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PubMed2004

A framework for understanding clinical reasoning in community nursing.

BACKGROUND: Clinical reasoning is employed to develop solutions to health needs. The impact of the clinical environment on the organization of knowledge-guiding practice has received limited attention. This gap in the clinical landscape restricts the sharing of decision-making processes. AIMS: Focusing on the community, and specifically the patient's home as a context for nursing, this paper describes the creation of a collective conceptual map for a group of community nurses. There is a twofold aim of exploring the process of exposing and articulating the clinical framework and enhancing and sharing understanding of the clinical paradigm in this context. DESIGN: An interpretive research approach was utilized. Hermeneutic phenomenology guided the level of meaning accessed and constructivism was used to build an educational picture. METHODS: Multiple methods including focus groups, observation and narrative recordings were utilized to collect and analyse research data. RESULTS: All nurses may engage with the same concepts--health, need, care and partnerships--but organized into particular frames by the guiding practice philosophy and service organization. A four-stage framework for understanding clinical reasoning in the community setting is presented. This acknowledges the multi-faceted nature of health, the lived experience of health deficits, and is located in a participation and negotiated model of care. Practice examples are presented to expose the construction of need and response which often occurs in a triadic decision-making process. CONCLUSIONS: Environment of care has significant implications on need identification and response. RELEVANCE TO CLINICAL PRACTICE: Mechanisms to enhance the sharing of clinical reasoning and decision-making transparency are essential to aid inter- and intra-professional communication. Presentation of a clinical reasoning framework exposes the breath of 'signals' encountered in practice and the range of knowledge employed in understanding and responding to patient need.

Community Health Nursing↗

PubMed1989

Surveying optometry school alumni: a multifaceted approach.

Surveying alumni of a college of optometry provides vital information on the effectiveness of academic and clinical programs which prepare students for the practice of optometry and for advancement of the profession. This University of Houston College of Optometry (UHCO) alumni study took a multifaceted approach, asking graduates of recent years--1984, 1985, 1986--to evaluate program areas and to tell how they practiced in the first years out. Although most young optometrists worked for someone else in the year after graduation, within 2 years, two-thirds of men and women were self-employed and located primarily in urban/suburban areas. A striking finding was the difference in type of practice entered by women and men: women far more often entered solo practice or, if employed, worked for a health maintenance organization (HMO), while men more often entered partnerships or worked for another optometrist. And, women reported much lower incomes than men regardless of type of practice. These differences merit attention, as does the familiar finding that alumni, although satisfied with their optometric training overall, rated their training in practice management most inadequate.

Education, Medical↗

PubMed1993

Preparing for parent-held child health records.

On 1 October 1992 health visitors in the Portsmouth and South Hampshire health district introduced parent-held child health records. The following reports by key participants in this major change in health visiting practice underline the importance of training to prepare staff for the challenge. Partnership between field staff and management is key if the principles of openness and trust underlying the concept of the parent-held record are to be implemented in practice.

Child↗

PubMedDate not supplied

Community development through faculty practice in a rural nurse-managed clinic.

This article describes a community-academic partnership that led to the development of a nurse-managed clinic (NMC) in 1996 in a rural Indiana area designated by the state as a medically underserved area (MUA) and a health professional shortage area (HPSA). Application of the community development model in faculty practice is described in relation to the clinic. The project is ongoing; lessons learned to date, which have implications for others involved in faculty practice, are described.

Community Health Centers↗

PubMed1986

Physician-hospital joint venture addresses mutual needs.

Establishing a system of family practice clinics with physicians from its medical staff enabled Mercy Hospital Medical Center, Des Moines, IA, not only to meet consumers' changing needs and wants but also to develop a long-term strategy for survival. The joint venture, which has grown to 9 clinics and 30 physicians since its inception in 1983, does not restrict the hospital from entering into similar relationships with other physician groups. Neither does it restrict physicians from entering new arrangements or using other hospitals. Each clinic operates quasi-autonomously in serving its own patients, and issues such as hiring, firing, hours of operation, and local public relations are handled in a decentralized manner. Other matters--insurance coverage, marketing programs, accounting and data processing systems--are standardized throughout the organization. Challenges involved in undertaking such a project include overcoming resistance from employees, building public awareness of the project, and creating an open, trusting relationship between physicians and administrators. It is particularly important to foster the support of physicians "outside" the partnership and to include those who remain in private practice in marketing efforts.

Family Practice↗

PubMed2000

From theory to practice: community health nursing in a public health neighborhood team.

