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Affiliation(s)
- Eric P Wittkugel
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, OH 45229, USA
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202
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Gabbay RA, Lendel I, Saleem TM, Shaeffer G, Adelman AM, Mauger DT, Collins M, Polomano RC. Nurse case management improves blood pressure, emotional distress and diabetes complication screening. Diabetes Res Clin Pract 2006; 71:28-35. [PMID: 16019102 DOI: 10.1016/j.diabres.2005.05.002] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2005] [Revised: 05/17/2005] [Accepted: 05/18/2005] [Indexed: 11/23/2022]
Abstract
We studied the impact of nurse case management (NCM) on blood pressure (BP), hemoglobin A1C, lipids, and diabetes complication screening. A 1-year randomized-controlled trial was conducted in two primary care clinics of the Penn State Hershey Medical Center. Diabetes patients were randomized to control group (CG) (n=182) who received usual care by their primary care provider and intervention group (IG) (n=150) who received additional NCM care, including self-management education, and implementation of diabetes guidelines. Primary outcomes included BP, A1C, lipid, process measures, and secondary outcome was diabetes-related emotional distress as assessed by Problem Areas in Diabetes (PAID). BP significantly decreased from 137/77 to 129/72 in IG as compared to an increase from 136/77 to 138/79 in CG after 1 year. PAID scores improved significantly in IG (from 23 to 10) due to reduced emotional stress. A1C (7.4) and LDL (105) were unaffected. Complications screening significantly improved in IG compared to CG: opthalmologic exam 26 to 68%, foot exam 47 to 64%, and nephropathy screening 34 to 72%. NCM improved BP, diabetes-related emotional distress, and process measures in primary care. Unchanged A1C and lipids might be due to a threshold effect. Intervention based upon initial risk assessment may prove more cost-effective.
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Affiliation(s)
- Robert A Gabbay
- The Penn State College of Medicine, Penn State Diabetes Center, Department of Endocrinology, Diabetes and Metabolism, 500 University Drive, HO44, Hershey, PA 17033, USA.
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203
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Seale C, Anderson E, Kinnersley P. Comparison of GP and nurse practitioner consultations: an observational study. Br J Gen Pract 2005; 55:938-43. [PMID: 16378563 PMCID: PMC1570503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023] Open
Abstract
BACKGROUND Studies show that satisfaction with nurse practitioner care is high when compared with GPs. Clinical outcomes are similar. Nurse practitioners spend significantly longer on consultations. AIM We aimed to discover what nurse practitioners do with the extra time, and how their consultations differ from those of GPs. DESIGN OF STUDY Comparative content analysis of audiotape transcriptions of 18 matched pairs of nurse practitioner and GP consultations. SETTING Nine general practices in south Wales and south west England. METHOD Consultations were taped and clinicians' utterances coded into categories developed inductively from the data, and deductively from the literature review. RESULTS Nurse practitioners spent twice as long with their patients and both patients and clinicians spoke more in nurse consultations. Nurses talked significantly more than GPs about treatments and, within this, talked significantly more about how to apply or carry out treatments. Weaker evidence was found for differences in the direction of nurses being more likely to: discuss social and emotional aspects of patients' lives; discuss the likely course of the patient's condition and side effects of treatments; and to use humour. Some of the extra time was also spent in getting doctors to approve treatment plans and sign prescriptions. CONCLUSIONS The provision of more information in the longer nurse consultations may explain differences in patient satisfaction found in other studies. Clinicians need to consider how much information it is appropriate to provide to particular patients.
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Affiliation(s)
- Clive Seale
- School of Social Sciences and Law, Brunel University, Uxbridge.
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204
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Hansen-Turton T. The Nurse-Managed Health Center Safety Net: a Policy Solution to Reducing Health Disparities. Nurs Clin North Am 2005; 40:729-38, xi. [PMID: 16324946 DOI: 10.1016/j.cnur.2005.08.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Nurse-managed health centers are critical safety net providers. Increasing support of these centers is a promising strategy for the federal government to reduce health disparities. To continue as safety net providers, nurse-managed health centers need to receive equal compensation as other federally funded providers. Ultimately, the long-term sustainability of nurse-managed centers rests on prospective payments or similar federally mandated funding mechanisms.
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Affiliation(s)
- Tine Hansen-Turton
- National Nursing Centers Consortium, 260 South Broad Street, 18th Floor, Philadelphia, PA 19102, USA.
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Vlastos IM, Mpatistakis AG, Gkouskou KK. Health needs in rural areas and the efficacy and cost-effectiveness of doctors and nurses. Aust J Rural Health 2005; 13:359-63. [PMID: 16313532 DOI: 10.1111/j.1440-1584.2005.00738.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Because of a lack of GPs in rural areas of Greece it is mandatory for junior doctors to offer medical service in those areas for a year. The aim of this study is to determine the possibility of replacement of internships with nurses and to suggest the most cost-effective way of covering health needs in remote areas. DESIGN Regional survey. SETTING AND PARTICIPANTS Patients of primary care offices in two remote areas of Crete, Greece within a year. MAIN OUTCOME MEASURES Comparative analysis of the level of preventive medicine (estimated by questionnaires) and health needs in the two areas. The reasons for visiting medical offices, references rates, percentages of glucose and blood pressure regulation are also studied. RESULTS Prescription of drugs for chronic diseases and blood pressure counting were the main reasons for office visits (2868/4594). Respiratory track infections (364/4594) follow. Apart from the high percentages of uncontrolled patients with blood pressure (34%) and diabetes mellitus (14%) there is a high percentage of ignorance or wrong opinions concerning preventive medicine, for example only 63% knew the value of a pap test. CONCLUSIONS More than two-thirds of "medical" visits in rural areas were for acts that nurses could easily do. The easy access to a junior doctor did not promote preventive medicine. Replacement of junior doctors with properly trained nurses cooperating with GPs responsible for greater regions would be more cost-effective than junior doctors improving health in rural areas. Legislation should change, mainly with regard to repeat prescriptions, in order to reduce house visits.
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Affiliation(s)
- Ioannis M Vlastos
- Department of General Surgery, Agios Nikolaos General Hospital, Lasithi, Greece.
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206
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MacDonald JM. Combination model of care for community nurse practitioners. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2005; 14:1144-8. [PMID: 16475435 DOI: 10.12968/bjon.2005.14.21.20075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Twenty-two community nurse practitioners were researched, primarily to establish whether or not they were able to achieve a 'higher level of practice'. Grounded theory, the qualitative research methodology developed by Glaser and Strauss, was used as a framework for the research. Data was gathered using primary observation with some participation (581 consultations being observed in the process), and by interviewing the community nurse practitioners and their clinical managers. From the overall theoretical framework that emerged from the research, a category, the 'combination model of care', was developed as a theoretical model, together with a conceptual framework for the process of nursing, 'HADPIPE'. This model of care/nursing and the HADPIPE framework provide a basis from which nurse practitioners can practice with a holistic nursing focus. The article analyses and discusses the combination model, and provides a detailed example of it in action.
