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PubMed2001

Practice autonomy among primary care physician assistants: the predictive abilities of selected practice attributes.

The practice autonomy of primary care physician assistants (PAs) is of interest to those organizing, financing, and delivering health services. This study examined the predictive abilities of practice attributes with respect to multidimensional aspects of practice autonomy (clinical decision making and prescriptive authority) in primary care PAs. A sample of 225 practicing PAs was used to construct the 16-item Physician Assistant Autonomy of Practice Instrument (PAAPI), which includes three subscales, routine prescriptive authority, advanced prescriptive authority, and clinical decision making. All were used as dependent variables in multiple regression analyses. The most significant correlates of practice autonomy included years in practice as a PA, years in practice with supervising physician, annual income from practice, recognition as the exclusive primary care provider for patients, primary practice in a rural county, and primary employment setting (single-specialty group practice). More primary care PAs continue to be used in under-served rural areas and in managed care. Organizational structure of the work setting may influence these PAs' practice autonomy.

Adult↗

PubMed2000

Clinical practice: new challenges for the advanced practice nurse.

This report describes the challenges for advanced practice nurses (APNs) relative to supply and demand issues. The article also includes opportunities with the Balanced Budget Act, physician acceptance of Advanced Practice Nurses, and expanding practice opportunities. The challenges include the nursing shortage (both in nursing students and faculty), the aging of the nursing workforce, and a lag in nursing salaries; increased demand for nursing based on aging baby boomers, increasing patient acuity and technology, and new arenas for practice. The Balanced Budget Act of 1997 provided new opportunities for advanced practice nurses, including enhanced autonomy to provide services and bill independently of physicians. With these changes come new opportunities for advanced practice nurse entrepreneurs in the areas of independent practice, including opportunities to positively impact the health of families and communities in alignment with the Federal government's vision for "Healthy People 2010." As physician acceptance of advanced practice nurses continues to grow and in light of the changes in medical practice and education (residency reduction), opportunities to expand collaborative practice arrangements also exist. APNs are best suited to make the most of these changes. One example of an opportunity for independent practice, a Community Wellness Center, is developed as an entrepreneurial venture benefiting both the APN and the health of a community. Who better than registered nurses (RNs), especially those practicing at the advanced level, can ensure that these opportunities and challenges are addressed in an ethical manner and focused on the needs and health of the community?

Government Programs↗

PubMedDate not supplied

A practice change model for quality improvement in primary care practice.

Faced with a rapidly changing healthcare environment, primary care practices often have to change how they practice medicine. Yet change is difficult, and the process by which practice improvement can be understood and facilitated has not been well elucidated. Therefore, we developed a model of practice change using data from a quality improvement intervention that was successful in creating a sustainable practice improvement. A multidisciplinary team evaluated data from the Study To Enhance Prevention by Understanding Practice (STEP-UP), a randomized clinical trial conducted to improve the delivery of evidence-based preventive services in 79 northeastern Ohio practices. The team conducted comparative case-study analyses of high- and low-improvement practices to identify variables that are critical to the change process and to create a conceptual model for the change. The model depicts the critical elements for understanding and guiding practice change and emphasizes the importance of these elements' evolving interrelationships. These elements are (1) motivation of key stakeholders to achieve the target for change; (2) instrumental, personal, and interactive resources for change; (3) motivators outside the practice, including the larger healthcare environment and community; and (4) opportunities for change--that is, how key stakeholders understand the change options. Change is influenced by the complex interaction of factors inside and outside the practice. Interventions that are based on understanding the four key elements and their interrelationships can yield sustainable quality improvements in primary care practice.

Female↗

PubMed2001

The impact of practice setting on physician perceptions of the quality of practice and patient care in the managed care era.

