Translational research projects based in England, New Zealand and Catalonia are described. In combination they provide real world evidence in support of the evolving discourse on translating the evidence on screening and brief intervention for problem use of alcohol so that it is acceptable and fit for routine practice. Acceptance and uptake was enhanced by encouraging primary health clinicians to use evidence-based screening and brief intervention processes which fit with the context in which they work and which build on the skills they already have and use in practice. Emerging general principles included: tailoring procedures to fit with local circumstances; breaking the process down into clinically acceptable steps and negotiating where there is flexibility. Key issues explored in each case study included how 'screening' is best conducted, what is a brief intervention best suited to which provider and which providers should run the process.
BackgroundDiabetes is a major health issue for individuals and for health services. There is a considerable literature on the management of diabetes and also on communication in primary care consultations. However, few studies combine these two topics and specifically in relation to nurse communication. This paper describes the nature of nurse-patient communication in diabetes management.MethodsThirty-five primary health care consultations involving 18 patients and 10 nurses were video-recorded as part of a larger multi-site study tracking health care interactions between health professionals and patients who were newly diagnosed with Type 2 diabetes. Patients and nurses were interviewed separately at the end of the 6-month study period and asked to describe their experience of managing diabetes. The analysis used ethnography and interaction analysis.In addition to analysis of the recorded consultations and interviews, the number of consultations for each patient and total time spent with nurses and other health professionals were quantified and compared.ResultsThis study showed that initial consultations with nurses often incorporated completion of extensive checklists, physical examination, referral to other health professionals and distribution of written material, and were typically longer than consultations with other health professionals. The consultations were driven more by the nurses’ clinical agenda than by what the patient already knew or wanted to know. Interactional analysis showed that protocols and checklists both help and hinder the communication process. This contradictory outcome was also evident at a health systems level: although organisational targets may have been met, the patient did not always feel that their priorities were attended to. Both nurses and patients reported a sense of being overwhelmed arising from the sheer volume of information exchanged along with a mismatch in expectations.ConclusionsConscientious nursing work was evident but at times misdirected in terms of optimal use of time. The misalignment of patient expectations and clinical protocols highlights a common dilemma in clinical practice and raises questions about the best ways to balance the needs of individuals with the needs of a health system. Video- recording can be a powerful tool for reflection and peer review.
PURPOSE We undertook a study to observe in detail the primary care interactions and communications of patients with newly diagnosed diabetes over time. In addition, we sought to identify key points in the process where miscommunication might occur.METHODS All health interactions of 32 patients with newly diagnosed type 2 diabetes were recorded and tracked as they moved through the New Zealand health care system for a period of approximately 6 months. Data included video recordings of patient interactions with the health professionals involved in their care (eg, general practitioners, nurses, dietitians). We analyzed data with ethnography and interaction analysis. RESULTSChallenges to effective communication in diabetes care were identified. Although clinicians showed high levels of technical knowledge and general communication skill, initial consultations were often driven by biomedical explanations out of context from patient experience. There was a perception of time pressure, but considerable time was spent with patients by health professionals repeating information that may not be relevant to patient need. Health professionals had little knowledge of what disciplines other than their own do and how their contributions to patient care may differ.CONCLUSIONS Despite current high skill levels of primary care professionals, opportunities exist to increase the effectiveness of communication and consultation in diabetes care. The various health professionals involved in patient care should agree on the length and focus of each consultation.
Developments in New Zealand primary care are likely to increase the role of primary health care nurses in diabetes. Research and evaluation is required to ascertain whether this increasing role translates into improved outcomes for patients.
To reduce health inequalities and improve quality in health care, health policy initiatives in countries including New Zealand and the United Kingdom are expecting general practice to share responsibilities for a population approach to health care. This is giving increased emphasis to preventative care, including health promotion. Reasoned debate on this policy is overdue, not least in New Zealand, where clinicians within general practice appear to have been seduced by the lack of clarity in health policy into accepting this policy without question. They appear to disregard implications of the policy for redefining the nature and scope of their discipline (and of public health), including their own role as providers of personal care. This paper suggests that a population health approach is inappropriate in general practice when this approach weakens personal care and involves health promotion activity of unknown safety and effectiveness. The example of intentional weight loss to reduce overweight is used to illustrate these issues. We argue for a restricted range of general practice services.
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