Skill mix between nurses and doctors working in primary care-delegation or allocation: a review of the literature

The collaborative and professional boundary challenges from a bottom-up perspective: an insider action research study on a hospital ward

PURPOSE

The aim of this study was to identify and describe the collaborative and professional boundary challenges at a hospital ward from a bottom-up perspective.

DESIGN/METHODOLOGY/APPROACH

The study was conducted as a bottom-up improvement project at a hospital ward in western Sweden. An insider action research (IAR) approach was used during the project. The theoretical framework for this project was based on the Cultural-Historical Activity Theory (CHAT). Data were collected between 2019 and 2021.

FINDINGS

The findings showed that unclear professional boundaries and limited resources challenged and hindered interprofessional collaboration. The project group had to reorganize its daily work to adjust to the different disciplines' legal responsibilities in relation to the patients' recovery process. To safely discharge patients, the professionals needed to talk about each other's professional responsibilities, professional boundaries and ethical codes.

ORIGINALITY/VALUE

The IAR project revealed that revising the daily team-round routine improved the status of assistant nurses and encouraged physicians to consider input from all professions during the patients' recovery process. However, the new approach faced resistance from clinic leadership, who believed it could prolong patients' stays in the ward. The findings underscore the challenges of modifying hierarchical structures and social orders within hospital settings.

How general practitioners in France are coping with increased healthcare demand and physician shortages. A panel data survey and hierarchical clustering

BACKGROUND

General practitioners (GPs) face quantitative and qualitative changes in patient demand and doctor shortages.

OBJECTIVES

To investigate how GPs cope with doctor shortage issues.

MATERIALS AND METHODS

Two cross-sectional surveys of a representative panel of 1530 GPs in 2019 and 2022 about their perceptions of physician shortages, working hours worked (WHW), and adaptive behaviors. Hierarchical clustering enabled identification of profiles with different adaptation patterns. Multiple Poisson or logistic regression models studied associations between GPs' profiles and professional characteristics.

RESULTS

87.4 % of GPs applied at least one adaptation to control patients' healthcare demand. 24 % adopted task-shifting while their average WHW decreased by 3.6 h between 2019 and 2022. Four GP profiles were identified. "Low adapters/low workload" and "Low adapters/high workload" (25 % of the sample each) reported 2.4 adaptive measures: 75.5 % refused to be new patients' preferred doctor in the former group (vs 5.1 %). "High adapters/unchanged consultations" (30.7 %) and "High adapters/shortened consultations" (18.9 %) reported 4.8 and 6.1 adaptations, respectively. They were more likely to practice in medically underserved areas.

CONCLUSION

These results call into question GPs' gatekeeper role in the French healthcare system. Moreover, the marked reduction in WHW in underserved areas is likely to exacerbate their uneven distribution nationwide. Encouraging vertical integration between HCPs while enhancing cooperation and task-shifting is probably a pathway toward improving the relative GP shortage.

Identifying strategies to support implementation of interprofessional primary care teams in Nova Scotia: Results of a survey and knowledge sharing event

BACKGROUND

Interprofessional primary care teams (IPCTs) work together to enhance care. Despite evidence on the benefits of IPCTs, implementation remains challenging. This research aims to 1) identify and prioritize barriers and enablers, and 2) co-develop team-level strategies to support IPCT implementation in Nova Scotia, Canada.

METHODS

Healthcare providers and staff of IPCTs were invited to complete an online survey to identify barriers and enablers, and the degree to which each item impacted the functioning of their team. Top ranked items were identified using the sum of frequency x impact for each response. A virtual knowledge sharing event was held to identify strategies to address local barriers and enablers that impact team functioning.

RESULTS

IPCT members (n = 117), with a mix of clinic roles and experience, completed the survey. The top three enablers identified were access to technological tools to support their role, standardized processes for using the technological tools, and having a team manager to coordinate collaboration. The top three barriers were limited opportunity for daily team communication, lack of conflict resolution strategies, and lack of capacity building opportunities. IPCT members, administrators, and patients attended the knowledge sharing event (n = 33). Five strategies were identified including: 1) balancing patient needs and provider scope of practice, 2) holding regular and accessible meetings, 3) supporting team development opportunities, 4) supporting professional development, and 5) supporting involvement in non-clinical activities.

INTERPRETATION

This research contextualized evidence to further understand local perspectives and experiences of barriers and enablers to the implementation of IPCTs. The knowledge exchange event identified actionable strategies that IPCTs and healthcare administrators can tailor to support teams and care for patients.

Embedding new technology into clinical ultrasound practice: Is role extension for sonographers the key to improving patient pathways?

Introduction

MicroUS is a new imaging technique that may have potential to reliably monitor prostate disease and therefore release capacity in MRI departments. Firstly, however, it is essential to identify which healthcare staff may be suitable to learn to use this modality. Based on previous evidence, UK sonographers may be well placed to harness this resource.

Topic

Currently, there is sparse evidence on the performance of MicroUS for monitoring prostate disease but early findings are encouraging. Although its uptake is increasing, it is believed that only two sites in the UK have MicroUS systems and only one of those uses just sonographers to undertake and interpret this new imaging technique.

Discussion

UK sonographers have a history of role extension dating back several decades and have proven repeatedly that they are reliable and accurate when measured against a gold standard. We explore the background of UK sonographer role extension and postulate that sonographers are best placed to adopt and embed new imaging techniques and technology into routine clinical practice. This is of particular importance given the dearth of ultrasound focussed radiologists in the UK. To effectively introduce challenging new work streams, multi-professional collaboration in imaging, alongside sonographer role extension, will ensure precious resources are maximised thus ensuring optimum patient care.

Conclusion

UK sonographers have repeatedly demonstrated reliability in many areas of role extension in various clinical settings. Early data indicate that the adoption of MicroUS for use in prostate disease surveillance may be another role suited to sonographers.

"Not shifting, but sharing": stakeholders' perspectives on mental health task-shifting in Indonesia

Background

Task-shifting, the distribution of tasks among health workers to address health workforce shortage, has been widely used to tackle mental health treatment gaps. However, its implementation in Indonesia has still been rarely explored. This study aimed to explore stakeholders’ perspectives on the implementation of mental health task-shifting to nurses in Indonesia's primary health care.

Methods

An exploratory descriptive approach using in-depth interviews and focused group discussions (FGDs) was used. The study involved 19 stakeholders from the government's ministry directorates, professional organisations, and mental health practitioners. Thematic analysis was used to analyse the data.