BACKGROUND: Managed care is practiced in both traditional institutional health maintenance organization (HMO) settings and in a variety of complex and decentralized office-based arrangements. This study examines how practice setting affects physician perceptions of the quality of professional practice and patient care in a managed care environment. PARTICIPANTS AND METHODS: A survey was conducted in 1998 of 1081 physicians in San Mateo County, California, who practice in either a traditional staff group model HMO (SGM-HMO) (n = 113) or office-based independent practice (OBIP) (n = 250). Respondents were surveyed about current and past practice characteristics, income changes, current satisfaction with professional and patient care matters, utility of treatment guidelines and formularies, and general perceptions of managed care. Responses were compared between practice settings using bivariate comparisons and logistic regression analyses. RESULTS: Physicians in the SGM-HMO and those in OBIP reported similar hours worked per week, time spent with patients during office visits, and total patient encounters per week. Declining income was more frequent in OBIP (61% vs 47%) and relatively more substantial (27% with income declines >25% vs 4% in SGM-HMO). Adjusting for income changes, practice setting, years in practice, and sex, SGM-HMO physicians were significantly more satisfied with a variety of professional and quality of care issues (P<.001), viewed more favorably the utility of treatment guidelines and drug formularies (P<.001), and held more positive general perceptions of managed care (P<.001) than OBIP physicians. CONCLUSIONS: In a managed care environment, SGM-HMO physicians are significantly more satisfied with the quality of practice and patient care than physicians in OBIP. This study suggests that the myriad managed care contracts, formularies, and guidelines received by physicians in OBIPs may lead to more negative perceptions of the quality of professional practice and patient care.

Attitude of Health Personnel↗

PubMed2001

Continuous quality improvement in small general medical practices: the attitudes of general practitioners and other practice staff.

OBJECTIVES: Continuous quality improvement (CQI) offers opportunities to improve care in small-scale office-based practice. Little is yet known about the implementation of CQI in small primary care practices. We studied the attitudes of physicians and staff in small family practices to a model of CQI tailored to office-based practice setting. PRACTICES AND DESIGN: An exploratory study in 20 family practices in The Netherlands. Practices were stimulated to adopt the model for continuous quality improvement. MAIN OUTCOME MEASURES: The use of the model at the end of the study period, the perception of the physicians and staff of their success with adopting the model, their view of its usefulness, their willingness to continue and personal and practical obstacles. Measurements were made using written questionnaires. RESULTS: The rate of implementation of the model varied between practices. Participants rated their success in performing improvement projects, holding regular quality meetings and setting targets and priorities. They were positive about the usefulness of the model and they were generally willing to continue to use it. Barriers included the size of workload and the tendency to postpone actions until external support by an outreach visitor was provided. Physician and staff attitudes were homogeneous at a practice level. CONCLUSION: Our findings stress the importance of starting CQI with small, easy-to-handle projects. Workload reduction might be an important issue to focus on. Personal obstacles should be addressed throughout the introduction. We found attitudes in small-scale practices to be homogeneous, so that it was important to pay explicit attention to commitment to CQI from the start of the introduction.

Attitude of Health Personnel↗

PubMed1994

Towards better practice management: a national survey of Scottish general practice management.

Surveys a 50 per cent sample of Scottish practices (stratified by health board area), concerning whether they had a practice manager and who had responsibility for practice management tasks. The overall response rate was 73 per cent, with 63 per cent of responding practices employed a practice manager. Reports the findings from practices employing a manager, and reveals marked variations in levels of managers pay and responsibility. The development of practice management structures varied with only 85 per cent of practices holding regular practice management meetings. The results suggest that practices which previously coped without a manager have recognized the need for one as the complexity of practice administration increases and that the traditional career path of managers involving internal promotion is changing.

Administrative Personnel↗

PubMed1996

Understanding practice management: a qualitative study in general practice.

Reports a qualitative study of practice managers' roles and responsibilities in eight practices in the Grampian region of Scotland. Observes wide variations in the roles and responsibilities of managers associated with the size and fundholding status of the practice. Notes that larger practices had better developed management structures allowing the managers to delegate tasks and undertake a more proactive planning and executive role, and that medium and smaller practices had less well developed management structures and managers were more likely to act as practice administrators with limited autonomy. Concludes that practice managers are playing an increasingly important role in general practice. Also that the influential role of the practice manager in the development of practice policies and the transfer of administrative responsibilities from the partners to the manager have all contributed to a change in general practitioners' perceptions of the practice manager.

