The Scottish Government

Reference

Summary

1

Alexander J Kroposki M (1999)

Outcomes for community health nursing practice. Journal of Nursing Administration 29 (5) 49-56

Type of study: Descriptive survey

Method: Expert modified Delphi technique. 22 experts: 152 community nurses.

Findings: Study generated list of 48 outcomes sensitive to nursing interventions in the community, categorised in 4 domains.

Limitations: USA study. Small scale - 48 nurses completed all 3 rounds of questionnaires.

Key messages: Recognises that outcomes for community nurses may differ from other settings. These identified outcomes may be used as basis for decision making and research.

2

Arthur A Matthews R Jagger C Clarke M Hipkin A Bennison D (2002) Improving uptake of influenza vaccination among older people: a randomized controlled trial. British Journal of General Practice 52 (482) 717-722

Type of study: Randomised controlled trial.

Method: compared 2 forms of approach to maximise uptake of vaccination in over 75s. First - personal letter of invitation to attend surgery, second - invitation issued by practice nurse on home visit health checks. Primary outcome measure - proportion of patients receiving vaccine by end date of study.

Findings: offering vaccination as part of nurse health checks has a moderate effect on increasing uptake. Effect more marked for those who do not routinely come forward.

Limitations: no control group (intervention free).Other variables may be unaccounted for e.g. contemporaneous national campaign. Confined to one large practice - wide variation in way over 75 health checks carried out, so may not be generalisable.

Key messages: participation in health promotion initiatives may be increased by incorporating them into community nursing visits.

3

Bennett JA Perrin NA Hanson G Bennett D Gaynor W Flaherty-Robb M Joseph C Butterworth S Potempa K (2005) Healthy aging demonstration project: Nurse coaching for behaviour change in older adults Research in Nursing & Health 28 187-197

Type of study: Quasi experimental clinical project

Aim: To test the feasibility of nurse coaching by telephone and email as a method to help older adults adopt changes in health behaviours and to determine whether the coaching intervention produced measurable changes in health status outcome

Method: Community dwelling adults over 60 years with one or more of five chronic conditions were enrolled and then assigned to control and intervention group . Intervention group met with coaches immediately and identified individual behavioural goals followed by telephone or email contact. Control group thanked for time and asked to continue usual care. Both groups were sent quarterly newsletters. Measurement surveys were done on completion of the project.

Findings: Coaching was feasible and acceptable. Significant higher health distress and illness intrusiveness in control group. No statistically significant differences between groups on social /role limitations, energy and general health

Limitations of study: Different number and duration of contacts by each coach. Different attrition rates in each group. Limited time to achieve outcomes. No measurement of behaviour changes only health outcomes

Key messages: Telephone and email are feasible methods to communicate with older adults about their health behaviours. There was less health distress and illness intrusiveness for those who received coaching. More research needed to measure change in behaviours

4

Bliss J While A (2003)

Decision making in palliative and continuing care in the community: an analysis of the published literature with reference to the context of UK care provision International Journal of Nursing Studies 40 881-888

Type of study: Literature review, aiming to identify theoretical framework for exploring decision making in palliative and continuing care.

Method: exploratory, snowball sampling, selection criteria relevance and ability to inform on decision making. Not true systematic review, but conducted systematically.

Findings: demonstrates complexity of community decision making. Identifies model of strategic decision making which would serve as framework for understanding process and outcomes.

Limitations: selective exploratory review; may have missed relevant studies

Key messages: Ethos of collaboration makes it difficult to distinguish contribution of community nurse to decision making, which is heavily influenced by employing organisations.

5

Bryans, A. (2000) District nursing assessment practice: Case study findings British Journal of Community Nursing 5(4) 197-202

Type of study: Qualitative, exploratory case study

Aim: To describe the knowledge and skills involved in initial patient assessment

Method: Simulated assessment, structured post-simulation interview and follow up observational visits

Findings: Nurses use referral information to glean background knowledge but do not necessarily accept it as accurate before visiting the patient. Interaction flowed naturally and covered a lot with little effort. Nurse was direct, open and explicit. Nurse made a rapid appraisal of patient's potential needs and was able to articulate her perception of these needs. This was informed by her knowledge of condition and psychology. Nurse offered immediate help to patient in coming to terms with her diagnosis and improving her everyday coping. Nurse did not attempt an exhaustive or complete assessment on the first visit

Limitations of study: Simulation of 4 case studies, one-shot approach may not reflect the long term contact

Key messages: It is important to examine the invisible elements of district nurses knowledge and its effectiveness in practice

6

Caffrey RA (2005) Community care gerontological nursing: The independent nurse's role Journal of Gerontological Nursing 31(7) Jul 18-26

Type of study: Qualitative ethnographic study

Aims: To describe the practices of independent community care gerontological non-Advanced Practice Nurse's (APN's).To identify from the client perspective the need for this nursing service, what service was provided and how client evaluated those services. To describe the inter-relationships and communication processes of these nurse with other healthcare providers

Method: Interviews were conducted with seven nurses who were providing care on a private-pay basis to the elderly population. The nurses were then observed during home visits with their clients, field notes were recoded. Audio taped interviews were performed at another time with six clients. Interview data was transcribed, analysed and shared with participants.

Findings: Activities described by the nurses are: Assessment, documentation, teaching, delegation and assignment, monitoring, advocacy and support. Service valued by the clients included assistance with problem-solving, nurses advocacy role, completing documentation to meet licensing requirements sand the development of close supportive relationships.

Limitations of study: Small study based in rural southern and central Oregon

Key messages: Services of community based nurses which were valued by older people were: development of the relationship, problem-solving, knowing their community/context, advocacy with physicians, support, and continuity of care

7

Carnwell R Daly W (2003) Advanced nursing practitioners in primary care settings: An exploration of the developing roles Journal of Clinical Nursing 12(5) Sept 630-642

Type of study: Qualitative exploratory, longitudinal study

Aim: To explore the current roles of Advanced Nurse Practitioners (ANP's) in Primary Care and how ANPs within three different nursing disciplines developed their role over time

Method: Purposive sample of three types of primary care nurses (HV, DN and PN) who had completed Masters in Advanced Clinical Practice were interviewed at one year and then 15 months later; their managers were interviewed once. Content analysis of interview transcripts, thematic analysis and co-researcher check.

Findings: Most ANP's returned to a different role. PN's were easily accommodated in clearly defined role. Some were allowed to make referrals and use agreed protocols. They were perceived by managers to be more highly qualified than DN & HV, as role was comparable to GP's, but were restricted in their development because of need to do mundane tasks. DN's ran minor-illness sessions and chronic disease management sessions. HV's raised awareness about public health and changed practice i.e. developing leadership qualities by involving colleagues in training including leadership and working across boundaries. DN's & HV's were often perceived as threat to CNS's who consider themselves leaders of practice, role perceived to be worthwhile but not sure how it fitted into service developments. They had no time for audit, lack of prescribing authority, lack of understanding about skills expertise and role. All wanted to develop a teaching role and saw future in a consultant role but there were no career prospects

Limitations of study: Authors did not distinguish between generalist and specialist knowledge.. Lack of clarity re aims of masters programme. Lack of comparison and synthesis of manager and community nurse themes. Lack of synthesis of data so the findings and recommendations are not clear.

Key messages: Advanced Nursing Practice is not clearly defined . There is a lack of understanding about the value of master's preparation in practice. Increasing knowledge to Masters level may enable nurses to develop practice but this maybe a threat to others in the team. Frustrations arose from lack of opportunity for career development

8

Carr J Bethea J Hancock B (2001) The attitude of GP's towards the Nurse Practitioner role British Journal of Community Nursing 6(9) 444-451

Type of study: Qualitative investigative study

Aim: To investigate the knowledge and attitudes of GP's who do not employ nurse practitioners to find out what prevents them from doing so.

Method: Semi-structured interviews were carried out with 10 GPs selected from 75 practices in Nottingham. Data was coded independently by two researchers

Findings: Participants were satisfied with practice nurses who carried out a range of activities but had little knowledge of advanced practice and how the role of the nurse practitioner could be integrated into the team. Participants agreed that key skills of the nurse practitioner should included diagnosis and prescribing but there was a lack of awareness regarding the qualifications required to become a nurse practitioners They supported the integration of nurse practitioner in primary healthcare but also identified potential difficulties arising from the blurring of roles

Limitations of study: Small study based in Nottingham

Key messages: Nurse practitioner role needs to be integrated into primary care. Need to improve understanding of the role, the boundaries and value of collaboration. GP's are not adverse to the role and believe that training is essential. Nurse practitioners need authority to prescribe. Protocols and guidelines should be used

9

Carter B (2000) Ways of working: Community Children's Nurses and chronic illness Journal of Child Health Care 4(2) 66-72

Type of study: Qualitative exploratory (UK)

Aim: 1. Explore the role/skills in relation to the physical and psychosocial needs of children and families with chronic illness; 2. examine ways in which these skills are used in decision making in relation to children and families with chronic illness in the community; 3. consider ways that Community Children's Nurses (CCN's) support the processes of adjustment to and coping with challenges of chronic illness in childhood.

Methods: A participant enquiry paradigm was used and data were generated using semi-structured interviews (18 CCN's interviewed), supported by field notes. Audiotapes were transcribed and subject to heuristic analysis to identify themes.

Findings: All the CCN's described the special relationship with the children and their families, which was characterised by deep understanding of current, and future needs. CCN's emphasised ' ways of working' which involved high degrees of trust, flexibility, support, reflexivity and empowerment. CCN's help families regain, maintain and develop control over their lives.

Most useful interventions:

Limitations: Small exploratory study.

Key messages: Identifies the 'special relationship' developed between the CCN and children and their families, which involved the depth of understanding about the child and family's needs, and depth of providing individualised, family-centred care. Identifies skills of skilled listening, 'ways of working', enabling, facilitating, empowering, planning and teaching.

10

Cowley S Houston A (2003). A structured health needs assessment tool: Acceptability and effectiveness for health visiting Journal of Advanced Nursing 43 (1) 82-92

Type of study: A two-phase qualitative study

Aim: to examine acceptability and effectiveness of a structured health needs assessment tool (HNAT) implemented in London

Methods: health visitors were interviewed about the HNAT - 30 via telephone interview. 21 assessments were then observed and tape recorded.

Stage two consisted of five in-depth case studies of the use of HNAT in practice, each from a different primary care division within the London area. Case study HVs were selected to reflect range of attitudes about the HNAT. These HVs were asked to introduce at least two families each who agree to their interaction with the HV observed and participate in a separate follow up interview. 19 clients were subsequently interviewed.

Findings: HNATs generally liked by nurses but often difficult to implement. Assessment tools frequently not used correctly with many using them as a checklist. Clients frequently dislike the tool as HVs tend to ask specific questions, make judgments and are reported to not listen to individual answers. The use of a HNAT does not encourage individualised care.

Consistency of service provision does not suit most vulnerable clients who need it tailored to their own needs.

Asking the same questions is inequitable for the variety of clients

Key Messages: HNATs focus on organisations' agenda and nurses asking routine questions instead of tailoring assessment to individual needs and listening to clients. Many HVs consider the completion of a HNAT form as an additional bureaucratic hoop not beneficial to their practice yet focus on its completion. The use of HNAT is not supported in the literature and is not effective in eliciting clients' needs.