Results

Three themes emerged namely, task-shifting feasibility and acceptability, shared task implementation, and nurse role enhancement issues, with 14 sub-themes.

Conclusions

Task-shifting on mental health issues in the eye of Indonesian stakeholders is viewed as a matter of sharing and collaboration. Implementation of task-shifting in Indonesia may require policies in place and political will across stakeholders. Further scrutiny on task-shifting implementation is needed by considering the local context and national environment.

Perspectives of pharmacists in general practice from qualitative focus groups with patients during a pilot study

BACKGROUND

Utilising skill mix in general practice is proposed as a solution to the demand-supply issue. Pharmacists can play an important role in this context leading to an increase in training and funding for independent prescriber roles. A role for Pharmacists in General Practice was funded, piloted and evaluated by NHSE from 2015.

AIM

What is the patient perspective of pharmacists in patient facing roles in general practice in the UK?

DESIGN & SETTING

Focus group interviews exploring patient perspectives on the pharmacist role.

METHOD

33 patients, five focus group interviews (January-December 2016). Data was iteratively analysed using the one sheet of paper technique.

RESULTS

While public are aware of the primary care crisis, they are less well informed about potential solutions. Data showed patients primarily sought access to a clinician over expressing a preference for any type of clinician. Low awareness was shown about the role and there was initial confusion about pharmacist's roles. Acceptability levels were high.Pharmacists add value and provide an expert medication focused service which can have a positive impact on medicines use.Patients reported benefit from longer appointments, feeling they weren't rushed, and that all their conditions were being considered holistically. They trusted pharmacists as experts in medication and trust was consolidated over time. Regular coaching from a pharmacist could lead to improved patient self-monitoring and self-care.

CONCLUSION IMPLICATIONS

Pharmacists can add value to the general practice team and this is recognised by patients.

Analytical typology of multiprofessional primary care models

Background

There is only limited evidence to support care redefinition and role optimization processes needed for scaling up of a stronger primary care capacity.

Methods

Data collection was based on a keyword search in MEDLINE, EMBASE and CINAHL databases. Three thousand, two hundred and twenty-nine documents were identified, 1851 met our inclusion criteria, 71 were retained for full-text assessment and 52 included in the final selection. The analysis process was done in four steps. In the end, the elements that were identified as particularly central to the process of transforming primary care provision were used as the basis of two typologies.

Results

The first typology is based on two structural dimensions that characterize promising multiprofessional primary care teams. The first is the degree to which the division of tasks in the team was formalized. The second dimension is the centrality and autonomy of nurses in the care model. The second typology offers a refined definition of comprehensiveness of care and its relationship with the optimization of professional roles.

Conclusions

The literature we analyzed suggests there are several plausible avenues for coherently articulating the relationships between patients, professionals, and care pathways. The expertise, preferences, and numbers of available human resources will determine the plausibility that a model will be a coherent response that is appropriate to the needs and environmental constraints (funding models, insurance, etc.). The typologies developed can help assess existing care models analytically or evaluatively and to propose, prospectively, some optimal operational parameters for primary care provision.

An ideal-typical model for comparing interprofessional relations and skill mix in health care

BACKGROUND

Comparisons of health system performance, including the regulations of interprofessional relations and the skill mix between health professions are challenging. National strategies for regulating interprofessional relations vary widely across European health care systems. Unambiguously defined and generally accepted performance indicators have to remain generic, with limited power for recognizing the organizational structures regulating interprofessional relations in different health systems. A coherent framework for in-depth comparisons of different models for organizing interprofessional relations and the skill mix between professional groups is currently not available. This study aims to develop an ideal-typical framework for categorizing skill mix and interprofessional relations in health care, and to assess the potential impact for different ideal types on care coordination and integrated service delivery.

METHODS

A document analysis of the Health Systems in Transition (HiT) reports published by the European Observatory on Health Systems and Policies was conducted. The HiT reports to 31 European health systems were analyzed using a qualitative content analysis and a process of meaning condensation.

RESULTS

The educational tracks available to nurses have an impact on the professional autonomy for nurses, the hierarchy between professional groups, the emphasis given to negotiating skill mix, interdisciplinary teamwork and the extent of cooperation across the health and social service interface. Based on the results of the document analysis, three ideal types for regulating interprofessional relations and skill mix in health care are delimited. For each ideal type, outcomes on service coordination and holistic service delivery are described.

CONCLUSIONS

Comparisons of interprofessional relations are necessary for proactive health human resource policies. The proposed ideal-typical framework provides the means for in-depth comparisons of interprofessional relations in the health care workforce beyond of what is possible with directly comparable, but generic performance indicators.

Influence of provider mix and regulation on primary care services supplied to US patients

Access to medical care and how it differs for various patients remain key policy issues. While existing work has examined clinic structure's influence on productivity, less research has explored the link between provider mix and access for different patient types - which also correspond to different service prices. We exploit experimental data from a large field study spanning 10 US states where trained audit callers were randomly assigned an insurance status and then contacted primary care physician practices seeking new patient appointments. We find clinics with more non-physician clinicians are associated with better access for Medicaid patients and lower prices for office visits; however, these relationships are only found in states granting full practice autonomy to these providers. Substituting more non-physician labor in primary care settings may facilitate greater appointment availability for Medicaid patients, but this likely rests on a favorable policy environment. Relaxing regulations for non-physicians may be an important initiative as US health reforms continue and also relevant to other countries coping with greater demands for medical care and related financial strain.

Skill mix, roles and remuneration in the primary care workforce: who are the healthcare professionals in the primary care teams across the world?

World-wide, shortages of primary care physicians and an increased demand for services have provided the impetus for delivering team-based primary care. The diversity of the primary care workforce is increasing to include a wider range of health professionals such as nurse practitioners, registered nurses and other clinical staff members. Although this development is observed internationally, skill mix in the primary care team and the speed of progress to deliver team-based care differs across countries. This work aims to provide an overview of education, tasks and remuneration of nurses and other primary care team members in six OECD countries. Based on a framework of team organization across the care continuum, six national experts compare skill-mix, education and training, tasks and remuneration of health professionals within primary care teams in the United States, Canada, Australia, England, Germany and the Netherlands. Nurses are the main non-physician health professional working along with doctors in most countries although types and roles in primary care vary considerably between countries. However, the number of allied health professionals and support workers, such as medical assistants, working in primary care is increasing. Shifting from 'task delegation' to 'team care' is a global trend but limited by traditional role concepts, legal frameworks and reimbursement schemes. In general, remuneration follows the complexity of medical tasks taken over by each profession. Clear definitions of each team-member's role may facilitate optimally shared responsibility for patient care within primary care teams. Skill mix changes in primary care may help to maintain access to primary care and quality of care delivery. Learning from experiences in other countries may inspire policy makers and researchers to work on efficient and effective teams care models worldwide.