Administrative Personnel↗

PubMed2002

A comparison of research general practices and their patients with other practices--a cross-sectional survey in Trent.

BACKGROUND: When interpreting results of studies undertaken by research networks we need to know how representative volunteer practices and their registered patients are of the total population of practices and patients in their locality. AIM: To compare the following in research and non-research general practices in one region: practice and population demography, morbidity and mortality, selected performance indicators, and health outcomes. DESIGN OF STUDY: Cross-sectional survey. SETTING: Sixty-six Trent Focus Collaborative Research Network general practices and 749 other general practices in Trent, United Kingdom. METHOD: Practice characteristics and GP contract data were obtained from the NHS Executive, Quarry House, Leeds. The Trent Regional NHS Hospital Admission Database was searched to identify all relevant admissions to hospital from all practices between 1 April 1993 and 31 March 1997. Ward-linked data on cancer were obtained from the Trent Cancer Registry. RESULTS: Of the 815 general practices in Trent Region in the study period, 66 (8%) were in the Trent Focus network. They were more likely to be involved in training GPs and to have a female partner. They tended to be larger, with fewer single-handed doctors and younger GPs. Network practices prescribed a higher proportion of generics (median % prescribed/practice = 70%, versus 51%, Mann-Whitney U = 1615, P<0.0001). There were no clinically important differences between hospital admission rates between the two groups or waiting times for surgical procedures. There was no difference in the incidence of cancer and standardised mortality ratios related to the electoral wards of the GP surgery. CONCLUSION: Although there were differences in practice structure and some aspects of performance, we found no important differences in the demography of registered patients, nor in morbidity, mortality, or access to or use of secondary care.

Cross-Sectional Studies↗

PubMed2005

Perceptions and practice of concordance in nurses' prescribing consultations: findings from a national questionnaire survey and case studies of practice in England.

BACKGROUND: The number of nurses able to independently prescribe medicines in England is increasing. Patient adherence to prescribed medicines remains a significant problem [Department of Health, 2000. Pharmacy in the Future: Implementing the NHS Plan. A Programme for Pharmacy in the NHS. Stationary Office, London]. Concordance-a partnership approach to medicine consultations-is advocated as an effective solution [Medicines Partnership, 2003. Project Evaluation Toolkit. Medicines Partnership, London]. OBJECTIVES: To investigate whether nurses were practising the principles of concordance within their prescribing interactions. DESIGN: Phase (i) postal questionnaire survey. Phase (ii): case studies of practice. SETTINGS: Phase (i) primary and secondary care trusts throughout England in which nurse prescribers were practicing. Phase (ii) six general practice settings; one community midwifery service; one specialist community palliative care service; one secondary care ophthalmology unit; one NHS walk-in centre. PARTICIPANTS: Phase (i) a random sample of 246 nurses registered as independent nurse prescribers with the Nursing and Midwifery Council in 2002/2003. Phase (ii) purposively selected sample of 14 nurse prescribers who participated in Phase (i) of the study; a total of 208 purposively selected patients completed self-administered questionnaires. METHODS: Phase (i) postal questionnaires. Phase (ii) structured non-participant observation of 118 nurse prescribing consultations; 115 post-consultation patient questionnaires; 93-patient postal questionnaires. RESULTS: 99% of the nurses in the national survey stated they were practising the principles of concordance. The majority of patients surveyed also reported experiencing concordance in practice. Observation of practice revealed that although some principles of concordance were regularly integrated into nurses' practice, other principles were less often in evidence. Some evidence from both observation of practice and patient questionnaires suggested that a professionally determined 'compliance' agenda may still be partially operating in practice. CONCLUSIONS: Most nurses believe they are practicing concordance in their prescribing consultations. The majority of patients also reported that they had experienced some of the principles of concordance in practice. Observation of practice highlighted that the shift from a professionally determined compliance agenda to the integration of concordance into nurses' prescribing consultations had not yet taken place.

