I am chair of Health Services Research at the University of Southampton, Executive Editor of the International Journal of Nursing Studies. From 2006 to 2010 I was Director of England's National Nursing Research Unit. I’m interested in the impact of change in the organisation, management and composition of the healthcare workforce on both patient and staff outcomes. Linked to this is an interest in quality measurement and in particular using outcome data to improve practice. My current or recent work includes the RN4CAST study – an international study being undertaken by a consortium of 13 countries in Asia, Africa, Europe and the united States – which is working with professor Linda Aiken to replicate and extend her seminal studies on the link between nurse staffing and mortality and a series of studies exploring links between nurse staffing and quality and outcomes in general practice. Amongst other on-going projects I’m also currently working with the Health Quality Council of Saskatchewan in Canada, to evaluate the Productive ward programme and the Health Quality Improvement Partnership in England to develop a national audit of nutritional care.
Abstract: Objective
Several systematic reviews have suggested that greater nurse staffing as well as a greater proportion of registered nurses in the health workforce is associated with better patient outcomes. Others have found that nurses can substitute for doctors safely and effectively in a variety of settings. However, these reviews do not generally consider the effect of nurse staff on both patient outcomes and costs of care, and therefore say little about the cost-effectiveness of nurse-provided care. Therefore, we conducted a scoping literature review of economic evaluation studies which consider the link between nurse staffing, skill mix within the nursing team and between nurses and other medical staff to determine the nature of the available economic evidence.
Design
Scoping literature review.
Data sources
English-language manuscripts, published between 1989 and 2009, focussing on the relationship between costs and effects of care and the level of registered nurse staffing or nurseâphysician substitution/nursing skill mix in the clinical team, using cost-effectiveness, cost-utility, or costâbenefit analysis. Articles selected for the review were identified through Medline, CINAHL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and Google Scholar database searches.
Review methods
After selecting 17 articles representing 16 unique studies for review, we summarized their main findings, and assessed their methodological quality using criteria derived from recommendations from the guidelines proposed by the Panel on Cost-Effectiveness in Health Care.
Results
In general, it was found that nurses can provide cost effective care, compared to other health professionals. On the other hand, more intensive nurse staffing was associated with both better outcomes and more expensive care, and therefore cost effectiveness was not easy to assess.
Conclusions
Although considerable progress in economic evaluation studies has been reached in recent years, a number of methodological issues remain. In the future, nurse researchers should be more actively engaged in the design and implementation of economic evaluation studies of the services they provide.
Abstract: Background: Health care professionals worldwide attend courses and workshops to learn evidence-based medicine (EBM), but evidence regarding the impact of these educational interventions is conflicting and of low methodologic quality and lacks generalizability. Furthermore, little is known about determinants of success. We sought to measure the effect of EBM short courses and workshops on knowledge and to identify course and learner characteristics associated with knowledge acquisition. Methods: Health care professionals with varying expertise in EBM participated in an international, multicentre before–after study. The intervention consisted of short courses and workshops on EBM offered in diverse settings, formats and intensities. The primary outcome measure was the score on the Berlin Questionnaire, a validated instrument measuring EBM knowledge that the participants completed before and after the course. Results: A total of 15 centres participated in the study and 420 learners from North America and Europe completed the study. The baseline score across courses was 7.49 points (range 3.97–10.42 points) out of a possible 15 points. The average increase in score was 1.40 points (95% confidence interval 0.48–2.31 points), which corresponded with an effect size of 0.44 standard deviation units. Greater improvement in scores was associated (in order of greatest to least magnitude) with active participation required of the learners, a separate statistics session, fewer topics, less teaching time, fewer learners per tutor, larger overall course size and smaller group size. Clinicians and learners involved in medical publishing improved their score more than other types of learners; administrators and public health professionals improved their score less. Learners who perceived themselves to have an advanced knowledge of EBM and had prior experience as an EBM tutor also showed greater improvement than those who did not. Interpretation: EBM course organizers who wish to optimize knowledge gain should require learners to actively participate in the course and should consider focusing on a small number of topics, giving particular attention to statistical concepts.
Abstract: There is considerable evidence of an association between nurse staffing levels and patient outcomes. The evidence has been used to support calls for mandatory nurse-patient ratios although the precise significance of the relationship remains unclear. In this article, the evidence is examined to establish what is known and, crucially, what is not known about this relationship.
Notes: Griffiths, Peter xD;England xD;Nursing management (Harrow, London, England : 1994) xD;Nurs Manag (Harrow). 2009 Oct;16(6):22-3.
Abstract: AIM: This paper is a report of a study to determine whether individualized performance feedback improved nurses' and physiotherapists' knowledge and practice of tracheal suctioning. BACKGROUND: Nurses' knowledge and practice of tracheal suctioning is often deficient. Whilst teaching has been shown to improve suctioning knowledge and practice, this is not sustained over time. METHOD: Ninety-five qualified healthcare professionals (nurses and physiotherapists) in two acute hospitals were randomly allocated to receive either individualized performance feedback or no additional feedback after a standardized lecture and practical demonstration of tracheal suctioning. Randomization was stratified by profession, seniority and site. Data were collected in 2005 in a clinical setting involving patients and a simulation setting. The outcome measures were knowledge and practice of tracheal suctioning, assessed by self-completion questionnaire and structured observation. RESULTS: In both settings, intervention groups performed statistically significantly better in terms of knowledge (P = 0.014) and practice (P = 0.037) at final follow-up. Those who received performance feedback had statistically significantly higher knowledge (P = 0.004) and practice (P < 0.01) scores than the control group. For practice, there was also a relationship between professions (P < 0.01), with physiotherapists performing better than nurses overall, and an interaction between group and setting (P < 0.01), with performance feedback showing a stronger positive effect in the simulation setting. CONCLUSION: Retention of knowledge and tracheal suctioning practice is improved when training is followed up by tailored feedback on performance. Further research would shed light on how long such improvements are sustained, and whether the improvements seen in a simulated setting can be generalized to clinical settings.
Notes: Day, Tina xD;Iles, Nicola xD;Griffiths, Peter xD;England xD;Journal of advanced nursing xD;J Adv Nurs. 2009 Jul;65(7):1423-31. Epub 2009 Mar 30.
Abstract: Evidence indicates that suicide rates are higher in South Asian women in the United Kingdom compared with other ethnic groups, suggesting increased vulnerability to attempted suicide and mental distress in these women. Specialist Community Public Health Nurses (SCPHNs, including health visitors) are in an ideal position to assess such risk. The objectives are to determine whether SCPHNs assess known risk factors for depression, self-harm, and suicide during initial contact with South Asian mothers in London; the extent to which these risk factors are documented in the nursing records; and whether their assessments of South Asian women differ from those of other ethnic groups. Structured content analysis of semistructured interviews with 8 SCPHNs and analysis of 60 matched pairs of SCPHN records were carried out in an inner London community. The results revealed that SCPHNs assessed general risk factors for postnatal depression and some culture-specific factors when assessing South Asian mothers. Documentation of risk factors was under-represented in the SCPHN records and there was a significant difference between the documented risk factors for South Asian women and women from other ethnic groups. While SCPHNs understood some aspects of South Asian culture, service improvements must be made to ensure better care provision.