Health and social care workforce planning and development--an overview

PURPOSE

The purpose of this paper is to discuss the issues relating to getting the right health and social care staff with the right skills in the right place at the right time and at the right price.

DESIGN/METHODOLOGY/APPROACH

Key points arising from several master-classes with health and social care managers, supported by a literature review, generated remarkable insights into health and social care workforce planning and development (WP&D).

FINDINGS

Flawed methods and overwhelming data are major barriers to health and social care WP&D. Inefficient and ineffective WP&D policy and practice, therefore, may lead to inappropriate care teams, which in turn lead to sub-optimal and costly health and social care. Increasing health and social care demand and service re-design, as the population grows and ages, and services move from hospital to community, means that workforce planners face several challenges. Issues that drive and restrain their health and social care WP&D efforts are lucid and compelling, which leave planners in no doubt what is expected if they are to succeed and health and social care is to develop. One main barrier they face is that although WP&D definitions and models in the literature are logical, clear and effective, they are imperfect, so planners do not always have comprehensive tools or data to help them determine the ideal workforce. They face other barriers. First, WP&D can be fragmented and uni-disciplinary when modern health and social care is integrating. Second, recruitment and retention problems can easily stymie planners' best endeavours because the people that services need (i.e. staff with the right skills), even if they exist, are not evenly distributed throughout the country.

PRACTICAL IMPLICATIONS

This paper underlines triangulated workforce demand and supply methods (described in the paper), which help planners to equalise workloads among disparate groups and isolated practitioners--an important job satisfaction and staff retention issue. Regular and systematic workforce reviews help planners to justify their staffing establishments; it seems vital, therefore, that they have robust methods and supporting data at their fingertips.

ORIGINALITY/VALUE

This paper stock-takes the latest health and social care workforce planning and development issues.

Comunicación, participación y liderazgo en la percepción del clima emocional en un hospital universitario de Andalucía, España

El objetivo de este artículo es conocer y analizar la valoración del personal de un hospital universitario de Andalucía, España, sobre el clima emocional, el tipo de liderazgo ejercido y la calidad de la información y comunicación interna, así como recoger sus propuestas de mejora. El estudio realizado con 730 profesionales facultativos, enfermeros y auxiliares, usa metodología cuantitativa y cualitativa. Los resultados reflejan la existencia de un clima emocional medio-bajo, que se correlaciona con el estilo de liderazgo y la percepción sobre el grado de información y comunicación. Se observan diferencias estadísticamente significativas en los resultados, en función de las categorías profesionales, así como de la unidad o servicio hospitalario. Las demandas de los y las profesionales reflejan una valoración positiva de sus responsables, aunque se evidencia la necesidad de más habilidades propias de un estilo de liderazgo orientador, participativo y afiliativo.

Implementing large-scale workforce change: learning from 55 pilot sites of allied health workforce redesign in Queensland, Australia

BACKGROUND

Increasingly, health workforces are undergoing high-level 're-engineering' to help them better meet the needs of the population, workforce and service delivery. Queensland Health implemented a large scale 5-year workforce redesign program across more than 13 health-care disciplines. This study synthesized the findings from this program to identify and codify mechanisms associated with successful workforce redesign to help inform other large workforce projects.

METHODS

This study used Inductive Logic Reasoning (ILR), a process that uses logic models as the primary functional tool to develop theories of change, which are subsequently validated through proposition testing. Initial theories of change were developed from a systematic review of the literature and synthesized using a logic model. These theories of change were then developed into propositions and subsequently tested empirically against documentary, interview, and survey data from 55 projects in the workforce redesign program.

RESULTS

Three overarching principles were identified that optimized successful workforce redesign: (1) drivers for change need to be close to practice; (2) contexts need to be supportive both at the local levels and legislatively; and (3) mechanisms should include appropriate engagement, resources to facilitate change management, governance, and support structures. Attendance to these factors was uniformly associated with success of individual projects.

CONCLUSIONS

ILR is a transparent and reproducible method for developing and testing theories of workforce change. Despite the heterogeneity of projects, professions, and approaches used, a consistent set of overarching principles underpinned success of workforce change interventions. These concepts have been operationalized into a workforce change checklist.

Changes to supervision in community pharmacy: pharmacist and pharmacy support staff views

Pharmacists now offer increasing levels and ranges of clinical, diagnostic and public health services, which may require a pharmacist to be absent from the pharmacy premises. Currently, in the UK, many pharmacy activities legally require the direct supervision and physical presence of the pharmacist. This study aimed to explore the potential for changes to supervision, allowing pharmacist absence, and greater utilisation of pharmacy support staff. Four nominal group discussions were conducted in May 2012 with community pharmacists (CPs), community pharmacy support staff, hospital pharmacists and hospital pharmacy support staff, involving 21 participants. Participants were asked to generate pharmacy activities, which they felt could/could not be safely performed by support staff in the absence of a pharmacist, followed by a discussion of these items and voting using an agreement scale. A written record of the items generated and voting scores was made and the group discussion elements were audio-recorded, transcribed verbatim and analysed thematically. The selling of general sales list medicines, assembly of prescriptions and provision of public health services received a high level of agreement between groups, as activities that could be performed. There was greater disagreement about the safety of support staff selling pharmacy medicines and handing out checked and bagged prescription items to patients. Group discussion revealed some of the main challenges to supervision changes, including CPs' perceptions about their presence being critical to patient safety, reluctance to relinquish control, concerns about knowing and trusting the competencies of support staff, and reluctance by support staff to take greater professional responsibility. The findings of this study aim to inform a future consultation on changes to pharmacy supervision in the UK. The empowerment of pharmacy technicians as a professional group may be key to any future change; this may require clarity of their professional responsibilities, enhanced career progression and appropriate remuneration to match greater responsibility.

Support matters: a mixed methods scoping study on the use of assistant staff in the delivery of community nursing services in England

Background

Community nursing (and health) services are faced with the growing challenge of caring for increasingly dependent patients with chronic conditions and complex care needs. Over the past decade there have been changes in the composition of the community nursing workforce with increasing numbers of assistants yet there is a lack of published literature on the roles, contribution and impacts of community nursing assistants to the delivery of care and services.

