Quality of HIV care provided by nurse practitioners, physician assistants, and physicians

BACKGROUND

Nurse practitioners (NPs) and physician assistants (PAs) are primary care providers for patients with HIV in some clinics, but little is known about the quality of care that they provide.

OBJECTIVE

To compare the quality of care provided by NPs and PAs with that provided by physicians.

DESIGN

Cross-sectional analysis.

SETTING

68 HIV care sites, funded by Ryan White Comprehensive AIDS Resources Emergency (CARE) Act Title III, in 30 different states.

PARTICIPANTS

The authors surveyed 243 clinicians (177 physicians and 66 NPs and PAs) and reviewed medical records of 6651 persons with HIV or AIDS.

MEASUREMENTS

8 quality-of-care measures assessed by medical record review.

RESULTS

After adjustments for patient characteristics, 6 of the 8 quality measures did not statistically significantly differ between NPs and PAs and either infectious disease specialists or generalist HIV experts. Adjusted rates of purified protein derivative testing and Papanicolaou smears were statistically significantly higher for NPs and PAs (0.63 and 0.71, respectively) than for infectious disease specialists (0.53 [P = 0.007] and 0.56 [P = 0.001], respectively) or generalist HIV experts (0.47 [P < 0.001] and 0.62 [P = 0.025], respectively). Nurse practitioners and PAs had statistically significantly higher performance scores than generalist non-HIV experts on 6 of the 8 quality measures.

LIMITATIONS

These results may not be generalizable to care settings where on-site physician HIV experts are not accessible or to measures of more complex clinical processes.

CONCLUSIONS

For the measures examined, the quality of HIV care provided by NPs and PAs was similar to that of physician HIV experts and generally better than physician non-HIV experts. Nurse practitioners and PAs can provide high-quality care for persons with HIV. Preconditions for this level of performance include high levels of experience, focus on a single condition, and either participation in teams or other easy access to physicians and other clinicians with HIV expertise.

Disclosing concerns of Latinas living with HIV/AIDS

This study described the disclosing experiences of Latinas with HIV/AIDS in the San Francisco Bay Area. Limited information is available on the disclosing processes, situations and consequences. The design was a descriptive study with 19 Latinas. Content analysis was used to analyze the data. Deciding to disclose was identified as the core category. Four major categories emerged from the data. Deciding to disclose has social, psychological and economical issues. Nurses need to be aware of the disclosing issues when caring for Latinas with HIV/AIDS.

HIV/AIDS and the workplace: perceptions of nurses in a public hospital in South Africa

AIM

The purpose of this article is to report a study of the perceptions and experiences of nurses caring for people living with HIV/AIDS in the public health sector in South Africa.

BACKGROUND

The number of people living with HIV/AIDS in South Africa has escalated at an alarming rate. Many people being hospitalized are HIV positive, and hence nurses are in more regular and prolonged contact with people suffering from HIV/AIDS than is the case in other working environments. Although studies focusing on nurses' experiences of caring for patients with HIV/AIDS have been done in numerous countries, little is known about nurses' views in Africa, and South Africa in particular. To ensure quality care for patients with HIV/AIDS, it is important to understand nurses' experiences of nursing HIV-positive patients and how they may influence their attitudes towards these patients.

METHOD

A qualitative approach was used, the primary method of data collection being in-depth interviews. These interviews were conducted with 35 nurses at a public hospital in the Gauteng province of South Africa in 2002-2003.

FINDINGS

Seven themes were identified: helplessness, emotional stress and fatigue, fear, anger and frustration, occupational-related concerns, empathy, and self-fulfilment.

CONCLUSIONS

Increased understanding of the stresses and rewards experienced by these nurses can contribute to policy development in this area. It is also important to provide appropriate preregistration and continuing education and support for nurses working in this field, and to ensure that the working environment is adequate in terms of resources.

An evaluation of a morphine public health programme for cancer and AIDS pain relief in Sub-Saharan Africa

BACKGROUND

Despite growing HIV and cancer prevalence in Sub-Saharan Africa, and WHO advocacy for a public health approach to palliative care provision, opioid availability is severely limited. Uganda has achieved a morphine roll-out programme in partnership with the Ministry of Health. This study aimed to evaluate that programme by identifying challenges to implementation that may inform replication.

METHODS

A multi-methods protocol appraised morphine regulation, storage, prescribing, and consumption in three phases: key informant interviews throughout the opioid supply chain, and direct observation and audit of clinical practice.

RESULTS

Regulation had achieved its goal of preventing misuse and leakage from the supply chain. However, the Government felt that relaxation of regulation was now appropriate. Confusion and complexity in storage and authorization rules led to discontinuation of opioid pain management at the patient level and also wasted service time in trying to obtain supplies to which they were entitled. Continued neglect to prescribe among clinicians and public fear of opioids led to under prescribing, and clinical skills showed some evidence of need for improvement with respect to physical assessment and follow-up.