11

Crisp B Lister PG (2004). Child protection and public health: Nurses' responsibilities Journal of Advanced Nursing Sep 447(6) 656-663

Type of study: Qualitative exploratory study

Aim: to explore nurses' understanding of their professional responsibilities in relation to child protection and the potential for nurses to be involved in the protection of the children from abuse.

Method: purposive, qualitative, interview based design. 99 nurses from an NHS trust in a Scottish city were interviewed - either in groups or individually. Thematic analysis was undertaken

Findings: No shared understanding of definition of child protection and what contribution nurses could or should make in relation to child abuse. Main themes identified were: (1) identification, detection and reporting of child abuse (2) monitoring (3) supporting families (4) client education and (5) service development.

Lack of agreement as to whether nursing emphasis should be proactive - an emphasis on child abuse or reactive - an emphasis on detection and reporting.

Limitations: interviews were not tape recorded and therefore full transcripts not available. Detailed notes only were written down by two experienced researchers. Themes supported by paraphrasing only, rather than verbatim. Once only interviews were conducted over periods of 30-45 mins each potentially limiting scope of findings. Sample was small, may not be fully representative and cannot not be generalised to wider population. Interviews conducted with those who had an interest or involvement in child protection work.

Key messages: Lack of consensus about the nurses' role in issue of child protection and abuse. This is particularly with respect to the extent to which nurses should actively seek to detect cases of child abuse. An emphasis on identification and detection was not easily accepted by many nurses and was perceived by some to be a change from their usual role of supporting parents. Detecting and reporting child abuse was also seen to be in conflict with some public health responsibilities. Some nurses believe there is a sharp divide between child protection work and public health interventions.

Many child protection roles identified by nurses, however, such as supporting families, parenting education and service development are clearly within the remit of contemporary notions of public health. There is an increasing recognition that other nurses, other than health visitors, can and do also make an important contribution including those who do not work directly with children.

12

Delasega CA Zerbe TM (2002) Caregivers of frail rural older adults effects of practice nursing interventions Journal of Gerontological Nursing October 40-49

Type of study: Randomised Control Trial

Aim: To investigate whether Advanced Practice Nurse (APN) intervention would promote more positive and emotional outcomes in caregivers of rural frail older adults recently discharged from hospital

Method: Random assignment of participants 65 years and over to treatment and control group with APN implementation in the treatment group only and comparison of the two groups before and after intervention. Treatment group received one in-hospital visit and two home visits at 48 hours and 1-2 weeks post discharge. Instruments used to collect data after discharge were Care giver Burden Inventory (CBI) and Health and Daily Living Form (HDL)

Findings: Both groups had similar levels of support from caregivers, similar demographic variables, similar use of healthcare resources and similar self-rated physical health. Significant difference in self-rated emotional health; the control group being worse than the treatment group. Number of disability days was greater in the control group. Through educating, supporting and counselling the APN was able to affect the caregiver's physical and emotional health in a positive way.

Limitations of study: Generalisability was limited by ethic background of the sample, small number of caregivers involved and limited region in which patients were recruited

Key messages: Advanced Practice Nurse's have a positive impact on caregiver outcomes for those caring for frail older adults in rural communities; they showed fewer physical health symptoms of a psychosomatic nature and fewer disability days, they missed less days of work which resulted in less financial loss. They also had fewer depressive symptoms, emotional responses and care giving stress. Providing support to carers may improve post-discharge outcomes for older adults and families

13

de Lusignan S Singleton A Wells S (2004) Lessons from the implementation of a near patient anticoagulant monitoring service in primary care. Informatics in Primary Care 12 27-33

Type of study: Evaluation of nurse led intervention, removing anticoagulation monitoring from hospital to community, using decision support software

Methods: Action research, supported by questionnaires and clinical audit

Findings: Monitoring remained satisfactory and safe, while patients appreciated the service as more convenient, more flexible and having quicker feedback. However, problems were experienced as procedures and software developed for hospital proved tricky to implement in community settings.

Limitations: Small scale. Started with 18 nurses, finished with 8.

Key messages: Moving traditional hospital service to community results in safe systems and better patient satisfaction

14

Drennan V Illiffe S Haworth D Tai S Lenihan P Deave T (2005) The feasibility and acceptability of specialist and social care team for the promotion of health and independence in 'at risk' older adults Health and Social Care in the Community 13(2) 136-144

Type of study: Qualitative evaluation study

Aim: To evaluate whether joint health and social review is feasible, , acceptable and effective in solving problems for older individuals

Method: Observation at management and team meetings in order to describe and understand the process of team development. Semi structured interviews were conducted with 13 older people, 6 GP's, 9 managers and all team members. Joint health and social care assessment for over 75's deemed at risk, agreeing a goals and then revisiting at 3 months to review agreed actions.

Findings: There was commitment to team development but reconciliation of objectives and cultural inclinations was problematic. This was compounded by lack of clarity as to where responsibility for different types of decision-making lay. Joint assessment was used for this study but not perceived to be an efficient way of working; nurses believed they could do this assessment alone. Time was needed to establish a relationship with the older people and using palm-top computers was counter productive to this process. The most frequently unmet need was mobility, Other unmet need were social relationships, clinical depression and problems with cognition. Referrals: 36% GP, 21% OT, 17% housing, 10% social services, 10% optician and 6% community dentist. Using knowledge of eligibility criteria helped financial problems. Older people found this service acceptable and felt it made a difference to their quality of life

Limitations of study: Longitudinal effects need further examination.

Key messages: Joint health and social review for older people was feasible, acceptable but costly. Initially it was difficult to identify older people with multiple unmet needs, which suggest needs for database of local population. There was a lack of vision, shared operational and local knowledge between GP's HS managers and LA managers along with a lack of expertise in the promotion and management of collaborative working. An optimistic approach to assessment identified risk in third of population. This type of anticipatory care enables early referral and intervention which made a difference to the quality of life for older people. Nurses need to value their contribution.

15

Drew J Nathan D Hall D (2003) Role of a paediatric nurse in primary care 2: research findings British Journal of Nursing 12(1) 34-43

Type of study: Qualitative evaluation (UK)

Aim: Not clearly stated, as this is 2nd of 2 articles, 1st article described methodology. Evaluates the role and function of two qualified children's nurses, each working within a different PHCT.

Methods: Application of naturalistic inquiry and the use of a formative evaluation strategy. Data collated detailing patient contacts, nurses kept a reflective diary, interviews with members of the PHCT (need more info from 1st article.

Findings: Identifies the specific skills of the paediatric nurse as having an acute and maintenance role; also skills as catalyst and facilitator, advanced practice skills, supporting children and families and meeting unmet need.

Limitations: Article states that methodology had to be invented and therefore unknown how robust or reliable it was. Also the 2 nurses were highly selected nurses with particular skills, very small sample.

Key messages: Identifies the contribution of the children's nurse working in a community setting with the greatest contribution being in raising the overall quality of care of a range of conditions, which are currently of low profile (e.g. eczema and other skin disorders, continence problems, and behavioural difficulties)

16

Duhamel F Talbot L (2004) A constructivist evaluation of family systems nursing interventions with families experiencing cardiovascular and cerebrovascular illness Journal of Family Nursing 10(1) 12-32

Type of study: Participatory research design using Guba and Lincoln's forth generation evaluation approach.

Aim: to evaluate family systems nursing interventions (Calgary family assessment and interventions models)

Methods: All participants were co researchers and their evaluations of the interventions informed subsequent interventions. Five families participated - 2 families where member had MI and three where member had a stroke.

Held preclinical, clinical and research meetings with families on five occasions. Summary report produced at end of each session and synthesis report at end of five sessions.

Findings: Humanistic attitude of the nurse - development of a trusting relationship and knowing the nurse. Constructing a genogram - useful to collect information about family structure and experiences of dealing with past and present illness in the family and their resources for doing so. Study revealed this was a useful process for family member rather then just HPs who have traditionally used these. Interventive questioning: stimulated discussion on specific topics. Offering educational information: essential intervention which reassured family members about aspects of illness and reduced stress. Normalization: normalizing consequences of illness was deemed useful. Exploring the illness in the presence of other family members: sharing and venting emotions was useful. Models promote therapeutic relationship between nurse and family. Nurse benefited from being co researchers - reflecting and reconstructing interventions helped them to advance their practice

Limitations: Small Canadian exploratory study

Key messages: The process allowed the participants to get to know each other and contribute on an equal basis to care planning and decision making. Intense interaction over a prolonged period of time. Identified tacit nature of nursing knowledge and practice

17

Duke C (2005) The frail elderly community - based case management project Geriatric Nursing 26(2) 122-127

Type of study: Qualitative evaluation Study

Aim: To investigate the effects of community-based case management for frail elderly and the effect this would have on healthcare utilisation

Method: Enrolment of 107 people 65 years or over, implementation of assessment and health care satisfaction survey, establishment of community-based case management programme, telehealth assessments for medically compromised patients and promotion of end of life decision-making and facilitation of monthly carer and family education sessions.

Findings: Positive outcomes in all areas that were studied

Limitations of study: Based a community in eastern North Carolina, USA

Key messages: Community-based geriatric case management for frail elderly using telehealth reduces hospital admissions, emergency room visits, length of stay and total hospital costs. Not clear of the impact on community costs

18

Evans C Drennan V Roberts J (2005) Practice Nurses and older people: A case management approach to care Journal of Advanced Nursing 51(4) August 343-352

Type of study: Qualitative, exploratory study

Aim: To explore whether practice nurses use the five cyclical elements of case management approach when caring for people over the age of 75 years and what determines or deters the use of this approach

Method: 26-item questionnaire was used to explore practice nurse current management of older people. 45% response rate from 500 practice nurses, 20% of their population were over 75. Was case management used?

Findings: Over-75 health check annually, assessment, planning and care giving. Evaluation and referral happened rarely although PN qualified in DN were likely to refer to social services

Immunization and cervical screening done as financially remunerated

Case management only used in chronic disease and over-75 health check. This maybe due to time pressure of disinterest in older people but there was no evidence.

Limitations of study: Self assessment via questionnaire

Key messages: Older peopled need proactive care to assess risk and prevent problems developing; case management may be the way forward

19

Forester S (2004). Adopting community development approaches, Community Practitioner 77 (4) 140-146

Type of study: Primary qualitative study

Aim: to explore factors that influence adoption of community development approaches within health visiting including skill development.

Method: purposive sampling technique to recruit health visitors using community development approaches within mainstream health visiting. Semi structured interviews, drawn from a feminist perspective were conducted with first 3 interviews conducted as a pilot. Subsequent interviews made more specific as a result. 11 participants interviewed from across England. Thematic analysis following Burnard's framework. Transcripts were coded and arranged into themes.

Findings: Four main themes identified. (1) Values and skills - participants described a number of ways in which they worked differently from 'traditional health visiting'. (2) Relationships with communities and other agencies (3) Teamwork. Difficulties faced by HVs in relation to lack of organisational support and feelings of isolation when working with clients.

Limitations: 11 health visitors interviewed. Discussion focussed mostly on health visitors relationships with other agencies rather than clients.

Key messages: Community development requires a more systematic approach incorporating both educational and management support.

To develop a public health agenda based on participation and multi-agency working, changes in practice are required in relation to power sharing and risk taking. Practitioners have to be equipped with relevant educational skills but also need to be supported at organisational and policy levels.