Notes: Baldwin, Sharin xD;Griffiths, Peter xD;Research Support, Non-U.S. Gov't xD;United States xD;Public health nursing (Boston, Mass.) xD;Public Health Nurs. 2009 May-Jun;26(3):277-89.
Notes: Griffiths, Peter xD;Maben, Jill xD;England xD;Nursing standard (Royal College of Nursing (Great Britain) : 1987) xD;Nurs Stand. 2009 Jan 21-27;23(20):62-3.
Abstract: AIM: To develop an early career job satisfaction instrument that is valid and reliable across the four UK nursing branches. BACKGROUND: Contemporary instruments are required to measure nurse job satisfaction and to explore potential links with quality of care and retention. METHOD(S): Factor analysis was used to explore and test the stability of job satisfaction components across branches and over time. RESULTS: Seven components (client care, staffing, development, relationships, education, work-life interface, resources) of job satisfaction were identified common to the adult, child and mental health branches that explained over 70% of the variance. The factor structure remained reasonably stable across time within each branch. Some differences between branches emerged at 6 and 18 months. The instrument has similarities and differences with existing generic and nursing facet job satisfaction scales. CONCLUSION: Findings support a generic instrument that can be used to measure the job satisfaction of adult, child and mental health nurses in their early career. IMPLICATIONS FOR NURSING MANAGEMENT: The instrument could be used for appraisal, annual staff surveys, for understanding retention locally and nationally, as an early warning system to identify organizational problems and to measure the impact of policies over time.
Notes: Murrells, Trevor xD;Robinson, Sarah xD;Griffiths, Peter xD;Department of Health/United Kingdom xD;Research Support, Non-U.S. Gov't xD;England xD;Journal of nursing management xD;J Nurs Manag. 2009 Jan;17(1):120-34.
Abstract: This scoping review sought evidence about organisational and management factors affecting infection control in general hospital settings. A literature search yielded a wide range of studies, systematic reviews and reports, but high quality direct evidence was scant. The majority of studies were observational and the standard of reporting was generally inadequate. Positive leadership at ward level and above appears to be a prerequisite for effective action to control infection, although the benefits of good clinical leadership are diffused by supervision of large numbers of staff. Senior clinical leaders need a highly visible presence and clear role boundaries and responsibilities. Team stability and morale are linked to improved patient outcomes. Organisational mechanisms for supporting training, appraisal and clinical governance are important determinants of effective practice and successful change. Rates of infection have been linked to workload, in terms of nurse staffing, bed occupancy and patient turnover. The organisational characteristics identified in the review should be considered risk factors for infection. They cannot always be eliminated or avoided completely, but appropriate assessment will enable targeted action to protect patients.
Abstract: Background Increasing mobility of healthcare professionals has led to concerns that certain countries or regions are depleted of sufficient staff to meet healthcare needs. In formulating appropriate strategies to ensure better retention locally, human resource managers are hindered by lack of information about migration patterns.Purpose and aims Purposes included studying movement of diploma nurses qualifying in England and contributing to literature on developing methods for obtaining migration data. Specific aims ascertained: regional variation in retention of locally trained nurses; associations between nurses' profile and retention in training region; and impact on each region of inter-regional movement of nurses.Method Questionnaires sent to a nationally representative cohort of adult branch nurses at qualification (n=1596) and at subsequent intervals thereafter provided data on all employment and other activities and geographical location of each. Event histories constructed from chart data were used to analyse length of retention in region of training and movements between regions. Retention was operationalised through developing the construct `engagement with nursing'.Results Older entrants and those with children were more likely to nurse in their training region than younger and childless counterparts. Regions differed in retention of locally trained nurses and in the impact on their diplomate workforce of inter-regional movement. Regional variations were insufficiently explained by differences in nurses' profiles; hence influences of regional characteristics were also considered.Conclusion Retention strategies should include maintaining the policy of recruiting greater diversity of entrants, particularly mature entrants and those who have children. In developing local strategies, each region needs: information about retention of different components of their workforce; and an understanding of how regional characteristics can facilitate or constrain retention. National and international workforce organisations need to plan how best to obtain accurate and comparable nurse migration data.
Abstract: BACKGROUND: The Nursing led inpatient Unit (NLU) is one of a range of services that have been considered in order to manage more successfully the transition between hospital and home for patients with extended recovery times. This is an update of an earlier review published in The Cochrane Library in Issue 3, 2004. OBJECTIVES: To determine whether nursing-led inpatient units are effective in preparing patients for discharge from hospital compared to usual inpatient care. SEARCH STRATEGY: We searched The Cochrane Library, the Specialized Register of the Cochrane Effective Practice and Organisation of Care (EPOC) group, MEDLINE, CINAHL, EMBASE, BNI and HMIC databases. Citation searches were undertaken on the science and social science citation indices. Authors were contacted to identify additional data. The initial search was done in January 2001. The register search was updated in October 2006, the other database searches were updated in November 2006 and the citation search was run in January 2007. SELECTION CRITERIA: Controlled trials and interrupted time series designs that compared the NLU to usual inpatient care managed by doctors. Patients over 18 years of age following an acute hospital admission for a physical health condition. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed study quality. MAIN RESULTS: Ten random or quasi-random controlled trials reported on a total of 1896 patients. There was no statistically significant effect on inpatient mortality (OR 1.10, 95% CI 0.56 to 2.16) or mortality to longest follow up (OR 0.92, 95% CI 0.65 to 1.29) but higher quality studies showed a larger non-significant increase in inpatient mortality (OR 1.52, 95% CI 0.86 to 2.68). Discharge to institutional care was reduced for the NLU (OR 0.44 95% CI 0.22 to 0.89) and functional status at discharge increased (SMD 0.37, 95% CI 0.20 to 0.54) but there was a near significant increase in inpatient stay (WMD 5.13 days 95% CI -0.5 days to 10.76 days). Early readmissions were reduced (OR 0.52 95% CI 0.34 to 0.80). One study compared a NLU for the chronically critically ill with ICU care. Mortality (OR 0.62 95% CI 0.35 to 1.10) and length of inpatient stay differ did not differ (WMD 2 days, 95% CI 10.96 to -6.96 days). Early readmissions were reduced (OR 0.33 95% CI 0.12 to 0.94). Costs of care on the NLU were higher for UK studies but lower for US based studies. AUTHORS' CONCLUSIONS: There is some evidence that patients discharged from a NLU are better prepared for discharge but it is unclear if this is simply a product of an increased length of inpatient stay. No statistically significant adverse effects were noted but the possibility of increased early mortality cannot be discounted. More research is needed.