Attitude of Health Personnel↗

PubMed1996

Why don't all general practices offer structured diabetes care? A comparison of practices that do not with those that do.

The aim of the study was to examine whether the minority of practices not qualifying for payment for structured diabetes care programmes differ systematically from those that do. Information was collected for all Leicestershire general practices on practice size, population structure, deprivation indices, diabetes related admissions over two years and number of insulin treated patients on the district register. The 21 practices not offering structured diabetes care had a median list size of 3204, compared to 6340 for the other 124 practices (P < 0.001). Jarman and Townsend scores were higher for these practices and estimated prevalence of diabetes was 29% higher (95% CI: 26-32%). Crude admission rates were significantly higher in those practices not offering structured care. However rates adjusted for diabetes prevalence were similar (39.3 vs 39.2 per 100 insulin treated diabetics per year, P = 0.9). These results suggest that some practices face specific problems related both to small practice size and higher prevalence. If these issues are not addressed, inequalities in access to diabetes care between practice populations will persist. There is no evidence that the provision of structured care is associated with lower admission rates in this district. However more information, particularly in relation to prevalence of diabetes, is needed in order to accurately quantify this relationship. Variations in prevalence between practices should be adjusted for in any comparison of admission rates or spurious conclusions may be drawn.

Diabetes Mellitus↗

PubMed2000

Detection of psychological distress by practice nurses in general practice.

BACKGROUND: The general practitioner (GP) has traditionally been the first port of call for people with psychiatric morbidity but increasingly other members of the primary care team see the patients first, particularly practice nurses. The numbers and roles of practice nurses have expanded greatly over the past decade and it is important that practice nurses are able to recognize patients with psychiatric morbidity. This paper reports a study to determine the abilities of 24 practice nurses to detect psychiatric morbidity in patients attending their clinics. METHODS: Twenty-four practices were randomly selected from 41 practices recruited from South London and Kent. One nurse per practice took part in the study. Patients were asked to complete a 12-item General Health Questionnaire (GHQ-12) while waiting for their appointment with the practice nurse. Following their consultation, the practice nurse rated the patients' level of psychological distress on a five-point rating scale. RESULTS: The response rate of patients was 97% (N= 1710). The GHQ case rate was 36%. The mean detection rate by practice nurses when identifying significant distress was 16% (between nurse variation, 0% to 61%). The mean specificity was 96% (variation 77% to 100%). A second analysis, changing the nurse criterion to recognition of distress increased the mean sensitivity rate to 58% (variation 31% to 84%) but the mean specificity rate decreased to 66% (variation 26% to 95%). CONCLUSIONS: These results demonstrate that practice nurses' caseloads include a high proportion of patients with psychiatric morbidity and that agreement with the GHQ classification of psychiatric morbidity is modest. Therefore, training in detection will be crucial for the nurses.

Adolescent↗

PubMed2003

[Self-reported level of skills in practical procedures following internship in general practice].

BACKGROUND: Previous reports have demonstrated variable and partly insufficient skills in standard practical procedures among young doctors who have served their internship. The present study examines the development of interns' self-reported level of skills in practical procedures during internship in general practice in relation to quantity and quality of supervision, gender and the size of the community they served in. MATERIAL AND METHODS: Between 1996 and 1999, all doctors going through internships in Norway were asked to indicate their level of skills in 88 practical clinical procedures before and after internship in general practice. Of 575 interns asked, 439 replied (76 %). RESULTS: All interns reported a significant overall improvement in self-reported practical skills during internship in general practice. Supervision and feedback was also significantly better in general practice than in internships in hospital. INTERPRETATION: The quality of the general practice internship in Norway is superior to the quality of hospital training. Supervision and feedback is a standard part of the education of general practitioners and represents a valuable tradition. A combination of internship in hospitals and in general practice is necessary for acquiring adequate skills in practical procedures.

Adult↗

PubMed1993

General practice workload during normal working hours in training and non-training practices.