20

Griffiths R Johnson M Piper M Langdon R. (2004) A nursing intervention for the quality use of medicines by elderly community clients International Journal of Nursing Practice 10(4) Aug 166-176

Type of study: Qualitative evaluation study

Aim: To evaluate the effectiveness of an intervention to improve knowledge, regime and adherence to medication taking in older people

Method: A pre and post test design with a cross sectional survey of older people receiving community nursing care was used. A follow up interview was conducted with a subgroup of clients with deficits in knowledge of medications or management ability.

Findings: Participants took an average of 10 medications per day. 79.2% were responsible for their own medication administration, 8.3% participants were able to manage their medication successfully. 70.8% needed some form of education about the scheduling and function of medication. Following intervention by community nurse their was a significant improvement in the percentage of medications and schedules correctly named, there was little change in medication regimes

Limitations of study: Community nurse were self reporting and not observed. Interviewing may have raised awareness rather than community nurses' interventions

Key messages: Overall, there was an improvement in medications named but no significant change in understanding of function of medications. No change in regime or adherence. Study identified that community nurses have an important role in identifying those at risk and to get early action or referral.

21

Grimmer K Moss J Falco J (2004) Becoming a carer for an elderly person after discharge from an acute hospital admission The Internet Journal of Allied Health Sciences and Practice 2(4) 13

Type of Study: Qualitative observational study

Aim: To describe the perceptions of people taking on a new or expanded caring role for an elderly patient recently hospitalised with a new or intensified health problem

Method: Twenty four primary carers of recently ill, elderly patients were interviewed over a six month period following patient discharge from an acute hospital admission. All interviews were recorded and transcribed for analysis. Qualitative analysis focused on identification of key themes, synthesised from carer interview data.

Findings: The physical, financial and emotional costs for the carer were highlighted. Being identified as the primary carer did not necessarily imply that the carer was physically or emotionally prepared to undertake the tasks of caring for their patient. Most carers are constrained by their lack of education about their role and their patient's condition, and by their own health status or other commitments. Carers were insightful about their situation and the services required to meet their needs. Carers have higher levels of anger, anxiety, sadness and depression than non-caregivers.

Limitations of Study: Discussion of data analysis limited Sampling strategy not justified. Fieldwork not well described. Only focused on discharges from four acute hospitals

Key Messages: It cannot be assumed that someone is willing to take on carer role . If unpaid carers are to continue to be the main source of patient support post-discharge they require to be appropriately resourced to maximise long-term independence in the community. Patients and carers require appropriate community supports, including education for the role

22

Groner J French G Ahijevych K Wewers ME (2005) Process evaluation of a nurse-delivered smoking relapse prevention program for new mothers Journal of Community Health Nursing 22(3) 157-167

Type of study: Quantitative and qualitative (American)

Aim: To evaluate the feasibility, recall, and acceptability of an evidence-based intervention using home-health nurses to provide smoking relapse prevention skills to new mothers.

Methods: Design of study used process evaluation. Purposive sample of 121 women who had quit smoking between conception and 7 days prior to delivery and had delivered a health baby within 48 hours. Women were screened whether they had smoked a cigarette confirmed by a saliva cotinine test.

Findings: The intervention was effective in doubling the rate of remaining smoke free at 3 and 6 months postpartum compared with baseline data collected from participants recruited at the same hospital 1 year previously.

Limitations: Ethical implications for exclusion of women who smoked, if they failed to meet criteria they did not get the follow-up support at home. Research methodology and analysis unclear.

Key messages: Home-based, nurse-delivered intervention provided smoking relapse prevention skills to new mothers. Successful interventions identified as clinician support providing cognitive restructuring, training in problem-solving skills.

23

Hill C Weinert C (2004) An evaluation of an online intervention to provide social support and health education

Computers and Informatics in Nursing 22 (5) 282-288

Type of study: Quasi-experimental, nurse-led project

Method: intervention - electronic support group, aimed at women living in rural areas with chronic illness. N=75.

Findings: women in intervention group experienced increase in social support, and increase in computer skills.

Limitations: difficult to disentangle the specifically nursing contribution from the technological, although all contributing researchers appear to be nurses. US study. Small scale.

Key messages: Nurse led initiatives such as these may be useful in reducing isolation of chronically ill, or disadvantaged, in rural communities.

24

Holcomb L (2000) A Delphi Survey to identify activities of nurse practitioners in primary care Clinical Excellence for Nurse Practitioners 4(3) 163-172

Type of study: Delphi Study

Aim: To identify activities of Nurse Practitioner's (NPs) in the provision of primary care

Methods: Primary care NPs (n = 139) responded to serial questionnaires asking them what activities they undertook in their practice. Sample covered paediatrics (n=12), family (n = 75) adult (n+15) and women's health (n + 37)

Findings: NPs spend most of their time providing care to patients and patient teaching is presumed to be one reason NP outcomes are superior to doctor especially in chronic illness.

Patient assessment and referral to other professionals and community resources reflect the gate keeping nature of the NP role. Diagnostic testing activities did not weigh heavily on these NPs. NPs practicing with less physician supervision spent less time with the patient and on nursing activities.

Limitations: US study

Key messages: Patients with chronic illness value the contributions of nurses to health promotion and illness prevention. Where nurses work with less physician supervision this leaves less time for patient interaction. NPs should be educated to Masters Level

25

Jansson A Petersson K Uden G (2001) Nurses' first encounters with parents of new-born children - Public health nurses' views of a good meeting. Journal of Clinical Nursing 10 (1) 140-151

Type of Study: qualitative using focus groups

Aim: To explore nurses' experience of first encounter with parents and new-borns.

Method: four focus group interviews held with nurses from different primary health car areas in Sweden. Each group consisted of four - seven nurses, representing areas characterised by both small towns and rural areas. Interviews audio taped and transcribed. Analysis using content analysis to identify main themes

A good study that confirms previous research in area

Findings: little difference between nurses in different focus groups with regard to content. 3 main categories identified: (1) creating trust (2) creating a supportive environment and (3) creating a picture of the family's life situation. The main factor that influenced nurses' experience of the first encounter was home visits - that was deemed an important tool for supporting the three main categories. The equality of the relationship was enhanced, promoting trust and more effective health care with the provision of home visits. Time spent establishing the relationship particularly during the first meeting was essential rather than spending that time completing a needs assessment. The study supports previous research by Mitcheson et al in that forming too formal an approach can be detrimental and impersonal to clients. Home visiting programs encourage and focus on the relationship rather than a more superficial needs assessment

Limitations: exploratory study using qualitative methods within a Swedish health area.

Key messages: A successful first meeting between client and nurse was crucial in establishing the ongoing, mutually trusting relationship necessary to provide effective health care. This study supports the need for early and good encounters to occur to establish longer lasting relationships with parents. Home visiting strengthens these relationships with a more equal relationship possible, which acts as a foundation for further health promotion activities.

26

Jiwa M Gerrish K Gibson A Scott H (2002) Preventing avoidable hospital admission of older people British Journal of Community Nursing 7(8) 426-431

Type of study: Evaluation study

Aim: To evaluate the effectiveness of a programme of enhanced primary care support intended to reduce the risk of hospital admissions for people aged 75 or over.

Method: All over 75 were seen by DN and GP assessed for risks and those at risk were phoned, seen and referred to wider team.

Findings: Risks can be identified. More at risk were not necessarily admitted. Only a minority willing to accept intervention, maybe due to fierce sense of independence or a refusal to accept at risk label imposed by healthcare professionals

Limitations of study: Assessment of risk was largely subjective

Key messages: GP's and DN's can identify older people at risk of hospital admission Many were at risk due to complex interplay between social, physical and psychological factors. Those at risk were referred to the wider primary care team. Assessing 'at risk' did not mean that more were admitted. Patients seemed more willing to receive information about how they could help themselves, rather than what others could grant them, in order to retain independence. Without a proactive approach, primary care will continue to 'fire fight' and crisis admissions of older people to hospital will continue

27

Kellett U Mannion J (1999) Meaning in caring: Reconceptualizing the nurse-family carer relationship in community practice Journal of Advanced Nursing 29 (3) 697-703

Type of Study: Qualitative methodology, ontological-hermeneutics

Aim: to examine the importance of understanding the human experience of family caring at home

Method: In-depth, audio-taped unstructured interviews of seven family caregivers were undertaken . All participants were interviewed twice. Thematic analysis of 14 transcribed interviews uncovered a number of common themes. General meaning to identify essential or contextual meaning which would illuminate the nature of family care giving was identified prior to the second interview. The data analysis package NUD*IST was used. These interpretations were shared and validated during the second interview.

Findings: Six common themes of meaning were generated. Sense of family life past - background and experience of family life shaped and influenced how people approached caring. Sense of change - can be natural progression or thrust upon carer, can lead to feelings of sadness, loss, guilt and self-doubt. Sense of engaged involvement - being in control and being able to manage allowed family carers to attribute meaning to caring practices. Sense of worth - having special knowledge of those cared for helped assist family carers to adjust to their caring role. Sense of concern - fear of being out of control and unable to care. Sense of continuity - need to develop an adaptive caring role to be able to continue to cope with caring situation.

Limitations of Study: Small qualitative study. No indications given of level of care being provided or range of disease processes involved. Extent of any involvement of community nurses not discussed.

Key Messages: Challenges community nurses to reflect upon their understanding of the processes by which family carer have a need and desire to be involved in providing care for an older relative. Need to engage family care givers in everyday caring practices in meaningful and stress-reducing ways. Through understanding human experience of caring nurses can work supportively with family caregivers.

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Kennedy CM (2002a) The decision making process in a district nurse assessment British Journal of Community Nursing 7 (10) 505-513

Kennedy CM (2002b) The work of district nurses: first assessment visits Journal of Advanced Nursing 40 (6) 710-720

Kennedy CM (2004) A typology of knowledge for district nursing assessment practice Journal of Advanced Nursing 45 (4) 401-409

Type of Study: Qualitative ethnographic study

Aim: To explore the nature of the knowledge required by district nurses to carry out first assessment visits and the relationship of this to the decisions they make.

Method: Eleven district nurses were accompanied on a first visit to observe real life examples (participant observation) and they were interviewed twice, immediately after the observed visit and approximately one year later when the initial data analysis had been undertaken. Interview schedules were used for both interviews. The interviews were taped, transcribed verbatim, the transcripts and field notes were coded thematically and inductively analysed.

Findings: Building a bigger picture of the patient and carer situation was found to be fundamental to the assessment process for short or long term cases. The nature of the assessment has to be individualised. Assessment was viewed as an ongoing process, which uses observation of the environment and has to be paced overtime to avoid 'interrogation'. Making the first visit work was a key theme. This required a balance between being the guest and being the professional in establishing the relationship and communication channels. The information search for different goals requires different information to inform the decision-making. Regardless of current nursing needs, district nurses felt they should anticipate patients' future needs. Maintaining contact when future care needs were anticipated emerged as an important insight into the DN role. The assessment process involves recognising salient issues, seeking information, interpreting the evidence collected, formulating ideas and making judgements to inform decision-making. The subsequent development of a typology of knowledge for district nursing assessment practice identifies six dimensions: getting to know the patient in their own setting, getting to know the carer, knowing what needs to be done now, knowing what may happen in the future, knowing/recognising knowledge deficits, and knowing the community resources and services.

Limitations of Study: Restricted range and timescale of assessment visits included. Potential subjectivity of researcher

Key Messages: Building the bigger picture through assessment requires knowledge from theoretical and experiential sources . Making the first visit work requires balancing professional and personal conversation to establish good rapport . District nurses need to know available resources to the community. Development of typology of knowledge for district nurse assessment practice provides framework for range and type of knowledge required for district nursing practice.