Abstract: Abstract Objectives To determine whether transfer to a nursing-led inpatient unit (NLIU) prior to discharge from hospital can improve clinical outcome and reduce length of stay and readmission rate for medically stable post-acute patients assessed as requiring inpatient care. Method Retrospective secondary data analysis of individual patient data (n = 471) from a programme of three, purposefully replicated, pragmatic randomized controlled trials. Patients were referred to the NLIU by their consultant (attending doctor/surgeon) for nursing-led subacute/post-acute care and randomly allocated to a treatment group for planned transfer to the NLIU for the remainder of their hospital stay or to a control group for traditional consultant-led care in acute wards. Outcome measures were physical function (Barthel Index), length of stay, discharge destination, mortality, psychological well-being (General Health Questionnaire-12), health-related distress (Nottingham Health Profile Distress Index), incidence of complications and readmission within 7, 28, 90 and 180 days. Results Patients allocated to the NLIU showed greater improvement in physical function (P < 0.001) and were more likely to be discharged to live independently in the community than controls [odds ratio (OR) = 0.42, P = 0.001] although they spent longer in hospital (P = 0.003). They showed greater improvement in psychological well-being (P = 0.001) and health-related distress (P = 0.025) and a lower incidence of pressure ulcers (OR = 0.33, P = 0.011). Conclusion Transfer to a NLIU can have a beneficial effect on outcomes of care for post-acute patients with complex health and social needs although length of stay is longer. This study strengthens the evidence of effectiveness of the NLIU model of care and provides evidence of effectiveness of post-acute and subacute models of care.
Abstract: Objective A Japanese version of the Rosenberg Self-Esteem Scale (RSES) was developed through the forward-backward translation procedure.Methods Married couples consisting of a native English speaker and a native Japanese speaker acted as translators to enhance the representativeness of language in the target population. Multiple translations were produced, and a panel of reviewers identified problems in conceptual and semantic equivalence between the original scale and the translated version. The Japanese version was altered accordingly with reference to alternate Japanese forms from the original English to Japanese translations. The altered translation was again retranslated into English, and problematic differences were checked. This forward-backward process was repeated until satisfactory agreement had been attained. The RSES was administered to 222 native English speakers, and the developed Japanese version (RSES-J) was administered to 1320 native Japanese speakers.Results Factor analysis revealed nearly identical factor structure and structural coefficients of the items between two sets of data. Target rotation confirmed the factorial agreement of the two scales in different cultural groups. High Cronbach's [alpha] coefficients supported the reliability of test scores on both versions.Conclusion The equivalence between the RSES and the RSES-J was supported in this study. It is suggested that the RSES and the RSES-J are potential tools for comparative cross-cultural studies.
Abstract: OBJECTIVES: To review the accuracy of brief screening tools for autism in pre-school children. DESIGN: Systematic review of diagnostic accuracy studies. DATA SOURCES: Medline, Embase, Cinahl and Psychlit plus references of identified papers and contact with authors. SUBJECTS: Children and infants aged 5 years or less without a prior diagnosis of autism or pervasive development delay. INTERVENTIONS: Tools/checklists appropriate for use in screening for autism in primary care settings. OUTCOME MEASURES: Sensitivity, specificity, positive and negative predictive value of screening tools and likelihood ratios relative to a diagnostic assessment made using either DSM-III/IV or ICD 10 diagnosis. RESULTS: Three studies considering two tools were identified. The CHecklist for Autism in Toddlers (CHAT) was tested on an appropriate population sample with moderate long-term follow-up but demonstrated poor sensitivity and positive predictive value. Weaker evidence suggested that the Modified CHecklist for Autism in Toddlers (M-CHAT) had high sensitivity but follow-up was of shorter term and less comprehensive. CONCLUSIONS: The CHAT demonstrated a level of sensitivity unlikely to be useful for population screening purposes, however, its high specificity suggests it has utility in secondary screening. The M-CHAT is a parent only report and might be more sensitive, and therefore appropriate for population screening. However, full conclusions regarding its accuracy cannot be drawn until follow-up data has been collected.
Abstract: Pain is a prevalent problem in community care and there is evidence that knowledge and understanding of pain management can be lacking among health professionals, leading to under-treatment. This mini-review aimed to assess the effectiveness of interprofessional education on health professionals' pain documentation and on the pain intensity reported by patients. A search of key databases identified two randomized controlled trials and two quasi-experimental studies. Two studies assessed change in pain documentation following interprofessional education; one revealed a statistically significant improvement and another indicated 29% increase in documentation of pain assessments. Two studies demonstrated no significant changes in patient outcomes, while the other revealed significant improvements. However, integration of the results was not possible because of the various methods of measurement used by the different researchers. Although broadly supportive of interprofessional education, the evidence is not helpful in determining the best way of improving pain management in the community.
Abstract: This mini-review aimed to systematically review the evidence on the effect of catheter valves compared to free drainage into a bag for patients with indwelling urinary catheters. Data sources used were Medline, British Nursing Index, CINAHL, Ahmed, EMBASE, EBM Reviews, the Cochrane Library and reference lists of relevant papers. Papers considered were controlled trials comparing the use of a catheter valve with the catheter bag that were published as a full report, or detailed abstract (containing sufficient information to critique) in Dutch, German or English. Two studies with a total of 122 subjects were identified. The main outcome measures considered were reduction of incidence of bladder spasm and urinary tract infection (UTI) and patient preference. No statistically difference in the incidence of bladder spasm or UTI was demonstrated but patients showed a clear preference for the valve. Further research into catheter valves is needed, with larger study groups, which include housebound male and female patients, and longer follow-up period.
Abstract: This mini-review provides an overview of evidence regarding the effectiveness, costs and patient experience relating the intermediate care in nursing-led units. The core of the evidence is derived from a high quality systematic review of 10 controlled trials involving 1669 patients. Other studies on patient experience and costs not included in the review are also considered. There is some evidence of patient benefit in the short term in terms of independence. However this does not seem to be sustained. Total inpatient stay is increased and hence overall costs of the initial episode are increased with no evidence of longer-term savings. The approach seems to be broadly acceptable to patients. Provided it is not simply used to house patients who cannot benefit, nursing-led units may be a viable alternative to acute care for some patients. However, the core features of the units that provided the evidence must be considered in order to maximize the potential for delivering quality care.