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Abstract
The role of the nurse practitioner has been described as the apex of nursing practice. Such a statement has significant implications for the professional status of nursing in its own right. The aim of this paper is to discuss the nature of the nurse practitioner role in Australia and the importance of distinguishing between advanced and expanded practice. Evaluations of the nurse practitioner role suggest that specifically nursing contributions lead to a high level of consumer satisfaction. If nursing in general, and mental health nursing in particular, is to maintain and further develop their professional status, debate about the implications of the nurse practitioner role, and the terminology used to describe its scope, is crucial.
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Affiliation(s)
- Stephen Elsom
- Centre for Psychiatric Nursing Research and Practice, School of Nursing, University of Melbourne, Carlton, Victoria, Australia
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208
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Flynn S. Nursing effectiveness: An evaluation of patient satisfaction with a nurse led orthopaedic joint replacement review clinic. ACTA ACUST UNITED AC 2005. [DOI: 10.1016/j.joon.2005.06.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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209
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Affiliation(s)
- Jacqui Carr
- School of Nursing, Queens Medical Centre, Nottingham
| | - Natasha Thom
- School of Nursing, Queens Medical Centre, Nottingham
| | - Sue Rogers
- School of Nursing, Queens Medical Centre, Nottingham
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Crampton P, Davis P, Lay-Yee R. Primary care teams: New Zealand's experience with community-governed non-profit primary care. Health Policy 2005; 72:233-43. [PMID: 15802157 DOI: 10.1016/j.healthpol.2004.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Community-governed non-profit primary care organisations started developing in New Zealand in the late 1980s with the aim to reduce financial, cultural and geographical barriers to access. New Zealand's new primary health care strategy aims to co-ordinate primary care and public health strategies with the overall objective of improving population health and reducing health inequalities. The purpose of this study is to carry out a detailed examination of the composition and characteristics of primary care teams in community-governed non-profit practices and compare them with more traditional primary care organisations, with the aim of drawing conclusions about the capacity of the different structures to carry out population-based primary care. The study used data from a representative national cross-sectional survey of general practitioners in New Zealand (2001/2002). Primary care teams were largest and most heterogeneous in community-governed non-profit practices, which employed about 3% of the county's general practitioners. Next most heterogeneous in terms of their primary care teams were practices that belonged to an Independent Practitioner Association, which employed the majority of the country's general practitioners (71.7%). Even though in absolute and relative terms the community-governed non-profit primary care sector is small, by providing a much needed element of professional and organisational pluralism and by experimenting with more diverse staffing arrangements, it is likely to continue to have an influence on primary care policy development in New Zealand.
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Affiliation(s)
- Peter Crampton
- Department of Public Health, Wellington School of Medicine and Health Sciences, Faculty of Medicine, University of Otago, New Zealand, PO Box 7343, Wellington, New Zealand.
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Ltd B. Do nurse practitioners provide equivalent care to doctors as a first point of contact for patients with undifferentiated medical problems? ACTA ACUST UNITED AC 2005. [DOI: 10.1016/j.ehbc.2005.03.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Roumie CL, Halasa NB, Edwards KM, Zhu Y, Dittus RS, Griffin MR. Differences in antibiotic prescribing among physicians, residents, and nonphysician clinicians. Am J Med 2005; 118:641-8. [PMID: 15922696 DOI: 10.1016/j.amjmed.2005.02.013] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2004] [Indexed: 11/25/2022]
Abstract
PURPOSE State legislatures have increased the prescribing capabilities of nurse practitioners and physician assistants and broadened the scope of their practice roles. To determine the impact of these changes, we compared outpatient antibiotic prescribing by practicing physicians, nonphysician clinicians, and resident physicians. METHODS Using the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS), we conducted a cross-sectional study of patients >/=18 years of age receiving care in 3 outpatient settings: office practices, hospital practices, and emergency departments, 1995-2000. We measured the proportion of all visits and visits for respiratory diagnoses where antibiotics are rarely indicated in which an antibiotic was prescribed by practitioner type. RESULTS For all patient visits, nonphysician clinicians were more likely to prescribe antibiotics than practicing physicians for visits in office practices (26.3% vs 16.2%), emergency departments (23.8% vs 18.2%), and hospital clinics (25.2% vs 14.6%). Similarly, for the subset of visits for respiratory conditions where antibiotics are rarely indicated, nonphysician clinicians prescribed antibiotics more often than practicing physicians in office practices (odds ratio [OR] 1.86, 95% confidence intervals [CI]: 1.05 to 3.29), and in hospital practices (OR 1.55, 95% CI: 1.12 to 2.15). In hospital practices, resident physicians had lower prescribing rates than practicing physicians for all visits as well as visits for respiratory conditions where antibiotics are rarely indicated (OR 0.56, 95% CI: 0.36 to 0.86). CONCLUSION Nonphysician clinicians were more likely to prescribe antibiotics than practicing physicians in outpatient settings, and resident physicians were less likely to prescribe antibiotics. These differences suggest that general educational campaigns to reduce antibiotic prescribing have not reached all providers.
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Affiliation(s)
- Christianne L Roumie
- Quality Scholars Program, Veterans Administration Tennessee Valley Healthcare System-Health Services Research and Development, Nashville, Tennessee, USA.
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Morcom J, Dunn SV, Luxford Y. Establishing an Australian nurse practitioner-led colorectal cancer screening clinic. Gastroenterol Nurs 2005; 28:33-42. [PMID: 15738730 DOI: 10.1097/00001610-200501000-00008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
In Australia, colorectal cancer is the most commonly occurring internal cancer affecting both men and women, and the second most common cause of cancer-related death. Flexible sigmoidoscopy has not been commonly used as a screening tool in Australia due primarily to lack of resources. Until now, people at average risk of developing bowel cancer frequently undergo colonoscopy after referral to a specialist. To fill an identified need, a nurse practitioner-led colorectal screening service providing fecal occult blood testing and flexible sigmoidoscopy, health education and promotion, patient counseling, information and a referral point for general practitioners, and a referral service for above average-risk patients was established in a South Australian metropolitan teaching hospital. Establishment of this clinic required advanced and extended theoretical and clinical preparation for the nurse practitioner, as well as development of interdisciplinary relationships, referral processes, clinical infrastructure, and a marketing strategy. An audit of the first 100 flexible sigmoidoscopy patients revealed service and procedural outcomes that compared favorably with other colorectal screening services as well as a high level of patient satisfaction.
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Affiliation(s)
- Joylene Morcom
- Colorectal Disorders, Repatriation General Hospital, Daw Park, South Australia.