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King N Bell D Thomas K (2004) Family carers' experiences of out-of-hours community palliative care: a qualitative study International Journal of Palliative Care Nursing 10 (2) 76-83

Type of Study: Qualitative exploratory study

Aim: to explore carer's experiences of out-of-hours care and support services

Method: A semi-structured interview topic guide was used to interview 15 bereaved carers on their experience of out-of-hours services. Interviews were tape recorded and transcribed in full. Data was analysed thematically using the 'template' approach.

Findings: Most of the carers had been provided with information on who to contact in a crisis out-of-hours. Carers felt reassured that they could contact an appropriate professional if necessary. In general out-of-hours district nursing service contacted rather than GP services. They were consistently praised for the quality of care they gave and their attitudes towards carers and patients. There were isolated incidents of less than optimal quality of care by district nurses. The role played by night-sitters was highly valued by those who used the service (approximately one third of sample). No general problems in relation to access to drugs or equipment were experienced. Some evidence found to indicate use of handover form improved quality of care.

Limitations of Study: Potential for bias in sample due to recruitment methods used. Small sample size may not have included those who had problems with the service

Key Messages: Important to provide good information to patients and carers about sources of support out-of-hours. It is important to listen to carers and recognise their expertise regarding the patient and their condition. Good communication is a prerequisite for the anticipatory approach to care

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Kinn S Clawson D (2002) Health Visitor risk assessment for preventing falls in elderly people British Journal of Nursing 11(5) 316-321

Type of study: Exploratory study

Aim: To explore the feasibility and usefulness of risk assessment as part of a routine health check for the over 75's

Method: 162 patients were invited for health check and risk assessment

Findings: 89 people took part between the ages of 75 and 95 years, Assessment took up to an hour in GP surgery or at home. Two risk factors that linked to falling were polypharmacy and living in sheltered housing

Limitations of study: Small study, some over 75's may have been missed. Dependent on accurate report of home hazards when interview carried out in surgery

Key messages: Assessing risks and risk prevention through health assessment is feasible . Risk assessment raises awareness of potential hazards. Health promotion is needed to understand risks. Risks need early intervention

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Kirk S (2000) Negotiating lay and professional roles in the care of children with complex health care needs Journal of Advanced Nursing 34(5) 593-602

Type of study: Qualitative (UK)

Aim: To assess how the transfer of responsibility from professionals to parents was negotiated, the tensions and contradictions that can ensue, and the implications for professional nursing roles and relationships with parents.

Methods: Grounded theory methodology, in-depth interviews conducted with 23 mothers, 10 fathers and 44 professionals. Families purposefully selected from 3 children's hospitals. Data collection and analysis occurred concurrently with codes and categories being inductively developed from the data (with use of NUD*IST).

Findings: From parents' perspective, their initial assumptions of responsibility for the care of their child were not subject to negotiation with professionals. Parents felt obligated to care for their child and this was affected by strong desire for their child to go home. Findings identified the absence of alternatives to parental care in the community. Professionals stated that they had concerns over the degree of choice parents had in the face of professional power.

Limitations: Generalising to the wider population is not appropriate as a small qualitative study. Acknowledges need to include more parents from ethnic minority groups.

Key messages: Parental choice to care for their child at home was constrained initially by parents' feelings of obligation and by the lack of community services. Being at home and being the expert in the caring for their child gave parents a sense of control to participate in negotiations with professionals.

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Kirk S Glendinning C (2002) Supporting 'expert' parents - professional support and families caring for a child with complex health care needs in the community International Journal of Nursing Studies 39 625-635

Type of study: Qualitative exploratory (UK)

Aim: To discover parents' and professionals' experiences of receiving and providing support in a context where parents rather than professionals are the expert caregivers.

Methods: Purposive sample of 24 technology-dependent children recruited from 3 specialist children's hospitals in the UK. Parents provided the names of all professionals involved in the home care of their child and 38 professionals were purposively selected to cover a range of different professionals. Face-to-face, in-depth qualitative interviews were conducted with parents and professionals. Grounded Theory methods were used in the data analysis with NUD*IST used to code and explore the data. Codes were identified in the data and systematically compared and contrasted and then clustered together to create categories.

Findings: Support has 3 dimensions 1. Emotional support (includes "being there", easy to contact, knowing the child, listening/counselling, promoting parents' self-confidence) 2. Instrumental or practical help (includes practical support, advocacy, "hands-on" care, organising services and equipment) 3. Information (includes advice and information giving, teaching, giving feedback.

Limitations: Small exploratory study.

Key messages: The study identified a high degree of congruence between parents and professionals' understanding of support and what it entailed. Community children's nursing services which were able to offer 24-hour contact in case of emergency were particularly valued (particularly in providing accessible information and advice to turn to in case of uncertainty or anxiety and practical help in obtaining services and care coordination). Identified key nursing skills of providing information, advice and education, counselling, emotional support and service co-ordination.

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Kirk S Glendinning C (2004) Developing services to support parents caring for a technology-dependent child at home Child Care, Health and Development 30(3) 209-218

Type of study: Qualitative (UK) This is same study as reported in Kirk and Glendinning (20020 but different aspects of findings presented

Aim: (Worded differently to Kirk and Glendinning, 2002). To explore the experiences of families caring at home for a technology-dependent child; to examine their needs for practical and other support; and to examine how far services are currently meeting these needs.

Methods: Same as Kirk and Glendinning, 2002

Findings: Services in the community were not sufficiently developed to support this group of families. Major problems were identified in the purchasing and provision of short-term care, home support services and specialist equipment/therapies in the community. Service provision could be poorly planned and coordinated at an operational level and few families had a designated key worker. Information giving to parents was often described as poor.

Limitations: Same as Kirk and Glendinning (2002)

Key messages: Important point identified re parents having more knowledge than community based professionals and also that hospital professionals failed to negotiate the transfer of care giving responsibility to parents. States that the roles of professionals focused on supporting parental care-giving rather than providing 'hands-on' care.

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Lazenbatt A Orr J Bradley M McWhirter L (2000) Community nursing achievements in tackling inequalities in health in Northern Ireland NT Research 5(3) 178-192

Type of Study: Descriptive survey and exploration of nursing contribution to targeting health and social needs.

Findings: No substantive evaluation of nursing interventions and evaluations.

Key messages: Identifies some of the difficulties of conducting RCTs in health inequalities research and discusses the use of qualitative approaches.

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Luker K A Austin L Caress A Hallett C (2000) The importance of 'knowing the patient': community nurses' constructions of quality in providing palliative care Journal of Advanced Nursing 31(4) 775-782

Type of Study: Qualitative exploratory, part of larger study

Aim: To explore community nurses' construction of quality of care in palliative care

Method: Random sample of community staff interviewed, all grades, working within district nursing service, using a critical incident approach to focus on palliative care and terminal care provision. The taped interviews were transcribed, coded thematically and inductively analysed

Findings: Getting to know the patient and family well emerged as the essential antecedent for the provision of good quality care. Affected by early access and success of communications. Community nurses perceive the foundations of high quality care to be grounded in the communication patterns which exist between nurses, patients, carers and families through having time to provide more than the physical aspects of care. All enable community nurse to respond to patient's individual needs. Early access facilitates the formation of relationships. It w\s viewed as being less stressful to work in a situation of open awareness where all participants were aware of the impending death. Preparing the patient and family for a changing trajectory ending in death was seen as core district nursing work, valued if time consuming.

Limitations of Study: Reports only one aspect of the overall study. Outcomes are from nurses' perspective not patient/carers. Type and grade of nurse involved not explicit. Undertaken in one trust only.

Key Messages: The centrality of knowing the patient and family was a key concept in the provision of high quality palliative care, individualised to the patient. Continuity of care requires to be maximised through early contact, acting in a friendly manner, limiting number of nurses involved.

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McGarry J (2003) The essence of 'community' within community nursing: a district nursing perspective Health and Social Care in the Community 11(5) 423-430

Type of Study: Qualitative exploratory

Aim: To explore how district nurses' defined the essence of community, both in terms of providing nursing care in the community setting and also in terms of defining community within the context of their work.

Method: 10 qualified district nurses, from two primary care trusts were interviewed. Data analysis was undertaken using an iterative approach.

Findings: Themes identified were: the maintenance of personal-professional boundaries, notions of holistic care and professional definitions of community. The location of care within the home affects the nurse-patient relationship, being a guest in the patient's home means patient more in control, having greater degree of input into their care, negotiates treatment and care, more time to build a relationship. Central concept of the role of the district nurse was provision of holistic care: seeing and being part of the whole picture; potential to be changed due to introduction of initiatives like rapid response teams etc. Need to maintain professional barriers or boundaries: avoid giving 'too much' emotional input and practical time, remain professional, protect confidentiality if live and work in area, but developing relationships with patients and families highly valued part of role. Being part of the community in a professional sense: raising the profile of the service, contributing to wider community health issues.

Limitations of Study: Methodology only briefly reported.

Key Messages: Location of care provision can affect nurse-patient relationship. Central concept of DN role is holistic care, from initial assessment through continuity of care and negotiated care. Tensions can exist balancing professional role, friendship and being part of community

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McLoughlin PA (2002) Community specialist palliative care: experiences of patients and carers International Journal of Palliative Care Nursing 8(7) 344-353

Type of Study: Qualitative study based on case studies

Aim: To gain insightful and credible accounts of participants experiences of the specialist palliative care nurse; to consider those dimensions of care which impact on satisfaction; to discover whether the SPCN provides improvements in QoL and to explore whether experiences match expectations.

Method: A specific, purposive sample known to SPCN and who met specific inclusion criteria of four patients and their carers formed the case studies for this study. Focused non-directive, in-depth interviews, two per case study, and self-completing diaries were used. The study took place over 20 weeks. Interviews were taped and transcribed. The data was analysed through an interactive cyclical process as the data was revisited and themes, concepts and ideas developed to form principal categories. Only one diary was completed.

Findings: Lack of knowledge about the care and role of the SPCN was evident from patient and carer. Most participants were surprised at the type of input, but valued the input they received. Often valued as someone to talk to by patients and carers. The SPCN positively influenced the perception of care and support received, but patient and carer differently interpreted this. Was seen as instrumental in attempting to defuse patient/carer anger. SPCN knowledge base assisted effective symptom control. The control of symptoms was linked to perceived benefits to QoL and subsequent increase in satisfaction. Patients tended to be more realistic about the future than carers. Earle referral was viewed as beneficial.

Limitations of Study: Very small sample size with acknowledged selection bias. Role confusion for researcher as SPCN

Key Messages: There is a need for early referral to SPCN services and greater understanding of and education about roles. Need for efficient communication channels for continuity of care.

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Mitcheson J Cowley S (2002) Empowerment or control? An analysis of the extent to which client participation is enabled during health visitor/client interactions using a structured health needs assessment tool. International Journal of Nursing Studies May 40(4) 413-26

Type of study: Qualitative, conversational analysis

Aim: To examine the interaction between the health visitor and client during an assessment process using a structured needs assessment tool

Method: Data were collected from two NHS community trusts in which health visitors were invited to participate. The two sites each used a different structured approach. Site A covered a multi-cultural population within a metropolitan area and Site B served a similar sized mostly rural area. Site B were particularly concerned to ensure child protection issues were addressed. Data collected by interviews and audio taping. Analysis was by conversational analysis.