Abstract: BACKGROUND: Specialist nurses are being promoted as a means of improving the health care provided to people with multiple sclerosis (MS). OBJECTIVES: To identify the impact of a programme of MS specialist nurses on MS health care provision and on the health and well-being of peoople with MS. DESIGN: A quasi-experimental design comparing an intervention group in which new MS nurse posts were installed with a control group that had no MS nurse posts. SETTING: Six neurological services in four English regions. PARTICIPANTS: Seven hundred and fifty-three of the 1510 people invited to participate returned completed questionnaires at baseline. Follow-up of participants was 82% with 616 patients participating in the main outcome analysis. METHOD: Data were collected prospectively before the appointment of the MS nurses and then at 12 and 24 months. Data were collected via a postal questionnaire comprising questions related to care processes (information provision and care quality) and health outcome measures, hospital admissions, MS complications, health-related quality of life (SF36) and disease impact (MS Impact Scale-29). Analysis repeated measures in CAT MOD for process variables and ANCOVA to longest follow-up for outcome measures. RESULTS: Information provision was higher in the intervention group (68% (n=153) compared to 53% (n=98) at 24 months) but no significant improvement was observed in information provision through time compared to the control group. There was an increase in the availability of a contact person in the intervention group, at 24 months 83% (n=42) had a contact person compared to 44% in the control (p=0.01). The only significant finding in relation to MS complications was a reduction of 17% in the incidence of pressure ulcers in the intervention sites compared to a 3% reduction in the control (p<0.001). In relation to the disease and health-related quality of life measures, the intervention group showed a small but significant (p<0.05) worsening in the physical and symptom scales of the SF36 compared to the control (mean differences: physical function -2.81, CI -5.45 to -0.1; bodily pain -4.09, CI -7.2 to -0.9; general health -5.35, CI -8.1 to -2.5; and energy and vitality -2.82, CI -5.5 to -0.1). No differences were observed in relation to disease impact or psychosocial well-being, although a relative benefit in mental health (with a 7.8 point advantage on the SF36 mental health scale, p=0.04) was observed in some of the intervention sites for people with relapsing/remitting MS. CONCLUSION: The specialist nurse programme was found to impact positively on the provision of MS-related health care. However, there was very limited evidence that the programme led to any improvements in disease-related problems, impact or health-related quality of life, These findings were in part explained by the inherent difficulties of measuring effects in evaluations of complex phenomena such as a nursing role. The deterioration observed in the intervention group on the physical outcome measures was explained by a selection bias in which people with worsening health were more likely to seek contact with a specialist nurse. It is contended that future research in this area may be better directed toward identifying specific interventions that nurses and other health professionals might employ in addressing the many problems confronting people with MS.
Abstract: OBJECTIVE: To explore the interrelationship between a number of common multiple sclerosis-related problems and health-related quality of life independent of the effect of physical disease impact. DESIGN: A cross-sectional postal survey. SETTING: The study was conducted in seven treatment centres within England. SUBJECTS: Nine hundred and twenty-nine people with multiple sclerosis. MEASURES: The severity of the multiple sclerosis problems (fatigue, pain, urinary incontinence, bowel, depression, pressure ulcers, sexual and employment problems) was assessed using 5-point self-report ordinal scales. Disease impact was measured using the Multiple Sclerosis Impact Scale-29. Health-related quality of life was measured using the 36-Item Short Form Health Survey, version 2 (SF-36). The relationship between the problems, disease impact and health-related quality of life was determined using multivariate analysis of covariance. RESULTS: Seventy four per cent of the sample experienced four or more of the selected problems. The extent and severity of problems increased with the level of disease impact (P< 0.001). Fatigue, pain, employment, depression and relationship problems were all found to have negative effect on the SF-36 scales independent to the effect of disease impact. SF-36 scores were most compromised in patients experiencing multiple problems. The data suggest an interdependent relationship between depression, fatigue and pain. CONCLUSION: The data suggest that many multiple sclerosis complications negatively affect health-related quality of life, independent of the effect of overall disease impact.
Abstract: This paper discusses the significance of postmodernism for healthcare practice, specifically the discourse known as 'evidence-based practice'. It considers two texts, both of which present postmodern analyses of contemporary issues. One text presents a deconstruction of evidence-based practice in an attempt to reveal its 'true' nature, which is portrayed as one that does not respect research paradigms other than the randomised controlled trial, merely pays lip service to expertise and fails to connect with the real nature of clinical practice. The second text considers the accusation that absolute relativism implied by postmodern approaches may permit an 'anything goes' mentality and provide succour to those advocating unacceptable practices. A 'defence' of postmodernism in relation to the accusation that it encourages holocaust denial is used to consider further the nature and limitations of postmodern critiques of evidence-based practice. This review concludes that postmodernism fundamentally challenges the apparent 'objectivity' of evidence-based practice but it does not challenge the fundamental rules for acquiring and testing evidence. Rather it is the selection of questions to be asked and answered by evidence-based practice/practitioners that is the true limitation. This is the ground upon which fruitful argument can be had about the significance of evidence without undermining the requirement that there be evidence and standards to judge such evidence.
Abstract: In vitro studies show that tea tree oil is capable of killing methicillin-resistant Staphylococcus aureus (MRSA) in a laboratory setting. This review of randomized controlled trials (RCTs) was undertaken to find out whether it is effective at eradicating MRSA colonization compared to standard mupirocin-based regimens in colonized patients. A wide range of databases and internet sources were searched to identify published and unpublished studies. Two RCTs were found that researched the effectiveness of tea tree oil preparations against MRSA. One small RCT (n = 30) showed a large but non-significant improvement at eradicating MRSA compared to traditional treatment, whereas a larger study (n = 224) demonstrated little difference in rates of eradication overall (41% for tea tree and 49% for mupirocin, p = 0.286). However, the larger study found that those with nasal colonization receiving a tea tree regimen were more likely to remain colonized with MRSA in the nose (absolute risk increase 31%, p<0.001). Currently there is insufficient evidence to support the routine use of tea tree oil in clinical practice for eradication of MRSA colonization.
Abstract: This article explores the meaning and significance of 'self-assessment', a term that is increasingly being used in relation to developments affecting community practice. Self-assessment for health and social care needs has been used over a considerable period of time and for purposes as diverse as case finding for depression to assessment of housing options. Self-assessment has usually involved the use of short scales and questionnaires, but it can involve the use of physiological tests (such as testing urine for glucose) or complex, computerized decision-support systems. Although often explored as a simple means for extending the 'reach' of professional assessments (e.g. mass screening) and ensuring 'appropriate' use of health services (e.g. self-care algorithms), self-assessment is increasingly being advocated as a means of actively involving and empowering service users. However, a recent review of the topic (Griffiths et al, 2005) revealed the complexity of the topic and the pitfalls of a simplistic approach to self-assessment, which those engaged in developing the process should bear in mind.
Abstract: OBJECTIVES: The long-term use of strong opioid analgesics among chronic noncancer pain (CNCP) patients remains controversial because of concerns over problematic drug use. However, previous surveys suggest that this is not necessarily the case. Therefore, we designed a controlled study to generate evidence in support of these findings. PATIENTS/SETTING: Ten CNCP patients attending the pain clinic in a district general hospital had been taking an average daily dose of 40 mg controlled-release morphine sulphate (mean 40, range 10-90, SD 21 mg), for an average of 2 years (mean 2.175, range 2-2.25, SD 0.2 years). DESIGN: Randomized, double-blind, placebo controlled cross-over study. The study was based on the premise that abrupt cessation of opioid drugs is most likely to highlight problematic use and the consequent inability to stop using opioids. Morphine was substituted with placebo for 60-hour periods to compare the effects of abstinence with those of continued use. Assessment of morphine cessation and abstinence effects was through direct observation, physiological measurements, questionnaire responses, and Brief Pain Inventory scores. RESULTS: Following cessation and abstinence, there were no indications of psychological dependence or drug craving, but there was evidence of the detrimental effects of pain intensity on activity, mood, relationships, sleep, and enjoyment of life. Three patients (30%) reported opioid drug withdrawal symptoms. Pharmacokinetic data demonstrated compliance with abstinence by all patients. CONCLUSION: The results suggest the existence of a group of CNCP patients whose long-term opioid consumption can be beneficial and remain moderate without them suffering from the consequences of problematic opioid drug use.