Design

We adopted a three-stage approach for the scoping study using mixed quantitative and qualitative methods. First, we established contact with senior managers in provider organisations where we had research governance approval (n = 76; 75% of total provider organisations) to determine whether or not (a) they employ assistants within community nursing teams and (b) they would be interested in participating in the study. Second, we carried out a short telephone interview with all senior managers who indicated a willingness to participate (census approach). We also analysed secondary data (using the NHS iView data source, from the Electronic Staff Record Data Warehouse) to scope the national use of community nursing assistant roles. Finally, we conducted telephone interviews with a purposive sample of managers from 10 organisations that participated in stage two to gain an in-depth understanding of assistant roles in community nursing teams

Setting

Community nursing provider organisations in England, UK.

Participants

Thirty-seven senior managers were interviewed for stage two (49% of all contacted). Thirty managers (20 service-level managers and 10 senior managers) were interviewed for stage three.

Results

Assistants promote flexibility in the community nursing workforce so as to respond to the changing demands on these services. However, the lack of consensus in defining the role of community nursing assistants has created inconsistency in the national deployment and development of these roles. These roles have tended to develop ad hoc, creating variations in numbers of assistants, the roles that they play and preparation for practice across different provider organisations and nursing teams. There is general enthusiasm among managers about the contribution of assistants. Their employment is regarded as fundamental to the ability of community nursing teams to deliver acceptable and appropriate services. However, the role may not always support career progression and development for those assistants who require this. The maturity and life experience of assistants is greatly valued in the nursing team to support care delivery and to offer stability and support to other members of the nursing team. Line management, responsibility and accountability in managing the work of assistants were highlighted as important for managing risk associated with an unregulated role. These have to be balanced with promoting flexibility in use and innovation.

Conclusions

Our scoping study highlights the opportunities and challenges associated with the use of assistants to deliver care by the community nursing team. Further attention at national and local levels is required to support and mediate the development of these roles in the future so as to promote the delivery of quality, safe and acceptable care. As provider organisations plan for delivering an ambitious community services agenda in the future, the role of the assistant is likely to have increasing importance.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Motivational interviewing within the different stages of change: an analysis of practice nurse-patient consultations aimed at promoting a healthier lifestyle

Combining the Stages of Change (SOC) model with Motivational Interviewing (MI) is seen as a helpful strategy for health care providers to guide patients in changing unhealthy lifestyle behaviour. SOC suggests that people are at different stages of motivational readiness for engaging in health behaviours and that intervention methods are most useful when tailored to a person's stage of change. However, it is unknown whether practice nurses (PNs) actually adapt their MI and more generic communication skills to a particular stage during real-life face-to-face consultations with their patients. The aim of this study was to explore whether and how PNs apply MI and general communication skills to the different SOC of patients, targeting behaviour change about smoking, alcohol use, dietary habits and/or physical activity. Real-life consultations between nineteen Dutch PNs and 103 patients were recorded on video between June 2010 and March 2011. All consultations focused on a discussion of patients' lifestyle behaviour. The Behaviour Change Counselling Index (BECCI) was used to code PNs' MI skills. Generic communication skills were rated with the MAAS-global. Patients' SOC was assessed for each consultation by observing the communication between patient and PN regarding the patient's current lifestyle behaviour. Multilevel analyses revealed that PNs adapt their MI skills to a patient's SOC to some extent. On average PNs apply MI skills more to patients in the preparation stage (P < 0.05) than during the other stages of change. PNs adjusted three MI skills and one generic communication skill to patients' SOC. This explorative study suggests that, at least to some extent, PNs intuitively assess the stage of patients' readiness to change and tailor their communication accordingly. However, differences between the stages were small. By teaching PNs to explicitly identify patients' SOC they could further enhance and adapt their MI and general communication skills to the individual.

Do trained practice nurses apply motivational interviewing techniques in primary care consultations?

Background

Reducing the prevalence of unhealthy lifestyle behaviour could positively influence health. Motivational interviewing (MI) is used to promote change in unhealthy lifestyle behaviour as part of primary or secondary prevention. Whether MI is actually applied as taught is unknown. Practice nurses’ application of motivational interviewing in real-life primary care consultations was examined. Furthermore, we explored if (and to what extent) practice nurses adjust their motivational interviewing skills to primary versus secondary prevention.

Methods

Thirteen Dutch practice nurses, from four general practices, trained in motivational interviewing participated, 117 adult patients visiting the practice nurse participated, 117 practice nurse-patient consultations between June and December 2010 were videotaped. Motivational interview skills were rated by two observers using the Behaviour Change Counselling Index (BECCI). Data were analyzed using multilevel regression.

Results

Practice nurses use motivational interviewing techniques to some extent. Substantial variation was found between motivational interviewing items. No significant differences in the use of motivational interviewing between primary and secondary prevention was found.

Conclusions

Motivational interviewing skills are not easily applicable in routine practice. Health care providers who want to acquire motivational interview skills should follow booster sessions after the first training. The training could be strengthened by video-feedback and feedback based on participating observation. A possible explanation for the lack of differences between the two types of prevention consultations may be the gain to help patients in primary consultations by preventing complications equals the necessity to help the disease from aggravating in secondary prevention.

Communication-related behavior change techniques used in face-to-face lifestyle interventions in primary care: a systematic review of the literature

OBJECTIVES

To systematically review the literature on the relative effectiveness of face-to-face communication-related behavior change techniques (BCTs) provided in primary care by either physicians or nurses to intervene on patients' lifestyle behavior.

METHODS

PubMed, EMBASE, PsychINFO, CINAHL and The Cochrane Library were searched for studies published before October 2010. Fifty studies were included and assessed on methodological quality.

RESULTS

Twenty-eight studies reported significantly favorable health outcomes following communication-related BCTs. In these studies, 'behavioral counseling' was most frequently used (15 times), followed by motivational interviewing (eight times), education and advice (both seven times). Physicians and nurses seem equally capable of providing face-to-face communication-related BCTs in primary care.

CONCLUSION

Behavioral counseling, motivational interviewing, education and advice all seem effective communication-related BCTs. However, BCTs were also found in less successful studies. Furthermore, based on existing literature, one primary care profession does not seem better equipped than the other to provide face-to-face communication-related BCTs.

PRACTICE IMPLICATIONS

There is evidence that behavioral counseling, motivational interviewing, education and advice can be used as effective communication-related BCTs by physicians and nurses. However, further research is needed to examine the underlying working mechanisms of communication-related BCTs, and whether they meet the requirements of patients and primary care providers.

