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

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

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

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

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

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

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

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

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

Objectives

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

Methods

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

Results

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

Conclusions

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

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

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

SETTING & PARTICIPANTS

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

RESULTS

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

CONCLUSION

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

Quality of care for individuals with osteoarthritis: a longitudinal study

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

METHOD

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

FINDINGS

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

CONCLUSION

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

Nurse prescribing from the community nurse's perspective

Background

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

Objective

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

Methods

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

Key findings

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

Conclusions

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

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

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

Colorectal cancer patients' attitudes towards involvement in decision making

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

AIMS AND OBJECTIVES

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

BACKGROUND

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

DESIGN

A narrative literature review.

METHODS

Thirty five papers were reviewed after searching electronic databases.

RESULTS

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

CONCLUSIONS

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

RELEVANCE TO CLINICAL PRACTICE

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

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

AIMS

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

BACKGROUND

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

DESIGN

Systematic review.

METHODS

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

RESULTS

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

CONCLUSION

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

RELEVANCE TO CLINICAL PRACTICE

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

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Quality of care for people with osteoarthritis: a qualitative study

AIM

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

RELEVANCE TO CLINICAL PRACTICE

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

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

AIM

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHOD

National postal survey of 2252 Macmillan nurses in the UK.

RESULTS

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

CONCLUSIONS

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

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

AIM

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

BACKGROUND

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

DESIGN

A qualitative exploratory study.

METHODS

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

RESULTS

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

CONCLUSION

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

RELEVANCE TO CLINICAL PRACTICE

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

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

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

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

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

At home in hospital? Interaction and stigma in people affected by cancer

Social research conducted in cancer hospitals has tended to focus on interaction between patients and staff, and studies of interaction amongst people with cancer often centre on group therapy and patient-patient support mediated by health professionals. Informal interaction between patients and fellow patients, and their carers/visitors, occurs in cancer hospitals every day but has remained largely unanalysed, particularly in the case of visitors. In this paper, based on data from 71 in-depth interviews, we compare patient and carer perceptions of interacting with fellow patients/visitors in a cancer centre with their perceptions of interacting in the outside world. We apply Erving Goffman's theories on stigma to the data and argue that these theories have both relevance and currency. The outside world can be seen as a 'civil place' where people with cancer often encountered difficulties such as undue admiration, uneasiness, avoidance and lack of tact, whereas the cancer centre appears to have been a 'back place' where, for most patients, stigmatisation was not an issue, and they could 'get on with it' in the company of fellow patients and their visitors. However, some groups of patients experienced social isolation in the hospital or seemed to be assigned to the lower strata of cancer patient society. We conclude that patients who are outside the informal support system in cancer hospitals may have psychosocial difficulties that might be recognised and addressed by healthcare staff, and that patients and their carers might benefit from enhanced support following discharge from hospital.

Exploring the decision-making preferences of people with colorectal cancer

OBJECTIVES

To explore patient views on participation in treatment, physical care and psychological care decisions and factors that facilitate and hinder patients from making decisions.

DESIGN

Qualitative study using semi-structured interviews with patients.

SETTING AND PARTICIPANTS

Three NHS Trusts in the north-west of England. Theoretical sampling including 41 patients who had been treated for colorectal cancer.

RESULTS

For patients, participation in the decision-making process was about being informed and feeling involved in the consultation process, whether patients actually made decisions or not. The perceived availability of treatment choices (surgery, radiotherapy, chemotherapy) was related to type of treatment. Factors that impacted on whether patients wanted to make decisions included a lack of information, a lack of medical knowledge and trust in medical expertise. Patients perceived that they could have a more participatory role in decisions related to physical and psychological care.

CONCLUSION

This study has implications for health professionals aiming to implement policy guidelines that promote patient participation and shared partnerships. Patients in this study wanted to be well informed and involved in the consultation process but did not necessarily want to use the information they received to make decisions. The presentation of choices and preferences for participation may be context specific and it cannot be assumed that patients who do not want to make decisions about one aspect of their care and treatment do not want to make decisions about other aspects of their care and treatment.