Abstract: Objective: In order to determine whether post-acute intermediate care in nursing-led inpatient units (NLUs) is effective in preparing patients for discharge from hospital we conducted a systematic review of the evidence.Review methods: The Cochrane Library, Effective Practice and Organisation of Care specialist register, Medline, Cinahl, Embase, British Nursing Index and the HMIC databases were searched for all available dates up to mid-2003. The science and social science citation indices were searched for papers that cited key works. Authors of papers were asked to identify additional research. Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time-series designs that compared the NLU to usual post-acute inpatient care for adults were included in the review. Studies were assessed for quality. Statistical meta-analysis on the results of controlled trials was performed. Sensitivity analyses were conducted to determine the impact of methodological quality on conclusions.Outcomes: Outcomes considered were mortality, institutionalisation after discharge, functional status early readmission, length of inpatient stay and cost.Results: Nine random or quasi-random controlled trials involving 1669 patients were reviewed. Quality was variable. The mean age of patients in all studies was over 70 years. There was no statistically significant difference in inpatient mortality between NLU and usual inpatient care (OR 1.10, 95% CI 0.56-2.16). The NLU was associated with reduced odds of discharge to institutional care (OR 0.44 95% CI 0.22-0.89), better functional status at discharge (SMD 0.37, 95% CI 0.20-0.54) and reduced odds of early readmission (OR 0.52 95% CI 0.34-0.80). Length of stay until discharge home was increased by 5.13 days (WMD) (95% CI-0.5-10.76 days). At longest follow up (3-6 months) there was no statistically significant difference in the proportion of patients in institutional care (OR 0.97, 95% CI 0.60-1.58). The results were not generally sensitive to study quality.Conclusions: The NLU successfully functions as a form of intermediate care, so far there is no evidence of adverse outcome from the lower level of routine medical care. However, more research is required to confirm safety. Patients discharged from NLUs have higher levels of function although it is unclear if the benefit is simply a product of an increased stay. There is no evidence of benefit over the longer term.
Abstract: Objective To evaluate the efficacy of two internet interventions for community-dwelling individuals with symptoms of depression--a psychoeducation website offering information about depression and an interactive website offering cognitive behaviour therapy. Design Randomised controlled trial. Setting Internet users in the community, in Canberra, Australia. Participants 525 individuals with increased depressive symptoms recruited by survey and randomly allocated to a website offering information about depression (n = 166) or a cognitive behaviour therapy website (n = 182), or a control intervention using an attention placebo (n = 178). Main outcome measures Change in depression, dysfunctional thoughts; knowledge of medical, psychological, and lifestyle treatments; and knowledge of cognitive behaviour therapy. Results Intention to treat analyses indicated that information about depression and interventions that used cognitive behaviour therapy and were delivered via the internet were more effective than a credible control intervention in reducing symptoms of depression in a community sample. For the intervention that delivered cognitive behaviour therapy the reduction in score on the depression scale of the Center for Epidemiologic Studies was 3.2 (95% confidence interval 0.9 to 5.4). For the "depression literacy" site (BluePages), the reduction was 3.0 (95% confidence interval 0.6 to 5.2). Cognitive behaviour therapy (MoodGYM) reduced dysfunctional thinking and increased knowledge of cognitive behaviour therapy. Depression literacy (BluePages) significantly improved participants' understanding of effective evidence based treatments for depression (P < 0.05). Conclusions Both cognitive behaviour therapy and psychoeducation delivered via the internet are effective in reducing symptoms of depression.
Abstract: A mini-review (Griffiths, 2002) of double-blind randomized controlled trials (RCTs) was undertaken to assess the long-term effect of lipid lowering treatments (statins versus placebo) in secondary prevention of myocardial infarction (MI). The population sample was adult patients with a history of MI, documented coronary heart disease or coronary artery disease. The Cochrane Library and the database Medline were searched and three RCTs appeared to possess all of the stipulated inclusion and exclusion criteria. The trials all compared statins against a placebo; one trial was of simvastatin--the Scandinavian Simvastatin Survival Study (1994)--and the other two were of pravastatin--the Cholesterol and Recurrent Events Trial (CARE) (Sacks et al, 1996) and Long Term Intervention with Pravastatin Ischaemic Disease (LIPID) (Anon, 1998). The trials demonstrated that statins had a clear and consistent effect in significantly reducing the risk of MI. Overall an approximate decline of 30% in MI was produced from the three trials.
Abstract: The aim of this mini-review was to establish if cleaning, dressing and removing crusts from external fixator or skeletal pin sites affected the risk of infection. A systematic search was conducted using Cochrane, Medline, CINAHL and Embase databases. Inclusion criteria were orthopaedic patients with skeletal pins or external fixator devices applied to either upper or lower limbs. The databases were searched for controlled studies comparing at least one aspect of pin site care (cleansing, dressing or crust removal) with a control group of 'observation only'. Only one study met the inclusion criteria. It focused on cleansing external fixator pin sites. The study included two treatment groups, one using 0.9% normal saline and one using 70% alcohol, and a control group which had no cleansing. While the control group had a more favourable outcome than the treatment groups, there is still insufficient evidence from this one study to recommend no cleansing. It is also important to note that the most frequently recommended solution for cleansing pin sites in UK protocols (0.9% normal saline) had the worst outcome, therefore its efficacy in this population may need to be challenged.
Abstract: BACKGROUND: Effective transition to adult services is required by an increasing number of children with ongoing needs. AIM: To identify practices that promote continuity at transition between child and adult services. METHODS: Systematic examination of the evidence from two search strategies yielding 5319 items. RESULTS: Only three of the 126 appraised items had strong external validity. A large range of different practices, which focused on the service, the young person and the family, were identified. Practices within the service addressed structural, process and outcome components. CONCLUSION: Four transition models are proposed for testing.
Abstract: Practitioners working with patients undergoing chemotherapy regularly encourage them to use acupressure in the form of Sea Bands for the relief of treatment-related nausea and vomiting. This mini-review sets out to uncover and examine the evidence base for this recommendation. A mini systematic review was carried out to identify randomized controlled trials comparing the use of acupressure plus usual care with usual care alone. The population was adult patients receiving cancer chemotherapy. The outcome was nausea or vomiting duration or intensity. Searches on Medline, Embase, AMED, the Cochrane Library, Cancerlit and Cinahl identified two randomized controlled trials involving 482 patients with compared acupressure to no intervention control. The results suggest that acupressure may decrease nausea among patients undergoing chemotherapy but further work is required before conclusively advising patients on the efficacy of acupressure in preventing and treating chemotherapy-induced nausea.