Findings: interactions between HV and client did not enable client participation or open assessment of needs. The HV tended to control the interactions and there was limited opportunity for clients to participate as a result of the structured assessment. Use of both tools did not support a mutual relationship to exist.

Key messages: The two structured tools used rendered the assessment process ineffective, as the use of the instruments were associated with a failure to either identify needs relevant to the client or to enable clients to participate in the process - (the aim of most interactions in the home). Missed cues, insensitivity of questioning style and controlling nature of interactions were potentially harmful to vulnerable clients. Clients were not empowered to participate or develop a more equal and trusting relationship with HVs due to time spent on completing routine assessment forms. Gap between HVs positive intentions and negative reality is supported in previous literature. Health Needs Assessment Tools foster a too structured and inflexible approach

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Navaie-Waliser M Misener M Mersman C. Lincoln P (2004) Evaluating the needs of children with asthma in home care: the vital role of nurses as caregivers and educators Public Health Nursing 21(4) 306-315

Type of study: Quantitative: exploratory, descriptive but used statistical analysis (American)

Aim: Examined the characteristics, risk factors, and needs of children with asthma, and the impact of home health nurses on improving parents'/family caregivers' knowledge about asthma triggers and management.

Methods: Records of 1007 children (19 years or younger, residing in 4 boroughs of New York City, who were admitted to home care with a primary or secondary diagnosis of asthma in 1999) were examined retrospectively. Data extracted onto a uniform survey instrument. Descriptive (e.g. frequencies, means, medians and SDs) and bivariate analyses were performed with the aid of the Statistical Analysis System. Reliability of extracted data assessed and higher interrelated reliability score was indicated = 0.95, SE=0.04.

Findings: Approximately 1 in 4 children with asthma suffered form additional co morbidities. Home environmental triggers were identified. Notable psychological triggers were family tensions, physical activity, anxiety/stress, and friends/peer pressure. Discharge assessments suggested that home health nurses could help improve caregivers' knowledge about asthma management.

Limitations: Not all of the children's medical records were available for review and some data were missing for important variables. Was unable to address questions related to the impact of asthma on the lives of children and their families, asthma severity, compliance with national guidelines for asthma care.

Key messages: Identified parents/carers lack of knowledge about asthma, treatment and triggers. Home care nurses education intervention increased parents' knowledge, and increased compliance and self-management.

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Naylor M Brooten D Campbell R Jacobsen B Mezey M Pauly M Schwartz J (1999) Comprehensive Discharge Planning and Home Follow-up of Hospitalised Elders: A Randomised Clinical Trial The Journal of American Medical Association 281(7) 17 Feb 613-620

Type of study: Randomised Controlled Trial

Aim: To examine effectiveness of Advanced Practice Nurse-centred discharge planning and home follow-up intervention for elders at risk of for hospital readmission.

Method: Intervention group received baseline assessment on admission to hospital, hospital visit, home visits, discharge summaries by advanced practice nurses who were masters prepared specialists with expertise in communication, collaboration, coordination and joint-decision-making Control group received routine discharge planning and standard home care if required from visiting nurses who were bachelors prepared generalists.

Findings: Control group were more likely to be readmitted than the intervention group. The intervention resulted in fewer hospital admissions. Time for first readmission for any reason was increased in the intervention group. Intervention and control groups were similar in mean functional status, depression scores and patient satisfaction. Functional status was not improved with this intervention.

Limitations of study: Philadelphia

Key messages: The intervention reduced readmissions, lengthened time between discharge and readmission and decreased costs of providing healthcare. The focus of clinical intervention on the combined effects of primary health problems, co-morbid conditions and other health and social issues common in the patient population rather than on the management of disease was a major factor in its effect. The intervention benefited from the APN's expertise in communication, collaboration and coordination of care.

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Offredy M (2002) Decision making in primary care outcomes from a study using patient scenarios. Journal of Advanced Nursing 40 (5) 532 - 541

Type of study: Quasi-experimental

Methods: explored decision making processes of nurse practitioners and GPs in relation to simulated scenarios via 'think-aloud' techniques.

Findings: little difference was found between cognitive processes and outcomes of professional groups.

Limitations: small scale (22 participants). Emphasis on describing processes, but with an evaluative element.

Key messages: no substantial difference in process or achievement between professional groups.

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Ohman M Soderberg S (2004) District nursing - sharing an understanding by being present. Experiences of encounters with people with serious chronic illness and their close relatives in their home Journal of Clinical Nursing 13 (7) 858-866

Type of Study: Phenomenological hermeneutic interpretation

Aim: To elucidate the meaning of district nurses' experiences of encounters with people with serious chronic illness and their close relatives at home.

Method: A purposive sample of 10 district nurses from two health care centres in Sweden was interviewed using a narrative approach with set initial questions. The interviews were taped and transcribed verbatim. The interpretation was in three phases: naïve understanding, structural analysis and interpretation of the text as a whole.

Findings: District nurses' experiences of encounters with people with serious chronic illness and their close relatives in their homes can be understood as district nurses being welcomed into the ill person's privacy, to share their intimacy and their understanding of being ill. To achieve a close relationship, district nurses need to be committed and available, to be accessible and have time for the person. Touch and active listening are important parts of developing intimacy and understanding. It is important to also keep a protective distance along with the closeness of a caring relationship. District nurses are available to alleviate and console a person who is suffering due to serious chronic illness in their own home.

Limitations of Study: Subjectivity of researcher in this approach. The closeness in age of the sample.

Key Messages: Being 'entirely present' in encounters between district nurse and patient/carers is a key area for reflection on care interventions. Key themes identified were: being in a close relationship, sharing an understanding and weaving a web of protection. The relationship between the district nurse and patient/carer was key to the ability to help them cope or deal with the situation of serious chronic illness

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Olsen R Maslin-Prothero P (2001) Dilemmas in the provision of own-home respite support for parents of young children with complex health care needs: evidence from an evaluation Journal of Advanced Nursing 34(5) 603-610

Type of study: Qualitative evaluation (UK)

Aim: Evaluation of a nurse-led, home-based, respite service for the families of children under the age of 5-years with complex health care needs.

Methods: A parent-centred, follow-up evaluation, using in-depth qualitative interviews with parents in 18 families consecutively referred to the Children's Outreach Service over an 8-month period. No information about data analysis.

Findings: Revealed mixed reactions (positive and negative feedback) to this service. Evidence of role of service contributing to family well being.

Limitations: Limited information about data analysis. Small evaluation specific to one service and therefore not able to generalise.

Key messages: Deemed an effective service and factors identified that influenced the change in 'family well-being' (e.g. child not requiring hospital admission).

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Perkins E MacFarlane J (2001). Family support by lay workers: a Health Visiting initiative British Journal of Community Nursing 6(1) 26-32

Type of study: Evaluation of health visiting initiative program - qualitative data

Aim: To Evaluate a program that offered lay visiting schemes with family support workers (FSW)providing social support, health promotion activities and assistance in accessing local facilities for isolated teenagers expecting their first baby

Methods: Evaluation took place 12 months following implementation of program. Qualitative interviews completed with family support workers, health visitors - 13. Focus group interview with clients (7). Content analysis performed. Review of client record system maintained by FSWs undertaken

Findings: main themes identified - prolonged contact with FSWs (approx 4-6 months) resulted in reduced isolation; practical help with home-making and improving confidence and self esteem in young mothers. Work carried out by FSWs assisted isolated mothers in changing their home environment such as home safety, dealing with council authorities. FSWs were able to offer young clients emotional support and unlike health visitors accompanied clients to mother and toddler groups and facilitated informal group meetings with other mothers increasing social opportunities for them. The program most successful in improving confidence and self esteem. Mothers believed FSWs were more approachable and were " people like us" and felt safe and well understood. FSWs enhance the service, they are not a substitute for HVs.

Limitations of the program: Confidences in the FSWs uncovered needs for assistance not previously known to the HVs who had made the referrals. Issues relating to drug abuse, child protection and violence were not fully addressed prior to introduction of FSWs. The intensity of the relationships created problems in defining boundaries of responsibility for the FSWs and at times confusion between personal issues and those of the clients. Recommendations for improving the service included strengthening the boundaries around FSW particularly when vulnerable clients experienced greater stress if FSWs were withdrawn or completed their period of visitation. These changes were as follows: focussing on practical tasks; moving away from an open ended supportive relationship to one focussed on dealing with a specific problem and limiting emotional support

Limitation of the study: not really stated how emotional support could be limited with no guidelines - clients stated that the strength of the program was that it enabled them to have more emotional support and improved confidence - at odds with recommendations. Small qualitative evaluation of a program limited to one area in inner city Sheffield. Any similar research on lay visiting schemes is not available to support findings. Further research in form of large scale quantitative studies required.

Key messages: FSWs enhance the service that professionals offer. They are not a substitute. FSWs do not save health visitor time. Programs such as this involves assessing clients for referral, supporting and supervising FSWs and acting on new needs identified by FSWs. Clients value the more informal approach and relationship that is established with FSWs. Lay visiting schemes beneficial when linked to health visiting practice. Both clients and professionals involved identified similar benefits: Progress in home making skills including child safety; reduced isolation through accessing groups and courses as well as one-to-one contact and improved self confidence and self esteem.

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Piette J (2000) Satisfaction with automated telephone disease management calls and its relationship to their use The Diabetes Educator 26(6) Nov/Dec 1003-1010

Type of Study: Randomised Control Trial (RCT)

Aim: assessment of automated telephone disease management for 256 adults with diabetes

Methods: 2 RCTs of ATDM with follow up by diabetes educator as a strategy for improving self care and health outcomes

Patients in intervention groups received ATDM calls every two weeks and reported health and self care information using a touch tone phone. They also had the opportunity to select information. The information provided made it possible for diabetes educators to allocate time more effectively.

Findings: Diabetes care supported by ATDM had positive outcomes - at 12 months intervention patients reported more frequent self monitoring of blood glucose, foot inspection, weight monitoring and fewer medication adherence problems. Patients were also more satisfied with care and reported fewer symptoms of depression and fewer days in bed due to illness .

Limitations: Not a nursing intervention but patients supported by what are called diabetes educators but their background not clear.

Key message: ATDM could be a useful organizational intervention for chronic illness management .

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Schoot T Proot I Ter Meulen R De Witte L (2005) Actual interaction and client centeredness in home care Clinical Nursing Research 14 (4) 370-393

Type of Study: Qualitative grounded theory study

Aim: To explore the phenomenon of client-nurse interaction from a client perspective to better understand client-centred care

Method: Data were collected by focus interviews with 8 client informants, participatory observations with 45 clients, and semi-structured interviews with 6 clients. South of the Netherlands. Nurses ranged from graduates to unqualified. Data collected over 8 months. Interviews were taped and transcribed and reports were written on the participatory observations. Analysis took place simultaneously with data collection. All data were coded and through comparative analysis patterns/categories identified.

Findings: Actual interaction between the client and the nurse emerged as the core category. Six patterns of actual interaction were identified: toeing the line where client obeys decisions made by nurse; reluctance where there is lack of commitment with and avoidance of nursing care by clients although clients values the social attention; consent entails client activities aimed at conforming with and adhering to the opinion and advice given by the nurse; dialogue manifests as a process of interactive discussion between equal, independent partners in care; consuming covers clients deliberately choosing the interventions, services, and resources they need and wish; and finally fighting emerged as client activities aimed at getting the care and participation desired.

