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Specialist nurse intervention to reduce unscheduled asthma care in a deprived multiethnic area: the east London randomised controlled trial for high risk asthma (ELECTRA).

ABSTRACT: OBJECTIVE: To determine whether asthma specialist nurses, using a liaison model of care, reduce unscheduled care in a deprived multiethnic area. DESIGN: Cluster randomised controlled trial. SETTING: 44 general practices in two boroughs in east London. PARTICIPANTS: 324 people aged 4-60 years admitted to or attending hospital or the general practitioner out of hours service with acute asthma; 164 (50%) were South Asian patients, 108 (34%) were white patients, and 52 (16%) were from other, largely African and Afro-Caribbean, ethnicities. INTERVENTION: Patient review in a nurse led clinic and liaison with general practitioners and practice nurses comprising educational outreach, promotion of guidelines for high risk asthma, and ongoing clinical support. Control practices received a visit promoting standard asthma guidelines; control patients were checked for inhaler technique. MAIN OUTCOME MEASURES: Percentage of participants receiving unscheduled care for acute asthma over one year and time to first unscheduled attendance. RESULTS: Primary outcome data were available for 319 of 324 (98%) participants. Intervention delayed time to first attendance with acute asthma (hazard ratio 0.73, 95% confidence interval 0.54 to 1.00; median 194 days for intervention and 126 days for control) and reduced the percentage of participants attending with acute asthma (58% (101/174) v 68% (99/145); odds ratio 0.62, 0.38 to 1.01). In analyses of prespecified subgroups the difference in effect on ethnic groups was not significant, but results were consistent with greater benefit for white patients than for South Asian patients or those from other ethnic groups. CONCLUSION: Asthma specialist nurses using a liaison model of care reduced unscheduled care for asthma in a deprived multiethnic health district. Ethnic groups may not benefit equally from specialist nurse intervention.

SUBMITTER: Griffiths C

PROVIDER: S-EPMC314511 | biostudies-literature | 2004 Jan

REPOSITORIES: biostudies-literature

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Specialist nurse intervention to reduce unscheduled asthma care in a deprived multiethnic area: the east London randomised controlled trial for high risk asthma (ELECTRA).

Griffiths Chris C Foster Gill G Barnes Neil N Eldridge Sandra S Tate Helen H Begum Shamoly S Wiggins Mo M Dawson Carolyn C Livingstone Anna Eleri AE Chambers Mike M Coats Tim T Harris Roger R Feder Gene S GS

BMJ (Clinical research ed.) 20040112 7432

<h4>Objective</h4>To determine whether asthma specialist nurses, using a liaison model of care, reduce unscheduled care in a deprived multiethnic area.<h4>Design</h4>Cluster randomised controlled trial.<h4>Setting</h4>44 general practices in two boroughs in east London.<h4>Participants</h4>324 people aged 4-60 years admitted to or attending hospital or the general practitioner out of hours service with acute asthma; 164 (50%) were South Asian patients, 108 (34%) were white patients, and 52 (16%) ...[more]

PMID: 14718266

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Project description:IntroductionThis paper examines one of the NHS England Pioneers programmes of Integrated Care, which was implemented in three localities in East London, covering the area served by one of the largest hospital groups in the UK and bringing together commissioners, providers and local authorities. The partners agreed to build a model of integrated care that focused on the whole person. This qualitative and participatory evaluation looked at how an ambitious vision translated into the delivery of integrated care on the ground. The study explored the micro-mechanisms of integrated care relationships based on the experience of health and social care professionals working in acute and community care settings.MethodsWe employed a participatory approach, the Researcher in Residence model, whereby the researcher was embedded in the organisations she evaluated and worked alongside managers and clinicians to build collaboration across the full range of stakeholders, develop shared learning, and find common ground through competing interests, while trying to address power imbalances. A number of complementary qualitative methods of data generation were used, including documentary analysis, participant observations, semi-structured interviews, and coproduction workshops with frontline health and social care professionals to interpret the data and develop recommendations.ResultsOur fieldwork exposed persistent organisational fragmentation, despite the dominant rhetoric of integration and efforts to build a shared vision at senior governance levels. The evaluation identified several important themes, including: a growing barrier between acute and community services; a persisting difficulty experienced by health and social care staff in working together because of professional and cultural differences, as well as conflicting organisational priorities and guidelines; and a lack of capacity and support to deliver a genuine multidisciplinary approach in practice, despite the ethos of multiagency being embraced widely.DiscussionBy focusing on professionals' working routines, we detailed how and why action taken by organisational leaders failed to have tangible impact. The inability to align organisational priorities and guidelines on the ground, as well as a failure to acknowledge the impact of structural incentives for organisations to compete at the expense of cooperation, in a context of limited financial and human resources, acted as barriers to more coordinated working. Within an environment of continuous reconfigurations, staff were often confused about the functions of new services and did not feel they had influence on change processes. Investing in a genuine bottom-up approach could ensure that the range of activities needed to generate system-wide cultural transformation reflect the capacity of the organisations and systems and address genuine local needs.LimitationsThe authors acknowledge several limitations of this study, including the focus on one geographical area, East London, and the timing of the evaluation, with several new interventions and programmes introduced more or less simultaneously. Some of the intermediate care services under evaluation were still at pilot stage and some teams were undergoing new reconfigurations, reflecting the fast-pace of change of the past decade. This created confusion at times, for instance when discussing specific roles and activities with participants. We tried to address some of these challenges by organising several workshops with different teams to co-interpret and discuss the findings.

