Fiona Ross

Working together for health

There is a crisis in human resources for health care, with a chronic and global shortage of well-trained health workers, most acutely felt in those countries where they are most needed, says Dr Lee Jong-Wook, the World Health Organization (WHO) Secretary General, in his foreword to the 2006 World Health Report (WHO, 2006). People, he says, are the vital ingredient in strengthening health care systems, but the solution is not straightforward; nor is there a consensus about how to proceed. Health care workers around the world, says the report, are experiencing increasing stress and insecurity, exacerbated by concentrations of population in urban areas and migration from the poorest to the richest countries, compounded where the skills of limited yet expensive professionals are ill-matched to the profile of local health care needs. That crisis has the potential to deepen in coming years as demand for services escalates in countries facing lower fertility and ageing populations. It has been recognized for some time that the shift from acute tertiary hospital care to patient-centred, home-based and team-driven care will require new skills and collaboration between workers and with patients. In particular a team approach is required to respond to the needs of individuals with chronic conditions and to address challenges in public health. Therefore health care employers and managers need to pay attention to building teams if they are to meet the challenges and targets of the future. Care for patients with chronic conditions must be organized and coordinated over time among providers and across settings, sharing power with patients and working with community groups. Outcomes will then improve, asserts the WHO in a related report (WHO, 2005). It argues that health care providers must work interdependently, demonstrating mutual respect, trust, support and appreciation of each discipline’s unique contribution. They must reconcile abstract notions of ‘‘public health’’ while responding to patients’ pressing needs and concerns. The report enunciates core competencies required for working with patients with chronic conditions: patient-centred care; partnering; quality improvement; information and communication technology; and a public health perspective. To dismiss these reports as merely re-treading familiar ground would be to miss their point. The force of their argument lies in the broad consensus of informed opinion that they represent, endorsed by the evidence that they muster. The case for concerted action is compelling and the challenge for readers of this Journal plain: to demonstrate how interprofessional education and practice development can and does help to deliver the required outcomes, as another WHO report argued so persuasively almost 20 years ago (WHO, 1988). We have learned much during the intervening years about means to ends in interprofessional education, which may well help to realize the WHO goals. But our credibility, and our capacity to respond to the needs where they are greatest, depends crucially upon our readiness, coming as we do overwhelmingly from developed countries, Journal of Interprofessional Care, January 2007; 21(1): 1 – 2

Supporting Family Caregivers in Stroke Care A Review of the Evidence for Problem Solving

Background and Purpose— Teaching effective problem-solving skills to family caregivers of patients with chronic disease has been shown to be useful for promoting physical and psychosocial well-being. However, the use and effectiveness of problem solving for supporting caregivers in stroke care has not been reviewed. This article aims to identify and review studies that have examined the effectiveness of teaching problem solving skills to caregivers in stroke care, highlight gaps in the evidence base, and recommend avenues for additional research. Methods— A structured review of literature identified from nursing, medicine, and psychology databases from 1970 to 2004 was conducted. Eleven articles reporting the development or evaluation of effective problem-solving interventions for caregivers of patients with stroke were critically appraised using recognized quality criteria. Results— The results of this review show that the strength of evidence for problem-solving interventions for caregivers of stroke patients is limited. Because some studies used small samples and varied methods and interventions, making a comparison was difficult. Caregivers’ problem-solving abilities were rarely measured, and the theoretical concepts and framework underpinning most studies were unclear. Conclusions— Evidence from the review suggests a need to additionally study the link between theoretical concepts of effective problem solving and outcomes using standardized measures and to examine also the processes involved in implementing the intervention using multimethod designs, including both quantitative and qualitative approaches.

Mainstreaming interprofessional education in the United Kingdom: A position paper

Summary Interprofessional education (IPE) is being built into the mainstream of professional education for all health and social care professions throughout the United Kingdom (UK) driven by the Labour Government elected in 1997, coincidentally the year that this Journal hosted the first All Together Better Health conference in London. The incoming government prioritized pre-qualifying IPE to be provided in partnership by universities and service agencies supported regionally by workforce development confederations, later absorbed into strategic health authorities (SHAs), and centrally by educational, professional and regulatory bodies. Ambitious agenda for pre-qualifying IPE set by government are being tempered by realistic assessment of current outcomes borne of experience and corroborated by evidence. This paper suggests some ways to ease constraints and improve outcomes, but emphasizes the need to generate continuing interprofessional learning opportunities that build on the basics. It argues that accumulating experience and evidence must be brought to bear in formulating criteria for the approval and review of IPE within regulatory systems for professional education. Can IPE be sustained within mainstream professional education once initial enthusiasm ebbs and earmarked funds run dry? That is the issue.