Inter-professional Barriers and Knowledge Brokering in an Organizational Context: The Case of Healthcare

Our study examines brokering of situated knowledge within an organizational context, characterized by professional hierarchy. We examine how professional affiliation and associated power differentials impact upon knowledge brokering at the individual and group levels within an organization. Our empirical case, which combines social network analysis and qualitative fieldwork, is set in healthcare with a focus upon integration of management, psychosocial and clinical component knowledge domains deemed necessary for treatment of a long-term condition. Our study shows that peer-to-peer knowledge brokering, which is framed by professional hierarchy, remains pervasive with respect to medical knowledge brokering. However, social structures might be mediated through developing architectural knowledge, reflected in both formal and informal organizational routines and schema, which engenders community tendencies that transcend professional hierarchy, so that knowledge brokering is more widely distributed to benefit patients.

Effectiveness of general practice nurse interventions in cardiac risk factor reduction among adults

Background  Cardiovascular disease is the leading cause of death for adults in Australia. In recent years there has been a shift in health service delivery from institutional to community-based care for chronic conditions, including cardiovascular disease. The general practice setting is seen to offer greater flexibility, higher levels of efficiency and more client focused healthcare delivery than is possible in the acute care sector. It has been suggested that practice nurses represent a useful adjunct to current models of cardiovascular disease management. To date, significant descriptive research has been conducted exploring the demographics, roles, educational needs and issues facing practice nurses. However, there is a need to evaluate the effectiveness of practice nurse interventions in terms of patient outcomes, clinician satisfaction and cost-effectiveness. Objectives  This review seeks to present the best available evidence regarding the efficacy of general practice nurse interventions for cardiac risk factor reduction in healthy adults, as well as those with established cardiovascular disease or known cardiac risk factors. Search Strategy  A systematic literature search was performed using Medline (1966 - 2005), CINAHL (1982 -2005), Cochrane Controlled Trials Register (Issue 4, 2005) and the Joanna Briggs Institute Evidence Library. In addition, the reference lists of retrieved papers, conference proceedings and the Internet, were scrutinised for additional trials. Selection Criteria  This review considered any English language randomised trials that investigated interventions conducted by the practice nurse for cardiovascular disease management or reduction of cardiac risk factors. Interventions conducted by specialist cardiac nurses in general practice were excluded. Outcomes measured included blood pressure, smoking cessation, total cholesterol, exercise, body weight/body mass index and cost-effectiveness. Results  Eighteen trials, reported in 33 papers, were included in the review. Ten trials investigated multifaceted interventions, while the remaining eight trials reported targeted interventions. Of the trials that reported multifaceted interventions, three trials investigated risk reduction in those with established cardiovascular disease, four trials focused on those with known cardiovascular disease risk factors and three trials included the general community. The eight trials which examined the efficacy of targeted interventions focused upon dietary intake (two trials), smoking cessation (three trials), weight reduction (one trial) and physical activity (two trials). The effect of both the multifaceted and targeted interventions on patient outcomes was variable. However, both the multifaceted and targeted interventions demonstrated similar outcome trends for specific variables. Improvements were demonstrated by most studies in blood pressure, cholesterol level, dietary intake and physical activity. The variation in outcome measures and contradictory findings between some studies makes it difficult to draw definitive conclusions. Conclusions  While interventions to reduce cardiovascular disease risk factors have produced variable results, they offer significant potential to assist patients in modifying their personal risk profile and should be developed. The public health importance of these changes is dependant upon the sustainability of the change and its effect on the health outcomes of these individuals. Further well-designed research is required to establish the effectiveness of practice nurse interventions for cardiovascular disease management and risk factor reduction in terms of patient outcomes and cost-effectiveness.

Integrated care in Norway: the state of affairs years after regulation by law

INTRODUCTION

A mandatory multidisciplinary plan for individual care, the 'Individual care Plan', was introduced by law in Norway in 2001. The regulation was established to meet the need for improved efficiency and quality of health and social services, and to increase patient involvement. The plan was intended for patients with long-term and complex needs for coordinated care. The aim of this study was to elaborate on knowledge of such planning processes in Norwegian municipalities.

METHOD

A piloted questionnaire was sent to 92 randomly selected municipalities in 2005-2006, addressing local organization and participation in the work with individual care plans. Local political governance, size of the population, funds available for health care, and problems related to living conditions were indicators for analysing the extent to which the individual care plan was used five years after the regulation was introduced.

RESULTS

Our results showed that 0.5% as opposed to an expected 3% of the population had an individual care plan. This was independent of the political, social and financial situation in the municipalities or the way the planning process had been carried out. The planning process was mostly taken care of by local health and social care professionals, rather than by hospital staff and general practitioners.

DISCUSSION AND CONCLUSION

The low number of care plans and the oblique responsibility among professionals for planning showed that the objectives of the national initiative had not been achieved. More research is needed to determine the reasons for this lack of success and to contribute to solutions for improved multidisciplinary cooperation.

Discussing patient's lifestyle choices in the consulting room: analysis of GP-patient consultations between 1975 and 2008

BACKGROUND

The increasing prevalence of chronic diseases and the growing understanding that lifestyle behaviour plays an essential role in improving overall health suggest a need for increased attention to lifestyle choices in the consulting room.This study aims to examine whether or not healthy and unhealthy lifestyle choices of patients are currently being discussed more often in primary care consultations than in former decades. Furthermore, we are interested in GPs' approach to lifestyle behaviour during consultations. Lastly, we examine whether lifestyle behaviour is discussed more with certain patients during consultations, depending on gender, age and educational background.

METHOD

We analysed video-recordings of medical consultations, collected between 1975 and 2008 in Dutch GP practices. Data were analysed using logistic regression.

RESULTS

This study shows that discussion of smoking behaviour and physical activity has increased somewhat over time. A change in discussion of nutrition and alcohol is, however, less clear. Overall, alcohol use is the least discussed and physical activity the most discussed during consultations. GPs mainly refer to lifestyle when it is relevant to the patient's complaints (symptom approach). GPs' approach to lifestyle behaviour did not change over time. In general, lifestyle behaviour is discussed more with older, male patients (except for nutrition). GPs talk about lifestyle behaviour with patients from different educational backgrounds equally (except for physical activity).