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Turris SA, Smith S, Gillrie C. Nurse practitioners in the ED: a rebuttal. CAN J EMERG MED 2005; 7:147-8; author reply 148. [PMID: 17355668 DOI: 10.1017/s1481803500013178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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216
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A satisfaction survey of a nurse led paediatric clinic for hip dysplasia in infants. ACTA ACUST UNITED AC 2005. [DOI: 10.1016/j.joon.2005.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B. Substitution of doctors by nurses in primary care. Cochrane Database Syst Rev 2005:CD001271. [PMID: 15846614 DOI: 10.1002/14651858.cd001271.pub2] [Citation(s) in RCA: 345] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Demand for primary care services has increased in developed countries due to population ageing, rising patient expectations, and reforms that shift care from hospitals to the community. At the same time, the supply of physicians is constrained and there is increasing pressure to contain costs. Shifting care from physicians to nurses is one possible response to these challenges. The expectation is that nurse-doctor substitution will reduce cost and physician workload while maintaining quality of care. OBJECTIVES Our aim was to evaluate the impact of doctor-nurse substitution in primary care on patient outcomes, process of care, and resource utilisation including cost. Patient outcomes included: morbidity; mortality; satisfaction; compliance; and preference. Process of care outcomes included: practitioner adherence to clinical guidelines; standards or quality of care; and practitioner health care activity (e.g. provision of advice). Resource utilisation was assessed by: frequency and length of consultations; return visits; prescriptions; tests and investigations; referral to other services; and direct or indirect costs. SEARCH STRATEGY The following databases were searched for the period 1966 to 2002: Medline; Cinahl; Bids, Embase; Social Science Citation Index; British Nursing Index; HMIC; EPOC Register; and Cochrane Controlled Trial Register. Search terms specified the setting (primary care), professional (nurse), study design (randomised controlled trial, controlled before-and-after-study, interrupted time series), and subject (e.g. skill mix). SELECTION CRITERIA Studies were included if nurses were compared to doctors providing a similar primary health care service (excluding accident and emergency services). Primary care doctors included: general practitioners, family physicians, paediatricians, general internists or geriatricians. Primary care nurses included: practice nurses, nurse practitioners, clinical nurse specialists, or advanced practice nurses. DATA COLLECTION AND ANALYSIS Study selection and data extraction was conducted independently by two reviewers with differences resolved through discussion. Meta-analysis was applied to outcomes for which there was adequate reporting of intervention effects from at least three randomised controlled trials. Semi-quantitative methods were used to synthesize other outcomes. MAIN RESULTS 4253 articles were screened of which 25 articles, relating to 16 studies, met our inclusion criteria. In seven studies the nurse assumed responsibility for first contact and ongoing care for all presenting patients. The outcomes investigated varied across studies so limiting the opportunity for data synthesis. In general, no appreciable differences were found between doctors and nurses in health outcomes for patients, process of care, resource utilisation or cost. In five studies the nurse assumed responsibility for first contact care for patients wanting urgent consultations during office hours or out-of-hours. Patient health outcomes were similar for nurses and doctors but patient satisfaction was higher with nurse-led care. Nurses tended to provide longer consultations, give more information to patients and recall patients more frequently than did doctors. The impact on physician workload and direct cost of care was variable. In four studies the nurse took responsibility for the ongoing management of patients with particular chronic conditions. The outcomes investigated varied across studies so limiting the opportunity for data synthesis. In general, no appreciable differences were found between doctors and nurses in health outcomes for patients, process of care, resource utilisation or cost. AUTHORS' CONCLUSIONS The findings suggest that appropriately trained nurses can produce as high quality care as primary care doctors and achieve as good health outcomes for patients. However, this conclusion should be viewed with caution given that only one study was powered to assess equivalence of care, many studies had methodological limitations, and patient follow-up was generally 12 months or less. While doctor-nurse substitution has the potential to reduce doctors' workload and direct healthcare costs, achieving such reductions depends on the particular context of care. Doctors' workload may remain unchanged either because nurses are deployed to meet previously unmet patient need or because nurses generate demand for care where previously there was none. Savings in cost depend on the magnitude of the salary differential between doctors and nurses, and may be offset by the lower productivity of nurses compared to doctors.
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Affiliation(s)
- M Laurant
- Centre for Quality of Care Research, University of Nijmegen, (229 HSV/WOK), PO Box 9101, 6500 HB Nijmegen, Netherlands, 6500 HB.
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Abstract
OBJECTIVES To determine the amount of time senior house officers (SHO) spent performing tasks that could be delegated to a technician or administrative assistant and therefore to quantify the expected benefit that could be obtained by employing such physicians' assistants (PA). METHODS SHOs working in the emergency department were observed for one week by pre-clinical students who had been trained to code and time each task performed by SHOs. Activity was grouped into four categories (clinical, technical, administrative, and other). Those activities in the technical and administrative categories were those we believed could be performed by a PA. RESULTS The SHOs worked 430 hours in total, of which only 25 hours were not coded due to lack of an observer. Of the 405 hours observed 86.2% of time was accounted for by the various codes. The process of taking a history and examining patients accounted for an average of 22% of coded time. Writing the patient's notes accounted for an average of 20% of coded time. Discussion with relatives and patients accounted for 4.7% of coded time and performing procedures accounted for 5.2% of coded time. On average across all shifts, 15% of coded time was spent doing either technical or administrative tasks. CONCLUSION In this department an average of 15% of coded SHOs working time was spent performing administrative and technical tasks, rising to 17% of coded time during a night shift. This is equivalent to an average time of 78 minutes per 10 hour shift/SHO. Most tasks included in these categories could be performed by PAs thus potentially decreasing patient waiting times, improving risk management, allowing doctors to spend more time with their patients, and possibly improving doctors' training.
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Perry C, Thurston M, Killey M, Miller J. The nurse practitioner in primary care: alleviating problems of access? ACTA ACUST UNITED AC 2005; 14:255-9. [PMID: 15902037 DOI: 10.12968/bjon.2005.14.5.17659] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Improving access to primary care services is an essential component of the NHS modernization plan and the advent of independent nurse practitioners in primary care has focused attention on the extent to which this group of nurses can effectively substitute for GPs. This study was designed to explore the role of a nurse practitioner in primary care, particularly whether the provision of a nurse practitioner facilitated access to care that met the needs of patients. Semistructured interviews were conducted with 14 patients who had consulted with the nurse practitioner, 10 staff within the practice who had knowledge of the role, and the nurse practitioner herself. With the permission of interviewees, interviews were audiotaped, the tapes transcribed verbatim, and the data were coded by theme. It was perceived by both groups of interviewees that access to care had been improved in that there were more appointments available, appointments were longer than they had been previously and were available at different times of the day. However, some areas in which access was 'restricted' were articulated by staff interviewees, such as limitations to the nurse practitioner's prescribing and problems with referring patients to secondary care. Additionally, while access to a member of the primary healthcare team was improved for many patients, access to a specific member of the team, such as a GP, was not always improved. Concerns were also expressed about how the role of the nurse practitioner needed to be developed in the practice. It can be concluded from this study that, potentially, the role of nurse practitioner has much to offer in terms of addressing problems of access in primary care for some patients. However, this is not a straightforward solution and in order for the role to be effective several issues highlighted in this study require addressing.