The aim of this study was to design and test a form to review workload in training and non-training practices. The study was conducted in the Oxford, Reading and Milton Keynes districts over a period of one week and involved 31 training and 21 non-training practices consisting of 156 and 66 doctors, respectively. Doctors in training practices (excluding trainees) spent a mean of one hour less per week in contact with their patients than doctors in non-training practices. Doctors in training practices spent approximately the same time per week on administration as those in non-training practices, one hour more in both meetings and non-practice work and almost two hours more in training and studying. The mean total practice workload per doctor in training practices was two hours more than in non-training practices and, when non-practice work was included, the difference increased to three hours. Compared with other doctors, trainees saw fewer patients in the surgery, in clinics and on visits, but spent more time on studying and training. This study produced broadly similar results to previous surveys, although doctors in the present study saw fewer patients each week and spent more time with each patient than in other studies.

Data Collection↗

PubMed1997

[The practice nurse in British Family practice. Lessons for Dutch experiments].

In the Netherlands, experiments are taking place in which nurses work in general practice with physicians. In the United Kingdom, so-called practice nurses have been working in general practice since the 1960's. In this article, the experiences in the United Kingdom with the practice nurse are outlined. The focus is on the lessons that can be learned from these experiences. In the United Kingdom, the majority of practice nurses are employed by general practitioners. The most important reason for introducing nurses into the general practice setting was to decrease the physicians' workload. The practice nurse in the United Kingdom has evolved from a 'cheap, task-oriented practice assistant' to a more or less autonomous colleague of the general practitioner. The practice nurses' activities vary greatly. Problems encountered in the United Kingdom primarily concern the lack of training, the absence of a clear definition of the function and responsibilities and the problems associated with working conditions which result from the employment contract with a specific general practitioner. The previously mentioned Dutch experiments show a great deal of variation in terms of the nurses' activities and their position within general practice. Consequently, the development of a clear definition of the function and an adequate training programme are also difficult in the Dutch situation. An additional point of consideration for the Dutch situation is the difference in tasks and responsibilities between the practice nurse and other nurses employed in primary care settings.

Clinical Competence↗

PubMed2003

Can surveying practitioners about their practices help identify priority clinical practice guideline topics?

BACKGROUND: Clinical practice guidelines are systematically developed statements designed to assist in patient and physician clinical decision making for specific clinical circumstances. In order to establish which guideline topics are priorities, practitioners were surveyed regarding their current practice. METHODS: One hundred ninety-seven practitioners in Ontario, Canada were mailed a survey exploring their current practice or opinion regarding the prophylactic use of anticonvulsant drugs in patients with malignant glioma who had never had a seizure. The survey consisted of seven questions regarding the relevance of a guideline on the subject to the practitioner's practice, the proportion of clinical cases involving anticonvulsant use, knowledge of existing guidelines on this topic, interest in reviewing a completed practice guideline and three clinical scenarios. RESULTS: There were 122 respondents who returned the survey (62% rate of return). Eighty percent of the practitioners who responded indicated that less than 25% of their clinical cases involved the use of anticonvulsants; however, only 16% of respondents indicated that a practice guideline would be irrelevant to their practice. Eighty percent of respondents volunteered to review a draft version of a practice guideline on the use of anticonvulsants. The survey presented the practitioners with three scenarios where anticonvulsants in patients with brain tumours may be appropriate: peri-operatively in patients without seizures, postoperatively in patients currently using anticonvulsants, and thirdly in patients not currently using anticonvulsants or undergoing surgery. In contrast to the third situation, the first two situations yielded considerable variation in practitioner response. CONCLUSION: The survey established that there is some variation present in the current practice of anticonvulsant use in the patients with brain tumours. Whether there is an optimal treatment practice has yet to be determined. Practitioners do seem to feel that a guideline on anticonvulsant use in warranted, and most practitioners would be interested in being part of the guideline development process.

Anticonvulsants↗

PubMed2003

Valuing both critical and creative thinking in clinical practice: narrowing the research-practice gap?

