Integrated mental health care: practitioners' perspectives

OBJECTIVE: Integrated mental health care (IMHC) is a community-based model that considers the patient and informal carers to be the major contributors to stable recovery from severe mental health problems. This study investigates the implementation of IMHC by 35 New Zealand practitioners 1 year after being trained in the model. It also explores their experiences and perceptions regarding the model. METHOD: Quantitative and qualitative data were gathered by combining a questionnaire survey with in-depth interviews. RESULTS: Few of the trainees had been able to implement the model as much as they would have liked. A primary barrier to implementation was created by the resource constraints that impede most innovative community care initiatives even when demonstrated to be more cost-effective than traditional hospital-based approaches. Concerns particular to IMHC included issues relating to flexibility, time-intensiveness and applicability to New Zealand. Many practitioners found some of the specific intervention strategies and the clear overall structure of the model useful. Its psychosocial emphasis had a positive impact on many practitioners' beliefs about the causes and prognosis of severe mental health problems. CONCLUSIONS: Participants offer a range of recommendations as to how IMHC might be applied and adapted. Consultation with staff, consumers, families and Maori, as well as a strengthening of the psychosocial components, are recommended.     

Chronic debilitating fatigue in Irish general practice: a survey of general practitioners' experience

BACKGROUND: Doctors are called upon to treat chronic debilitating fatigue without the help of a protocol of care. AIMS: To estimate the incidence of chronic debilitating fatigue in Irish general practice, to obtain information on management strategy and outcome, to explore the attitudes of practitioners (GPs) towards the concept of a chronic fatigue syndrome (CFS), and to recruit practitioners to a prospective study of chronic fatigue in primary care. METHOD: A total of 200 names were selected from the database of the Irish College of General Practitioners (ICGP); 164 of these were eligible for the study. RESULTS: Altogether, 118 questionnaires were returned (72%). Ninety-two (78%) responders identified cases of chronic fatigue, giving an estimated 2.1 cases per practice and an incidence of 1 per 1000 population. All social classes were represented, with a male to female ratio of 1:2. Eleven disparate approaches to treatment were advocated. Many (38%) were dissatisfied with the quality of care delivered, and 45% seldom or hardly ever referred cases for specialist opinion. The majority (58%) accepted CFS as a distinct entity, 34% were undecided, and 8% rejected it. Forty-two (35%) GPs volunteered for a prospective study. CONCLUSION: Chronic fatigue is found in Irish general practice among patients of both sexes and all social classes. Doctors differ considerably in their management of patients and are dissatisfied with the quality of care they deliver. Many cases are not referred for specialist opinion. A prospective database is required to accurately assess the scale of this public health problem and to develop a protocol of care.     

Spiritual pain in dying people: the nurse's role

Spirituality is a vital aspect of health care, as it affects physical, psychological and social needs. In a dying person spiritual pain may preclude a peaceful death. Nurses are in an ideal position to assess, plan and provide care for those in spiritual pain. 'Being with' a person in spiritual pain is often more important than any intervention. Evaluation of relief from spiritual pain is often difficult but should be attempted.     

Assessment of medical care by elderly people: general satisfaction and physician quality

OBJECTIVE: To identify personal characteristics and factors related to health and patterns of healthcare utilization associated with the elderly people's satisfaction with medical care. DATA SOURCES/STUDY SETTING: Data from the 1991 Medicare Current Beneficiary Survey (MCBS) on 8,859 persons age 65 and over living in the community. STUDY DESIGN: Items reflecting general satisfaction with care and views of physician quality are examined and, based on factor analysis, grouped in dimensions of two (global quality, access) and three (technical skills, interpersonal manner, information-giving), respectively. The relationship of high levels of satisfaction in each dimension to personal characteristics of elderly people, and to measures of access and utilization, is assessed using logistic regression. PRINCIPAL FINDINGS: While satisfaction is high, with over 90 percent surveyed expressing some satisfaction, there is substantial variation with less likelihood of high satisfaction among those 80 or older, with less education and income and in poorer health. Longer waiting time at visits and less frequent visits are factors in lower satisfaction as well. A favorable perception of physician quality, especially regarding technical skills, appears to play a significant role in satisfaction with global quality of care. CONCLUSIONS: Studies of patient satisfaction in elderly people are rare. Some factors expected to be related to positive assessment based on earlier studies, were, e.g., better health and shorter waiting time, while others were not, e.g., increasing age. Elderly people appear to place greater importance on physician technical skills, as opposed to interpersonal dimensions, in assessing global quality. These findings suggest the need for a better understanding of how elderly people evaluate care and what they value in interactions with the healthcare system.     

