Improving patient recruitment to multicentre clinical trials: the case for employing a data manager in a district general hospital-based oncology centre

One of the most frequently cited reasons for poor recruitment to multicentre randomized clinical trials is the additional workload placed on clinical staff. We report the effect on patient recruitment of employing a data manager to support clinical staff in an English district general hospital (DGH). In addition, we explore the effect data managers have on the quality of data collected, proxied by the number of queries arising with the trial organizers. We estimate that the cost of employing a data manager on a full-time basis is 502 per patient recruited but may amount to 326 if the appointment is part-time. Data quality is high when full responsibility lies with a data manager but falls when responsibility is shared. Whether the costs of employing a data manager to recruit patients from a DGH are worth incurring depends on the value placed on the speed at which multicentre trials can be completed, how important it is to broaden the research base beyond the traditional setting of teaching hospitals, and the amount of evaluative data required.

The role of the palliative care nurse consultant in promoting continuity of end-of-life care

The provision of end-of-life care through a multidisciplinary integrated palliative-care approach is dependent on effective communication between professional groups and services. We did a qualitative study, using semi-structured individual and focus group interviews, in Melbourne, Australia. The research aim was to explore the experiences and strategies used by palliative care nurses to communicate with general practitioners. We found that palliative care nurse consultants in acute hospitals not only provided inpatient consultation, but also played an important part in facilitating continuity of care across healthcare services by improving existing communication strategies and establishing further communication networks. However, there were several issues that had the potential to disrupt communication, and this article reports on the role of the palliative care nurse consultant in addressing these issues.

The interplay of knowledge and decision making between nurses and doctors in critical care

This paper explores the complex interrelationships between knowledge and decision making as nurses and doctors interacted with each other in a critical care unit, which comprised a combined general intensive care and cardiothoracic surgical unit. The critical ethnographic study upon which this paper is based, involved a research group of six nurses who worked in the unit. Nurses differentially valued their knowledge, depending on the situation, experience and level of medical input. They were also involved in decision making based on their differential visibility in the process. Nurses' specialised knowledge of the critical care unit played a major role in influencing how they interacted during decision making.

From individual to group: use of narratives in a participatory research process

AIMS

This paper provides a theoretical understanding of narrative research and its use in research. It aims to expose the ways narrative research, when taken beyond the researcher's lone analysis of text, can contribute to the development of clinical knowledge.

BACKGROUND

Methodological approaches involving the construction of narratives are increasingly apparent in the nursing and allied health literature. Narratives, constructed from stories of nursing practice, become texts available for analysis. This is undertaken predominantly by a researcher engaged in a lone activity with little involvement of those contributing the stories.

METHODS

This paper is drawn from a critical praxis study of nurse-patient friendship utilizing participatory research processes. The nurses involved in the study were co-researchers in an indepth study of their relationships with patients.

FINDINGS

The paper traces the movement from naïve story, through individual narratives during interviews with each nursing and demonstrates the changes in understanding about the narrative accounts that occurred during the participatory group process.

CONCLUSION

The nurses involved in this study were able, through the use of narrative stories reexamined in a group context, to develop new insights and understandings about their practice. Knowledge generated in these ways remains grounded in the real life world of clinical nursing and gives voice to the complexity of those aspects of nursing practice that are taken for granted.

Nurses and doctors communicating through medication order charts in critical care

The structure and content of written forms of communication dynamically interact with the social and historical conditions underlying critical care nursing activities. One important form of documentation regularly used in the critical care area is the medication order chart. This paper considers the ways in which medication order charts are used to structure interactions among nurses and between nurses and doctors. The critical ethnographic study upon which this paper is based involved a research group of six nurses who worked in one critical care unit. Data collection methods involved professional journalling, participant observation and individual and focus group interviews. Data analysis identified four major issues for consideration: imbalance between medical knowledge and legal authority; the nurse as go-between and medication expert; coaching the doctor; and the self policing nurse. The critical care nurse's role extends beyond the traditional passive activity of medication administration. By exploring the power relations underlying this role, there is greater opportunity for improved nursing relationships and patient care.