Follow-up in breast cancer clinics: reassuring for patients rather than detecting recurrence

Despite evidence that questions the value of routine hospital follow-up after treatment for breast cancer, there is little evidence to indicate what actually takes place during follow-up consultations and whether patients benefit from the experience. This study aimed to investigate the nature and content of hospital follow-up visits following treatment for breast cancer using a mixed methods approach. Methods included direct observation and audio-recording of 104 consultations, semi-structured interviews with 14 health care professionals (HCP) involved in follow-up service provision and a patient survey. Consultations were focused on detection of recurrent disease by clinical examination, despite this being a rare event. HCPs' style of interaction could foster the illusion that follow-up visits were intended to detect recurrence. Consultations were generally of brief duration (mean 6 min) and were overwhelmingly optimistic, although patients gained reassurance from minimal interaction. Few opportunities were available to meet information and psychosocial needs. The costly system of follow-up currently in operation is historically rather than evidence based, and subject to increasing demands and limited resources. Alternative approaches are needed that address the diversity of patients' needs rather than searching for recurrent disease. However, when formulating policy and evaluating new approaches, patients' expectations of what constitutes follow-up care need to be clearly addressed.

Everyday death: how do nurses cope with caring for dying people in hospital?

In the UK, policies on health recognise the importance of supporting healthcare professionals if they are to realise their potential for delivering quality services. Little is known about how nurses working in hospitals cope with caring for dying people and, hence how they might be best supported in this work. This paper reports a qualitative study informed by phenomenological philosophy, which developed a theory of how newly qualified nurses cope with caring for dying people in acute hospital medical wards. On the basis of the theory, interventions are proposed that could help support nurses in their work with dying people.

Changes in patterns of knowing the patient: the case of British district nurses

British district or home nurses, have until recent years been hidden from the wider context of the British National Health Service. Policy changes in UK over the last two decades of the 20th century have increasingly focussed on Primary Care Services and district nurses (DNs) have seen substantial changes to their workload. This paper addresses the question of how the changes in the organisation of Primary Care Services affected some aspects of DNs' work. Thus, the focus of this paper is an examination of the relationship DNs had with patients through a period of turbulent change. Knowing the patient is a central element of nursing practice. Data are presented here form a multi-site ethnographic study of DNs' work undertaken in four purposively sampled study sites. Applying Carper's (1978) framework, the data presented here show that there has been a shifting emphasis in knowing the patient from aesthetic and personal knowing to knowing about and empirical knowing.

Caring for dying people in hospital

BACKGROUND

Fifty-four per cent of people who die in England and Wales do so in hospital. Evidence suggests that care delivered to dying people in hospital does not match up to the ideal of a good death. These studies have provided organizational and structural explanations of nurses' behaviour that support argument for change at the macro level, in order to improve the quality of care delivered to dying people. There has been little study of the perceptions of nurses working in acute medical settings in relation to their experience of caring for dying people. Therefore, there is little evidence on which to base supportive strategies at the level of individual nurses.

AIM

In this study we set out to develop an understanding of care for dying people in hospital, from the perspective of newly qualified staff nurses in the UK. The purpose was to build a theory of how nurses might be helped to deliver quality care to dying people in hospital.

METHODS

This paper is based on an exploratory study underpinned by phenomenological philosophy. In-depth interviews were conducted with 28 newly qualified nurses, focusing on their experiences of caring for dying people on medical wards in two acute hospitals in England in 1999. The interview transcripts were interpreted using a phenomenological approach.

FINDINGS

The findings presented in this paper relate to commonalities found to underlie study participants' perceptions of their experiences. All the nurses' stories were found to be built around six essences - the personal ideal, the actual, the unknown, the alone, tension and anti-tension. These essences, and the relationships between them, were used to build a model of the experience of caring for dying people in hospital.

LIMITATIONS

This descriptive study of the experience of individual nurses does not examine the wider social context. It attempts to complement existing sociological theory of death and dying.

CONCLUSION

The study revealed how a group of newly qualified nurses experienced caring for dying people. We theorize that the model developed has utility as a tool for gaining understanding of the experience of caring for dying people. It is assumed that nurses, through using this model to find explanations for their emotions and behaviours, may gain emotional support that might have a positive impact on the quality of care delivered to dying people in hospital.