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Affiliation(s)
- Catherine Perry
- Centre for Public Health Research, University College Chester, Chester
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Reviewing emergency care systems 2: measuring patient preferences using a discrete choice experiment. Emerg Med J 2005; 21:692-7. [PMID: 15496695 DOI: 10.1136/emj.2002.003707] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To investigate patients' strength of preferences for attributes associated with modernising delivery of out of hours emergency care services in Nottingham. METHODS A discrete choice experiment was applied to quantify preferences for key attributes of out of hours emergency care. The attributes reflected the findings of previous research, current policy initiatives, and discussions with local key stakeholders. A self complete questionnaire was administered to NHS Direct callers and adults attending accident and emergency, GP services and NHS walk-in centre. Regression analysis was used to estimate the relative importance of the different attributes. RESULTS Response was 74% (n = 457) although 61% (n = 378) were useable. All attributes were statistically significant. Being consulted by a doctor was the most important attribute. This was followed by being consulted by a nurse, being kept informed about waiting time, and quality of the consultation. Respondents were prepared to wait an extra 2 hours 20 minutes to be consulted by a doctor. There were no measurable preference differences between patients surveyed at different NHS entry points. Younger respondents preferred single telephone call access to health care out of hours. Although having services provided close to home and making contact in person were generally preferred, they were less important than others, suggesting that a range of service locations may be acceptable to patients. CONCLUSIONS This study showed that local solutions for reforming emergency out of hours care should take account of the strength of patient preferences. The method was acceptable and the results have directly informed the development of a local service framework for emergency care.
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Abstract
Nursing leaders used evidence-based thinking to engage key stakeholders when implementing advanced practice nursing roles in a traditional medically oriented tertiary oncology center. A strategic orientation to the policy change initiative was guided by a theoretical framework for connecting research and policy. Policy approaches that addressed stakeholder values and beliefs, while attending to questions of competence, standards of practice, fiscal savings, medical and nursing workload, and ongoing multidisciplinary teamwork were essential to facilitate change.
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Affiliation(s)
- Greta Cummings
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada.
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Twinn S, Thompson DR, Lopez V, Lee DTF, Shiu ATY. Determinants in the development of advanced nursing practice: a case study of primary-care settings in Hong Kong. HEALTH & SOCIAL CARE IN THE COMMUNITY 2005; 13:11-20. [PMID: 15717902 DOI: 10.1111/j.1365-2524.2005.00524.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Different factors have been shown to influence the development of models of advanced nursing practice (ANP) in primary-care settings. Although ANP is being developed in hospitals in Hong Kong, China, it remains undeveloped in primary care and little is known about the factors determining the development of such a model. The aims of the present study were to investigate the contribution of different models of nursing practice to the care provided in primary-care settings in Hong Kong, and to examine the determinants influencing the development of a model of ANP in such settings. A multiple case study design was selected using both qualitative and quantitative methods of data collection. Sampling methods reflected the population groups and stage of the case study. Sampling included a total population of 41 nurses from whom a secondary volunteer sample was drawn for face-to-face interviews. In each case study, a convenience sample of 70 patients were recruited, from whom 10 were selected purposively for a semi-structured telephone interview. An opportunistic sample of healthcare professionals was also selected. The within-case and cross-case analysis demonstrated four major determinants influencing the development of ANP: (1) current models of nursing practice; (2) the use of skills mix; (3) the perceived contribution of ANP to patient care; and (4) patients' expectations of care. The level of autonomy of individual nurses was considered particularly important. These determinants were used to develop a model of ANP for a primary-care setting. In conclusion, although the findings highlight the complexity determining the development and implementation of ANP in primary care, the proposed model suggests that definitions of advanced practice are appropriate to a range of practice models and cultural settings. However, the findings highlight the importance of assessing the effectiveness of such models in terms of cost and long-term patient outcomes.
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Affiliation(s)
- Sheila Twinn
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong, China.
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Adams G, Gulliford MC, Ukoumunne OC, Eldridge S, Chinn S, Campbell MJ. Patterns of intra-cluster correlation from primary care research to inform study design and analysis. J Clin Epidemiol 2004; 57:785-94. [PMID: 15485730 DOI: 10.1016/j.jclinepi.2003.12.013] [Citation(s) in RCA: 411] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2003] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To provide information concerning the magnitude of the intraclass correlation coefficient (ICC) for cluster-based studies set in primary care. STUDY DESIGN AND SETTING Reanalysis of data from 31 cluster-based studies in primary care to estimate intraclass correlation coefficients from random effects models using maximum likelihood estimation. RESULTS ICCs were estimated for 1,039 variables. The median ICC was 0.010 (interquartile range [IQR] 0 to 0.032, range 0 to 0.840). After adjusting for individual- and cluster-level characteristics, the median ICC was 0.005 (IQR 0 to 0.021). A given measure showed widely varying ICC estimates in different datasets. In six datasets, the ICCs for SF-36 physical functioning scale ranged from 0.001 to 0.055 and for SF-36 general health from 0 to 0.072. In four datasets, the ICC for systolic blood pressure ranged from 0 to 0.052 and for diastolic blood pressure from 0 to 0.108. CONCLUSION The precise magnitude of between-cluster variation for a given measure can rarely be estimated in advance. Studies should be designed with reference to the overall distribution of ICCs and with attention to features that increase efficiency.
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Affiliation(s)
- Geoffrey Adams
- Department of Public Health Sciences, King's College London, Capital House, 42 Weston Street, London SE1 3QD, UK
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Barnes H, Crumble A, Carlisle C, Pilling D. Patients' perceptions of ߢuncertainty' in nurse practitioner consultations. ACTA ACUST UNITED AC 2004; 13:1350-4. [PMID: 15687903 DOI: 10.12968/bjon.2004.13.22.17275] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The aim of this qualitative study was to explore patients' perceptions of consulting with a nurse practitioner in situations of clinical uncertainty. Uncertainty in this context is defined as one where there is no obvious diagnosis, treatment or where the outcome of the consultation is not definite. Three general practice sites were recruited to participate. 43 patients who consulted with one of three nurse practitioners were interviewed using a semistructured schedule. The nurse practitioners identified uncertainty in 30 of these consultations; only two patients expressed any awareness of uncertainty with the consultation. The results showed that patients appear to accept that there will be a level of uncertainty in some consultations. Recognition of uncertainty within the consultation does not appear to have a negative effect on patients' perception of the nurse practitioner as they feel that the nurse will refer to a doctor if necessary.
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227
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Abstract
Human resources are the crucial core of a health system, but they have been a neglected component of health-system development. The demands on health systems have escalated in low income countries, in the form of the Millennium Development Goals and new targets for more access to HIV/AIDS treatment. Human resources are in very short supply in health systems in low and middle income countries compared with high income countries or with the skill requirements of a minimum package of health interventions. Equally serious concerns exist about the quality and productivity of the health workforce in low income countries. Among available strategies to address the problems, expansion of the numbers of doctors and nurses through training is highly constrained. This is a difficult issue involving the interplay of multiple factors and forces.