CONCLUSION

In recent years there is greater awareness of a healthy lifestyle, which is reflected to a limited extent in this study. Still, lifestyle behaviour is discussed in only a minority of consultations. GPs do not refer to lifestyle behaviour as a routine procedure, i.e. do not include it in primary prevention. This highlights the importance of the introduction of prevention consultations, where GPs can discuss lifestyle issues with patients who do not (yet) have risk symptoms.

[Emotional climate in Primary Health Care teams. A qualitative approach]

OBJECTIVE

The social interactions met in the Primary Health Care work teams are driven by important emotional aspects that affect the environment, results and the satisfaction of the professional and the patients. The objective of this work is to describe the emotional climate of Primary Care work teams, looking for the perceptions of different professional category and different work groups (selected by the quality of their emotional climate).

METHODS

A qualitative methodology was used: 2 nominal groups and 2 focal groups, with 18 physicians and nurses working in the Andalusian Primary Health Care system. The information was recorded and then a content analysis was made.

RESULTS

Health care professionals identify the following explanatory dimensions: professional relationship (high scored), shared work project, professional recognition, leadership, burnout and personal attitudes, as well as work conditions. Different opinions were recorded among physicians and nurses, especially when the group had a bad emotional atmosphere.

CONCLUSIONS

More studies on the emotional climate in Primary Health Care are needed in order to propose strategies to improve satisfaction and quality of work life among professionals.

Mid-level providers in gastroenterology

One response to the challenges of modern day clinical practice has been to employ "mid-level providers" (MLPs), such as physician assistants and nurse practitioners. MLPs may complement physicians by supporting patient self-management and performing routine, protocol-guided management. In turn, MLPs may improve health outcomes and simultaneously lower costs. Within gastroenterology, the prevalence of MLPs remains unknown, though it appears to be significant and increasing. Additionally, professional organizations predict that in the future, MLPs will play a central role in digestive disease care. Although incorporating MLPs into gastroenterology has great potential, numerous challenges exist, and their specific roles must first be defined and evaluated.

Déploiement de nouveaux rôles infirmiers au Québec et pouvoir médical

Université de Montréal.Le contexte actuel des systèmes de santé occidentaux réclame que des transformations soient opérées dans les modes d’organisation et de dispensation des soins de santé. Pour faire face à ces nouveaux défis, de nombreux établissements ont introduit de nouveaux rôles infirmiers ayant le potentiel de transformer l’offre de services. Cet article a comme but de mieux comprendre le déploiement de ces nouveaux rôles infirmiers en contexte québécois et d’identifier les facteurs qui favorisent ou entravent leur mise en oeuvre, en portant un intérêt particulier à la dimension du pouvoir médical. Notre analyse montre que l’introduction de nouveaux rôles nécessite que soient redéfinis les espaces d’autorité exercés par la profession médicale sur la prestation de l’ensemble des services de santé, incluant les services infirmiers. La question du pouvoir médical, aussi délicate soit-elle, est d’autant plus importante que la négociation des frontières entre la profession infirmière et la profession médicale se présente comme un incontournable pour maximiser le plein potentiel de ces rôles et atteindre les objectifs poursuivis en termes d’accessibilité, de globalité et de qualité des services.

Relative professional roles in antenatal care: results of a survey in Scottish rural general practice

There is evidence of variation and some ambiguity about self-perceived relative professional roles in antenatal care in the UK. There is little information about models of antenatal care provision in UK rural areas. In rural areas, in particular, women have limited choice in accessing health care professionals or alternative primary care delivery settings. In the light of a recent review of Scottish maternity services, it is important and timely to examine models of care and interprofessional working in antenatal care in rural areas. This study explores midwives' and GPs' perceptions about their relative professional roles in remote and rural general practice in Scotland. A questionnaire survey involving all 174 Scottish remote and rural general practices (using one definition of rurality) was conducted, followed by 20 interviews. At least one professional returned a completed questionnaire from 91% of rural practices. A number of areas of dissonance were noted between GPs' and midwives' perceptions of their roles in maternity care and, given the context of service provision, these may impact upon rural patients. Findings are relevant to wider debates on extending the primary care team and strengthening inter-disciplinary working, particularly in rural areas.

Perceiving and practicing the nature of nursing in Poland

INTRODUCTION

The social and political transition taking place in Poland during the last decade has resulted in changes in the system of education. The results of empirical studies indicate that both the system of education and the period of its transition exerted an influence on the qualifications of nurses.

AIM

The focus of the study was the relationship between the selected education factors and the occupational experience of nurses.

METHODS

The study was conducted by the method of a diagnostic survey with the use of the authors' version of a questionnaire form. The variables were tested by means of chi-square test and Spearman's correlation test. The investigations covered a group of 324 occupationally active nurses in area of the city of Lublin.

CONCLUSIONS

The analysis indicates that among many variables concerning education and occupational improvement, only the type of education (1st and 2nd level of occupational differentiation) has a statistically significant effect on auto-defining of nursing in the the nature of occupational activities performed.

Impact of the 2004 GMS contract on practice nurses: a qualitative study

BACKGROUND

The new GMS contract has led to practice nurses playing an important role in the delivery of the Quality and Outcomes Framework (QOF).

AIM

This study investigated how practice nurses perceive the changes in their work since the contract's inception.

DESIGN OF STUDY

A qualitative approach, sampling practice nurses from practices in areas of high and low deprivation, with a range of QOF scores.

SETTING

Glasgow, UK.

METHOD

Individual interviews were conducted, audiotaped, transcribed, and analysed using a thematic approach.

RESULTS

Three themes emerged: roles and incentives, workload, and patient care. Practice nurses were positive about the development of their professional role since the introduction of the new GMS contract but had mixed views about whether their status had changed. Views on incentives (largely related to financial rewards) also varied, but most felt under-rewarded, irrespective of practice QOF achievement. All reported a substantial increase in workload, related to incentivised QOF domains with greater 'box ticking' and data entry, and less time to spend with patients. Although the structure created by the new contract was generally welcomed, many were unconvinced that it improved patient care and felt other important areas of care were neglected. Concern was also expressed about a negative effect of the QOF on holistic care, including ethical concerns and detrimental effects on the patient-nurse relationship, which were regarded as a core value.

CONCLUSIONS

The new GMS contract has given practice nurses increased responsibility. However, discontent about how financial gains are distributed and negative impacts on core values may lead to detrimental long-term effects on motivation and morale.