General practitioners' opinions of continence care training

AIMS: To examine general practitioners' confidence in the diagnosis and management of urinary incontinence, to define their unmet continence training and educational needs, and to evaluate the current provision of continence care in general practice, including the role of practice nurses. METHODS: A pre-tested postal questionnaire was sent to 600 general practitioners throughout New Zealand to obtain information about their demography and training in incontinence management, their confidence in diagnosis and treatment, and their perceptions of met and unmet educational needs in continence care. They were also asked about current provision of continence promotion in their practice and their views on the role of practice nurses in caring for incontinent patients. Confidence data were recorded on five point scales and analysed using chi square tests. Cluster analysis was used to describe groups with different opinions on practice nurses' roles. RESULTS: The response rate from eligible contacts was 81.3%. Although most respondents provide continence care, only 2.6% offered special clinics for continence promotion. Fewer than half felt confident to diagnose the causes of incontinence. Confidence in managing incontinence in children was consistently lower than for other incontinence presentations. There was no difference by sex in confidence in caring for incontinent patients although female respondents were more likely to consider management of continence care part of a practice nurse's role (chi 2 = 47.5, p < 0.01) and to routinely ask well women about incontinence (chi 2 = 243.6, p < 0.01). Most respondents (71.9%) could not remember having had any formal training in the management of incontinence at either undergraduate or postgraduate level. Recall of postgraduate education was associated with greater levels of confidence in management of continence problems. There was general agreement that it was appropriate to include training in continence management in vocational and continuing medical education. CONCLUSION: A substantial proportion of general practitioners perceive a lack of adequate medical training in incontinence care at both undergraduate and postgraduate levels. There is a need for improved education for both general practitioners and practice nurses.     

A study of general practitioners' skin surgery in Canterbury

AIMS: To evaluate skin surgery done by general practitioners in Christchurch. METHODS: Twenty-eight general practitioners performing regular skin surgery were studied. Their clinical accuracy and completeness of excision was analysed. Skin lesions referred for specialist treatment were also studied. RESULTS: Three hundred and three lesions were sent to the laboratory for analysis by participating practitioners. Sixty-one malignancies were present comprising 29 basal cell carcinomas, 28 squamous cell carcinomas, three malignant melanomas and one cutaneous lymphoma. Nineteen of the 61 malignant lesions were incompletely excised. Twenty eight further lesions were referred to specialists for treatment. CONCLUSIONS: General practitioners in Canterbury perform more skin surgery and remove more malignant lesions than their British counterparts. Although the adequacy of their skin surgery is better than other groups studied overseas there is considerable room for improvement.     

An instrument for assessment of videotapes of general practitioners' performance

OBJECTIVES: To identify those important characteristics of doctors' and patients' behaviour that distinguish between "good" and "bad" consultations when viewed on videotape; to use these characteristics to develop a reliable instrument for assessing general practitioners' performance in their own consultations. DESIGN: Questionnaires completed by patients, general practitioner trainers, and general practitioner trainees. Reliability of draft instrument tested by general practitioner trainers. SETTING: All vocational training schemes for general practice in the Northern region of England. SUBJECTS: First stage: 76 patients in seven groups, 108 general practice trainers in 12 groups, and 122 general practice trainees in 10 groups. Second stage: 85 general practice trainers in 12 groups. MAIN OUTCOME MEASURES: Trainers' ratings of importance; alpha coefficients of draft instrument by trainee, group, and consultation. RESULTS: 6890 characteristics of good and bad consultations were consolidated into a draft assessment instrument consisting of 46 pairs of definitions separated by six point bipolar scales. Nine statement pairs given low importance ratings by trainers were eliminated, reducing the instrument to 37 statement pairs. To test reliability, general practitioner trainers used the instrument to assess three consultations. With the exception of one group of trainers, all alpha coefficients exceeded the acceptable level of 0.80. CONCLUSION: The instrument produced is reliable for assessing general practitioners' performance in their own consultations.     

Home care: addressing the needs of people living with AIDS and their caregivers

Home care has become an important community resource for the care of people living with AIDS (PLWA). Another important resource to maintaining PLWAs in the home environment is the availability of informal caregivers who are willing to provide support and assistance in the home setting. Because of the stressful nature of AIDS care, home care nurses must anticipate and address the needs of both PLWAs and their caregivers.     

Health care access of young people not attending school in precarious situations

The legislations of July 1992 and January 1993 and the decree of 27th March 1993 offer the possibility for medical care to all, including many young people who do not have any rights when they need urgent medical attention. This study covers the proposals of professionals from the Languedoc and Roussillon regions who are responsible for the social and professional insertion of young people and their rights of access to medical care. These professionals serve both as the principal means of access to medical aid for young people and as the main obstacles to this aid which occurs as a result of the interaction between professional occupational practice and the behaviour of the young people concerned. From this study the following conclusions were drawn: this legislation excludes alien young people in an illegal situation; the potential availability of these rights is limited by arbitrary decision in administration; the period of coverage of these rights is long and complex; the financial obstacle is real for all young people who do not have free access to medical aid; the obstacles resulting from social interactions are frequent; there are many holes in the institutional network.     