CONCLUSION

The Ugandan programme offers a successful model for both advocacy and Governmental support in achieving opioid roll-out across health districts. Despite initial concerns, abuse of opioids has not been evident. Further work is required to ensure that available supplies of opioids are prescribed to those in need, and that clinical standards are met. However, the programme for roll-out has proved a useful model to expand opioid availability as the first step in improving patient care, and may prove a useful template for other Sub-Saharan African countries.

[Greater survival among patients with immunogenetic markers of rapid progression to AIDS: subsidies for nursing care]

This study sought subsidies for improving nursing care programs for AIDS patients and aimed to verify the influence of changes in sexual behavior, including the adoption of safe sex practices, associated with the survival of AIDS patients with immunogenetic markers of rapid disease progression. 27 AIDS patients were interviewed, with genetic predisposition to rapid progression to AIDS. Genes were typified through the polymerase chain reaction. In spite of the presence of immunogenetic factors, associated with individual predisposition to a rapid evolution of the disease, changes in sexual behavior, including safe sex practices and antiretroviral therapy, may be related to greater survival. This suggests that counseling, detection of risk attitudes and health education, focusing on positive health behavior, are tools nursing must use with HIV-positive patients, with a view to better quality of life and greater survival among these individuals, even among those with genetic predisposition to rapid disease progression.

Extending Palliative Care Is There a Role for Preventive Medicine?

Historically, the concept of palliative care has been limited to hospice and end-of-life services. Recently, palliative care has been expanded to emphasize its integration throughout an illness. We suggest that palliative care provides an opportunity to prevent illness. Palliative care providers can effectively reduce the risk of illness in families by employing methods and strategies of preventive medicine. We illustrate three such cases. Patients and survivors may benefit from appropriate recognition and referral to prevent potential medical, social, and psychological problems. For preventive medicine to become fully exploited by palliative care providers, curricula will need to be developed. Risk assessment indicators of heritable and acquired conditions will define core functions of this educational process. Relevant topics should encompass basic preventive medicine methods, methods to disseminate assigned risk to the palliative care team, and referral mechanisms to specialists with expertise in the identified area(s) of concern. Opportunities to integrate preventive care into end-of-life services will create a new dimension for comprehensive palliative care.

[The actualization of nursing care for the child living with AIDS: being, knowing and shared doing]

This article is the result of considerations resulting from the dissertation Meeting of care, lived and dialogued, of the nursing team with the child-being who lives with AIDS, which aimed at understanding the meaning of such care under the look of the Humanistic Nursing Theory of Paterson and Zderad. It is a phenomenological-existential and qualitative study with hermeneutic analysis proposed by Motta and Crossetti in the light of Ricouer. The expressiveness of caring was unveiled as: act of life; authentic; the lived and dialogued meeting; need for taking care of oneself as an opening for the meeting; maternity handling; the need of approaching the hospital world to the child's world and compassion attitude.

[Health decision making in AIDS family caregiver]

AIDS infected patients receive care at home; a family member assumes the caregiver role and takes health decisions that affect the person's life. It is important to know the conflicts that the families are confronting in relation to health decision making, in order to plan intervention strategies according with their real needs. This is a descriptive study, in which a sample of 38 family caregivers of AIDS persons receiving ambulatory care at the Clinica Familia, were used for this research. An O'Connor and Jacobsen instrument was used for this study.

CONCLUSIONS

the family caregivers are women, the majority of them are mothers that live with their sick son or daughter, and who had assumed the role at least for 2 years. The family caregivers have conflicts about to continuing or not caring for the sick person, and of telling others about the disease. The family caregivers are in one of the phases of the changing process. Consequently, they are receptive to helping strategies that must be based in interventions oriented to listening and supporting, more than just providing information.

The managerial duties of the nurse in charge of a unit in combating the spreading of HIV/AIDS

The charge sister has an essential role to play in combating the spreading of the HIV in the environment of the nursing unit. The HIV/AIDS dilemma is a reality in the health care environment. On a daily basis nurses is treating patients with the HIV. Through the basic conceptual framework of the management process, the charge sister can play her part and contribute in keeping the disease under control in her work environment. An explorative, descriptive study was done through a structured questionnaire with four open questions. This study was aimed at developing and formulating guidelines to be included in a policy to be used in the combating of spreading of HIV in the health care unit by the charge sister and her staff. The results indicate the absence of policy regarding the prevention of the spreading of the HIV, necessary for orientation and in service training of staff.