An interdisciplinary team in a local public health district tested its ability to implement the core public health functions of assessment, policy development, and assurance by changing its practice to a community-driven model of building partnerships for health with groups and communities in a designated locale. Evaluation of this innovation revealed that the public health nurse members of the team enacted their community health nursing knowledge to strengthen agency to cocreate health. Interdisciplinary collaboration was essential to the team's community mobilization efforts. Additional findings suggested that this organizational innovation was associated with developing a more participatory organizational climate, increasing system effectiveness, and building community capacity.

Community Health Nursing↗

PubMed2005

Boundary workers and the management of frustration: a case study of two Healthy City partnerships.

Partnerships between local governments, health districts and non-governmental and community-based organiza-tions are an increasingly important part of health promotion practice, as well as other policy and programme areas. Two inherent tensions in partnership working have been widely described. First, partnerships are generally set up as 'top down' initiatives, which advocate a 'bottom up' approach, with the inevitable power imbalances that this implies. Secondly, the gains made by partnerships tend to be limited compared with the claims made for them. Despite these tensions, individuals and organizations continue to devote considerable effort to making partnerships 'work'. This paper describes a study, which explored the implications of these apparent contradictions of power imbalance and potential disillusionment within partnerships. The study explored partnership working between community and statutory organizations within two very different Healthy Cities initiatives, one in the UK and the other in South Africa. This paper focuses on why the partners contributed continued effort and energy into maintaining the partnerships, despite their awareness of the constraints. Findings suggest that partners dealt with the tensions first by assuming a discrete identity as an 'entity of boundary people' that operates at the interface between the statutory sector authorities and the communities in question; and secondly, by reducing their activities to specific 'boundary' issues that do not threaten the main agenda of the authorities.

Community Participation↗

PubMed1997

The national Healing Web partnership. An innovative model to improve health.

The authors describe the Healing Web, a partnership between nursing service and education that encourages the best use of nurses education clinical experience and personal competencies. Based on differentiated practice and education of nursing students in multi-level roles the Healing Web partnership is demonstrating at multiple institutions, that education and nursing service can work collaboratively to position the profession of nursing for maximum effectiveness in the 21st century.

Education, Nursing, Associate↗

PubMed1994

HIV and AIDS: the nursing response and some ethical challenges.

AIDS has challenged many concepts and practices within nursing. Because of the serious implications attending a positive diagnosis, and because patients with AIDS have become articulate and well informed, familiar principles have been exposed to renewed scrutiny. Anomalies and dilemmas have been revealed. Results from a recent Institute of Medical Ethics survey carried out by the author have illustrated some of the theoretical concepts. Confidentiality has assumed new dimensions. Partnership and mutual empowerment are seen as keys to sound practice involving the patient in decision-making. A vital ingredient relates to the preparation of professionals; they need to be aware of those attitudes and prejudices within themselves which potentially stand in the way of caring well.

Confidentiality↗

PubMedDate not supplied

Changing nursing practice--trisectoral collaboration in decision making.

In an age of cost containment, agency partnerships have become an essential element for future planning and program implementation. This paper describes a trisectoral collaboration of a hospital, health department, university and school of nursing to compare the efficacy and efficiency of referral decisions of hospital staff nurses to those of the public health liaison nurses (LNs). A process to identify decision criteria was undertaken and an educational programme was designed to assist the staff nurses with the referral process and to assure consistency of decision making. The two groups were then compared. The results of the study found staff nurses, using the decision criteria, identified more patients who required public health nursing visits than did the liaison nurses, refusal rate of the patients to participate was no different, staff nurses cost less than LNs and job satisfaction was not significantly altered for either group. In addition to providing information to guide administrative and clinical decision making, the project also provided a learning experience for the staff of three agencies in conducting research and in using evidence-based practice to change traditional practice.

Decision Making, Organizational↗

PubMed2006

Capturing complexity: integrating health and education research to inform health-promoting schools policy and practice.

Despite the intersectoral nature of health promotion practice many programs limit their evidence base to health sector research and do not draw on evidence from other sectors' research in program design. To help ensure programs are relevant and acceptable to intersectoral partners and intended outcomes are of value to all sectors involved, utilising evidence from more than one discipline is essential. This article identifies the narrow interpretation of existing evidence for health promoting schools and discusses the challenges faced by practitioners and policy makers when reviewing evidence. These issues include the various perspectives on what is 'quality' evidence and how to ensure multidisciplinary evidence is used to inform practice, particularly with the education sector that has a strong research base of its own. A data extraction tool was developed to help address these issues and assist the design of a health promoting schools program. A description of the tool's elements and two case studies provide examples of how research from two different disciplines can be integrated to inform planning and strengthen partnerships. The tool expands the evidence base for policy and practice decision-making for health promoting schools, acknowledging the practical realities of both sectors.