Issues of death and dying: the perspective of critical care nurses

A major shift in the care of terminally ill people, due to advances in technology, and the development of legislation regarding patient self-determination and autonomy, has occurred over recent years. Critical care nurses (CCNs) are involved daily in issues of death and dying and are very aware of the needs, fears and psychosocial issues of patients and their families. Professional associations see a legitimate role for nurses in assisting the dying to achieve a dignified death. For legislation, policies and guidelines surrounding end-of-life issues to be effective, and to assist nursing staff with these sensitive, often difficult concerns, it is important that data on the opinions and perspectives of CCNs be objectively obtained. In a study by the Department of Social and Preventive Medicine at the University of Queensland, questionnaires were sent to 1100 randomly sampled community members and almost 1200 health professionals (nurses, general practitioners and specialists), including 299 CCNs. The response rate of CCNs to a 30-page postal questionnaire was 79 per cent (n = 231), indicating those nurses' high levels of interest in and/or concern regarding this area. CCNs supported the use of advance directives, the appointment of proxies and the need for doctors and nurses to give sufficient medication to relieve pain, even if this hastened the death of the patient. In addition, CCNs, more than any other professional group, supported the right of the terminally ill patient to physician-assisted suicide or euthanasia, their responses being very similar to those of community members. CCNs clearly face issues which, from legal, medical and ethical viewpoints, cause them concern. In sharing their personal experiences, CCNs stressed the need for more communication between doctors and patients, as well as between doctors and nurses. In addition, CCNs saw a clear role for themselves as advocates for patients/families in the decision-making process.     

Special care units for people with Alzheimer's disease. Only for the privileged few?

The number of Special Care Units (SCUs) for people with Alzheimer's disease (AD) in nursing homes have increased dramatically in the past 10 years. Despite the rapid increase in number of SCUs and the concern that most SCUs report higher costs than traditional nursing home units where residents with AD are integrated with cognitively intact residents, the evaluation of costs has been largely unsystematic and noncomparative. Studies are urgently needed to assess comparative costs so that administrators and policy makers can make informed decisions. This article reviews studies that examine the costs of care in SCUs and presents cost-related data comparing the outcomes of care for residents with AD on a SCU and on traditional units in one long-term care setting.     

Assessing medical care of dying residents in nursing homes

A rational approach to hemodialysis access in the patient with renal failure requires an understanding of many factors. The initial approach to such patients and subsequent decisions have a significant impact on quality of life as well as the morbidity of access choices. Autogenous vascular access remains the gold standard in the care of these patients. Alternatives are less desirable but are necessary in an increasing number of situations. Careful thought before embarking on a procedure will provide better long-term function and preserve the patient's options for the future.     

The nurse as coach in care of the dying

Nurses' inability to articulate many aspects of their work leads to its invisibility, a problem compounded in home-based palliative care where the nurse's work is rarely seen by others. A staff development exercise was undertaken which aimed to assist specialist palliative care nurses to articulate their relationships with patients to members of the inter-disciplinary team. The process was specifically aimed at understanding patients' and families' refusals to receive psycho-social care from other team members. It explores, through four narrative vignettes, the tension between nursing and non-nursing roles when patients refuse non-nurse care. At the centre of this tension are the issues inherent in nursing roles which frequently sit at the boundaries of other health practitioners.     

Psychiatric disorders and medical care utilization among people in the general population who report fatigue

OBJECTIVE: To study the prevalence of fatigue in the general population and its association with psychiatric disorders, somatization, and medical utilization. SETTING: The public-use data tape from the 1984 National Institute of Mental Health Epidemiologic Catchment Area Study. PARTICIPANTS: Household sample of 18,571 subjects. INTERVENTIONS: Structured psychiatric interviews were reviewed to study the prevalence of complaints of current and lifetime fatigue and their relationship to selected psychiatric disorders. RESULTS: Fatigue has high current (6.7%) and lifetime (24.4%) prevalences in the general population. Medically unexplained fatigue also has high current (6.0%) and lifetime (15.5%) prevalences. When compared with those reporting no current fatigue, subjects who reported current (one-month) fatigue were significantly more likely to have experienced current and lifetime episodes of major depression, dysthymic disorder, panic disorder, and somatization disorder. They also had significantly higher mean numbers of lifetime and current DSM-III psychiatric diagnoses, medically unexplained physical symptoms (not just fatigue-related symptoms), and visits to health care providers than did patients without current episodes of fatigue. CONCLUSIONS: The high prevalence of fatigue in the general population appears to be significantly associated with increased lifetime and current risk for affective, anxiety, and somatoform disorders, as well as increased utilization of medical services. These data suggest that assessment of both medical and psychological health may be essential for the proper care of patients with fatigue.