Limitations of Study: Sample focused on those who were chronically ill and receiving home care from a variety of nurses in one specific area of Netherlands. Further research required with other client groups

Key Messages: Client-centred care is about congruence between desired and allowed participation. In different conditions different patterns of interaction may be appropriate. Individualised care obliges nurses to ascertain on a continuous basis in which way and to what extent clients really want to participate in care

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Shum C Humphreys A Wheeler D Cochrane M Skoda S Clement S (2000) Nurse management of patients with minor illnesses in general practice: Multicentre, randomised controlled trial British Medical Journal 320(7241) 15 April 1038-1043

Type of study: Multicentre Randomised Controlled Trial

Aim: To assess the acceptability and safety of a minor illness service led by practice nurses in general practice

Method: Patients from 5 practices requested and were offered same day appointments by receptionists and were assigned to a specially trained nurse or general practitioner. Patient satisfaction was measured using a satisfaction questionnaire with 75% response rate.

Findings: Patients were more satisfied with consultations with nurses than with doctors and the clinical outcomes were similar. Nurses gave more advice and spent longer time

Limitations of study: Care was effective but quality was not observed. Cost and long term outcome were not considered

Key messages: Same day appointment service led by a practice nurse is acceptable to most patients. Nurses are able to offer a clinically effective service, although uncertainty remains regarding rare clinical outcomes. Further research needed into the longer term effects of the nurses service on patients attitudes to their illness and behaviour in seeking health care

50

Speed S Luker KA (2004) Changes in patterns of knowing the patient: the case of British district nurses International Journal of Nursing Studies 41 921-931

Type of Study: Multi-site ethnographic qualitative study.

Aim: To examine the relationship district nurses had with patients through a period of turbulent change.

Method: Using non-participant observation, polyphonic interviews, and informal conversations a purposeful sample from four sites was used to examine the question 'how are the changes in the organisation of primary care affecting DN relationships with patients'? Following participant observation field notes were transcribed. Unstructured and polyphonic interviews were taped and transcribed. Initially open coding was used and these codes were then collapsed into meaningful categories. The process of axial coding was used.

Findings: In the past the provision of extra non-nursing services evolved as part of the response to the socio-political context, could be seen as an active or passive strategy which enabled the patient to stay in the community. However, could be said to foster a sense of dependency on the district nurse, but not on other services. Resulted in variety of care provision dependent on the discretion of the individual nurse and her knowledge of the patient. This system changed in the 1990s when care provision was divided between health and social care and district nurses were not providing the same level of personal care. It is argued that the district nurses moved from a position of knowing to knowing about their patients. Technical and evidence based knowledge of practice has replaced the personal knowing of the patient.

Limitations of Study: Not all aspects of relationship explored. Lack of clarity regarding types of nurses involved.

Key Messages: Community nurses ways of knowing patients have changed. In the past had personal knowledge of patients, some dependence by doing for and caring for. Has moved to division of work with nurse involved in more technical care and families and carers undertaking social care. At present district nurses know about patients or know by proxy and deliver technical rather than personal care.

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Tuttle J Bidwell-Cerone S Campbell-Heider N Richeson, G Collins S (2000) Teen club: a nursing intervention for reducing risk-taking behaviour and improving well-being in female African American adolescents Journal of Paediatric Health Care 14(3) 103-108

Type of study: Qualitative evaluation (American)

Aim: Describes a nursing intervention called Teen Club that was designed to reduce risk-taking behaviour and improve well-being in female African American adolescents.

Methods: 3-year retrospective evaluation of Teen club, retrospective focus group interview with 11 participants of Teen Club and interview with the 2 adult co-leaders to determine their reactions to the experiment. Analysis of responses to the interview questions for themes and shared meanings.

Findings:

Evaluation of a Teen Club in America, established in response to female adolescents presenting for pregnancy tests with background of substance misuse, poor school attendance and performance, lack of housing, clothing and food. Teen Club provided a 10-week nursing intervention to create a more supportive environment with follow-up of home visits and additional support. Interventions identified as social and family support, role modelling responsible adult behaviour, and practical support.

Limitations: Small evaluation specific to one service and therefore not able to generalise. Limited information re methodology.

Key messages: Suggests that interventions improved the young people's quality of life but the change came at a significant investment of resources (states "were the results commensurate with the size of investment?" and "does preventing things from getting worse, as compared to making them better, qualify as a successful outcome?)

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Vass M Avllund K Lauridsen J Hendriksen C (2005) Feasible model for prevention of functional decline in older people: Municipality-randomized controlled trial Journal of American Geriatrics Society 53(4) April 563-568

Type of study: Randomised controlled trial

Aim: To investigate the effects of an education program for preventative healthcare professional in routine primary care on functional ability, nursing home admissions and mortality in older adults.

Method: Home visitors in intervention municipalities received education and local GP's introduced to a short geriatric assessment program. 2863 74 year old and 1171 80 year olds received assessment of functional ability. Control municipalities received no education and conducted the national preventative programme in their own way. Functional ability was measured using questionnaires

Findings: Educational intervention was associated with improved functional ability in persons living in the intervention municipalities. No effects on mortality or rates of nursing home admission were seen although nursing home rates were insignificantly higher in participants living in the control municipalities.

Limitations of study: Study must be seen in the context of the Danish Healthcare system. It is not clear if the visitors are GP's, nurses or both

Key messages: Brief, manageable and ongoing educational intervention for professionals working with preventative home visits was feasible and improves older people's functional mobility. This program helped preserve older people's functional ability. Preventative home visits demand skill, there is a need for an integrative education and a common language. Greater attention should be paid to early triggers of functional decline.

53

Walsh N Roe B Huntington J (2003) Delivering a Different Kind of Primary Care? Nurses Working in Personal Medical Service Pilots Journal of Clinical Nursing 12(3) May 333-340

Type of study: Qualitative evaluation

Aim: To evaluate 12 Personal Medical Service (PMS) pilot sites

Method: Data from workshops, interviews and documentations until saturation, analysis using themes and member check.

Findings: Nurses 'oiled' the system, seen positively, their extended role included diagnosis of simple and chronic conditions, ordering investigations and making referrals. In response to local needs some had developed specialist clinics for example skin allergy, family planning, substance misuse, sexual health information for men. Being 'consciously competent' and knowing limitations were seen as important. Aware of gaps in knowledge and sought out new skills, also keen to build on knowledge and pursue areas of interest to them. Shared learning increases awareness of each others roles i.e. nurses holistic, doctor's disease focussed or doctors holistic in medical care and nurses holistic in dealing with emotional and social needs. Relationships, teamwork and being able to consult with medical colleagues were all important. There was evidence of values of equity and respect for each others professional competence, there was shared leadership through collaboration. Professional partnership rather than nurse-led was seen as the way forward. Community and patient focussed - used epidemiological data, community profiles and local health needs to shape services. Motivation - greater autonomy, pushing out and challenging traditional boundaries particularly with vulnerable population i.e. homeless, travellers, ethnic minority groups and asylum seekers. There was high commitment and determination. The difficulties were with lack of support, isolation, exposure and long hours. Nurses needed more organisational support in prescribing issues and signing sick certificates. Liability and negligence was not always clear. Attitudes, rivalries, career goals and political environment could also be obstacles

Limitations of study: Focus on new initiative launched in England in April 1998 - PMS pilot sites

Key messages: Focus on roles, professional partnership and nurse/patient relationship that provided a more responsive service. Patients were considered as partners encouraged to be involved in decisions about their care and to influence service developments. Good IT enabled them to use protocols, guidelines and NHS library for information

54

Ward-Griffin C (2001) Negotiating care of frail elders: relationships between community nurses and family caregivers Canadian Journal of Nursing Research 33(2) 63-81

Type of study: Critical ethnography

Aim: To describe and analyse the relationship between nurses and female family members caring for frail elders in the home

Method: 38 in depth interviews were conducted with nurses and caregivers who gave care at least once a week to a frail family member. Analysis focussed on key phrases and themes that emerged from the data. Demographic data was collected and analysed using descriptive statistics.

Findings: Relationships - complex multifaceted and dynamic with ambiguity and tensions. Boundaries of care - personal care, monitoring & emotional all described by nurses as unskilled labour. Whilst nurses carried out periodic assessment and supervision providing relief, building trust and assessing condition

Limitations of study: Nurses may have avoided approaching 'difficult' family care givers to be involved in the study, which may have introduced bias

Key messages: Four key interchangeable roles of the nurse described as: nurse-helper, manager-worker, worker-worker and nurse-patient. Cost cutting led to feeling of powerlessness. Familism was evident i.e. view that women are natural care givers leads to exploitation and coercion. Home care better than institution care. Make curricular changes to build collaborative relationships and teaching to support social change

55

Ward-Griffin C McKeever P (2000) Relationships between Nurses and Family Caregivers: Partners in Care Advances in Nursing Science 22(3) 89-103

Type of Study: Qualitative ethnographic study

Aim: To examine the relationship between community nurses and family members providing home care to older persons in urban Canada

Method: A purposive sample of 23 family caregiver-nurse dyads was drawn from three community nursing agencies in south-western Ontario. Using an in-depth focused interviewing approach, both types of caregiver were asked to talk in private about their experiences of working together. The interview data along with field note data were transcribed and analysed. Analysis was facilitated through the use of NUD*IST.

Findings: Relationships involved four distinct types. In nurse-helper relationships, nurses provide and co-ordinate the majority of care, while family caregivers assume supportive roles to nurses. Tends to be visible at the beginning of a relationship. Least common relationship in study. A worker-worker relationship was also seen as a stage within relationship development. Nurses aimed to work with family caregivers in a way that recognised their expertise, but in an essentially co-opting and controlling way. The most common relationship was the manager-worker. The family caregiver provides the majority of care with the nurse monitoring the coping skills and competence. This stage coincided with a reduction in the number of visits from the nurse. The final relationship is the nurse-patient type where the family caregivers were seen as people in need of care in their own right. Conflict for nurse between ensuring care is provided for elder and the caregiver remains well.

Limitations of Study: Small convenience sample. Influenced by context of service provision - public funded

Key Messages: The shift of boundaries between formal and informal care givers overtime must be recognised and understood. The relationships are quite complex and change over time.

56

Wiggins M Oakley A Roberts I Turner H Rajan L Austerberry H Mujica R Mugford M Barker M (2005) Postnatal support for mothers living in disadvantaged inner city areas: A randomised controlled trial Journal of Epidemiology & Community Health 59(4) 288-295

Type of Study: Randomised controlled trial

Aim: To evaluate the effect of two forms of postnatal social support for disadvantaged inner city mothers on maternal and child health outcomes.

Methods: eligible participants were randomly allocated to one of two groups (1) the Support Health Visitor (SHV) offering supportive listening home visits and (2) Community Support Group (CSG) - (non nurse led community support) that included drop in sessions, home visits and/or telephone support within the London area. Both interventions continued over a period of one year with follow up evaluations at 12 and 18 months. Both intervention groups were compared with a control group that received standard health visitor services

Outcomes measured: Child injury, maternal smoking, maternal depression. Secondary outcomes were: uptake and cost of health services, household resources, maternal and child health, experiences of motherhood and breastfeeding. 800 participants were recruited and analysis was carried on intention to treat basis.

Findings: No impact on maternal depression, child injury or maternal smoking in participants allocated to either intervention group. SHV women showed different patterns of health service use with fewer visits to GPs and twice as many using NHS health visitors. There was a statistical significance between SHV women and the control group in anxious experiences of motherhood.

