support and health-related quality of life (HRQoL). Biomedical outcomes were pain, physical function and stiffness. The primary outcome was the Short-Form 36 (SF-36) Health Survey Total Physical Function. Potential predictors of outcome were age, sex, body mass index, previous joint replacement, involvement in the decision for THR, any comorbidities, any complications, type of medication, and pre-operative ENRICHD Social Support Instrument score, Hospital Anxiety and Depression scores and Western Ontario and McMaster Universities osteoarthritis index score.

Results

The study included 206 patients undergoing THR. There were 88 men and 118 women with a mean age of 66.3 years (sd 10.4;36 to 89). Pain, stiffness and physical function, severity of OA, HRQoL, anxiety and depression all improved significantly from pre-operative to 12-month assessment (all p < 0.001), with the greatest improvement occurring in the first six months (all p < 0.001). The predictors that were found to influence recovery six months after THR were: pain (p < 0.001), anxiety (p = 0.034), depression (p = 0.001), previous joint replacement (p = 0.006) and anti-inflammatory drugs (p = 0.012).

Conclusions

The study identified the key psychosocial and biomedical predictors of recovery following THR. By identifying these predictors, we are able to identify and provide more support for patients at risk of poor recovery following THR.

Cite this article: Bone Joint Res 2013;2:248–54.

Quality of care for individuals with osteoarthritis: a longitudinal study

OBJECTIVES

The objectives of this paper were to investigate quality of care for individuals with osteoarthritis (OA) and to determine if those most in need had the outcome of a total joint replacement (TJR). Key quality indicators were involvement in treatment decisions, appropriate information provision and outcomes of care.

METHODS

A longitudinal study was conducted on individuals newly referred to an orthopaedic specialist at one hospital in North West England. A total of 268 participants were recruited consecutively and followed up at 3, 6 and 12 months. Validated measurement tools such as, a Visual Analogue Scale for pain and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) assessed pain and physical functioning. Mean scores on the outcome measures were estimated and plotted over time by joint affected and whether or not the participant had a TJR by 12 months.

RESULTS

Most participants (82%) felt that they were involved in the decision about their care, although 21% reported that they had not received a diagnosis of OA. Information was not provided on OA, pain management and exercise to 58%, 65% and 57% of participants, respectively. However, 98% of the 109 having a TJR reported receiving information about the procedure. Among the 118 known not to have had a TJR, pain and physical functioning remained relatively stable over time.

CONCLUSION

It appears that patients with the most severe symptoms of pain and physical functioning were selected for TJR. However, care for individuals with OA could be improved by providing standard information on OA in general and pain management and exercise. In particular, effective strategies for the implementation of the research evidence and guidelines are required to improve quality of care.

Individuals' expectations and challenges following total hip replacement: a qualitative study

PURPOSE

Hip replacements are one of the most common operations for individuals with hip osteoarthritis. There have been numerous quantitative studies investigating the recovery from joint replacement surgery and these show how effective and satisfied patients are. However, little qualitative work has been conducted to explore patients' actual experiences. Therefore, this study aimed to detail the experiences of individuals undergoing a total hip replacement (THR) to determine whether their expectations were met.

METHOD

The qualitative study was nested within a longitudinal study (n = 215) that was investigating biomedical and psychosocial outcomes from THR. We interviewed a purposive sample of individuals (n = 25) 6 months after THR to explore their experiences of having a THR.

FINDINGS

Participants were aged 48-82 years. They felt disabled following the THR and some had unrealistic expectations of recovery. Most of them received minimal information and health professional support. Participants had to overcome a number of challenges such as diminished confidence, frustration over slow progress and reduced physical functioning.

CONCLUSION

Individuals undergoing THR need to have the opportunity to discuss their expectations of THR, so there is no "false optimism". Support requirements, following THR, need to be reviewed as they were often underestimated by patients and health professionals.

Nurse prescribing from the community nurse's perspective

Background

Since 1994, district nurses and health visitors in the United Kingdom have been able to prescribe from a limited formulary. Items which are prescribed by these nurses are wound care products, incontinence appliances and medicinal preparations such as paracetamol and emollients. There is a planned expansion of prescribing by nurses, in terms of both the range of products and drugs that are prescribable and the types of nurses eligible for training for this new role.

Objective

To investigate patterns of nurse prescribing among community nurses in three primary care trusts in the United Kingdom.

Methods

Postal survey to 164 community nurses who were qualified to prescribe. Responses were received from 129 (79 per cent) with 35 nurses identifying themselves as not prescribing and excluded from the sample; 93 (72 per cent) of the questionnaires were entered on a database for analysis.