Abstract: This mini-review describes a parent's search for evidence on the relative merits of two commonly used treatments for conjunctivitis. It was conducted in a very limited period of time with access to free databases (Pub Med, Cochrane Library) and only the abstracts of papers. Five relevant studies were identified that compared fusidic acid eye drops to chloramphenicol. Three of the five studies reported no difference in effectiveness between the two preparations with both drugs performing equally well. Two studies undertaken in less-developed countries showed fusidic acid to be far more effective but the cure rate with chloramphenicol was low, suggesting resistance or different causal agents. However, there was some evidence that chloramphenicol was less well tolerated and so fusidic acid may be the drug of choice. The review illustrates that evidence for practice can be found rapidly with access to limited facilities by an appropriately skilled practitioner.
Abstract: There has long been an interest in the use of cranberry, usually as a juice, to prevent and treat urinary tract infections (UTI). This mini-review examined the evidence available using a simple search on an internet-based resource designed to make evidence readily available to practitioners in the South Eastern NHS regions of the UK. The resource, known as KA24, provides access to a range of databases and full text of journal articles. The first stage of the review identified two existing Cochrane Reviews, one examining cranberry as a treatment, the other as prevention. Both concluded that there was insufficient evidence to recommend the use of cranberry in treating UTIs, although some weak research did offer support for cranberry juice in preventing UTIs. A search for further evidence not included in the Cochrane review identified several new reviews and two randomized controlled trials (RCTs) of cranberry as prevention. The reviews were not systematic and came to contradictory conclusions. They were based on a selective reading of the evidence base and gave no criteria for determining the inclusion or validity of studies. One of the RCTs was available for full scrutiny and was appraised as a valid study. Both RCTs found that cranberry (as juice or capsule) significantly reduced the rate of UTI in sexually active women. There is evidence to support the use of cranberry to prevent UTI in some populations but none to support its use as a treatment. [References: 22]
Abstract: ABSTRACT Objectives. Opioid analgesic drugs are sometimes advocated for chronic noncancer pain (CNCP). However, due to the paucity of studies assessing problematic opioid drug use in this population, evidence for such is inconclusive, and this issue remains controversial. This survey assessed problematic drug use among CNCP patients. Patients/Setting. Patients (N=104) prescribed opioids (mean duration of treatment 14.1 months) for severe CNCP at a pain clinic within a National Health Service hospital in London, United Kingdom. Design. A review of pain clinic records to identify CNCP patients who had been prescribed opioids and subsequent assessment of those patients for problematic drug use using a substance use questionnaire. Results. A total of 90 (86.5%) patients reported stopping opioid therapy at some point and, of these, 59 (65%) had ceased opioid therapy permanently. Of those patients who stopped opioids, 13 reported opioid withdrawal symptoms, two with severe and two with very severe symptoms. However, 72.5% of all patients derived benefit from opioids, although 77% of all patients reported opioid side effects. The addiction rate was 2.8%. Conclusion. These findings indicate that opioid therapy for CNCP does not necessarily lead to problematic drug use. Some problematic side effects are likely to be surmountable through appropriate prescribing. Further research is required into the long-term use of opioids in CNCP.
Abstract: BACKGROUND: Multiple sclerosis is a chronic neurological condition demanding a broad range of interventions and support. Multiple sclerosis nurse specialists are emerging as a leading force in providing care to this group of patients. AIM: This review aimed to identify and synthesize the evidence on the role of clinical nurse specialists in meeting the care needs of people with multiple sclerosis. METHODS: A systematic review of the literature addressing the role of the multiple sclerosis nurse specialist was undertaken. The review examined both the appropriateness and effectiveness of the multiple sclerosis nurse specialist role. The content of each item identified in the review was analysed, examining the structure, process and outcomes variables associated with the role. Materials containing an explicit methodology were critically appraised using established schedules and graded as strong, moderate or weak. The data were then synthesized in tables, thematically and using a quasi-judicial approach called the 'System of Reasoning'. FINDINGS: Fifty-five items were examined and most (53%; n = 18) were descriptive in nature. There was insufficient evidence to demonstrate that the multiple sclerosis nurse role makes a difference to care. However, evidence was found to support current descriptions of the role - meaning? and there appeared to be a good fit between the role and the care needs of people with multiple sclerosis. CONCLUSION: A systematic overview of the attributes of the multiple sclerosis nurse role is provided which should help service providers, nurses and other professionals consider how multiple sclerosis nurse specialists roles can contribute to the care of people with this condition. While there is little current evidence of effectiveness for the multiple sclerosis nurse specialist role, there is evidence for its appropriateness, although more rigorous primary research is required to test this.
Notes: 0309-2402 xA;Journal Article xA;Review xA;Review Literature
Abstract: Breastfeeding has a number of benefits for both mother and baby, which appear to increase with longer duration of breastfeeding. The use of pacifiers has been negatively associated with shortened breastfeeding duration. The aim of this review was to determine whether the use of pacifiers actually shortens breastfeeding duration in infants. The Cochrane library, Medline, CINAHL and Embase databases were searched for systematic reviews, randomized controlled trials and cohort studies examining the effect of pacifier use on breastfeeding duration. After applying appropriate inclusion criteria only two cohort studies were identified. In one the overall breastfeeding duration was longer in non pacifier-using infants compared to those given pacifiers (10 months vs. 7.5 months). The mean breastfeeding duration in children who were given pacifiers before 6 weeks of age was 168.5 days compared to 196.0 days for children who had a pacifier introduced later or never. However, there is no evidence to suggest any effect from occasional pacifier use, and it remains unclear whether pacifiers are an independent causal factor for reducing breastfeeding duration in infants.
Notes: England xA;1462-4753 xA;Journal Article xA;Meta-Analysis xA;English
Abstract: Fear of growth retardation may account for the underuse of inhaled corticosteroids in children with asthma, despite compelling evidence of their effectiveness. This fear may be reduced with newer agents with lower oral bioavailability if their theoretical advantage of fewer systemic adverse effects than the standard treatment of inhaled beclometasone is realized in practice. This review aims to determine if one of the newer agents, inhaled fluticasone, has less effect on the growth of pre-pubertal asthmatic children than inhaled beclometasone. The outcome measure was growth velocity. Two double blind, randomized controlled trials were identified. In one of the studies the mean growth velocity in the fluticasone group was 0.7 cm/year greater than in the beclometasone group. In the second, smaller study the mean growth velocity in the fluticasone group was 0.8 cm/year greater. There is therefore some evidence that fluticasone has less (if any) adverse effect on growth.
Notes: 1462-4753 xA;Journal Article xA;Review xA;Review Literature
Abstract: To determine the effectiveness of modified cow's milk formulas on the symptoms of infant colic, a mini-review (Griffiths, 2002) of double-blind randomized controlled trials was undertaken. The population was infants diagnosed with colic and the outcome was a reduction in infant distress. Medline, Embase, CINAHL and the Cochrane Library were searched and seven clinical trials and two systematic reviews were identified. After applying inclusion criteria, two studies were examined in the review. One study compared the effects of a modified formula and a standard cow's milk formula on bottle-fed infants. The other examined the effects of a low-allergen diet on breast-fed and bottle-fed infants. Results could only be retrieved from one study, which showed that hydrolysed formulas have a positive effect on reducing the symptoms of infant colic although sample sizes were small and the magnitude of benefit unclear. There is evidence to support advice to parents of bottle-fed infants with colic to consider changing to such formulas.