The role of district nursing: perspectives of cancer patients and their carers before and after hospital discharge

The role of the district nurse (DN) is difficult to define. Knowledge about the perspectives of patients with cancer, and their informal carers, on the roles of DNs and community services is lacking. The aim of this study is to identify the roles of DNs and community services as perceived by patients with cancer and their carers before and after hospital discharge. Seventy-one pre- and post-discharge conversational interviews were conducted with cancer patients and carers, and analysed thematically. Some interviewees lacked knowledge about services, were confused about differential roles and/or held stereotypical views. Some failed to disclose needs to services, received insufficient support or experienced unnecessary and inconvenient visits. Patients with few or no physical care needs were surprised to receive DN visits. Those receiving personal care from agency carers expressed dissatisfaction. Cancer patients and carers may benefit from post-discharge/ongoing assessment by DNs. However, effectiveness could be inhibited by limited disclosure caused by confusion, stereotyping, negative experiences and ideas that other patients have greater needs. Information might diminish these factors but, first, services need to clarify their roles. Organization and delivery of personal care services varies locally and DNs provide personal care during terminal illness. Community services should perform intra- and interservice clarification before publicizing differential roles to cancer patients and carers. This might facilitate disclosure of need to DNs. Patient and carer needs for information on service roles, and patients' preferred roles in self-care are under-researched.

Continuing care after cancer treatment

BACKGROUND

Despite nearly three decades of debate and policy guidance there is evidence that, in the United Kingdom, patient hospital discharge remains problematic. District nurses, who deliver skilled home nursing care, receive referrals from hospitals for continuing nursing care needs. However, district nurses' expectations of appropriate patient referral from hospitals are not always achieved. In an attempt to improve services after hospital discharge, government policy has emphasized partnership between care providers, highlighting the need for smooth transition between care settings.

AIM

To explore hospital discharge and referral procedures for patients with cancer, with particular emphasis on referrals made by hospital nurses to district nurses.

METHOD

In-depth interviews were carried out with nurses actively involved in the discharge process as both referrers and recipients of referrals. Twenty nurses from a regional cancer centre and 20 district nurses from three adjacent primary care trusts were interviewed. Interviews were transcribed and analysed thematically, and themes compared between the two care settings.

CONCLUSIONS

We conclude that competing sets of expectations, not only between hospital and community nursing settings, but amongst district nurses themselves, are a major factor impeding agreement on referral criteria and satisfaction with the referral process.

Vulnerability of family caregivers in terminal palliative care at home; balancing between burden and capacity

This paper reports on a grounded theory interview-based study with 13 family members aged 28-80 years caring for terminally ill people at home (with a life expectancy of 3 months or less) in the Netherlands. The project was approved by the ethics committee of the Maastricht University Hospital. The aim of this study was to explore the experiences of family caregivers, their needs for home care, and which health services they receive. Data were analysed using the constant comparative method. 'Vulnerability' was identified as the core category. Caring for a terminally ill person at home requires continuous balancing between care burden and capacity to cope. Whether or not the carer will succeed in keeping in optimum balance is dependent on a number of factors impinging on the caregiver's vulnerability. Care burden, restricted activities, fear, insecurity, loneliness, facing death, lack of emotional, practical and information-related support were identified from the data as factors having the potential to increase the caregiver's vulnerability, and may be risk factors for fatigue and burnout. Continuing previous activities, hope, keeping control, satisfaction and good support are factors which may decrease the caregiver's vulnerability, and may protect against fatigue and burnout. The experiences of the caregivers in our study showed that the support from informal and professional caregivers was not sufficient. Education and practical tools may make professionals more sensitive for the vulnerable position of family caregivers, even when these caregivers do not show their vulnerability.

Macmillan cancer and palliative care specialists: their practice development support needs

This study explores the practice development support needs of specialist nurses working in cancer and palliative care, in order to assist in the improvement of cancer and palliative care services. Using a whole population survey, postal questionnaires were sent to 1144 Macmillan post holders in England, Scotland and Wales. There was a 75.7% response rate. Three focus groups consisting of a total of 21 respondents were also used as a secondary form of data collection to supplement and expand upon the questionnaire responses. The findings reveal substantial practice development needs, particularly in relation to organizational support and guidance, education support, resources and access to evidence. The study demonstrates that nurses felt unable to engage in improving care unless initiatives were supported in practical ways by their organizations.