Rethinking ethnography: reconstructing nursing relationships

AIMS OF THE STUDY

Critical ethnography is being adopted increasingly by nurses as a legitimate form of research methodology. This paper explores the research practices and dilemmas that emerge from this methodology using a recently completed ethnographic study of nurse-nurse and nurse-doctor interactions in a critical care hospital setting.

BACKGROUND

Critical ethnography provides a useful methodology that facilitates mutual dialogue among participants. It may be limited, however, by the central role of researchers and by a tendency to negotiate participants' realities according to a particular 'truth'. These concerns have been strongly critiqued by poststructuralists using concepts such as discourse, subjectivity and power. By incorporating the notion of a poststructural analysis into critical ethnography, researchers are in a position to examine critically the tensions in their own practices, and their struggles with documenting and analysing ethnographic accounts.

DESIGN

Six registered nurses comprised the participants of the research group. Through the method of professional journalling, the first author of this paper explored her professional interactions with doctors and other nurses in her role as a nurse in the critical care setting under investigation. Other methods included participant observation, and individual and focus group interviews with nurse participants. ISSUES OF METHODOLOGICAL CONCERN: This paper considers three issues of methodological concern: researcher/participant subjectivity; the movement from empowerment to reflexivity and the construction of one form of ethnographic 'truth'. These issues are discussed in reference to the research relationships with the nurse participants and the process of analysing ethnographic accounts.

CONCLUSIONS

In working with critical ethnography using a poststructural analysis, we were able to generate valuable insights about previously hidden areas of relationships among nurse participants in a research group during all stages of the research process. It also provided a means of informing the analysis of ethnographic texts.

The handover: uncovering the hidden practices of nurses

This paper considers the ways in which the nursing handover involves a complex network of communication that impacts on nursing interactions. The critical ethnographic study upon which this paper is based involved a research group of six nurses who worked in one critical care unit. Data-collection methods involved professional journalling, participant observation, and individual and focus group interviews. The nursing handover took on many forms and served different purposes. At the start of a shift, the nurse coordinator of the previous shift presented a 'global' handover of all patients to oncoming nurses. Nurses proceeded then to the bedside handover, where the intention changed from one that involved a broad overview of patients, to one that concentrated on a patient's individual needs. Data analysis identified five practices for consideration: the global handover serving the needs of nurse coordinators; the examination; the tyranny of tidiness; the tyranny of busyness; and the need to create a sense of finality. In challenging nurses' understanding of these practices, they can become more sensitive to other nurses' needs, thus promoting the handover process as a site for collaborative and supportive communication.

Legitimation of nurses' knowledge through policies and protocols in clinical practice

Health care professionals use policies and protocols in varying ways to guide their clinical activities and to promote quality patient care. The critical ethnographic case study upon which this paper is based, involved a research group comprising six registered nurses who worked in a critical care setting. Research methods included professional journalling, participant observation, and focus group and individual interviews. This paper examines the power relations at play between doctors and nurses, and among nurses, and the ways in which nurses used policies and protocols as a means of mediating communication. While policies and protocols provided nurses with legitimacy of their knowledge in the clinical arena, doctors tended to rely on their past experience and background to inform their knowledge and activities. For nurses to believe that they provided valued and collaborative input in patient decisions, they actively sought out written evidence through policies and protocols to confirm and support their knowledge. Policies and protocols of critical care activities provided nurses with expected standards of care, which they used to legitimize their knowledge and to communicate with doctors about 'undesirable' medical decisions. The doctors valued their professional authority and autonomy over policies and protocols, while nurses used these written guidelines to assert power and demonstrate resistance. Policies and protocols do not exist in isolation; they occur within a complex network of power relations that create tensions in clinical practice. In challenging these tensions, it is important that nurses and doctors establish a fine balance between using policies and protocols to provide directions for practice, and to allow sufficient latitude and flexibility in addressing the complexities of patient care.