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228
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van Klei WA, Hennis PJ, Moen J, Kalkman CJ, Moons KGM. The accuracy of trained nurses in pre-operative health assessment: results of the OPEN study. Anaesthesia 2004; 59:971-8. [PMID: 15488055 DOI: 10.1111/j.1365-2044.2004.03858.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We quantified the accuracy of trained nurses to correctly assess the pre-operative health status of surgical patients as compared to anaesthetists. The study included 4540 adult surgical patients. Patients' health status was first assessed by the nurse and subsequently by the anaesthetist. Both needed to answer the question: 'is this patient ready for surgery without additional work-up, Yes/No?' (primary outcome). The secondary outcome was the time required to complete the assessment. Anaesthetists and nurses were blinded for each other's results. The anaesthetists' result was the reference standard. In 87% of the patients, the classifications by nurses and anaesthetists were similar. The sensitivity of the nurses' assessment was 83% (95% CI: 79-87%) and the specificity 87% (95% CI: 86-88%). In 1.3% (95% CI: 1.0-1.6%) of patients, nurses classified patients as 'ready' whereas anaesthetists did not. Nurses required 1.85 (95% CI: 1.80-1.90) times longer than anaesthetists. By allowing nurses to serve as a diagnostic filter to identify the subgroup of patients who may safely undergo surgery without further diagnostic workup or optimisation, anaesthetists can focus on patients who require additional attention before surgery.
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Affiliation(s)
- W A van Klei
- Department of Perioperative Care and Emergency Medicine, University Medical Centre Utrecht, 3508 GA Utrecht, The Netherlands.
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229
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Banning M. Nurse prescribing, nurse education and related research in the United Kingdom: a review of the literature. NURSE EDUCATION TODAY 2004; 24:420-427. [PMID: 15312950 DOI: 10.1016/j.nedt.2004.05.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/17/2004] [Indexed: 05/24/2023]
Abstract
This literature review aims to explore nurse education and the impact this has had on preparing nurses to become nurse prescribers and nurse prescribing research. Research about the initial nurse prescribing education and training programme indicated that although patients were content with nurses prescribing medication, nurses lacked confidence in applied pharmacology and therapeutics and hence, required additional scientific education. With the implementation of extended nurse prescribing, it is conjectural to assume that nurses have been prepared more effectively until results from the national evaluation are available. One can suggest that pre-registration nurses should receive a comprehensive scientific foundation in applied pharmacology and therapeutics and professional knowledge in order to prepare them for post graduate education and training in medication management.
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Affiliation(s)
- Maggi Banning
- Department of Adult Nursing, Canterbury Christ Church University College, North Holmes Road, Canterbury CT1 1QU, UK.
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230
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Affiliation(s)
- Eleanor Bradley
- Mental Health Nursing for the Faculty of Health and Sciences,Staffordshire University
| | - Peter Nolan
- Mental Health Nursing for the Faculty of Health and Sciences,Staffordshire University
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231
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232
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Campbell P. The role of nurses in sexual and reproductive health. JOURNAL OF FAMILY PLANNING AND REPRODUCTIVE HEALTH CARE 2004; 30:169-70. [PMID: 15222923 DOI: 10.1783/1471189041261465] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Pam Campbell
- Primary Care Nursing, Staffordshire University, Stafford, UK
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233
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Abstract
OBJECTIVE The objective of this study was to evaluate the association of patient satisfaction with type of practitioner attending visits in the primary care practice of a managed care organization (MCO). STUDY DESIGN We conducted a retrospective observational study of 41,209 patient satisfaction surveys randomly sampled from visits provided by the pediatrics and adult medicine departments from 1997 to 2000. Logistic regression, with practitioner and practice fixed effects, of patient satisfaction versus dissatisfaction was estimated for each of 3 scales: practitioner interaction, care access, and overall experience. Models were estimated separately by department. Independent variables were type of practitioner attending the visit and other patient and visit characteristics. RESULTS Adjusted for patient and visit characteristics, patients were significantly more likely to be satisfied with practitioner interaction on visits attended by physician assistant/nurse practitioners (PA/NPs) than visits attended by MDs in both the adult medicine and pediatrics practices. Patient satisfaction with care access or overall experience did not significantly differ by practitioner type. In adult medicine, patients were more satisfied on diabetes visits provided by MDs than by PA/NPs. Otherwise, patient satisfaction for the combined effects of practitioner type and specific presenting condition did not differ. CONCLUSIONS Averaged over many primary care visits provided by many physicians and midlevel practitioners, patients in this MCO were as satisfied with care provided by PA/NPs as with care provided by MDs.
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Affiliation(s)
- Douglas W Roblin
- Research Department, Kaiser Permanente, Atlanta, Georgia 30305, USA.
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234
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Abstract
RATIONALE Community health practitioners (CHPs) in Korea are Registered Nurses with a 6-month special training who have responsibility for delivering primary health care to remote or isolated communities. Research has indicated that these practitioners' contribution to improving the health of rural and remote populations has been effective. Despite this, CHP programmes have been fundamentally re-examined by the Korean government, as a consequence of the national economic crisis of 1998 and restructuring of the health care delivery system. AIM The aim of this paper is to analyse CHP services in primary health care, and evaluate some of the economic impacts of these services through a cost-minimization analysis. METHODS A retrospective, descriptive-correlational design was used. A self-administered questionnaire was sent to 600 CHPs who were randomly selected from the target population, and 272 returned the questionnaire after one reminder letter, a response rate of 45.3%. RESULTS There was a significant difference in average cost of care between a model based on CHP services and one including no CHP services, in which equivalent care was provided by physicians (t = -6.833, P < 0.001). The average costs ratio was 2.16 (sd = 1.24), with a range of 0.09-9.63, indicating that CHP services were almost half the price of the 'no CHP services' model. CONCLUSIONS The results provide evidence of the economic validity of the CHP's role in the public sector, where there is no net income to serve as a policy guideline. The conclusion can be drawn that CHP services are more effective than physician services (or 'no CHP services').
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Affiliation(s)
- Taewha Lee
- College of Nursing, Nursing Policy Research Institute, Yonsei University, Seoul, South Korea.
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235
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Roblin DW, Howard DH, Becker ER, Kathleen Adams E, Roberts MH. Use of midlevel practitioners to achieve labor cost savings in the primary care practice of an MCO. Health Serv Res 2004; 39:607-26. [PMID: 15149481 PMCID: PMC1361027 DOI: 10.1111/j.1475-6773.2004.00247.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To estimate the savings in labor costs per primary care visit that might be realized from increased use of physician assistants (PAs) and nurse practitioners (NPs) in the primary care practices of a managed care organization (MCO). STUDY SETTING/DATA SOURCES Twenty-six capitated primary care practices of a group model MCO. Data on approximately two million visits provided by 206 practitioners were extracted from computerized visit records for 1997-2000. Computerized payroll ledgers were the source of annual labor costs per practice from 1997-2000. STUDY DESIGN Likelihood of a visit attended by a PA/NP versus MD was modeled using logistic regression, with practice fixed effects, by department (adult medicine, pediatrics) and year. Parameter estimates and practice fixed effects from these regressions were used to predict the proportion of PA/NP visits per practice per year given a standard case mix. Least squares regressions, with practice fixed effects, were used to estimate the association of this standardized predicted proportion of PA/NP visits with average annual practitioner and total labor costs per visit, controlling for other practice characteristics. RESULTS On average, PAs/NPs attended one in three adult medicine visits and one in five pediatric medicine visits. Likelihood of a PA/NP visit was significantly higher than average among patients presenting with minor acute illness (e.g., acute pharyngitis). In adult medicine, likelihood of a PA/NP visit was lower than average among older patients. Practitioner labor costs per visit and total labor costs per visit were lower (p<.01 and p=.08, respectively) among practices with greater use of PAs/NPs, standardized for case mix. CONCLUSIONS Primary care practices that used more PAs/NPs in care delivery realized lower practitioner labor costs per visit than practices that used less. Future research should investigate the cost savings and cost-effectiveness potential of delivery designs that change staffing mix and division of labor among clinical disciplines.