Giving care to people with symptoms of AIDS in rural sub-Saharan Africa

In rural sub-Saharan Africa, most care for patients with AIDS is provided at home by relatives. Caring for those with AIDS is assumed to be a substantial burden, but little is known from the perspectives of those who provide the care. In this paper we use interviews with caregivers, supplemented with survey data from a larger study in rural Malawi, to investigate this issue. We focus on the caregivers' diagnoses of the illness of their patients, the type and duration of the care they provided, the support they received from relatives and other members of the community, and the extent to which caregiving was experienced as an emotional, physical, and financial burden. Although none of the caregivers knew of a formal diagnosis and few explicitly named their relative's disease as AIDS, most appeared to suspect it. They described the illness using the typical symptoms of AIDS as they are locally understood and sometimes related the illness to their patient's sexual history. The care, typically given by close female relatives of the patient, was limited to the care that would be given to anyone who was seriously ill. What was striking, however, was the compassion of the caregivers and the attempts they made to provide the best care possible in their circumstances. For most caregivers, kin and members of the community provided social, moral, and physical support, as well as modest financial assistance. Caregiving was physically and emotionally demanding and confined the caregivers to their home, but most caregivers did not consider caregiving a problem primarily because the patients were close relatives. The financial impact of caregiving was typically modest because the caregivers had very little income and few possessions to sell.

Representações sociais do HIV/AIDS entre adolescentes: implicações para os cuidados de enfermagem

Objetivando-se discutir as implicações das representações sociais do HIV/AIDS para as relações interpessoais e práticas de proteção entre adolescentes, foram realizadas 15 entrevistas semi-diretivas com adolescentes, portadares e não portadores do HIV, atendidos em um Hospital Escola do Rio de Janeiro. Para análise dos dados utilizou-se o software ALCESTE 4.5 que realiza uma análise hierárquica descendente de material textual. Observou-se que a representação social da aids estrutura-se em torno de cognições ligadas à prevenção, revelando uma contradição entre os conteúdos de conhecimento e as práticas relatadas pelo grupo. Sugere-se que as práticas de enfermagem devem ter como objetivo reduzir a distância entre práticas, representações e o conhecimento científico.

A strategy for the management of HIV/ AIDS in the health sector of the city of Johannesburg

The HIV/AIDS pandemic is posing major challenges to all sectors in South Africa, including the health sector of the city of Johannesburg. The health sector of the city of Johannesburg, as a result of the pandemic, is faced with increasing demands on its scarce resources at a time of major reform at local government level including transformation of the health sector. The overall objective of the study is to explore and describe a strategy for the management of HIV/AIDS by the health sector of the city of Johannesburg. An exploratory, descriptive and quantitative research design was utilized and the UNAIDS "Guide to the strategic planning process for a national response to HIV/AIDS" (1998), was employed to formulate the strategy. The content validity of the strategy was determined according to the process originally described by Lynn (1986) and adopted by Muller (in Booyens, 1998:607-609). The research was conducted in two phases. The first phase, the developmental phase, involved the exploration and description of the theoretical framework and the response to the pandemic, and formulation of a draft strategy. The second phase, the quantification phase, involved the assertion of the content of the strategy by a group of experts and determination of the content validity index (CVI). The final strategy focused on the following: to lead and facilitate intersectoral collaboration; to strengthen primary health care services to provide comprehensive community-based care; prevention of new infections; community mobilization towards prevention, non discrimination and non stigmatization and empowerment of the health sector to deal with the AIDS.pandemic. The CVI results showed that the average content validity index determined during this study was adequate: full score (1.0) for acceptability and technical soundness, and 0.89 for feasibility and perceived affordability. The strategy formulated for the management of HIV/AIDS by the health sector of the city of Johannesburg is therefore acceptable, technically sound and feasible and perceived as affordable. It was finally recommended that the strategy be adopted for implementation within the health sector of the city of Johannesburg.

A focus for nursing intervention: Realistic acceptance or helping illusions?

Despite having a life-threatening disease, some people decide to live every remaining moment with intensity. Although they have accepted that their deaths might be imminent, they do not dwell on the possibility. They choose life and are sustained by vivid thoughts and inspirations. What can a nurse do to nourish such thoughts? Traditional theories of grief and loss maintain that one way to adjust to advanced stages of progressive disease is to accept death and prepare for it. Is it possible that these theories are simplistic and limiting in their assumptions about the way people "work through" the stage of adjusting to loss? This article is a critical reflection of the process.