Evidence-Based Medicine↗

PubMedDate not supplied

Hospitalists and case managers: the perfect partnership.

Part of every hospital case manager's strategic advocacy is the promotion of a consistent partnership with the patient's primary clinical player. The presence of hospitalists, a new and growing specialty, offers the case manager an opportunity to advance that partnership. Instead of having to wait for a doctor whose practice is outside the hospital to review a test result or order a procedure, hospitalists can do the same thing faster--leading to greater efficiency, better care, and shorter stays for patients. Unlike private attendings who visit their hospitalized patients once a day for a few minutes, hospitalists spend all their time at the hospital. It's a perfect arrangement for a dynamic point-of-care partnership.

Case Management↗

PubMedDate not supplied

Adverse effect monitoring: opportunity for patient care and pharmacy practice.

OBJECTIVES: To present an adverse effect monitoring tool with theoretical, practical, and data-supported explanation and justification for use in pharmacy practice for the purpose of building patient-pharmacist partnerships and improving medication-management outcomes. DESIGN: Randomized pretest-posttest experimental design. SETTING: Ambulatory patients in three multidisciplinary cancer clinics. PATIENTS: 74 patients who were beginning chemotherapy. INTERVENTIONS: A calendar for daily adverse drug event tracking by ambulatory patients was adapted from The WriteTrack: Personal Health Tracker and provided to those assigned to the intervention group, who were asked to record symptoms and possible adverse drug events during their first two chemotherapy cycles. Patient reports of self-monitoring activities were gathered through posttests (n = 74) and semistructured interviews (n = 7). MAIN OUTCOME MEASURES: Self-reported use and perceived usefulness of the tool. RESULTS: A total of 88.4% of the experimental group (38 of 43 individuals) reported using the monitoring tool to keep written track of adverse effects, while 38.7% of the control group (12 of 31 individuals) reported keeping some form of written record of their experiences. A total of 65.8% of those in the intervention group found patterns in their adverse effects, 47.4% indicated they took the calendar to the clinic to help them recall events, and 26.3% reported using the calendar at the clinic to show their health care team what was happening. Experimental group subjects most often shared the adverse effect monitoring information with nurses alone (23.7%). Patients using the diary indicated that it had a high degree of utility and value and that they would use it again and recommend it to other patients with cancer. CONCLUSION: A system for adverse effect monitoring by patients in the context of cancer drug management was acceptable and useful, and pharmacists could incorporate this tool into their daily practice with minimal effort, time, and expense. Patients' self-documented symptoms and adverse effects can be valuable data when used to help tailor medication regimens to improve clinical status while satisfying patients' personal priorities.

Ambulatory Care↗

PubMed2000

The adolescent years: an academic-community partnership in Harlem comes of age.

Much has been written about the potential benefits in health promotion that are possible through partnerships between academic institutions and community-based organizations, but little practical advice has been provided on how to sustain these relationships when the original grant funds have been exhausted. Here we document our experiences in Harlem, New York City, a community with grave social, structural, and physical environmental inequities, and describe the successes and failings of a partnership now in its "adolescence" between researchers at the Joseph L. Mailman School of Public Health of Columbia University and community activists at West Harlem Environmental Action (WE ACT).

Community Participation↗

PubMed1991

Cervical screening in Perth and Kinross since introduction of the new contract.

OBJECTIVE: To determine changes in the cervical screening service since the introduction of the new general practitioner contract on 1 April 1990. DESIGN: Analysis of computerised records of cervical screening both before and after introduction of the new contract. SETTING: General practices in Perth and Kinross Unit, Tayside. PATIENTS: A total of 30,071 women aged 21-60 on 26 general practitioner partnership lists. MAIN OUTCOME MEASURES: Percentage average of target population for cervical screening in each practice for first three quarters on introduction of the contract. RESULTS: Perth and Kinross Unit completed a computerised cervical screening call programme in July 1989, which produced an increase from 71% to 78% in the mean percentage of women aged 20-60 who had had cervical smear tests within 5.5 years. Six months after the introduction of the new general practitioner contract the mean population coverage was increased to 85% in women aged 21-60 and only four practices had not attained the 80% upper target compared with 10 on 1 April 1990. Detailed examination of randomly selected practices immediately before the new contract was introduced showed an average artificial list inflation of 4.3% in health board records when compared with practice records, a hysterectomy rate of 6.2%, and an additional 3% of women who were considered to be ineligible for smear testing due to putative virginity or illness or infirmity, or both. There was a considerable shift away from use of well woman clinics (2.7% of smears in 1990 compared with 5.6% in 1988) for taking cervical smears, potentially threatening the long term viability of the clinics. CONCLUSION: The introduction of the new contract for general practitioners has brought about a further sustained increase in population coverage for cervical screening in a small Scottish unit with a stable population, well motivated general practitioners, and a fully integrated computerised call and recall system based on the community health index. To optimise the screening service revision of the targets levels is necessary.