Key findings

Prescribing costs for district nurses ranged from £7.65 to £18,053 (median £2,023.64) and for health visitors from £0.73 to £2,556 (median £42.77) for a 12-month period. Nineteen per cent (n=28) of community nurses had decided not to prescribe even though they were trained to do so. Infrastructures and mechanisms to support nurses with nurse prescribing have been slow to emerge. Nurses perceived that their ability to prescribe was benefiting their patients and that they were providing better care. Community nurses cautiously welcomed the proposed extension of nurse prescribing.

Conclusions

Nurse prescribing has allowed community nurses more autonomy in managing a patient's total care. Our findings suggest that around one-quarter of nurses qualified to prescribe are not doing so. With the imminent extension of nurse prescribing for other nurses, action is needed by primary care trusts to put structures in place to ensure that nurses take on board this extension and challenge to their role.

Specialist community nurses: a critical analysis of their role in the management of long-term conditions

The aim of this narrative review is to identify strategies in use by specialist community and public health nurses in the prevention, care and management of individuals with long-term conditions, specifically chronic obstructive pulmonary disease (COPD) and musculoskeletal disorders. These conditions have been selected as they are highly prevalent; a burden on health services globally and a major public health issue. From a UK policy perspective, specialist community nurses have been placed at the forefront of taking a lead role in the coordination and delivery of more responsive services for individuals with long-term conditions; whether this has been an effective use of skills and resource is questionable. We systematically searched relevant databases between 1999-2009 to identify interventions used by specialist community nurses and critically appraised the studies. This review reports on impact and value of interventions used by specialist community nurses in the prevention and management of COPD and musculoskeletal conditions, and makes recommendations for improving services.

Colorectal cancer patients' attitudes towards involvement in decision making

OBJECTIVES

To design and administer an attitude rating scale, exploring colorectal cancer patients' views of involvement in decision making. To examine the impact of socio-demographic and/or treatment-related factors on decision making. To conduct principal components analysis to determine if the scale could be simplified into a number of factors for future clinical utility.

METHODS

An attitude rating scale was constructed based on previous qualitative work and administered to colorectal cancer patients using a cross-sectional survey approach.

RESULTS

375 questionnaires were returned (81.7% response). For patients it was important to be informed and involved in the decision-making process. Information was not always used to make decisions as patients placed their trust in medical expertise. Women had more positive opinions on decision making and were more likely to want to make decisions. Written information was understood to a greater degree than verbal information. The scale could be simplified to a number of factors, indicating clinical utility.

CONCLUSION

Few studies have explored the attitudes of colorectal cancer patients towards involvement in decision making. This study presents new insights into how patients view the concept of participation; important when considering current policy imperatives in the UK of involving service users in all aspects of care and treatment.

A review of the information and support needs of family carers of patients with chronic obstructive pulmonary disease

AIMS AND OBJECTIVES

The objectives of this narrative review were to identify: (1) The information and support needs of carers of family members with chronic obstructive pulmonary disease; (2) appropriate interventions to support carers in their caregiving role; (3) information on carers' needs as reported in studies of patients living with COPD in the community.

BACKGROUND

Chronic obstructive pulmonary disease is a major health problem in the UK resulting in significant burden for patients, families and the health service. Current National Health Service policies emphasise, where medically appropriate, early discharge for acute exacerbations, hospital-at-home care and other models of community care to prevent or reduce re-hospitalisations of people with chronic conditions. Understanding carers' needs is important if health care professionals are to support carers in their caregiving role.

DESIGN

A narrative literature review.

METHODS

Thirty five papers were reviewed after searching electronic databases.

RESULTS

Few studies were identified which addressed, even peripherally, carers' needs for information and support, and no studies were found which described and evaluated interventions designed to enhance caregiving capacity. Several studies of hospital-at-home/early discharge, self care and home management programmes were identified which included some information on patients' living arrangements or marital status. However, there was little or no detail reported on the needs of, and in many cases, even the presence of a family carer.

CONCLUSIONS

This review highlights the dearth of information on the needs of carers of chronic obstructive pulmonary disease patients and the need for future research.

RELEVANCE TO CLINICAL PRACTICE

There is little research based knowledge of the needs of carers of chronic obstructive pulmonary disease patients and interventions to assist them in providing care. This knowledge is critical to ensure that carers receive the information they need to carry out this role while maintaining their own physical and emotional health.

A systematic review of informal caregivers' needs in providing home-based end-of-life care to people with cancer

AIMS

This paper presents the results of a systematic review examining the practical information needs of informal caregivers providing home-based palliative and end-of-life care to people with advanced cancer.