Patient and carer needs following a cancer-related hospital admission: the importance of referral to the district nursing service

BACKGROUND

Despite 30 years of research attention, discharge planning and district nurse (DN) referral remain problematic and few cancer-related publications exist. With shorter hospitalizations, discharged cancer patients and their carers may experience unmet needs for assessment, information and support. Although DN referral might enable patient/carer needs to be met, the DN role lacks clarity.

AIM

To investigate the needs of people with cancer, and their lay carers during discharge from hospital to home, and identify the role of DNs in meeting these needs.

METHOD

In this qualitative study, 71 pre- and postdischarge interviews were performed with cancer patients and (where possible) their carers. Predischarge interviews focused on expectations and postdischarge interviews on experiences of discharge and aftercare. Interview tapes were transcribed and analysed thematically.

RESULTS

Interviewees anticipated few aftercare needs during predischarge interviews but described met and unmet needs during postdischarge interviews. Unmet needs of those referred and not referred to the district nursing service were similar. Patients and carers had unmet needs for psychological support related to nutrition. Carers, especially those not resident with and not related to patients, had informational needs. Even very elderly, ill and isolated patients felt that other people had greater needs than their own and many thought that DNs only performed physical tasks.

CONCLUSION

All cancer patients discharged from hospital might be referred to a DN for ongoing assessment of needs. However, to ensure optimal results, the DN role needs to be clarified and public perceptions altered. Further research on psychological aspects of nutrition and the needs of carers not resident with/not related to patients is necessary.

Information and support needs of women with primary relatives with breast cancer: development of the Information and Support Needs Questionnaire

AIMS OF THE STUDY

The aim was to develop and pilot test a newly developed measure, The Information and Support Needs Questionnaire (ISNQ), for use with women with primary relatives with breast cancer.

BACKGROUND/RATIONALE

Breast cancer is a major risk to the health of women in the United Kingdom (UK). Increasingly, research is documenting women's needs for information and support, particularly at the time of diagnosis. However, to date there is little understanding of the information and support needs of women who have a family history of breast cancer. Contributing to the dearth of understanding of female relatives' needs is the lack of valid and reliable instruments for use in descriptive and intervention research with this population.

DESIGN/METHODS

The ISNQ and survey items documenting family history, sources of information and support for breast cancer risk, breast self-care practices, and other variables were pilot tested for the acceptability of the measures, appropriateness of the data collection methods, initial psychometric properties of the ISNQ, and time and financial costs of administration. Data were collected from 39 women living in the North-west of England who had primary relatives with breast cancer using mailed questionnaires and follow-up telephone interviews.

FINDINGS

The items on the ISNQ were reported to be clear, acceptable to women and to yield relevant data. The psychometric properties of the new measure were satisfactory with a high reliability coefficient alpha. Descriptive findings indicate that women had moderate to high needs for information and support, but reported that these needs were not well met.

CONCLUSIONS

The results of this pilot are guiding the development of a larger study in which the information and support needs of women with a family history of breast cancer are explored.

A descriptive study of meaning of illness in chronic renal disease

AIM

To explore the subjective meaning of illness in a sample of renal patients.

BACKGROUND

Patients' illness representations, such as the meaning they attach to illness, may affect their coping and adaptation. Improved understanding in this area may therefore benefit patient care. Meaning of illness has not previously been explored in renal disease.

DESIGN AND METHODS

Cross-sectional survey (n=405) in a single regional renal unit in the North of England. Ethical approval was obtained and patients gave written consent. The instrument used was an eight-item schema, based on the work of Lipowski (1970, Psychiatry in Medicine 1, 91-102). Field notes regarding rationale for choice were recorded concurrently, then content analysed to enable identification of themes. The chi-square test (significance level P < 0.05) was used to analyse differences in selected meaning in older and younger patients; males and females; and patient groups (predialysis, haemodialysis and transplant).

FINDINGS

'Challenge' was selected by most patients (n=253, 62.5%), with similar results in all three patient groups. Slightly more older than younger patients selected 'challenge', although the difference was not statistically significant and older patients more commonly had a fatalistic interpretation of the option. More men selected 'challenge' than women. Those selecting 'challenge' and 'value' appeared to have a more positive outlook than other patients.