BACKGROUND: Nurturing critical thinking skills in the classroom is considered an important educational activity. It is believed that critical thinking skills are transferable and that they can be applied in practice when appraising, evaluating and implementing research. That more nurses than ever before have been judged academically knowledgeable in research has not guaranteed the transfer of such knowledge to practice. AIM OF THE PAPER: This paper discusses some of the reasons for the failure to narrow the gap between research and practice. In particular we argue that, if nurses are encouraged to develop creative and generative thinking alongside their critical thinking skills, then the art of nursing will have fuller representation in education, research and practice. DISCUSSION: The successful development of critical thinking skills for academic purposes does not necessarily mean that these skills are used in practice in relation either to research or clinical decision-making. This suggests that the transferability of critical thinking skills is less than straightforward. Indeed, there has been little narrowing of the research-practice gap since students started to learn critical thinking for academic purposes. However, we propose that thinking skills can be encouraged in the context of practice and that regular educational events, such as journal clubs, can contribute to developing critical thinking in the practice environment. CONCLUSIONS: The research-practice gap will reduce only if research becomes part of practitioners' ideology, which includes the art and science of nursing. Critical and creative thinking are prerequisites to narrowing the disjuncture between research and practice, and we suggest that educators and practitioners explore structured ways of meeting together to appraise literature as a possible means of making use of their thinking and knowledge in clinical practice.

Clinical Competence↗

PubMed2003

Family practice training over the first 26 years: a cross-sectional survey of graduates of the University of Washington Family Practice Residency Network.

PURPOSE: To describe the current practice setting, scope of practice, and adequacy of residency training of a large cohort of family practice (FP) residency graduates. METHOD: In February 2000, questionnaires containing 120 demographic, practice, and training items were mailed to 1,498 graduates (1973-1999) of the University of Washington Family Practice Residency Network. RESULTS: A total of 983 (71%) graduates completed the survey. Of the 870 who were currently practicing family physicians, 38% were women, 73% worked full-time, 45% practiced in FP groups, and 97% were board certified in FP. A total of 37% practiced in communities of fewer than 25,000 residents, and 29% practiced in federally designated health provider shortage sites. Most cared for their patients in the hospital: 79% for adult medical patients, 54% for adult ICU/CCU patients, and 71% for children. Most provided maternity care: 63% delivered babies and 58% assisted at cesarean sections (12% as primary surgeon). Even in cities of over 100,000, 58% delivered babies. Large numbers of responders performed colposcopy, flexible sigmoidoscopy, vasectomy, and minor surgery. A higher proportion of the most recent graduates provided maternity care and performed colposcopy. Most graduates reported that residency training prepared them well. CONCLUSIONS: FP residency training is modeled to prepare primary care physicians to meet the needs of all patients in all communities. These data document the success of this model in producing and sustaining family physicians to fulfill these roles in practice.

Cross-Sectional Studies↗

PubMed1998

Physician practice styles and patient outcomes: differences between family practice and general internal medicine.

OBJECTIVES: This study compared patient health status, patient satisfaction, and physician practice style between family practice and internal medicine. METHODS: New adult patients (n = 509) were prospectively and randomly assigned to family practice or internal medicine clinics at a university medical center and followed for 1 year of care. Practice styles were characterized by the Davis Observation Code. Self-reported health status (Medical Outcomes Study, Short Form-36) and patient satisfaction also were measured. RESULTS: There were no significantly different changes in self-reported health status or patient satisfaction between family practice and internal medicine physicians during the course of the study. Family practice initial encounters, however, were characterized by a style placing greater relative emphasis on health behavior and counseling, whereas internists used a more technical style. Improved health status scores after treatment were predicted by a practice style emphasis on counseling, whereas improvements in patient satisfaction scores were predicted by a style of care stressing patient activation. Although this is the first known randomized trial studying this issue, the conclusions are limited by a 38% loss of patients from enrollment to care and a loss of 18% at the 1-year follow-up evaluation. CONCLUSIONS: There were significant differences in practice styles between family physicians and internists; however, it was the physician's behavior, not specialty per se, that affected patient outcomes. A practice style emphasizing psychosocial aspects of care was predictive of improvements in patient health status, whereas a practice style emphasizing patient activation was predictive of improvements in patient satisfaction.

Adult↗