BACKGROUND

Modern hospice care has led to increases in home-based palliative care services, with informal caregivers assuming responsibility for the majority of care. In response, health policy emphasises the provision of palliative care services in which both the patient and carer receive adequate support throughout illness and death. While the emotional needs of carers have been extensively researched, their practical needs with respect to the provision of physical care are yet to receive systematic attention.

DESIGN

Systematic review.

METHODS

Eligible articles were identified via electronic searches of research and evidence-based databases, hand-searching of academic journals and searches of non-academic grey literature websites. Quality of research was assessed via accepted guidelines for reviewing non-randomised, observational and qualitative literature. Data were synthesised by comparing and contrasting the findings to identify prominent themes.

RESULTS

Research consistently highlights this lack of practical support, often related to inadequate information exchange. These deficits typically manifest in relatives adopting a 'trial and error' approach to palliative care. Informal carers request a greater quantity of practically-focussed information, improvements in quality and increased methods of dissemination.

CONCLUSION

Synthesis of the literature suggests that home-based palliative care services have been insufficiently focussed on assisting informal caregivers acquire practical nursing skills.

RELEVANCE TO CLINICAL PRACTICE

Enhanced access to professional advice represents a potentially effective method of increasing carers' confidence in their ability to undertake practical aspects of home-based care. Evidence suggests that nurses and other health providers may better assist home-based carers by providing the information and skills-training necessary to facilitate this. This may necessitate the involvement of carers in the design and testing of new educational interventions.

Patients waiting for a hip or knee joint replacement: is there any prioritization for surgery?

OBJECTIVE

To investigate whether patients are prioritized for joint replacement surgery on the basis of severity of osteoarthritis, pain and physical functioning.

METHOD

A total of 105 patients on the waiting list for primary total knee or hip replacement from a UK regional orthopaedic centre were interviewed at baseline and followed up at 3, 6 and 9 months or until joint replacement. Measurement tools were the visual analogue scale (VAS), Western Ontario and McMaster Universities (WOMAC) osteoarthritis index and the Oxford hip or knee score.

RESULTS

Most participants (81, 77%) were categorized on the waiting list as 'routine', despite having high levels of pain according to the measurement scales. There was no significant correlation between the waiting list categorization and the actual waiting time for a hip or knee joint replacement operation (Kendall's tau = 0.17; P = 0.062) and the waiting list categorization did not appear to ensure that patients were operated upon earlier. There were also no significant differences in measures (VAS pain, WOMAC and Oxford hip or knee scores) between those individuals who had their operations earlier (before 6 months) compared with those participants who had their operations later (6 months or greater) or even not at all. Of the 105 patients who were listed for joint replacement, 24 (25%) patients did not have their operation due to: a medical delay (14); self-delay/cancellation (7); arthroscopy instead (2); and death (1).

CONCLUSION

With the expected increase in demand for joint replacement, there needs to be a re-examination of assessment procedures of patients listed for joint replacement. The use of measurement tools to assess symptoms such as pain and physical function would be one way forward.

Pain, physical functioning and quality of life of individuals awaiting total joint replacement: a longitudinal study

OBJECTIVES

To investigate if pain, physical function and the quality of life changed among adults with osteoarthritis while on the waiting list for hip or knee joint replacement.

METHODS

A longitudinal study of patients listed for primary hip or knee joint replacement. Participants were interviewed at baseline (n = 105) and followed up at 3 (n = 84), 6 (n = 47) and 9 months (n = 24), or until their joint replacement. Measurement tools used were a visual analogue scale (VAS), Western Ontario and McMaster's Universities (WOMAC) Osteoarthritis Index and the Medical Outcomes Study Short Form Health Survey (SF-36).

RESULTS

Baseline data indicated high levels of pain as measured by VAS [mean 7.0 (SD 2.2)] and WOMAC pain [mean 11.2 (SD 3.5)]. At baseline, the mean physical function measured by WOMAC was 40.3 (SD 12.1). At the 3-month follow-up, there was significant deterioration in VAS pain scores (0.6; 95% CI mean difference 0.3, 1.0); WOMAC pain scores (1.2; 95% CI mean difference 0.7, 1.8) and WOMAC physical function scores (4.8; 95% CI mean difference 2.8, 6.7) compared with baseline.

CONCLUSION

The often long wait for joint replacement surgery and deterioration in pain and physical function has highlighted the need for active management by health professionals while patients are on the waiting list.

Quality of care for people with osteoarthritis: a qualitative study

AIM

The overall aim of this qualitative study was to explore within primary care the experiences of management and care of individuals with end-stage lower limb osteoarthritis who are on the waiting list for joint replacement.