CONCLUSIONS

Patients had identifiable meanings for their illness, and these may be associated with their response to renal disease. The schema appeared to be comprehensive, but is in need of further refinement. Consideration of the possible influence of social desirability is necessary.

Protecting children: intuition and awareness in the work of health visitors

Protecting children: intuition and awareness in the work of health visitors This paper is based upon an ethnographic study of a group of health visitors engaged in child protection work. The purpose of this paper is to explore the meanings individual health visitors attach to events concerned with identifying children who may be at risk of harm from child abuse, and also the idiosyncratic nature of health visiting in this complex but everyday social situation. The paper focuses on understanding the importance of a particular form of knowledge which the health visitors referred to as 'intuitive awareness'.

Community nurses' perceptions of patient 'compliance' in wound care: a discourse analysis

As part of an interview study of community nurses' perceptions of their work, 62 staff working within the district nursing service in one English National Health Service Trust (grades B-H) were asked to recount occasions when they had been involved in wound care and to discuss the ways in which working with patients who required such care could be either enhanced or made difficult. A large number of respondents expressed the view that non-compliance could pose serious problems for the management of wounds. Data relating to compliance are presented here and are interpreted in the light of discourse analysis, an approach which permits the researcher to focus on the meanings underlying the communications of research participants and to interpret those meanings in the light of social and cultural mores and influences. The authors found that non-compliance could be explained by nurses in a number of different ways. These ranged from passive resistance, which could be due to ignorance or lack of motivation, through overt refusal, to deliberate interference in order to prolong treatment. It also seeks to outline some of the factors that appear to motivate the nurses' desire to achieve compliance.

Primary care services received during terminal illness

The World Health Organization (1990) provides guidelines on what constitutes effective palliative care. However, it remains unclear whether people with a terminal illness living in their own homes have access to the services they need. This article reports on a study carried out in the United Kingdom on the views of people with a terminal illness (n = 15), their lay carers (n = 10) and bereaved carers (n = 19). Participants were asked about the primary care services they had received and their views on both helpful and unhelpful aspects of service provision. All terminally ill people in the study (except one) had cancer, which raises questions about access to palliative care services for non-cancer populations. Participants had contact primarily with district nurses, general practitioners and Macmillan nurses (specialist nurses). Few other services were received. A number of important issues arose from the data, indicating that lay carers in particular were not always receiving the information and support they needed in order to be effective caregivers.

The importance of 'knowing the patient': community nurses' constructions of quality in providing palliative care

This paper reports findings from a study conducted in one community health care trust where 62 members of the district nursing team (grades B-H) were interviewed. An adaptation of the critical incident technique was used to determine factors which contributed or detracted from high quality care for a number of key areas including palliative care. The centrality of knowing the patient and his/her family emerged as an essential antecedent to the provision of high quality palliative care. Factors enabling the formation of positive relationships were given prominence in descriptions of ideal care. Strategies used to achieve this included establishing early contact with the patient and family, ensuring continuity of care, spending time with the patient and providing more than the physical aspects of care. The characteristics described by the community nurses are similar to those advocated in 'new nursing' which identifies the uniqueness of patient needs, and where the nurse-patient relationship is objectified as the vehicle through which therapeutic nursing can be delivered. The link with 'new nursing' emerges at an interesting time for community nurses. The past decade has seen many changes in the way that community nursing services are configured. The work of the district nursing service has been redefined, making the ideals of new nursing, for example holism, less achievable than they were a decade ago. This study reiterates the view that palliative care is one aspect of district nursing work that is universally valued as it lends itself to being an exemplar of excellence in terms of the potential for realizing the ideals of nursing practice. This is of increasing importance in the context of changes that militate against this ideal.