Experience with continuous infusion of recombinant activated factor VII in the Asia-Pacific region

There is increasing interest in continuous infusion of recombinant activated factor VII (rFVIIa) as a convenient and safe alternative to intermittent bolus therapy. In the Australian patients reported in this paper, cost savings of up to 25% in the first 12 h of treatment with continuous infusion of rFVIIa have been achieved safely, suggesting that substantial overall savings are possible. However, in the Thai patient reported, a dose reduction of 35% in the first 12 h was associated with poor haemostatic control, suggesting that a dose reduction of >25% may be inadvisable. The indications for treatment in the five Australian patients were: retroperitoneal haemorrhage (n = 3); right forearm compartment syndrome (n = 1); wrist haemarthrosis and median nerve compression (n = 2); sublingual haematoma (n = 1); and cerebral (mid-brain) haemorrhage (n = 1). Treatment was effective in four out of five patients (six bleeding episodes) and there was one treatment failure where treatment had been substantially delayed. The Thai patient was treated as part of a prospective, uncontrolled, observational study of 34 bleeding episodes in 22 patients in the Asia-Pacific region. Treatment was judged ineffective after 24 h, but full haemostatic control was subsequently achieved with intermittent rFVIIa therapy.

A revised model of platelet aggregation

In this study we have examined the mechanism of platelet aggregation under physiological flow conditions using an in vitro flow-based platelet aggregation assay and an in vivo rat thrombosis model. Our studies demonstrate an unexpected complexity to the platelet aggregation process in which platelets in flowing blood continuously tether, translocate, and/or detach from the luminal surface of a growing platelet thrombus at both arterial and venous shear rates. Studies of platelets congenitally deficient in von Willebrand factor (vWf) or integrin alpha(IIb)beta(3) demonstrated a key role for platelet vWf in mediating platelet tethering and translocation, whereas integrin alpha(IIb)beta(3) mediated cell arrest. Platelet aggregation under flow appears to be a multistep process involving: (a) exposure of vWf on the surface of immobilized platelets; (b) a reversible phase of platelet aggregation mediated by the binding of GPIbalpha on the surface of free-flowing platelets to vWf on the surface of immobilized platelets; and (c) an irreversible phase of aggregation dependent on integrin alpha(IIb)beta(3). Studies of platelet thrombus formation in vivo demonstrate that this multistep adhesion mechanism is indispensable for platelet aggregation in arterioles and also appears to promote platelet aggregate formation in venules. Together, our studies demonstrate an important role for platelet vWf in initiating the platelet aggregation process under flow and challenge the currently accepted view that the vWf-GPIbalpha interaction is exclusively involved in initiating platelet aggregation at elevated shear rates.

Possibilities for critical social theory and Foucault's work: a toolbox approach

The benefits and constraints of philosophical frameworks using the work of Michel Foucault and critical social theorists, such as Fay, Giroux and McLaren, are examined in the light of their traditions. The reasons nurse researchers adopt these frameworks are explored, as are the tensions between the respective theories. A complementary 'toolbox' approach to the research process addresses some of the theoretical and methodological challenges presented by each framework. Such an approach provides distinctive insights into nursing practice that the other has ignored or missed. It is argued that by converging the two frameworks into a toolbox approach, it is possible to examine or deconstruct existing practices, whilst also providing an avenue for nurses to reconstruct or change such practices.

Nurses of NESB working in a multicultural community

Ensuring that the cultural composition of the nursing population reflects the multicultural mix of the general population assumes that culturally appropriate care will occur when people of non-English background (NESB) are encountered in nursing practice. In a feminist praxis study involving twenty-six nurse participants, seven of whom were of NESB, the nurses discovered that the structure of the health care institution not only overlooked the cultural and linguistic needs of children and NESB families, but also created a dominant Anglo-Australian health culture that taught NESB nurses to ignore the traditions and practices of their NESB culture. This paper will explore the nurses' discovery of their own collusion in sustaining an Anglo-Australian health care culture.