BACKGROUND

Osteoarthritis, one of the most common chronic diseases, causes loss of physical function and severe pain among sufferers. Improving quality of care and service provision for individuals with chronic diseases is high on the UK's NHS agenda.

METHODS

Data were collected by semi-structured qualitative interviews with 21 individuals with osteoarthritis who were waiting for a hip or knee replacement operation. Interviews were analysed using framework analysis.

RESULTS

Participants had been suffering with osteoarthritis for between seven months and 38 years. The management by health professionals for people on the waiting list for joint replacement was minimal. However, participants spoke of 'hiding' their symptoms from health professionals and were trying to 'self-manage' their symptoms. Families became more involved in helping individuals with osteoarthritis to manage with everyday life.

CONCLUSION

Management of individuals' osteoarthritis while on the waiting list needs to be given consideration by health professionals in primary and secondary care. Health professionals need to be working with each other to provide more comprehensive care across the primary and secondary care interface.

RELEVANCE TO CLINICAL PRACTICE

Case managers or community matrons could be identified as the co-ordinator and assessor of the needs of patients with osteoarthritis so as to try and improve pain management and service provision for these individuals especially while on the waiting list.

Smoking cessation interventions in chronic obstructive pulmonary disease and the role of the family: a systematic literature review

AIM

This paper is a report of a systematic review to assess the effectiveness of family-focused smoking cessation interventions for people with chronic obstructive pulmonary disease and to determine what data on families are documented in studies of smoking cessation interventions.

BACKGROUND

Chronic obstructive pulmonary disease is a major public health problem and cigarette smoking is the most important factor contributing to its development and progression. However, smoking cessation rates are low and relapse is common. The role of families in smoking cessation efforts has received little attention.

METHODS

All studies were included in the review that (i) addressed an evaluation of a psycho-social/educational smoking cessation intervention for people with chronic obstructive pulmonary disease, (ii) addressed some information on the family (i.e. living arrangements, marital status, smoking history of family members, support for quitting) and/or included the family as part of the intervention and (iii) were published between 1990 and 2006. Electronic data sources, existing systematic reviews of smoking cessation interventions and the grey literature were reviewed.

RESULTS

Seven studies were included. Six studies (11 papers) included data on marital status, smoking status of household members, support for quitting smoking and related variables. In two of the studies, the variable on the family was used to analyse smoking cessation outcomes. One additional study met the inclusion criterion of an evaluation of a smoking cessation intervention, which also included a family focus in the intervention.

CONCLUSION

No conclusions about the effectiveness of a family-focused smoking cessation intervention could be drawn from this review. Further research is needed to determine if a more family-focused intervention, in conjunction with pharmacological and counselling approaches, would lead to improved smoking cessation outcomes.

Prescribing by specialist nurses in cancer and palliative care: results of a national survey

BACKGROUND

This study investigates Macmillan nurses' views on nurse prescribing in cancer and palliative care and explores perceived motivators and barriers to training for and the implementation of this extended nursing role.

METHOD

National postal survey of 2252 Macmillan nurses in the UK.

RESULTS

A response rate of 70% (1575) was achieved. Eleven percent (168 of 1575) of Macmillan nurses surveyed were trained as extended formulary independent nurse prescribers. Half (88 of 168) of the Macmillan nurses who could prescribe from the extended formulary were prescribing, representing just 6% (88 of 1575) of the sample. Training deficits highlighted included poor organization and insufficient length, depth and specificity of courses (to meet the needs of nurses working in palliative care) and a lack of medical mentorship. Among Macmillan nurses who had not undergone extended formulary independent nurse prescribing training, 25% (335) perceived that prescribing was not part of their specialist nursing role. A further 40% (538) expressed reluctance to undergo training.

CONCLUSIONS

A clear lack of enthusiasm amongst specialist nurses in cancer and palliative care to undertake prescribing training was identified. It is noteworthy that half of the Macmillan nurses trained as extended formulary independent nurse prescribers were not prescribing. Since government targets for nurse prescribing are not yet being met, these findings raise important questions concerning whether extended nurse prescribing is likely to be a successful initiative in cancer and palliative care.

Patient participation in decision making: views of health professionals caring for people with colorectal cancer

AIM

The aim of this study was to explore views on patient participation in decision making, as described by health professionals caring for people with colorectal cancer.

BACKGROUND

Patient participation in health-care decision making is on the policy agenda at an international level. However, many aspects of cancer care and treatment are complex and it is unclear how health professionals view their role as promoters of patient participation.

DESIGN

A qualitative exploratory study.

METHODS

In depth interviews with 35 health professionals in clinical practice. Data were analysed using thematic content analysis, assisted by a computer software package for analysis of qualitative data (N-VIVO).