Wound care in the community setting: clinical decision making in context

Sixty-two community nurses in northern England of grades B and D to H were interviewed by a team of four researchers. The interviews were semi-structured, and were tape-recorded, fully transcribed and content analysed. They were conducted as part of a larger study, the aim of which was to examine community nurses' perceptions of quality in nursing care. One of the main themes the work focused on was decision-making as an element of quality. Data relating to wound care were considered from the perspective of the insights they offered into clinical decision-making. Data were interpreted in the light of a literature review in which a distinction had been made between theories which represented clinical decision-making as a linear or staged process and those which represented it as intuitive. Within the former category, three sub-categories were suggested: theorists could be divided into 'pragmatists', 'systematisers' and those who advocated 'diagnostic reasoning'. The interpretation of the data suggested that the clinical decisions made by community nurses in the area of wound care appeared largely intuitive, yet were also closely related to 'diagnostic reasoning'. They were furthermore based on a range of sources of information and justified by a number of different types of rationale.

Decision-making role preferences and information needs: a comparison of colorectal and breast cancer

OBJECTIVE: An exploratory study has been carried out to examine decision-making role preferences and information needs for a sample of people with colorectal cancer (n=48). The work replicated a larger study carried out for women with breast cancer (n=150), and this paper compares and contrasts findings for both disease groups. DESIGN: A cross-sectional design was employed, involving structured interviews. The main variables investigated were decision-making preference (using a decisional role preference card sort), perceived decisional role and information need (using an information needs questionnaire). RESULTS: The majority (78%) of the colorectal cancer patients preferred to play a passive role in decision making, in contrast to 52% of women with breast cancer in previous work. Eighty per cent of the colorectal sample and 61% of the women with breast cancer perceived that the doctor had made treatment decisions. Priority information needs for both groups related to cure, spread of disease and treatment options. CONCLUSIONS: The two most striking findings from the comparison between the two disease groups relate to the differences in decision-making role preferences and the similarities in information needs. The process of involving people with colorectal cancer in treatment decision making warrants further investigation. The similarity in information needs of the two disease groups has implications for health care professionals providing information to people with cancer.

Skills competency in nurse education: nurse managers' perceptions of diploma level preparation

This paper reports on part of a national study conducted between 1994 and 1996, the overall aim of which was to examine the 'fitness for purpose' of the Project 2000 nursing education reforms. The study used multiple methods of data collection, including an individual and group interview study of nurse managers (n = 132) and a national survey of Project 2000 diplomates and traditionally prepared registered nurses (n = 5417). Findings in relation to the managers' expectations and experiences of diplomates are presented. This includes views on the level of skills achievement and skills acquisition of diploma level education. The qualities of the diplomates are discussed and this includes those areas where the skills of the diplomates are felt to achieve what is required of the role. Also included is an exploration of those skills which the managers felt fell short of expectations. Managers raised the long-standing concerns of clinical skills and competencies and discussed these in relation to the changing health care environment and the relative roles of other health care workers. The conclusions highlight the need to identify what could be seen as the 'core skills' required of a registered nurse and the need to explore the environment in which the diplomate takes up first appointment.

Nurse-patient relationships: the context of nurse prescribing

Nurse prescribing was initiated in the United Kingdom in October 1994 in eight demonstration sites. The evaluation of this extension to the community nurses' role explored both economic and qualitative benefits to patients, carers, nurses and other health care professionals. In this paper the impact of nurse prescribing on patients is explored. Benefits experienced by patients are described along with the difficulties encountered. The patients' views regarding nurses as prescribers are also explored. Data were collected by means of interviews with patients/carers, the focus of which was to evaluate changes associated with nurse prescribing. Patients raised a number of issues associated with their relationship with nurses. Patients valued nurses for both their accessibility and approachability, which led them to discuss health issues which would not otherwise have been brought to the attention of the general practitioner. The arguments which support the incorporation of these qualities into an expanded nursing role are presented.

Students' knowledge of and attitudes towards primary health care

The aims of this study were to assess nursing students' knowledge of and attitudes towards primary health care using a newly developed Canadian instrument, the Primary Health Care Questionnaire (PHCQ). The instrument was refined for use in the UK prior to collecting data from 427 students in degree, Project 2000, health visitor and district nursing courses. Findings indicate that students in all programmes surveyed have been exposed to the concepts of primary health care. Students have acquired knowledge about primary health care and, generally, positive attitudes to the concepts. Significant differences were found between several student groups on both the knowledge and attitude measures. Although further psychometric evaluation of this new measure is recommended, the PHCQ shows promise as a valuable measure for use in assessing the move toward an increased emphasis on primary health care concepts in nursing education.