Ações de enfermagem identificadas no Projeto CIPESC(a) e utilizadas no cuidado de pacientes com AIDS

Estudo do tipo exploratório-descritivo, desenvolvido numa abordagem quantitativa com os objetivos de identificar, nos resultados do Projeto de Classificação Internacional das Práticas de Enfermagem em Saúde Coletiva - CIPESC, as ações de enfermagem que podem ser utilizadas por enfermeiros, no cuidado dos pacientes com Aids e confirmar essa utilização, na prática profissional de enfermeiros. Das 2.754 ações de enfermagem identificadas no Projeto CIPESC, 157 foram apontadas como possíveis de serem utilizadas no cuidado de pacientes com Aids. Os resultados do estudo apontam para a utilização de todas as 157 ações de enfermagem, as quais estão, em sua maioria, nos conceitos: Atender (86), Informar (25), Gerenciar (19), Observar (17) e Desempenhar (10).

Physical and Psychosocial Health in Family Caregiving: A Comparison of AIDS and Cancer Caregivers

The objectives of this study were to compare cancer and AIDS family caregivers in regard to their physical and emotional health. The sample consisted of 26 caregivers of persons with cancer or AIDS. Study participants completed a questionnaire that included measures of depression, grief, symptoms of stress, caregiving demands, interpersonal relationships, health status, and quality of life. The data revealed that both AIDS and cancer caregivers reported high levels of stress and depression as compared to community norms. No significant differences were found between AIDS and cancer caregivers for any of the scale scores; however, the two groups differed on several individual subscales. Cancer caregivers demonstrated higher social functioning and were more likely to report that the work of caregiving itself disrupted their ability to socially engage with others. In contrast, AIDS caregivers were more likely to report that their own health limited their ability to socialize. Even though AIDS caregivers experienced less family support than cancer caregivers, they reported more rewards from caregiving. Results suggest that support delivered to caregivers emphasize a more inclusive approach to program delivery, versus a disease-specific perspective, in order to increase the depth and breath of services provided to families undertaking these challenges.

Nursing interventions in the Kingston Paediatric and Perinatal HIV/AIDS Programme in Jamaica

BACKGROUND

Nursing care has been the "grass roots" of healthcare management even before nursing became a profession. Literature on the nursing experience with HIV is minimal and so it is challenging to comment on, or to compare experiences.

PURPOSE

This paper highlights the nursing interventions as a key feature in the ongoing development and success of a prevention of mother-to-child HIV transmission (pMTCT) programme in a resource-limited setting.

METHOD

In the Kingston Paediatric and Perinatal HIV/AIDS Programme, the nurses and midwives were carefully selected and then trained in the management of preventing mother-to-child transmission (pMTCT) of HIV/AIDS, voluntary counselling and testing and the identification and nursing management of paediatric and perinatal HIV/AIDS. The sites of the programme included three large maternity centres and four paediatric centres, with several feeder clinics for pregnant women. A nurse coordinator supervised the interventions at each site. A multidisciplinary team followed protocol-driven management for the care of pregnant HIV-positive women and children. There was strong collaboration with the Jamaican government and other agencies.

RESULTS

The nursing interventions served to: sensitize and encourage other healthcare workers in the care of persons living with HIV/AIDS; sensitize persons in the community about the disease; improve the comfort level of women and families with accessing healthcare; enable prospective data collection for programme assessment and research purposes and to enhance multidisciplinary collaboration to widen the scope of patient care and prevent duplication of healthcare services.

CONCLUSION

Nursing intervention is a vital part of a pMTCT HIV programme; however, ongoing education and training of the entire healthcare team needs to be continued in order to strengthen the programme. It is hoped that much of what is done in the Kingston Paediatric and Perinatal HIV/AIDS Programme will become integrated in the nursing management of maternal and child health nationally.

Creating contexts for effective homebased care of people living with HIV/AIDS

Home-based care (HBC) plays a vital role in the care of people living with AIDS. Most carers perform their arduous role in adverse conditions. Yet little is known about how to facilitate contexts that maximise the effectiveness of carers. This paper reviews existing research into home-based care in sub-Saharan Africa to highlight gaps in understanding and to outline new conceptual frameworks for future research. Current research identifies multi-level factors that undermine carers in performing their role. These include e.g. lack of knowledge, skills and support - both at the individual and organisational levels; physical and psychological burnout; the destruction of household economies in the face of the demands of care; community stigma and rejection. Research and policy documents repeatedly advocate ‘partnerships’ or ‘linkages’ between carers/ patients and more powerful groupings (locally, nationally and/or internationally) as a solution to these problems. Yet they give no indication as how best to mobilise already over-burdened carers and their terminally ill charges. Furthermore, partnerships between poor communities and more influential groupings and agencies are notoriously difficult to promote and sustain. If partnerships are indeed to play such a key role in supporting carers and their patients, there is an urgent need for systematic research into the effectiveness of various partnership styles and strategies. The concepts of bonding, bridging and linking social capital - within a framework sensitive to the interaction between social capital and poverty - are put forward as a valuable starting point for the development of better understandings of the types of networks and partnerships most likely to support carers and their local communities.