District nursing workforce planning: a review of the methods

District nursing services in Northern Ireland face increasing demands and challenges which may be responded to by effective and efficient workforce planning and development. The aim of this paper is to critically analyse district nursing workforce planning and development methods, in an attempt to find a suitable method for Northern Ireland. A systematic analysis of the literature reveals four methods: professional judgement; population-based health needs; caseload analysis and dependency-acuity. Each method has strengths and weaknesses. Professional judgement offers a 'belt and braces' approach but lacks sensitivity to fluctuating patient numbers. Population-based health needs methods develop staffing algorithms that reflect deprivation and geographical spread, but are poorly understood by district nurses. Caseload analysis promotes equitable workloads but poorly performing district nursing localities may continue if benchmarking processes only consider local data. Dependency-acuity methods provide a means of equalizing and prioritizing workload but are prone to district nurses overstating factors in patient dependency or understating carers' capability. In summary a mixed method approach is advocated to evaluate and adjust the size and mix of district nursing teams using empirically determined patient dependency and activity-based variables based on the population's health needs.

Junior doctors' working hours: perspectives on the reforms

The European Working Time Directive for junior doctors came into force in Britain in August 2004. The reforms themselves have been a long time in development and implementation since the inception and debates regarding the New Deal, to the current formations under health and safety legislation. This study, undertaken within a hospital trust setting in England, provides an insight into the perspectives of doctors, nurses and human resources managers in relation to the European Working Time Directive. Critical consideration is given to the impact of the reforms upon the National Health Service and more specifically to daily working relationships at the point of implementation. The results demonstrate some ambivalence towards the reforms because of the major shift in culture for the professions per se, but also for the future of health-care delivery where there are considerable tensions.

Tailoring intervention procedures to routine primary health care practice; an ethnographic process evaluation

BACKGROUND

Tailor-made approaches enable the uptake of interventions as they are seen as a way to overcome the incompatibility of general interventions with local knowledge about the organisation of routine medical practice and the relationship between the patients and the professionals in practice. Our case is the Quattro project which is a prevention programme for cardiovascular diseases in high-risk patients in primary health care centres in deprived neighbourhoods. This programme was implemented as a pragmatic trial and foresaw the importance of local knowledge in primary health care and internal, or locally made, guidelines. The aim of this paper is to show how this prevention programme, which could be tailored to routine care, was implemented in primary care.

METHODS

An ethnographic design was used for this study. We observed and interviewed the researchers and the practice nurses. All the research documents, observations and transcribed interviews were analysed thematically.

RESULTS

Our ethnographic process evaluation showed that the opportunity of tailoring intervention procedures to routine care in a pragmatic trial setting did not result in a well-organised and well-implemented prevention programme. In fact, the lack of standard protocols hindered the implementation of the intervention. Although it was not the purpose of this trial, a guideline was developed. Despite the fact that the developed guideline functioned as a tool, it did not result in the intervention being organised accordingly. However, the guideline did make tailoring the intervention possible. It provided the professionals with the key or the instructions needed to achieve organisational change and transform the existing interprofessional relations.

CONCLUSION

As tailor-made approaches are developed to enable the uptake of interventions in routine practice, they are facilitated by the brokering of tools such as guidelines. In our study, guidelines facilitated organisational change and enabled the transformation of existing interprofessional relations, and thus made tailoring possible. The attractive flexibility of pragmatic trial design in taking account of local practice variations may often be overestimated.

Primary and community care workforce planning and development

AIM

This article reports a study that provided primary and community care managers with information, allowing them to: (a) evaluate the size and mix of their workforce; and (b) develop knowledgeable and skilled teams to meet the demands of growing and changing services.

BACKGROUND

Primary and community care services are growing in the United Kingdom, but workforce planning and development, despite their wide-ranging cost and quality implications, have not received the same attention. Indeed, most primary and community care workforce planning and development issues are universal. Demand 1-1 side workforce planning is concerned not only with the number, but also with staff mix; but how these autonomous and isolated practitioners spend their time is unique. The other side of the equation, workforce supply, raises many recruitment and retention challenges for managers in many countries. Any country's main workforce planning methods apply equally well to primary care, but each is flawed. A second, main problem is that the methods lead to fragmented services, whereas modern workforce planning methods should be multidisciplinary. Consequently, it has never been more important for managers to have data and algorithms to develop appropriate care teams.

METHOD

A large and versatile workforce database, profiling 304 English primary care trusts using demographic, socio-economic, mortality, morbidity, staffing and performance workforce-related variables, compiled in 2002 and updated yearly, is described. Data were supplemented with a systematic literature review leading to a 340-item annotated bibliography; and qualitative interviews with managers.

RESULTS

Workforce size and mix are historical and irrational at best. Moreover, the number of variables that influence staffing is growing, thereby complicating workforce planning.

CONCLUSION

Evaluating and adjusting the size and mix of teams using empirically determined community demand and performance variables based on the area's socio-economic characteristics is feasible.

Effectiveness of general practice nurse interventions in cardiac risk factor reduction among adults

BACKGROUND

Cardiovascular disease is the leading cause of death for adults in Australia. In recent years there has been a shift in health service delivery from institutional to community-based care for chronic conditions, including cardiovascular disease. The general practice setting is seen to offer greater flexibility, higher levels of efficiency and more client focused healthcare delivery than is possible in the acute care sector. It has been suggested that practice nurses represent a useful adjunct to current models of cardiovascular disease management. To date, significant descriptive research has been conducted exploring the demographics, roles, educational needs and issues facing practice nurses. However, there is a need to evaluate the effectiveness of practice nurse interventions in terms of patient outcomes, clinician satisfaction and cost-effectiveness.

OBJECTIVES

This review seeks to present the best available evidence regarding the efficacy of general practice nurse interventions for cardiac risk factor reduction in healthy adults, as well as those with established cardiovascular disease or known cardiac risk factors.

SEARCH STRATEGY

A systematic literature search was performed using Medline (1966 - 2005), CINAHL (1982 -2005), Cochrane Controlled Trials Register (Issue 4, 2005) and the Joanna Briggs Institute Evidence Library. In addition, the reference lists of retrieved papers, conference proceedings and the Internet, were scrutinised for additional trials.

SELECTION CRITERIA

This review considered any English language randomised trials that investigated interventions conducted by the practice nurse for cardiovascular disease management or reduction of cardiac risk factors. Interventions conducted by specialist cardiac nurses in general practice were excluded. Outcomes measured included blood pressure, smoking cessation, total cholesterol, exercise, body weight/body mass index and cost-effectiveness.