Limitations: study restricted to socio-economically disadvantaged mothers living in two areas in London, UK

Key messages: Offering community support to women does not result in a large enough take up or have a dramatic enough effect on those who use it to change health outcomes of maternal well being and childhood injury.

57

Wilson K Pateman B Beaver K Luker KA (2002) Patient and carer needs following a cancer-related hospital admission: the importance of referral to the district nursing service Journal of Advanced Nursing 38(3) 245-253

Type of Study: Qualitative exploratory study

Aim: To investigate the needs of people with cancer, and their lay carers during discharge from hospital to home, and identify the role of district nurses (DN's) in meeting these needs.

Method: 71 pre and post discharge interviews were performed with cancer patients and (where possible) their carers. Pre discharge interviews focused on expectations and post discharge interviews on experiences of discharge and aftercare. Taped interviews were transcribed and analysed thematically. Critical examination and comparative interpretation was carried out.

Findings: Pre discharge interviews did not identify strong needs and expectations. Post discharge those not referred to district nurses revealed a lack of support and information for carers as a major issue. However, those referred also had unmet needs, including difficulties with nutrition. If the carer was not a domicile relative there appeared to be greater unmet information needs. There were numerous instances of DN's assessing and meeting patient/carer needs for physical care, information and emotional support.

Limitations of Study: Small sample size. Limited analysis of findings

Key Messages: All cancer patients discharged from hospital should be referred to a district nurse for ongoing assessment of needs. District nurse role needs to be clarified and public perceptions altered.

58

Wilson A Wynn A Parker H (2002) Patient and career satisfaction with hospital at home quantitative and qualitative results from a randomized controlled trial British Journal of General Practice 52 9-13

Type of study: Pragmatic Randomised Control Trial and qualitative interviews

Aim: To compare hospital at home patient and carer satisfaction with hospital care.

Methods: Consecutive patients were randomised to Hospital at home scheme (n+102) or one of three acute hospitals (n=97). Using a questionnaire patient satisfaction was assessed two weeks after randomisation or at discharge. Qualitative interviews with patients (n=42) and carers (n= 25) were also carried out.

Findings: patients are more satisfied with hospital at home. Some reasons include more personal care and better communication. Carers (and patients) had some concerns about safety but did not feel HaH produced greater burden of care

Limitations: Process of randomization inadequately described

Key message: Staying at home was perceived to be therapeutic and patients were more satisfied due to the time spent with them and better communication.

59

Woodward CA Abelson J Tedford S Hutchison B (2004) What is important to continuity in home care? Perspectives of key stakeholders Social Science and Medicine 58 177-192

Type of Study: Qualitative study

Aim: To identify factors that was important to experiencing continuity of care in home care.

Method: Home care clients and their caregivers, workers in the home care system and physicians whose patients use home care were interviewed. Conducted in City of Hamilton, Ontario, Canada. Most interviews were conducted by telephone and were tape-recorded. Transcribed interviews were entered into a qualitative data analysis programme, NVivo. Preliminary coding scheme identified by researchers reading samples of the transcripts and patterns developed following coding of all transcripts.

Findings: Care that is experienced as running smoothly, that responds to client's needs and requires no special effort for clients to maintain, was seen as having continuity. The attributes of care experienced as having continuity that emerged had two dimensions of care - managing care and direct care provision - that were important to continuity of care in the home. Physicians and case managers described the development of a care plan as key to ensuring continuity of care. The goals of care should be negotiated with the clients and their families and communicated to the team of service providers. The management of the plan through good care co-ordination was also seen as important for continuity. Key aspects of service provision were: consistent and appropriate knowledge and skills of service providers; ongoing accurate observation to identify change in needs; trusting relationships between service provider and client/caregiver; rapport among team members; consistent timing. Communication and consistent personnel were two key ingredients of in providing continuity in home care.

Limitations of Study: Participant checking not included. Sample size limited. Study specific to home care system in one area

Key Messages: To ensure continuity of care in home care, attention must be paid to both the management of care and its delivery. Effective communication strategies and consistent personnel are two vehicles that help ensure continuity of care

60

Worobey J Pisuk J Decker K (2004) Diet and behaviour in at-risk children: evaluation of an early intervention program Public Health Nursing 21(2) 122-127

Type of study: Quantitative evaluation (American)

Aim: Evaluation of children eligible for a 'Prevention-Oriented System for Child Health Project, an early intervention program aimed at improving health and developmental status in at-risk families. Evaluation focuses on the effectiveness of the nutrition education component.

Methods: Through a series of home visits by public health nurses, 60 families received lessons on nutrition and health related topics determined by the child and family's needs. On 2 occasions, 8-months apart, the children were evaluated using the Development Assessment of Young Children, and their energy intake over the previous day was recorded. Diet recall records were analysed by using Food Processor 2.2 (a computer software program that provides nutritional analysis).

Findings: Analyses of dietary and behavioural records indicated that the children's scores on the physical subtest improved significantly. Suggest that the intervention was successful.

Limitations: Acknowledges limited numbers and that it may not be generalized beyond the demographic characteristics of the sample. No control group.

Key messages: High risk, vulnerable families were included and public health nurse provided case management and parent-focused intervention strategies that were effective in improving vulnerable children's physical development.

61

Worth A (2001) Assessment of the needs of older people by district nurses and social workers: A changing culture Journal of Interprofessional Care 15(3) 257-266

Type of study: Qualitative exploratory study using ethnographic approach

Aim: To explore the nature of and knowledge and values underpinning assessments of the needs of older people by district nurses (DN) and social workers (SW)

Method: 18 observation visits to assess practice and 15 interviews with SW and DN practitioners

Findings: Context of assessment: SW had guidelines and more structure than DN. SW perceived that they should finish assessment during one visit. Assessing health needs: SW had limited knowledge of health needs so experience difficulty in gathering health information. DN assessed health needs in a more comprehensive manner. Assessing social needs: Received less attention in district nurses than in SW assessment. Care management team DN assessed social needs more comprehensively. Assessing functional ability: DN assessment was more comprehensive than SW Assessing finances: Is a central part of SW assessment and there expertise in negotiating the complex benefits system was appreciated by patients. Assessing risk: DN have greater flexibility than SW in their attitudes to risk but their involvement and awareness create dilemmas, whereas social workers could be less involved and allow others to monitor risks

Value base of assessment: DN - Holism, promoting independence, person-centred care and primacy of practitioner-client relationship. SW - client self determination, minimal interference and importance of social networks Knowledge and assessment: Knowledge gained from experience was seen as important by both DN and SW as was 'being trained'. SW also gained knowledge through supervision which was less evident in DN

Limitations of study: One locality in Scotland

Key messages: DN assessed health, safety, functional environment and support whilst SW made financial and broad social assessment. Both roles of value and there was a need to move towards joint working, supervision and shared knowledge.

1

Elkan R Kendrick D Dewey M Hewitt M Robinson J Blair M Williams D Brummell K (2001) Effectiveness of home-based support for older people: systematic review and meta-analysis British Medical Journal 323(7315) 29th Sept 719-724

Type of study: Systematic review and meta-analysis of 15 studies of home visiting

Aim: To evaluate the effectiveness of home visiting programmes that offer health promotion and preventative care to older people

Method: Systematic review and meta-analysis of 15 studies of home visiting for general elderly population (9 studies) and vulnerable at risk elderly population (6 studies) including surveillance, support, health promotion and prevention of illness can reduce mortality and admissions to institutional care

Findings: 13 randomised controlled trials and two quasi-experimental studies. Home visiting had a significant effect on mortality and admission to long term institutional care in older people, no significant reduction in hospital admission, no evidence of improvement in health and functional status

Limitations of study: Two studies were not randomised, so not included in meta-analysis

Key messages: Home visiting had a significant effect on mortality and admission to long term institutional care in older people.

2

Fritch L (2003) Nursing interventions for people with chronic conditions Journal of Advanced Nursing 44(2) 137-153

Type of study: Integrative literature review and meta-analyses

Aims: to describe nursing interventions during home visits and their effects on people suffering from a range of chronic conditions

Methods: Structured descriptive literature review using Medline, Embase, PsycINFO, CINAHL and Cochrane databases to explore the effects of nurse interventions (older people, diabetes and rheumatology) during home visits on:

Patient outcome (patient satisfaction, quality of life, well being)

Socio-economic outcome (hospitalization, numbers and length of stay, nursing home admissions, use of health services, cost savings)

Clinical outcome (mortality, disability, monitoring of physical status e.g. blood-glucose control)

Findings: In older people the best outcomes are reached if the target is the younger old (not defined) or if the interventions are tailored to particular health problems. The effect depends on the duration of the follow up period, number of follow up visits and personality of the nurse. In diabetes, education and behavioural interventions improve psychosocial and health outcomes. Nurses can play a role in education and helping patients to adhere to treatment and time important for outcome. Interventions should be individualized. In Rheumatology, a nurse specialist can produce equally good results compared with a rheumatologist or multidisciplinary team but disagreement about the outcomes using the arthritis self management programmes.

Limitations: Information about education preparation of nurses but difficult to ascertain professional focus of nurses

Key messages: Patient education and time spent with patient is important. A range of interventions need to be tailored to individual needs. Interventions should be delivered over the long term.

3

Hastings SN Mitchell TH (2005) A systematic review of interventions to improve outcomes for elders discharged from the emergency department Academic Emergency Medicine 12(10) Oct 978-986

Type of study: Systematic Review

Aim: To evaluate the evidence for interventions designed to improve outcomes for elders discharged from the emergency department

Method: 27 studies met criteria and were reviewed: 6 randomised clinical trials, 2 nonrandomised clinical trials and 19 observational studies.

Findings: 3 trials showed that assessment and home-based care showed improvements in functional status. Targeting high risk groups seems to be more effective

Limitations of study: Incomplete identification of relevant studies and publication bias. Meta-analysis was not appropriate due to heterogeneity in trial design and outcome measures.

Key messages: Functional decline in high risk elders following an emergency department visit can be reduced using various interventions models that include geriatric nursing assessment and home-based nursing services but development of interventions requires further research into system and patient-centred factors that impact on health care delivery in this situation.

4

Horrocks S Anderson E Salisbury C (2002) Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors British Medical Journal 324(7341) 6th April 819-823

Type of study: Systematic Review

Aim: To determine whether NP's can provide care at the first point of contact equivalent to doctors in primary care setting.

Method: As term NP is inconsistently used criteria developed to determine whether papers should be included. These were: Nurse first point of contact anywhere in primary care, made an initial assessment, managed patient autonomously. Patients previously undiagnosed with undifferentiated health problems. Studies had to include data about: patient satisfaction, health status, health service costs or process of care measure.

Findings: The review showed there was no significant difference between doctors and nurse practitioners in health outcomes, that patients were more satisfied with NP than doctor. NP invested more time and had longer consultation. NP seemed to identify physical abnormalities more often, gave more information, made more complete records and scored better on communication; they offered more advice on self-care and management. NP's were as accurate as doctors at ordering and interpreting X ray films

Limitations of study: Different outcome measures, focus on minor illnesses, no study was adequately powered to detect rare but serious adverse outcomes, no study was adequately powered for economic analysis, ambiguity about NP role and training required, factors that lead to increased satisfaction need to be elucidated, NPs and GPs not always working under same time constraints

Key messages: Patients are more satisfied with their care from a nurse practitioner that from a doctor, with no difference in health outcomes. Nurse practitioners provide longer consultation and carry out more investigations than doctors. Most recent research has related to patient requesting same day appointments for minor illness, which is only a limited part of a doctors role.