Laboratory testing, diagnosis, and management of von Willebrand disease. Current practice in Australasia. RCPA Quality Assurance Program in Haematology Scientific Haemostasis Advisory Panel

We report an evaluation of current laboratory and clinical practice for the diagnosis and management of von Willebrand disease (VWD) for a wide geographic area including Australia, New Zealand, and parts of Southeast Asia. This assessment has been undertaken in conjunction with the RCPA Quality Assurance Program (QAP) in Haematology. This external QAP currently comprises around 550 participating laboratories, of which some 450 perform coagulation testing, and from which 32 laboratories were identified to be actively involved in testing for VWD. These laboratories were targeted and their current laboratory and clinical practice evaluated by using various questionnaires. Our overall findings indicate a wide variation in laboratory test practice for VWD-based investigations. There was considerable variation among laboratories in the tests and test methods used, the control and calibration material used, the reported test reference intervals and units used, and the composite test panels used to diagnose VWD. However, substantial consensus in the clinical evaluation process, as undertaken by hematologists, also was identified. Despite the observed variations, most laboratory professionals seemed to understand the complexities involved in the diagnosis and subclassification of VWD, and the laboratories can provide an effective diagnostic service.

Discharge planning and transitional care: issues in Thai nursing

Discharge planning is part of the care process that places nurses in a pivotal position in facilitating continuity of care for clients. This ethnographic study explored the current discharge practices of Thai nurses and examined how transitions from hospital to home were incorporated into Thai nursing practice. The study was conducted with registered nurses in an acute hospital in central Thailand. Results indicated that the discharge process in this community was highly informal with several factors affecting the effectiveness of nurses' discharge functions. Consequently, strategies to improve this care process were proposed for further implementation.

Cost-sharing and pharmaceutical utilisation and expenditure in Russia

This paper presents estimates of the impact of exemption status, and other socio-economic variables, on pharmaceutical use in Russia. Estimates are derived from a newly collected household survey covering around four thousand households. Separate results for a zero-inflated negbin model of utilisation of prescriptions and for a two-part model of the overall level of household expenditure on pharmaceuticals are presented. Full exemption from prescription charges is shown to increase the utilisation of prescription items and reduce the probability of the households incurring drug expenditure.

Problem-based learning: an educational strategy to support nurses working in a multicultural community

Physical dislocation of people from their homelands either as refugees, immigrants or exiles has resulted in the creation of multicultural communities which have diverse health needs. Like elsewhere, nurses in Australia have been faced with the challenge of responding to an ever-changing migrant population. A modified problem-based learning project was conducted in Melbourne to assist nurses to enhance their practice of caring for children and families of non-English speaking backgrounds (NESB). Clinical nurses worked with the researchers to develop and trial problem-based educational packages. The packages were designed for use in the clinical areas and graduate nursing programs to assist nurses overcome the cultural and communication difficulties they experienced when caring for people of NESB.

The economic consequences of reorganizing hospital services in Bishkek, Kyrgyzstan

Kyrgyzstan gained independence from the Soviet Union in 1991 and has since been thrown into severe financial crisis. All public sector funding has been significantly reduced and international aid agencies are supporting the government in rebuilding the economy. The health sector requires a radical overhaul and a major part of this process involves rationalization of existing facilities, particularly in the capital Bishkek, where 26 secondary and tertiary hospitals support a population of approximately 800000 people. This paper describes the development of a plan for rationalization with particular emphasis on the economic aspects of the process. This involved calculating future hospital requirements by modelling a variety of policy options, ranging from changes to clinical practice to hospital closures. The model generates estimates of resource requirements at each hospital, from which the costs falling on the health budget and patients are derived.

Is hospital performance related to expenditure on management?