RESULTS

Eighteen trials, reported in 33 papers, were included in the review. Ten trials investigated multifaceted interventions, while the remaining eight trials reported targeted interventions. Of the trials that reported multifaceted interventions, three trials investigated risk reduction in those with established cardiovascular disease, four trials focused on those with known cardiovascular disease risk factors and three trials included the general community. The eight trials which examined the efficacy of targeted interventions focused upon dietary intake (two trials), smoking cessation (three trials), weight reduction (one trial) and physical activity (two trials). The effect of both the multifaceted and targeted interventions on patient outcomes was variable. However, both the multifaceted and targeted interventions demonstrated similar outcome trends for specific variables. Improvements were demonstrated by most studies in blood pressure, cholesterol level, dietary intake and physical activity. The variation in outcome measures and contradictory findings between some studies makes it difficult to draw definitive conclusions.

CONCLUSIONS

While interventions to reduce cardiovascular disease risk factors have produced variable results, they offer significant potential to assist patients in modifying their personal risk profile and should be developed. The public health importance of these changes is dependant upon the sustainability of the change and its effect on the health outcomes of these individuals. Further well-designed research is required to establish the effectiveness of practice nurse interventions for cardiovascular disease management and risk factor reduction in terms of patient outcomes and cost-effectiveness.

A comprehensive systematic review of evidence on the structure, process, characteristics and composition of a nursing team that fosters a healthy work environment

OBJECTIVES

The overall aim of this comprehensive systematic review was to identify the best available evidence on the effect of team characteristics, processes, structure and composition within the context of collaborative practice among nursing teams that create a healthy work environment.

SEARCH STRATEGY

The search strategy sought to find both published and unpublished studies and papers written in the English language. An initial limited search of Medline and CINAHL databases was undertaken to identify optimal search terms. A second extensive search using all identified keywords and index terms was then undertaken.

METHODOLOGICAL QUALITY

Two independent reviewers assessed the methodological quality of retrieved papers using the corresponding checklist from the System for the Unified Management, Assessment and Review of Information (SUMARI) package.

RESULTS

The papers included in the review included nine experimental or quasi-experimental studies, 11 descriptive studies and four qualitative studies. A variety of different team structures such as interdisciplinary teams, primary nursing, team nursing, multidisciplinary models of care delivery and the use of a Partner in Patient Care model were investigated. Team characteristics should include accountability, commitment, enthusiasm and motivation. Social support within a team from a supervisor or colleague increased satisfaction levels of staff.

CONCLUSION

The results of the review lead to the development of a number of recommendations for practice that could assist with creating a health work environment.

Dynamic professional boundaries in the healthcare workforce

The healthcare professions have never been static in terms of their own disciplinary boundaries, nor in their role or status in society. Healthcare provision has been defined by changing societal expectations and beliefs, new ways of perceiving health and illness, the introduction of a range of technologies and, more recently, the formal recognition of particular groups through the introduction of education and regulation. It has also been shaped by both inter-professional and profession-state relationships forged over time. A number of factors have converged that place new pressures on workforce boundaries, including an unmet demand for some healthcare services; neo-liberal management philosophies and a greater emphasis on consumer preferences than professional-led services. To date, however, there has been little analysis of the evolution of the workforce as a whole. The discussion of workforce change that has taken place has largely been from the perspective of individual disciplines. Yet the dynamic boundaries of each discipline mean that there is an interrelationship between the components of the workforce that cannot be ignored. The purpose of this paper is to describe four directions in which the existing workforce can change: diversification; specialisation and vertical and horizontal substitution, and to discuss the implications of these changes for the workforce.

The rules of the game: interprofessional collaboration on the intensive care unit team

Background

The intensive care unit (ICU) is a nexus for interspecialty and interdisciplinary tensions because of its pivotal role in the care of the hospital's most critically ill patients and in the management of critical care resources. In an environment charged with temporal, financial and professional tensions, learning how to get results collaboratively is a critical aspect of professional competence. This study explored how team members in the ICU interact to achieve daily clinical goals, delineate professional boundaries and negotiate complex systems issues.

Methods

Seven 1-hour focus groups were conducted with ICU team members in two hospitals. Participants consisted of four nursing groups (n = 27), two resident groups (n = 6) and one intensivist group (n = 4). Interviews were audio-recorded, anonymized and transcribed. With the use of a standard qualitative approach, transcripts were analyzed iteratively for recurrent themes by four researchers.

Results

Team members articulated their perceptions of the mechanisms by which team collaboration was achieved or undermined in a complex and high-pressure context. Two mechanisms were recurrently described: the perception of 'ownership' and the process of 'trade'. Analysis of these mechanisms reveals how power is commodified, possessed and exchanged as team members negotiate their daily needs and goals with one another.

Conclusion

Our data provide a non-idealized depiction of how health care professionals function on a team so as to meet both individual and collective goals. We contend that the concept of 'team' must move beyond the rhetoric of 'cooperation' and towards a more authentic depiction of the skills and strategies required to function in the competitive setting of the interprofessional health care team.

Quality monitoring of nurse telephone triage: pilot study

BACKGROUND

Nurse telephone triage is a popular way of managing workload in primary care and has been shown to be as safe as general practitioner (GP)-delivered alternatives. No studies have tested a routine method of assessing the quality of decision-making by triage nurses in primary care.

AIMS

The aim of this paper is to describe a study to evaluate accuracy and utility of audiotaping telephone consultations to assess the quality of decisions made by practice nurses triaging same day appointment requests in routine practice.

METHOD

An observational study was carried out using external assessment by GPs and nurse practitioners of triage quality in 218 audiotaped nurse telephone triage consultations.

RESULTS

There were high levels of agreement between triage nurses and assessors on identifying the presenting problem. However, there were only moderate levels of agreement between GPs and nurse assessors both on level of information sought (kappa = 0.434) and appropriateness of outcome (kappa = 0.614). Assessors rated information-gathering as poor in 19.3% of calls (95% confidence interval 14.6 to 25.0), and seven (3.2%) consultations were rated as potentially dangerous (95% confidence interval 1.6 to 6.5). A 1% sample of all consultations would have a probability of 0.48 of identifying unsafe consultations and 0.99 probability of identifying consultations with poor information-gathering.

CONCLUSIONS

External assessment of triage quality may be of only moderate accuracy and reliability. Nonetheless, considerable information can be gleaned from assessing audiotapes to assess consultation quality. Even where nurses are generally highly skilled and competent, a 1% review of triage consultations would be sufficient to identify their information-gathering learning needs in relation to patients' presenting problems. Audio-taped consultations could be an important part of clinical governance strategies.