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Affiliation(s)
- Douglas W Roblin
- Research Department, Kaiser Permanente, 3495 Piedmont Road NE, Building 9, Atlanta, GA 30305, USA
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236
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Holdsworth LK, Webster VS. Direct access to physiotherapy in primary care: now?—and into the future? Physiotherapy 2004. [DOI: 10.1016/j.physio.2004.01.005] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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237
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Abstract
A substantial body of research evidence has accumulated in support of the efficacy of brief interventions for a number of alcohol and drug-related problem areas, most notably alcohol and tobacco. This evidence has been used to exhort a range of professional groups such as general practitioners (GPs), and more recently emergency department hospital staff to engage in brief interventions. Internationally, however, these secondary prevention efforts have largely failed. Why have these proven interventions not been embraced by frontline workers? This is a little-asked question as efforts to press-gang unwilling professionals to take up the cudgel continue. This paper examines the characteristics of brief interventions and their principal delivery agents and explores reasons for the failure to move from efficacy to effectiveness. Given the prevention potential that rests with brief intervention, these are crucial questions to address. A key feature of brief intervention delivery also examined is the role of GPs versus the less well-explored option of the practice nurse. It will be proposed that perhaps we have the right vehicle but the wrong driver and that until closer scrutiny is made of this issue efforts in this key prevention area will continue to fail to achieve optimum results.
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Affiliation(s)
- Ann M Roche
- National Centre for Ecudation and Training and Addiction, Flinders University, Aaustralia
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238
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Williams A, Heyerdahl EH. Primary care priorities in Europe. J Res Nurs 2004. [DOI: 10.1177/136140960400900313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Anne Williams
- School of Health Sciences, University of Wales, Swansea
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239
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Chapman JL, Zechel A, Carter YH, Abbott S. Systematic review of recent innovations in service provision to improve access to primary care. Br J Gen Pract 2004; 54:374-81. [PMID: 15113523 PMCID: PMC1266174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND In England, there are particularly pressing problems concerning access to adequate primary care services. Consequently, innovative ways of delivering primary care have been introduced to facilitate and broaden access. AIMS The aim of this study was to review the evidence of seven recent innovations in service provision to improve access or equity in access to primary care, by performing a systematic review of the literature. DESIGN OF STUDY Systematic review. SETTING Primary care in the United Kingdom (UK). METHOD Seven electronic databases were searched and key journals were hand-searched. Unpublished and 'grey' literature were sought via the Internet and through professional contacts. Intervention studies addressing one of seven recent innovations and conducted in the UK during the last 20 years were included. Two researchers independently assessed the quality of papers. RESULTS Thirty studies (32 papers and two reports) were identified overall. Variation in study design and outcome measures made comparisons difficult. However, there was some evidence to suggest that access is improved by changing the ways in which primary care is delivered. First-wave personal medical services pilots facilitated improvements in access to primary care in previously under-served areas and/or populations. Walk-in centres and NHS Direct have provided additional access to primary care for white middle-class patients; there is some evidence suggesting that these innovations have increased access inequalities. There is some evidence that telephone consultations with GPs or nurses can safely substitute face-to-face consultations, although it is not clear that this reduces the number of face-to-face consultations over time. Nurse practitioners and community pharmacists can manage common conditions without the patient consulting a general practitioner. CONCLUSION The evidence is insufficient to make clear recommendations regarding ways to improve access to primary care. In the future, it is important that, as new initiatives are planned, well-designed evaluations are commissioned simultaneously.
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Affiliation(s)
- Jenifer L Chapman
- Centre for Infectious Disease, Institute of Cell and Molecular Sciences, Queen Mary's, University of London, London.
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Breen A, Carr E, Mann E, Crossen-White H. Acute back pain management in primary care: a qualitative pilot study of the feasibility of a nurse-led service in general practice. J Nurs Manag 2004; 12:201-9. [PMID: 15089958 DOI: 10.1111/j.1365-2834.2004.00469.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES (1) To determine the acceptability of the Royal College of General Practitioner Guidelines to small samples of nurses, General Practitioners and acute back pain patients, (2) to determine what additional roles for nurses in the management of acute back pain in primary care might be acceptable to these samples, (3) to evaluate the responses of General Practitioners, nurses and patients to a suggested service model based on the RCGP Guidelines, (4) to identify opportunities for and barriers to the further development of such models and to obtain the appraisal of the above by an external group of assessors. METHODOLOGY Using a qualitative design the pilot study included Primary Care (General Practitioners, Practice Nurses and Patients) with the main outcome measures as: appraisal questionnaires (for RCGP Guideline), qualitative content analysis of focus group narratives, and appraisal of process and outcomes by an external panel. RESULTS Attitudes towards the RCGP guidelines were positive, but professionals and patients alike did not think their recommendations could be implemented with the current service provision in primary care. There was criticism by professionals of the capacity for a nurse-led service within practices. Access to chiropractors, osteopaths and/or specialist physiotherapists in National Health Service primary care was raised as a need by both groups. All members of the Advisory Panel approved the processes for the recruitment of participants, focus group questions and analysis. DISCUSSION Barriers to implementation of the RCGP Guideline and to a nurse-led acute back pain service in general practice, were illustrated. These mainly relate to grossly inadequate capacity to deal with multidimensional patient needs, allowing progression to chronic pain states and much higher health care costs. There was a strong desire to include a different group of professionals in primary care. We recommend a local needs assessment and consideration of a national strategy for the implementation of the RCGP Guideline in primary care.
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Affiliation(s)
- Alan Breen
- Institute for Musculoskeletal Research and Clinical Implementation, Anglo-European College of Chiropractic, Bournemouth, UK. imrci@
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241
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Lindsay B. Randomized controlled trials of socially complex nursing interventions: creating bias and unreliability? J Adv Nurs 2004; 45:84-94. [PMID: 14675304 DOI: 10.1046/j.1365-2648.2003.02864.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The randomized controlled trial is viewed by many researchers as the 'gold standard' research design. It is used increasingly to evaluate the effectiveness of socially complex activities such as nursing interventions. This use is seen by many commentators as problematic, while others are concerned about the quality of many published trial reports. One area of concern is that of intervention bias: the impact that a sentient intervention, such as a nursing one, may have consciously or unconsciously on study outcomes. This paper reports on an analysis of intervention definitions and possible intervention bias in 47 reports of randomized controlled trials of nursing interventions published in 2000 or 2001. AIMS This study evaluates four characteristics of the included reports: intervention sample size, intervention definition, involvement of intervention nurses in other aspects of the trial, and the claimed generalizability of results. METHODS Reports of randomized controlled trials published in 2000 or 2001 were identified. Full-text versions of 47 papers were obtained and information about the four characteristics was extracted and analysed. RESULTS Problems relating to possible intervention bias were identified in each of the papers. Inadequate intervention definition was the commonest problem, leading to difficulties in calculating the 'intervention dose' and in replicating or generalizing from the studies. DISCUSSION None of the included studies met the requirements of the Consolidated Standards of Reporting Trials. Four types of intervention bias were identified, and their possible implications for the reporting of trials of nursing interventions are discussed. This was a small-scale study, limited by time and resources. Its results are suggestive of a major problem of intervention bias but larger-scale investigations are necessary to quantify its extent. CONCLUSIONS Intervention bias is potentially a problem in randomized controlled trials. Lack of detail about interventions in published papers could be corrected by stricter adherence to guidelines such as the Consolidated Standards of Reporting Trials, but this will not correct the underlying problem of inadequate study design that appears to be widespread in randomized controlled trials of nursing interventions.