Notes: 1462-4753 xA;Journal Article xA;Review xA;Review Literature
Abstract: The effectiveness of current approaches to workplace stress management for nurses was assessed through a systematic review. Seven randomised controlled trials and three prospective cohort studies assessing the effectiveness of a stress management programmes were identified and reviewed. The quality of research identified was weak. There is more evidence for the effectiveness of programmes based on providing personal support than environmental management to reduce stressors. However, since the number and quality of studies is low, the question as to which, if any, approach is more effective cannot be answered definitively. Further research is required before clear recommendations for the use of particular interventions for nursing work related stress can be made.
Abstract: Community health practitioners are frequently faced with the problem of indwelling catheters failing to drain. This mini-review examines the evidence regarding the effectiveness of citric acid-based bladder washout solutions (solution G, solution R), compared with saline for preventing blockage of long-term catheters in older adults. Although there is some evidence on the effect of citric acid solutions in laboratory conditions, the search yielded no evidence measuring catheter patency in humans. Only one randomized controlled trial addressing the use of citric acid solutions with human subjects was found. This provided some confirmation that solution G had immediate effect but gave no evidence of long-term benefit. No difference was apparent on examination of catheter tips. As the evidence is weak, practitioners should consider the use of citric acid maintenance solution as non-routine and only following formal evaluation in a one-off trial on appropriate patients.
Abstract: * The effectiveness of post-acute intermediate care in nursing-led intermediate care in-patient units (NLIU) has been studied over the past 20 years.* Accounts, both positive and negative, have tended to view it as a uni-disciplinary intervention. The previous studies are in effect a series of single case studies and as such need to be accompanied by richer descriptions of care processes in order to be useful.* A survey was conducted, in parallel with a randomized-controlled trial (n=177), to compare multidisciplinary care and discharge planning practice on the NLIU with 16 wards that referred patients to it.* The findings identify that a wide range of professions participate in care on the NLIU with physiotherapists and occupational therapists most widely involved.* In general the team composition and care processes differed little between the NLIU and control wards. There was some evidence that there was lower participation in care on the NLIU from occupational therapy and social work. It is concluded that the NLIU is a complex multidisciplinary intervention.* Positive results from some NLIUs may only be generalizable to settings with similar skill mix across the multidisciplinary team as that found in the acute hospital. Reduced skill mix may be a causal factor leading to extended stays and increased total care costs.* This caution should be extended to other models of intermediate care, whether or not they are nursing-led.
Abstract: This paper addresses the limitations of current methods supporting 'evidence-based health-care' in relation to complex aspects of care, including those questions that are best supported by descriptive or non-empirical evidence. The paper identifies some new methods, which may be useful in aiding the synthesis of data in these areas. The methods detailed are broadly divided into those that facilitate the identification of evidence and those that enable the interpretation of the data retrieved. To illustrate some of the issues involved, reference is made to a multimethod review recently completed by the authors, which aimed to identify factors that promote continuity in the transition from child to adult health and social care. It is argued that as healthcare organisations are becoming increasingly preoccupied with the evidence base of practice, such methods may help ensure that aspects of care and approaches that are outside the dominant pharmaco-medical domain maintain a prominent position on the healthcare agenda while remaining open to external scrutiny. Healthcare professionals who use such approaches need to know their relative utility and benefits to inform clinical decisions, so as to ensure that best practice is observed.
Abstract: District nurses manage the care of the majority of patients with leg ulcers, but there have been reports of variations in the practice and effectiveness of treatment provided by district nurses (Audit Commission, 1999). Evidence-based health care aims to promote clinical and cost-effective care/treatment through the explicit, conscientious, and judicious use of the currently available best evidence from research to guide decisions (Sackett et al, 1996). Following the method of Griffiths (2002), a mini-systematic review was undertaken, to find out whether leg ulcer clinics provide more effective treatment to patients with leg ulcers than care provided in patients' homes by district nurses. Five databases were searched to find valid randomised controlled trials (RCTs) or systematic reviews to answer the question. The search was supplemented by hand searching of relevant publications. Only one trial met the inclusion criteria of the review. Although it concluded that leg ulcer clinics delivered improved outcomes the evidence provided was limited due to the comparison treatment being outdated, inadequate information regarding costs, and that as a relatively small isolated RCT it provided insufficient evidence to answer the question. [References: 26]
Abstract: To determine the most effective way of monitoring glucose levels as an indicator of glycaemic control in people with type 2 diabetes in the community, we conducted a criteria-based review of randomized controlled trials and systematic reviews of randomized controlled trials that studied the efficacy of various glucose monitoring strategies. We searched the Cochrane Library, Medline, Embase, CINAHL and BNIPlus databases for relevant studies. The journals 'Diabetes', 'Diabetic Medicine', 'Diabetologica', 'Evidence-Based Medicine' and 'Evidence-Based Nursing' were hand searched. The outcome of interest was glycaemic control, as measured by glycated haemoglobin (HbA(1c)). A total of 642 titles were identified from the search; three studies answered the question criteria and only one study met all the quality criteria. The study that met the criteria was a systematic review of four trials measuring the efficacy of self-monitoring of glucose levels. The reduction in HbA(1c) in those who monitored glucose levels was estimated to be -0.25% (95% Cl -0.61 - +0.10). This result shows a small improvement, but it is not statistically significant. A meta-analysis was also performed on three studies (n=278) comparing HbA(1c) in subjects who performed blood glucose monitoring with those who performed urine monitoring. The reduction in HbA(1c) when monitoring blood glucose rather than urine glucose was -0.03% (95% Cl -0.52 - +0.47). This result is not statistically significant. The efficacy of blood and urine glucose monitoring testing, for people with type 2 diabetes, in improving glycaemic control as measured by HbA(1c) levels is still questionable. A rigorous randomized controlled trial is needed to establish these answers although there is no evidence of harm. Clinical protocols that make recommendations for glucose monitoring strategies for people with type 2 diabetes should acknowledge that the evidence is weak. There is no basis to recommend one method above another.