Project description:BackgroundIn our region, it was acknowledged that the process of assessment needed to be improved, but before developing a system for this, there was a need to define the "competent or satisfactory trainee".ObjectiveTo outline the process by which a consensus was achieved on this standard, and how a system for formally assessing competency across a wide range of knowledge skills and attitudes was subsequently agreed on, thus enabling increased opportunities for training and feedback and improving the accuracy of assessment in the region.MethodsThe opinions of trainees and trainers from across the region were collated, and a consensus was achieved with regard to the minimum acceptable standard for a trainee in emergency medicine, thus defining a competent trainee. The group that set the standard then focused on identifying the assessment methods most appropriate for the evaluation of the knowledge, skills and attitudes required of an emergency medicine trainee. The tool was subsequently trialled for a period of 6 months, and opinion evaluated by use of a questionnaire.ResultsThe use of the tool was reviewed from both the trainers' and trainees' perspectives. 42% (n = 11) of trainers and 31% (n = 8) trainees responded to the questionnaire. In the region, there were 26 trainers and 26 trainees. Five trainees and nine trainers had used the tool. 93% (14/15) of respondents thought that the descriptors used to describe the satisfactory trainee were acceptable; 89% (8/9) of trainers thought that it helped them assess trainees more accurately. 60% (3/5) of trainees thought that, as a result, they had a better understanding of their weak areas.ConclusionWe believe that we achieved a consensus across our region as to what defined a satisfactory trainee and set the standard against which all our trainees would subsequently be evaluated. The use of this tool to assess trainees during the pilot period was disappointing; however, we were encouraged that most of those using the tool thought that it allowed an objective assessment of trainees and feedback on areas requiring further work. Those who used the tool identified important reasons that may have hindered widespread use of the assessment tool.

Project description:BackgroundInadequate health human resources is a key challenge to advancing child survival in Ghana. Nurses are an essential human resource to target because they represent the largest portion of the health workforce. Building on lessons learned from our pilot pediatric nurse training project and World Health Organization guidelines for transforming and scaling up health professional education, this project aimed to; train 500 pediatric nurse specialists through a one-year training program; develop and integrate a critical mass of pediatric nursing faculty and establish a national standardized pediatric nursing curriculum. This study aimed to evaluate the effectiveness of a national pediatric nurse training program in Ghana at the end of 4 years, including eight cohorts with 330 graduates.MethodsThis was a mixed-method evaluation with surveys, focus groups and a pre-test/post-test design. Before and after surveys were used to measure knowledge and confidence at baseline and graduation. Objective Structured Clinical Examinations (OSCE) were used to measure clinical skills at baseline, graduation, and 14 months follow-up. At the end of every module, surveys were used to measure students' satisfaction. Focus groups at graduation qualitatively measured program outcomes. Repeat focus groups and surveys at 14 months after graduation captured the graduates' career progress, experiences reintegrating into the health system and long-term program outcomes.ResultsOverall, the graduates completed the program with significantly increased knowledge, confidence, and clinical skills. They also had increased job satisfaction and were able to apply what they learned to their jobs, including leadership skills and gender-sensitive care. Data from 14-month follow-up OSCEs showed that all graduates remained competent in communication, physical assessment, and emergency care, although some obtained a lower mark compared to their performance at graduation. This finding is linked with the observation that the amount of mentorship, support from leadership and equipment that the graduates accessed from their respective facilities varied.ConclusionsMixed-methods evaluations demonstrated significant increases in knowledge confidence and skills by completing the program and maintenance of skills more than 1 year after graduation. Findings have implications for those working on the design, implementation, and evaluation of nursing education interventions in low- and middle-income countries.

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Specialist nurse intervention to reduce unscheduled asthma care in a deprived multiethnic area: the east London randomised controlled trial for high risk asthma (ELECTRA).

Publications

Specialist nurse intervention to reduce unscheduled asthma care in a deprived multiethnic area: the east London randomised controlled trial for high risk asthma (ELECTRA).

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