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Affiliation(s)
- Bruce Lindsay
- Nursing and Midwifery Research Unit, School of Nursing and Midwifery, University of East Anglia, Norwich, UK.
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242
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Abstract
This review examines the origins of primary care and the pressures currently faced in terms of patient expectation, regulation, accountability, and work force shortages. It recognises the appropriateness of adding to the burden in primary care further by the shift both of more services and more medical education from secondary care. Some conclusions are drawn concerning potential solutions including skill mix changes, centralisation of services, a change in attitudes to professional mistakes, increased protected development time, evidence based education, and academic, leadership, and feedback skills for general practitioners. Six recommendations are offered as a prescription for organisational and educational change.
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Affiliation(s)
- J Lord
- School of Human and Health Sciences, Harold Wilson Building, University of Huddersfield, Huddersfield, West Yorkshire HD1 3DH, UK.
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243
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Eijkelberg IMJG, Spreeuwenberg C, Wolffenbuttel BHR, van Wilderen LJGP, Mur-Veeman IM. Nurse-led shared care diabetes projects: lessons from the nurses' viewpoint. Health Policy 2003; 66:11-27. [PMID: 14499163 DOI: 10.1016/s0168-8510(03)00041-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
This paper explores the experiences of four nurse practitioners specialised in diabetes care, in the development and implementation of two Dutch nurse-led shared care projects to improve quality of care. The focus is on the impeding factors involved. The nurses' views are compared to those of the 38 participating physicians by using instruments of qualitative research. Both nurses and physicians consider the way shared care delivery has been structured as the most impeding factor, particularly downward substitution of care from doctor to nurse. In the end, lessons are drawn for nurses, doctors and managers, to solve the assessed impediments to shared care.
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Affiliation(s)
- Irmgard M J G Eijkelberg
- Faculty of Health Sciences, Department of Health Organisation, Policy and Economics, University of Maastricht, P.O. Box 616, 6200 MD, Maastricht, The Netherlands.
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Abstract
BACKGROUND Nurse-managed clinics (NMCs) have been in existence for over 30 years. Evaluation of such clinics has been sparse and most have used entirely quantitative techniques. This article explores the importance of evaluation of NMCs using the Mana Health Clinic in Auckland, New Zealand as an example. DISCUSSION Fourth generation evaluation is offered as an appropriate methodology for undertaking evaluation of NMCs. Fourth generation evaluation actively seeks involvement of clients in the process and outcome of the evaluation, resulting in participation and empowerment of stakeholders in the service - a precept often forgotten in traditional evaluation strategies and of vital importance in understanding why people use NMCs. The method proposed here also incorporates the need for quantitative data. CONCLUSION The main argument proposed here is that a combination of qualitative and quantitative data sources is likely to give the greatest understanding of NMCs utilization. Evaluation of NMCs is vital to the continuation of this type of health service. However, evaluation must be appropriate to the service being studied. Fourth generation evaluation used to elicit client's perceptions of the clinic along with quantitative data is offered as an appropriate means of achieving this.
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Affiliation(s)
- Jill M Clendon
- School of Health Sciences, Massey University at Albany, North Shore Mail Centre, Auckland, New Zealand.
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245
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Carnwell R, Daly WM. Advanced nursing practitioners in primary care settings: an exploration of the developing roles. J Clin Nurs 2003; 12:630-42. [PMID: 12919209 DOI: 10.1046/j.1365-2702.2003.00787.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Recent health care policies have resulted in patients having access to an integrated system of care that is quick and reliable. In concert with these changes, opportunities for professional development in nursing have increased, together with a reduction in the numbers of doctors. Advanced Nurse Practitioners (ANPs) have, therefore, developed to meet the complex demands of health care systems. This paper reports on a study that aimed to explore the current role of ANPs in primary care in the West Midlands region of the UK and how ANPs within three different nursing disciplines in primary care developed their roles over time. The study utilized a qualitative exploratory design incorporating a longitudinal element. Twenty-one ANPs were interviewed during phase one, 15 of whom were interviewed again during phase two, approximately 15 months later. Their managers (where appropriate) were also interviewed during phase one. The findings reveal that the nature and focus of practice varies between disciplines. At the extreme practice end of the practice-strategic continuum, Practice Nurse ANPs' expertise lies in their advanced practical assessment and diagnosis of individual patients, with little opportunity for strategic development. Health Visitor and District Nurse ANPs operate at the strategic end of the practice-strategic continuum, but operate differently at this level. Health Visitors, being community and public health focused are involved in multi-agency work, practice development and policy formulation. District Nurses work with individual patients/carers and the nursing team, thus their involvement in strategic developments tends to focus at the patient care level, such as protocol and practice developments, although their work also involves work in all three other domains. Overall, the findings reveal a unique role for all three with a potential career pathway for ANPs to become Nurse Consultants in the future.
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Affiliation(s)
- Ros Carnwell
- Health and Community Research, Centre for Health and Community Research, North East Wales Instiute, Mold Rd, Wrexham, UK.
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246
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Price A, Williams A. Primary care nurse practitioners and the interface with secondary care: a qualitative study of referral practice. J Interprof Care 2003; 17:239-50. [PMID: 12850875 DOI: 10.1080/1356182031000122861] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
In the United Kingdom nurse practitioners are assuming responsibilities traditionally considered to be within the domain of general practitioners. Important amongst these is the referral of patients to medical consultants in secondary care, a responsibility commonly associated with the general practitioner's role as 'gatekeeper' to health care. This paper describes a study designed to identify issues raised by the challenge that a developing nursing role presents to interprofessional working at the interface between primary and secondary care. When invited to comment, study participants (nurse practitioners, nurse educators, medical consultants and general practice registrars) related nursing referrals to issues associated with professional boundary changes, namely: teamwork, regulation of practice, communication, professional conflict and professional relationships. This paper discusses the views of primary and secondary care practitioners about who should take responsibility for the referral of patients in the light of concerns raised about professional competence and accountability. Individual nurse practitioners and their colleagues have found pragmatic ways to manage their work however, although UK government policy supports development of advanced clinical nursing, there remains much work to be done to provide the professional and legal infrastructure to support the role.