Abstract: District nurses manage the care of the majority of patients with leg ulcers, but there have been reports of variations in the practice and effectiveness of treatment provided by district nurses (Audit Commission, 1999). Evidence-based health care aims to promote clinical and cost-effective care/treatment through the explicit, conscientious, and judicious use of the currently available best evidence from research to guide decisions (Sackett et al, 1996). Following the method of Griffiths (2002), a mini-systematic review was undertaken, to find out whether leg ulcer clinics provide more effective treatment to patients with leg ulcers than care provided in patients' homes by district nurses. Five databases were searched to find valid randomised controlled trials (RCTs) or systematic reviews to answer the question. The search was supplemented by hand searching of relevant publications. Only one trial met the inclusion criteria of the review. Although it concluded that leg ulcer clinics delivered improved outcomes the evidence provided was limited due to the comparison treatment being outdated, inadequate information regarding costs, and that as a relatively small isolated RCT it provided insufficient evidence to answer the question. [References: 26]
Abstract: The aim of this review was to identify whether, in children under 2 years of age, pacifier (dummy) use results in an increased risk of ear infection (acute otitis media). The Cochrane Library, Medline, CINAHL and Embase databases were searched for cohort studies and randomised controlled trials that compared infants who used pacifiers with those who didn't or examined the effect of reducing pacifier use in a group of infants. One cluster randomised trial and two cohort studies met the review criteria and were available to be included in the body of the review. These studies show a clear increase in risk of ear infection to be associated with use of a pacifier that may well be causal. The risk of ear infections is up to three times higher in those who use a pacifier and there does appear to be a 'dose response' with continual users more at risk than occasional users. However, this relationship may be confounded by socio-demographic factors. Rather than advising a parent not to use a pacifier for fear of causing otitis media, advice in relation to this issue might best be restricted to pacifier users suffering from the problem in order to reduce the chances of recurrence. [References: 19]
Abstract: To determine the effectiveness of oral glucosamine with ibuprofen for the relief of joint pain in osteoarthritis a mini-review (Griffiths, 2002) of double-blind randomized controlled trials comparing the two was undertaken. The population was adult patients diagnosed with osteoarthritis at any site. The outcome was arthritic pain reduction. Searches on Medline, Embase, AMED, the Cochrane Library and the Merck index identified four trials. Of these, two studies were obtainable and were included in the review. Both compared 1.2 g ibuprofen daily with 1.5 g glucosamine sulphate daily, in three divided doses. The combined number of participants in the studies was 218. The results of these studies showed glucosamine to be of similar efficacy to ibuprofen. The conclusion is that glucosamine is effective in relieving joint pain associated with osteoarthritis. Glucosamine's pain-relieving effects may be due to its cartilage-rebuilding properties; these disease-modifying effects are not seen with simple analgesics and are of particular benefit. In practice glucosamine can be used as an alternative to anti-inflammatory drugs and analgesics or as a useful adjunct to standard analgesic therapy. [References: 14]
Abstract: OBJECTIVES: The prescription of strong opioid analgesics for chronic non-cancer pain (CNCP) is described as controversial and can result in misidentification of patients as drug abusers or individuals with an addiction. This study compared the effects of opioid drugs on CNCP patients and "street" users. SUBJECTS/SETTING: The groups comprised 36 CNCP patients attending a pain clinic and 39 street users, recruited on London streets. DESIGN: CNCP patients were interviewed in a pain clinic and street users in a street setting. A questionnaire was used to assess drug craving, dose escalation, cessation of use, compulsion to use, effects on career, relationships and activities, experience of "highs," and problems due to intoxication. To assess physiological dependence, subjects answered questions on specific effects e.g. stomach pains, nausea/vomiting, cramps/aches, etc.). Efficacy was assessed in CNCP patients by determining analgesia and physical function. RESULTS: CNCP patients started therapy in the low dose range for oral morphine (</=60 mg/day) and most (83%) did not move into a higher dose range once adequate levels of analgesia were attained. Street users started smoking heroin intermittently, before daily use. Most escalated their dose by increasing the amount used and by switching from smoking to injecting. Unlike CNCP patients, street users demonstrated patterns of compulsive drug use, social problems and intoxication. Only 3 / 31 (9.5%) pain patients that discontinued opioid therapy reported withdrawal symptoms on abstaining from the drug compared to 35 (89.5%) of street users. CONCLUSION: Findings suggest that CNCP patients prescribed strong opioid analgesics derive more benefit than harm.
Abstract: The aim of this study is to evaluate the reliability and validity of the Byron Physical Assessment Framework (BPAF). The BPAF is a systems based checklist of physiological measurements, signs, and symptoms designed to structure and document the assessment of a patients physical condition by nursing staff. Initially the BPAF was refined using extensive literature review and expert opinion to improve the comprehensiveness and clarity for its intended purpose. As a result the content validity of the BPAF was supported. Inter-rater reliability between both expert-expert and novice-expert pairings was assessed. A total of 68 assessments were conducted by pairs of qualified nurses with patients on general medical and surgical wards and a nursing-led unit in one London Hospital. Reliability of the dichotomous data items of the BPAF was found to be generally good (kappa > 0.6) with only one item showing a poor reliability (kappa < 0.20). Reliability for continuous items such as pulse and respiratory rate was surprisingly low with evidence of large variation between raters in addition to systematic bias. With relatively little teaching, novice assessors were able to use the BPAF and achieve good inter-rater reliability with expert assessors although this was lower than the reliability of the expert diads. The utilisation of the BPAF to fulfil intended purpose was assessed by examining completed assessments and the outcome in terms of nurses' actions in light of new abnormal findings. Both were found to be fair, showing that the BPAF does affect the actions of nurses although it could be utilised more.
Abstract: A literature search was conducted to identify 'nursing led in-patient units' where the nurse is the designated leader of the clinical team. The review concentrates on studies which have attempted to measure the impact of nursing-led in-patient units and reviews both the methodology and outcomes. Three major bodies of work were identified. Lydia Hall's evaluation of the Loeb Center for Nursing and Rehabilitation (USA) is reviewed in some detail. This work was the model for 'nursing beds' at the two Oxfordshire Nursing Development Units (UK) in the 1980s. Studies evaluating these centres are reviewed and reports of similar UK units discussed. A third body of work evaluates a nurse-managed critical care environment. Common features include a case mix based on nursing need with nurses having authority to admit and discharge patients. While results are generally favourable, with improved patient independence, fewer readmissions, lower mortality and cost savings reported in some or all of the studies, all studies reviewed demonstrate the difficulties of applying an experimental model to real life clinical services. Methodological limitations render firm conclusions difficult. Techniques adopted from studies in field settings, the so-called 'quasi-experiment', are advocated as a remedy, as is further study of the process of care in investigating this model of care delivery.
Notes: Nursing Studies, Kings College London, England
Abstract: This article explores the meaning and significance of 'self-assessment', a term that is increasingly being used in relation to developments affecting community practice. Self-assessment for health and social care needs has been used over a considerable period of time and for purposes as diverse as case finding for depression to assessment of housing options. Self-assessment has usually involved the use of short scales and questionnaires, but it can involve the use of physiological tests (such as testing urine for glucose) or complex, computerized decision-support systems. Although often explored as a simple means for extending the 'reach' of professional assessments (e.g. mass screening) and ensuring 'appropriate' use of health services (e.g. self-care algorithms), self-assessment is increasingly being advocated as a means of actively involving and empowering service users. However, a recent review of the topic (Griffiths et al, 2005) revealed the complexity of the topic and the pitfalls of a simplistic approach to self-assessment, which those engaged in developing the process should bear in mind.