Management of knee osteoarthritis in primary care: Pain and depression are the major obstacles☆

OBJECTIVES Osteoarthritis (OA) management is a challenge, as OA consists of a spectrum of pathologies requiring a multifaceted treatment approach. Patient education programmes (PEP) are attractive, as they may be cost effective and potentially efficacious. The goals of the study were to determine what may hinder the efficacy of a PEP for knee OA by determining the relevance of depression, pain, disease knowledge and physical ability in patients to their response to a PEP. METHODS Clinical and demographic data relating to 170 patients who completed a trial of a PEP were analysed to determine how they interrelate during patient management. RESULTS All patients showed a progressive decrease in mental health over the duration of the study (P<.001). Greater pain was associated with reduced coping, increased depression and reduced physical ability (P<.05). Women were more likely to experience disability (P<.05). Disability was associated with reduced ability to cope, increased depression and the experience of more pain (P<.05). Subjects with a Caucasian background were significantly (P<.05) more likely to possess knowledge of OA than other ethnic groups. The lowest knowledge group experienced more pain; the highest knowledge group was coping better and had less depression (P<.05). CONCLUSION A complex interrelationship between depression, pain, disease knowledge, and physical ability in patients with knee OA has been demonstrated. Specifically, the treatment of depression and pain may be paramount to the successful treatment of knee OA, and these factors should be considered in each patient and management priorities made.

World Health Organization Announcement

Co-Chair, WHO Study Group on Interprofessional Education and Collaborative Practice and Chief Scientist for Nursing & Midwifery, Department of Human Resources for Health, World Health Organization, Geneva, Switzerland, Co-Chair, WHO Study Group on Interprofessional Education and Collaborative Practice; Principal and Professor Emeritus, College of Health Disciplines, University of British Columbia, Vancouver, Canada; Project Lead, Canadian Interprofessional Health Collaborative, Project Manager, WHO Study Group on Interprofessional Education and Collaborative Practice, Department of Human Resources for Health, World Health Organization, Geneva, Switzerland

Integration or pragmatic coalition? An evaluation of nursing teams in primary care

Changing structures and organisations in primary care raise questions about the role and fit of traditional nursing disciplines. This paper discusses recent findings from an evaluation of integrated nursing teams. The study design used a mixed method approach measuring workload activity of health visitors, practice nurses and district nurses, through time diaries; and teamwork using the Primary Care Teamwork Questionnaire, in conjunction with semi-structured interviews exploring the views of key stakeholders and the nurses themselves. The main themes arising from the interviews are discussed, taking account of the findings from the assessment of workload and teamwork questionnaire. The key themes addressed are implementation of change, shifting role boundaries, communication and teamwork. The findings indicate that this type of organisational change is concerned predominately with structure, professional and organisational issues rather than patient care. In the teams studied the opportunity of integration led to a pragmatic coalition that encouraged its members to plan, execute and manage change by themselves, according to a vague definition rather than a patient focused agenda. In order to ensure a quality nursing service and avoid old historical rivalries this needs to be addressed as nursing teams are reconfigured in primary care groups.

Learning together in medical and nursing training: aspirations and activity

Policy documents about service innovation, education priorities and professional development exhort professions to learn together and work collaboratively. However, the literature suggests that the existence of shared learning in medical and nursing pre‐qualifying education is patchy.

Patient compliance - whose responsibility?

This paper focuses on general practitioner and district nurse knowledge of prescribed drugs taken by their elderly patients, and the evaluation of a method of improving that knowledge by a patient held drug guide. Serious differences were identified in the knowledge of doctors, nurses and patients about drugs. The drug guide was associated with an improvement in patient knowledge of drugs as well as a reduction in disagreements between doctors and nurses. A key issue addressed is patient culpability in compliance. It is argued that this is a simplification which overlooks important factors such as inadequate communication and lack of knowledge on the part of doctors and nurses as well as the difficulties the patient may have with the regime.

Emotions at work: what is the link to patient and staff safety? Implications for nurse managers in the NHS

AIMS This paper sets the discussion of emotions at work within the modern NHS and the current prioritisation of creating a safety culture within the service. BACKGROUND The paper focuses on the work of students, frontline nurses and their managers drawing on recent studies of patient safety in the curriculum, and governance and incentives in the care of patients with complex long term conditions. METHODS The primary research featured in the paper combined a case study design with focus groups, interviews and observation. RESULTS In the patient safety research the importance of physical and emotional safety emerged as a key finding both for users and professionals. In the governance and incentives research, risk emerged as a key concern for managers, frontline workers and users. CONCLUSION The recognition of emotions and the importance of emotional labour at an individual and organizational level managed by emotionally intelligent leaders played an important role in promoting worker and patient safety and reducing workplace risk. IMPLICATIONS FOR NURSE MANAGERS Nurse managers need to be aware of the emotional complexities of their organizations in order to set up systems to support the emotional wellbeing of professionals and users which in turn ensures safety and reduces risk.

A portrait of district nursing: its contribution to primary health care

This paper explores the role and contribution of district nursing within primary health care. Examples of how this service is organised within different health care systems are used to discuss the context-dependent nature and challenges of the work. By drawing on UK policy change, health priorities and recent research into district nursing, the paper concludes that, in attempting to deal with the challenges of health care in the 21st century, the significance and potential of district nursing services are frequently overlooked. It is recommended that a research strategy for district nursing should build on the professions comprehensive understanding of the needs of families and communities and should aim to provide evidence for practice that will further improve patient and client outcomes.