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Affiliation(s)
- Anne Price
- The Ashgrove Surgery, Pontypridd, Mid Glamorgan, University of Wales Swansea, Swansea, UK.
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Krasuski RA, Wang A, Ross C, Bolles JF, Moloney EL, Kelly LP, Harrison JK, Bashore TM, Sketch MH. Trained and supervised physician assistants can safely perform diagnostic cardiac catheterization with coronary angiography. Catheter Cardiovasc Interv 2003; 59:157-60. [PMID: 12772231 DOI: 10.1002/ccd.10491] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Using a prospectively collected database of patients undergoing cardiac catheterization, we sought to compare the outcomes of procedures performed by supervised physician assistants (PAs) with those performed by supervised cardiology fellows-in-training. Outcome measures included procedural length, fluoroscopy use, volume of contrast media, and complications including myocardial infarction, stroke, arrhythmia requiring defibrillation or pacemaker placement, pulmonary edema requiring intubation, and vascular complications. Class 3 and 4 congestive heart failure was more common in patients who underwent procedures by fellows compared with those undergoing procedures by PAs (P = 0.001). PA cases tended to be slightly faster (P = 0.05) with less fluoroscopic time (P < 0.001). The incidence of major complications within 24 hr of the procedure was similar between the two groups (0.54% in PA cases and 0.58% in fellow cases). Under the supervision of experienced attending cardiologists, trained PAs can perform diagnostic cardiac catheterization, including coronary angiography, with complication rates similar to those of cardiology fellows-in-training.
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Affiliation(s)
- Richard A Krasuski
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina 27710, USA
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248
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Miles K, Penny N, Power R, Mercey D. Comparing doctor- and nurse-led care in a sexual health clinic: patient satisfaction questionnaire. J Adv Nurs 2003; 42:64-72. [PMID: 12641813 DOI: 10.1046/j.1365-2648.2003.02580.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND A new model of comprehensive care nurse-led clinics has enabled experienced genitourinary medicine nurses to co-ordinate the first-line, comprehensive care of female patients presenting with sexually transmitted infections and other sexual health conditions and issues. AIM This paper describes the development of a patient satisfaction questionnaire to compare the satisfaction of women attending nurse-led or doctor-led clinics at a central London genitourinary medicine clinic. METHODS A previously validated questionnaire was adapted using the findings of qualitative interviews exploring patient expectations of the service. The draft questionnaire was tested for internal consistency, sub-scale homogeneity, construct validity and stability. The final version consisted of a 34 item, five-point Likert scale, which was found to be both reliable (Cronbach's alpha 0.91) and stable (test-retest 0.95). There was some evidence of construct validity. The questionnaire was then distributed to a convenience sample of 132 women attending a nurse-led clinic and 150 seen at a doctor-led clinic. RESULTS There was a 90% response rate. The median total satisfaction scores, out of a total of five, were 4.47 and 4.30 for the nurse-led and doctor-led groups, respectively (P = 0.05). Significantly higher scores on the sub-scales measuring quality and competence of technical care (P < 0.001), provision of information (P = 0.01) and overall satisfaction (P = 0.01) were seen for the nurse-led group. No significant differences were found in the sub-scales measuring service attributes and specific attributes of interpersonal relationships. CONCLUSION The rigorous development, piloting and testing phases of this satisfaction questionnaire led to reliable and valid results. This study demonstrated that nurse-led clinics within this service are an acceptable alternative to the existing doctor-led clinics.
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Affiliation(s)
- Kevin Miles
- Mortimer Market Centre, Camden Primary Care Trust, London, UK.
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Sakr M, Kendall R, Angus J, Sanders A, Nicholl J, Wardrope J, Saunders A. Emergency nurse practitioners: a three part study in clinical and cost effectiveness. Emerg Med J 2003; 20:158-63. [PMID: 12642530 PMCID: PMC1726060 DOI: 10.1136/emj.20.2.158] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIMS To compare the clinical effectiveness and costs of minor injury services provided by nurse practitioners with minor injury care provided by an accident and emergency (A&E) department. METHODS A three part prospective study in a city where an A&E department was closing and being replaced by a nurse led minor injury unit (MIU). The first part of the study took a sample of patients attending the A&E department. The second part of the study was a sample of patients from a nurse led MIU that had replaced the A&E department. In each of these samples the clinical effectiveness was judged by comparing the "gold standard" of a research assessment with the clinical assessment. Primary outcome measures were the number of errors in clinical assessment, treatment, and disposal. The third part of the study used routine data whose collection had been prospectively configured to assess the costs and cost consequences of both models of care. RESULTS The minor injury unit produced a safe service where the total package of care was equal to or in some cases better than the A&E care. Significant process errors were made in 191 of 1447 (13.2%) patients treated by medical staff in the A&E department and 126 of 1313 (9.6%) of patients treated by nurse practitioners in the MIU. Very significant errors were rare (one error). Waiting times were much better at the MIU (mean MIU 19 minutes, A&E department 56.4 minutes). The revenue costs were greater in the MIU (MIU pound 41.1, A&E department pound 40.01) and there was a great difference in the rates of follow up and with the nurses referring 47% of patients for follow up and the A&E department referring only 27%. Thus the costs and cost consequences were greater for MIU care compared with A&E care (MIU pound 12.7 per minor injury case, A&E department pound 9.66 per minor injury case). CONCLUSION A nurse practitioner minor injury service can provide a safe and effective service for the treatment of minor injury. However, the costs of such a service are greater and there seems to be an increased use of outpatient services.
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Affiliation(s)
- M Sakr
- Accident and Emergency Department, Northern General Hospital, Herries Road, Sheffield S5 7AU, UK
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Daly WM, Carnwell R. Nursing roles and levels of practice: a framework for differentiating between elementary, specialist and advancing nursing practice. J Clin Nurs 2003; 12:158-67. [PMID: 12603547 DOI: 10.1046/j.1365-2702.2003.00690.x] [Citation(s) in RCA: 172] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The recent profusion of new nursing roles in the UK has led to much confusion in the minds of health care consumers, employers, nursing practitioners and educationalists regarding the meaning, scope of practice, preparation for, and expectations of such roles. Titles such as Clinical Nurse Specialist (CNS), Nurse Practitioner (NP), Advanced Nurse Practitioner (ANP), Higher Level Practitioner (HLP) and more recently Nurse Consultant (NC) are being adopted in a variety of care settings with little understanding or consensus as to the nature of or differences between such roles. Further, the former United Kingdom Central Council for Nursing, Midwifery and Health Visiting (1992) initiative for extending the scope of professional practice allows for the prospect that nurses can adopt additional clinical tasks or alter the nature of service provision provided that they acquire the appropriate education or training, levels of competence and are prepared to be accountable for their new practices. Consequently, nursing practice is becoming more diverse than ever before and the boundaries of inter- and intraprofessional practices are becoming increasingly blurred. The UKCC (1999a) has recently contributed to an understanding of the levels of clinical practice undertaken at the specialist level but the situation at advanced or consultant levels remains unclear.
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Affiliation(s)
- William M Daly
- Secondary Care Nursing Research, School of Health, University of Wolverhampton, Walsall Campus, West Midlands, UK.
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