RESULTS

Choices in relation to surgical treatment were viewed as limited. Although it was perceived that patients could be more involved in decisions related to adjuvant treatment, providing information on various chemotherapy regimes was challenging. It was acknowledged that patients could be involved in treatment choices but there was far less clarity concerning aspects of physical and psychological care. Age was a factor when determining which patients should be offered treatment choices.

CONCLUSION

The availability and presentation of choices to patients is context specific and tailored to the preferences of individuals. If health professionals focus only on aspects of decision making related to treatment, the potential for shared partnerships with patients in relation to choices about physical and psychological care may be lost. This may be particularly pertinent for nurses and allied professions who engage with patients throughout the illness trajectory.

RELEVANCE TO CLINICAL PRACTICE

Policy makers should arguably appreciate that health professionals have an awareness of current thinking on patient participation, but may find policy recommendations challenging to implement in clinical practice when faced with the individual needs and preferences of patients and the complexities and uncertainties of disease management.

Meeting the information needs of women with breast cancer: Piloting a nurse-led intervention

This study evaluated a telephone intervention, administered by specialist breast care nurses, that aimed to meet the information needs of women with breast cancer. The intervention was developed from previous work that examined priority information needs. Participants were allocated to a telephone intervention (n = 67) or control group (n = 68). Data were collected by means of semi-structured interviews with participants at two time points (3 months and 8-12 months post-diagnosis) and focused on patient satisfaction with sources of information, information needs and psychological morbidity. Interviews were also conducted with breast care nurses to ascertain their views on administering the intervention. The intervention group reported fewer physical problems at Time 2 and were more likely to have had their information needs met than women in the control group. The control group were more likely to utilise media sources of information at Time 2 whereas women in the intervention group reported breast care nurses as their most prominent source of information. There were no significant differences in psychological morbidity between the two study groups. The findings indicate that the intervention is a feasible and acceptable approach to meeting the information needs of women with breast cancer. Further research is required to evaluate the intervention in a randomised controlled trial.

Getting a visit: how district nurses and general practitioners 'organise' each other in primary care

This paper examines the ways in which district nurses and general practitioners interacted and influenced each other's work within primary care services. The data presented here examine how the developments in the organisation of primary care affected the work of district nurses during a time of turbulent change. Qualitative data from 300 hours of participant observation and 40 semi-structured interviews with 33 district nurses were analysed using grounded theory, after which a literature review was undertaken. The findings from this study were interpreted using a Foucauldian notion of power and Fox's (1995) analysis of 'organisation'. The shift in power to general practitioners (GPs) has meant that they can exercise ever-increasing authority over nurses in their employ. Strict rules governed the process of inter-professional work and nurses and doctors used creative strategies to overcome the problems that existed between them. The data show that nurses could and did resist the power of GPs but this resistance generally elicited other more punishing forms of authority. Direct and indirect threats were commonplace. The data suggest that district nurses were moving into a closer, more business-like and tightly-controlled working relationship with general practitioners, through which competing discourses interplayed and circulated between GPs and district nurses in the organisation of primary care services.

A longitudinal study exploring pain control, treatment and service provision for individuals with end-stage lower limb osteoarthritis

OBJECTIVE

To investigate the level of pain control, treatment and service provision amongst individuals with end-stage lower limb osteoarthritis who were on the waiting list for hip or knee joint replacement.

METHODS

A total of 105 patients on a waiting list for primary knee or hip replacement from a regional orthopaedic centre in the UK were recruited. The study was longitudinal and based on direct interviews at baseline and 6 months, with a postal questionnaire at 3 months. Data were collected on pain by a visual analogue scale (VAS) and the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index. In addition, medication and the use of services and treatments were recorded.

RESULTS

Participants experienced high levels of pain as measured by VAS [mean 7.0; 95% confidence interval (CI) 6.6-7.5] and WOMAC pain (mean 11.2; 95% CI 10.6-11.9). The majority of participants (78, 74%) was taking analgesics more than once a day. Primary care utilization was variable. Of the 74 (70%) participants who had consulted their GP in the previous 3 months, 41 (55%) had not discussed their pain or osteoarthritis during these consultations. Just below one-third of participants (31, 30%) reported to have received information on osteoarthritis.

CONCLUSIONS

Pain appears to be difficult to manage in individuals with end-stage lower limb osteoarthritis. Individuals appeared not to be taking appropriate levels of analgesia in relation to levels of pain. Improvements are required in the provision of information on pain and osteoarthritis. Patients would benefit from more proactive management by health professionals (especially by GPs).