Adult↗

PubMedDate not supplied

Fathers' reflections on parenting young children with type 1 diabetes.

PURPOSE: To describe fathers' experiences in parenting and managing the care of their young children with type 1 diabetes. DESIGN AND METHODS: This qualitative descriptive study used 16 open-ended, in-depth interviews with 14 purposively selected, involved, educated, stably employed fathers of 15 children younger than 10 years old. The fathers were asked to describe their perspective of the initial diagnosis, how they learned diabetes care, their day-to-day care and parenting experiences, and what strategies they used in the day-to-day management. Data were managed using NVivo software and analyzed using principles of naturalistic inquiry and qualitative content analysis. RESULTS: The overarching theme was "From sadness to action," with six categories emerging: (1) "shock and awe" (after diagnosis), (2) quick response to the diagnosis and learning diabetes care: "suck it up and do it," (3) "staying in the loop" (practicing the skills, tasks, and responsibilities of diabetes management), (4) "partnerships in care" (tag teaming or co-parenting), (5) active participation (being actively involved in their children's day-to-day care and benefiting from participating in this care), and (6) mantra for living with diabetes: child first, diabetes second. CLINICAL IMPLICATIONS: Nurses working with children with diabetes can use the results of this study to better understand the role of fathers in the care of these children. Fathers underscored the importance of practicing diabetes care-related tasks to improve their confidence when caring for children alone. Their practical and philosophical strategies for managing their children's chronic illness have recently been incorporated into a parent mentor intervention for children newly diagnosed with type 1 diabetes.

Adaptation, Psychological↗

PubMedDate not supplied

Student pharmacist perspectives of rural pharmacy practice.

OBJECTIVE: To evaluate the level of interest of upper-level doctor of pharmacy students in rural pharmacy practice, rural pharmacy ownership, and a proposed rural pharmacy practice model. DESIGN: Cross-sectional study. SETTING: Minnesota, North Dakota, and South Dakota in October through December 2003. PARTICIPANTS: Third- and fourth-year professional student pharmacists at the University of Minnesota, North Dakota State University, and South Dakota State University. INTERVENTION: Self-administered questionnaire completed by study participants. MAIN OUTCOME MEASURES: Student interest in rural pharmacy practice and potential future directions for maintaining access to medications and the knowledge of pharmacists in rural communities. RESULTS: Of 177 respondents, 62.7% has given serious consideration to practice in rural communities with populations of 5,000 or fewer residents. Of these 111 students, 81% would be interested in the proposed practice model explained in the survey. Of the 108 total students expressing interest in the proposed rural pharmacy practice model, 63% had not previously given serious consideration to pursuing ownership (full or partnership) of a community pharmacy. CONCLUSION: Students from the schools that have traditionally supplied the majority of Minnesota rural pharmacists indicated an interest in practicing in rural areas as long as opportunities align with their personal and professional interests.

Community Pharmacy Services↗

PubMed2002

Clinical practice guidelines on bronchial asthma in adults.

Effective management of asthma requires a partnership between the patient and the health care provider. This depends on the patient having a good understanding of the disease and its management. As the level of literacy is widely variable in India, patient education methods may have to be tailored according to the patient's ability to understand. In any case, patients with asthma should be able to a) Understand that asthma is a chronic disease requiring prolonged treatment b) Understand that treatment for asthma should be continued even when symptoms have abated c) Understand that control of asthma needs to be assessed by using objective methods periodically e.g. PEFR measurement d) Recognise when asthma control is deteriorating e) Take appropriate steps when asthma control deteriorates f) Understand the basic nature of the drugs they need to take e.g. preventers, relievers, and protectors g) Recognise the advantages of the inhaled route over the oral route h) Take steps to avoid "triggers" which can aggravate or precipitate an asthma attack. Patients who are more literate can be instructed further on drug interactions, safety, efficacy and side effects of steroids as well as the influence of other diseases on asthma and its treatment.

Adult↗