OBJECTIVES

Reducing the costs of management appears an easy target for those seeking to generate savings or to promote better spending in the National Health Service (NHS). However, an assessment of the appropriate amount of spending on management requires an evaluation of how much management contributes to organizational performance.

METHODS

Using routinely available NHS acute hospital data, an econometric analysis was undertaken to test the hypothesis that there is a relationship between the proportion of a hospital's income spent on management and the performance of the hospital measured along three dimensions: the achievement of financial targets; performance against waiting time standards defined in the Patient's Charter; and costs of service provision.

RESULTS

No general relationship was found between management costs and hospital performance. However, there was some evidence of a quadratic relationship between management spending and the amount of operating surplus generated and performance against the three-month waiting time standard for an inpatient admission specified in the Patient's Charter. These results suggest that performance returns reach an optimum when management expenditure is around 5-6% of hospital income.

CONCLUSIONS

The evidence is not yet strong enough to draw a general conclusion that management costs in NHS acute hospitals are too high or that an undiscriminating reduction in management costs would have no detrimental effects on hospital performance. However, the findings should prompt managers to identify ways in which their activities are productive and how these can be measured, and what distinguishes effective from ineffective management.

Primary cares. Messages from the frontline

The biggest hurdle in the establishment of primary care groups is practices' reluctance to co-operate. GPs will want compensation for the time spent on administration. There is little awareness of the fact that PCG budgets may run out. The development of PCGs is expected to lead to an increase in salaried GPs. Current IT systems are seen as inadequate for PCGs.

Seven deaths in Darwin: case studies under the Rights of the Terminally Ill Act, Northern Territory, Australia

BACKGROUND

During the 9 months between July, 1996, and March, 1997, the provision of euthanasia for the terminally ill was legal in the Northern Territory of Australia. Seven patients made formal use of the Rights of the Terminally Ill (ROTI) Act; four died under the Act. We report their clinical details and the decision-making process required by the Act.

METHODS

We taped in-depth interviews with the general practitioner who provided euthanasia. Further information was available from public texts created by patients, the media, and the coroner.

FINDINGS

All seven patients had cancer, most at advanced stages. Three were socially isolated. Symptoms of depression were common. Having met criteria of the Act, some patients deferred their decision for a time before proceeding with euthanasia. Medical opinions about the terminal nature of illness differed.

INTERPRETATION

Provision of opinions about the terminal nature of illness and the mental health of the patient, as required by the ROTI Act, created problematic gatekeeping roles for the doctors involved.

Cost effectiveness of shortening screening interval or extending age range of NHS breast screening programme: computer simulation study

OBJECTIVE

To compare the cost effectiveness of two possible modifications to the current UK screening programme: shortening the screening interval from three to two years and extending the age of invitation to a final screen from 64 to 69.

DESIGN

Computer simulation model which first simulates life histories for women in the absence of a screening programme for breast cancer and then assesses how these life histories would be changed by introducing different screening policies. The model was informed by screening and cost data from the NHS breast screening programme.

SETTING

North West region of England.

MAIN OUTCOME MEASURES

Numbers of deaths prevented, life years gained, and costs.

RESULTS

Compared with the current breast screening programme both modifications would increase the number of deaths prevented and the number of life years saved. The current screening policy costs 2522 pounds per life year gained; extending the age range of the programme would cost 2612 pounds and shortening the interval 2709 pounds per life year gained. The marginal cost per life year gained of extending the age range of the screening programme is 2990 pounds and of shortening the screening interval is 3545 pounds.

CONCLUSIONS

If the budget for the NHS breast screening programme were to allow for two more invitations per woman, substantial mortality reductions would follow from extending the age range screened or reducing the screening interval. The difference between the two policies is so small that either could be chosen.

Glycopeptide-induced vasculitis--cross-reactivity between vancomycin and teicoplanin

Teicoplanin has been suggested for use in patients suffering complications from vancomycin. We describe two patients who developed a vasculitic rash whilst on vancomycin with recrudescence of the rash with subsequent teicoplanin therapy.