5

Kendrick D Hewitt M Dewey M Elkan R Blair M Robinson J Williams D Brummell K (2000) The effect of home visiting programmes on uptake of childhood immunization: A systematic review and meta-analysis, Journal of Public Health Medicine, 22 (1) 90-98

Type of study: Systematic review with meta-analysis

Aim: To evaluate effectiveness of home visiting programmes on the uptake of childhood immunization

Methods: Systematic review included studies resulting from search encompassing 'clinical trials' 'evaluation and follow up' studies. Inclusion criteria: empirical study with a comparison group evaluating home visiting programmes that had to include at least one post-natal home visit. Only studies that reported interventions within the remit of British health visitors were included.

Findings: 11 studies included in the systematic review. 11 studies reported uptake of immunization. Home visiting programmes were shown to be ineffective in increasing the uptake of immunizations. Other methods of increasing uptake need to be explored further

Limitations: Only studies using socio-economically disadvantaged participants were included in the analysis

limited to British studies in which only health visitor visits were included. While inclusion criteria was that at least one post-natal visit was necessary, the number of home visits is unknown. Limited knowledge of any recent studies that test effectiveness of a separate immunization intervention or of immunization in the home as part of existing home visiting programme on uptake.

Key messages: Failure to demonstrate a beneficial effect of home visiting on the uptake of immunization rates. Most home visiting programmes do not offer immunization in the home, requiring clients to visit a local clinic. Multifaceted home visits are not sufficient to increase uptake and more specific interventions may be required.

6

Loveman E Royle P Waugh N Specialist nurses in diabetes mellitus The Cochrane Database of Systematic Reviews 2003 Issue 2 Art No: CD003286. DOI: 10.1002/14651858.CD003286.

Type of study: Cochrane systematic review

Aims: to assess the effects of diabetes specialist nurses/nurse case manager in diabetes on the metabolic control of patients with type1 and type 2 diabetes mellitus

Methods: systematic review of 5 RCTs and 1 controlled trial included

Limitations: considerable heterogeneity between studies so meta analysis not possible.

Findings: Diabetes specialist /nurse case manager may improve patients' control over short periods but no available trials over longer period. Some short term gains but no long term care improvements or improvements when compared with usual care in hospital clinics or PHC

Key message: Insufficient evidence to demonstrate the effects of input from diabetic specialist nurses over longer periods of time.

7

McNaughton D (2000) A synthesis of qualitative home visiting research, Public Health Nursing 17(6) 405-414

Type of study Systematic review of qualitative studies using Miles & Huberman's (1994) framework for qualitative data analysis

Aim To review process and outcomes of home visiting

Methods - included 14 qualitative studies from US, Canada, Finland and England. Results of each study were content coded and related to (1) nurse-client relationship; (2) nurse's role during home visits, (3) client's role during home visit; (4) desired outcome of the interaction (5) other

Findings good systematic review of key qualitative literature.

For the nurse-client relationship to be effective, trust needs to be established. Establishment of the relationship needs to be developed long term with regular visits from the nurse. The nurses roles were identified as multifaceted: giving of health information; counselling and supporting; linking clients to community resources; health assessments and detection of health problems.

Limitations limited to 14 qualitative studies. Only literature investigating home visits between public health nurses and mothers of young children were included. Studies included investigated home visiting from the nurses' perspective only

Key messages Relationship between the nurse and client (mother) was integral to the role of the nurse.

Effective home visiting programmes had to be based on long term, mutual trusting relationships.

8

NHS Centre for Reviews and Dissemination (2002) Effective health care: Improving the recognition and management of depression in primary care NHS Centre for reviews and dissemination 7(5) 2-12

Type of study: Summary of research evidence (NHS Centre for Reviews and Dissemination)

Aims: To review evidence for improving the recognition and management of depression in primary care

Methods: Reviews use of questionnaires to detect depression (part B of review, 16 studies) and part D (34 studies) is a systematic review of educational and organizational interventions to improve management and outcome of depression in primary care.

Findings: Routine administration and feedback of questionnaires has no impact on recognition, outcome or management of depression in PC. Case management role of practice nurses identified. Telephone support, patient education, counselling and medication monitoring by practice nurses clinically and likely to also be cost effective in managing and outcomes of depression. Effects evident in the short but not longer term.

Limitations: Most studies were US based

Key messages: Nurses have a major contribution to make to the management and outcome of depression in PC but requires substantial enhancement of role and greater integration with secondary care . Interventions for chronic illness need to be prolonged.

9

Renders CM Valk GD Griffin S Wagner EH Eijk JThM van Assendelft WJJ Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings The Cochrane Database of Systematic Reviews 2000 Issue 4 Art. No: CD001481 DOI: 10.1002/14651858.CD001481.

Type of study: Systematic review

Aim: Effects of different interventions, targeted at HCPs or the structure in which they deliver care in the management of patients with diabetes in primary care, outpatient and community settings

Multidisciplinary review - organizational, professional and financial interventions and 41 studies included in review

Type of outcome measures reviewed: (1) health professional: performance including measurements of BP, weight and cholesterol. (2) patient outcomes : glycaemic control, blood glucose, complications such as nephropathy, retinopathy, hospital admissions and mortality (3) Self report measures: quality of Life, well being, satisfaction of patient and provider

Findings: Difficult to know if post graduate education did contribute to improvements in care. Post graduate education in combination with other interventions such as reminders, audit and feedback and peer reviews had an effect. Strategies for structured recall useful and patient tracking also had an effect (computerized or nurses making contact) - loss to follow up carries increased risk of diabetes complications but impact of these professional and organizational interventions on patient clinical outcomes less clear. Patient orientated intervention (education) generally led to improvements in process outcomes and enhanced role of nurse can improve patient outcomes (facilitating adherence and patient education, glycaemic control) In seven studies nurses replaced physicians and demonstrated positive impact on care.

Limitations: Studies were heterogeneous and methodological quality limited. No studies evaluating effectiveness of financial interventions found.

Key messages: Patient education is important. Nursing care had as good or better outcomes than physician care

10

Shepperd S Parkes J McClaran J Phillips C Discharge planning from hospital to home The Cochrane Database of Systematic Reviews 2004 Issue 1 Art. No: CD000313 DOI: 10.1002/14651858.CD000313.pub2.

Type of study: Cochrane systematic review

Aim: To determine the effectiveness and cost of managing patients in hospital at home compared with acute in-patient care

Methods: Cochrane systematic review of Randomised Controlled Trials (RCTs) including meta analysis.22 studies included in the review: 1 scheme to avoid hospital admission 4 trials of schemes operating from A&E department 17 evaluating early discharge from hospital

Findings: Early discharge of elderly medical patients; no compelling evidence that hospital at home produces cost savings and may increase overall days of care. Patient outcomes : hospital at home increase patient satisfaction compared with hospital care but not clear which aspects improve satisfaction Carer outcomes; views of carers are mixed. Use of health service resources and cost; no compelling evidence of cost savings and early discharge can prolong the overall days of care. Some evidence of increased costs for some groups such as women recovering from hysterectomy and patients with COPD. No cost difference for patients recovering from hip or knee replacement or elderly patients with a medical condition

Limitations: Only 1 trial evaluating the effectiveness of a community based admission avoidance schemes and reviewers recommend future research should focus on rigorous evaluations of these.

Key messages: Review does not support the widespread development of hospital at home services as cheaper substitutes for in-patient care within health care systems that have well developed primary care services but nor has it demonstrated that existing schemes should be discontinued. Meta analysis failed to detect a difference in health outcomes. Future hospital at home schemes should be developed around community based admission avoidance schemes

11

Smith B Appleton S Adams R Southcott A Ruffin R Home care by outreach nursing for chronic obstructive pulmonary disease The Cochrane Database of Systematic Reviews 2001 Issue 3 Art. No: CD000994 DOI: 10.1002/14651858.CD000994.

Type of study: Systematic review

Aim: To evaluate the effectiveness of outreach respiratory health care worker programmes in terms of improving lung function, exercise tolerance and health related quality of life of patient and carer and reducing mortality and hospital service utilization.

Methods: Cochrane systematic review of 4 studies and mortality data were meta analyzed.

Findings: Mortality data suggest there could be a difference between patients with moderate and those with severe airflow limitations. No effect was found in the most severe patients and effects in less severe patients should be treated with caution as this was a post hoc analysis. Lung function or exercise tolerance; no improvements noted in any study ( may be due to irreversible and characteristic decline of lung function in COPD). Hospital service utilization; included in 1 study and this found hospital utilization/admissions were not reduced Patient and carer health related Quality of Life (QoL); insufficient published relevant data

Limitations: Reviewed 4 RCTS but all had important methodological limitations (randomization and blinding)

Key messages: Patients with moderate COPD may have some mortality and health related QoL gains from a nursing outreach programme but there are no data about reductions in hospital utilization. Patients with severe COPD do not appear to benefit from such programmes with 1 study identifying no reduction in hospital admissions. Outreach programmes are resource intensive and aims should be to reduce hospital admissions. Insufficient data to suggest this can be achieved.

12

Taylor S Candy B Bryar R Ramsay J Vrijoef JM Esmond G Wedzicha J Griffiths C (2005) Effectiveness of innovations in nurse led chronic disease management for patients with chronic obstructive pulmonary disease: systematic review of evidence British Medical Journal 2005 331-485

Type of study: Systematic review

Aims: to determine the effectiveness of innovations in management of chronic disease involving nurses for patients with chronic obstructive pulmonary disease (COPD)

Methods: Systematic review of 9 randomised controlled trials (RCTs) (in 1 study nurses were community nurses and in the other 8 they were respiratory nurses or case managers).Review included studies evaluating clinical service interventions or packages of care aimed at improving the management of patients with COPD in the community (excluded drug trials, hospital at home or early discharge schemes)

Findings: Equivocal evidence of effect on: hospital readmissions, respiratory cause or all causes; long or intensive interventions or days spent in hospital. Visits to GP or physician Absent or weak evidence of effects on: patients' self management skills, coping or self confidence, smoking cessation among patients or their adherence with recommended treatment, patients' and carers' satisfaction with interventions or their preferences for care, carers quality of life, effects on other community services and the opinion of the providers of other community services

Limitations: The reviewers report methodological limitations in all included studies

Key messages: Little robust evidence to support nurse management of chronic disease services for patients in the community with moderate or severe COPD. The interventions to date have not had a detectable effect on mortality, disability and patients' health related quality of life or psychological wellbeing and evidence around hospital readmission is equivocal. The evidence around outcomes such as patient's adherence to treatment regimens or satisfaction with care and the effect on care is weak or absent. Future research should focus on nurse led hospital at home or early discharge schemes for patients with COPD living on the community. Evidence for long term, intensive case management or hospital admission is equivocal and requires further study as does benefits in terms of fewer hospital admissions and visits to emergency departments.

Titles of reviews and studies

Reasons for exclusion

1

Allan K Hazelett S Jarjoura D Wright K Clough L Weinhardt J (2004) Improving stroke outcomes: implementation of a post discharge care management model

Journal of Clinical Outcomes Management 11(11) 707-714

Reports on an ongoing randomized trial of intervention. Advanced practice nurse contribution appears to be important part of this, but not singled out for evaluation.

2

Appleton JV Cowley S (2003) Valuing professional judgment in health visiting practice Community Practitioner 76(6) 215-220

Descriptive study examining health visitors' professional judgments. Key finding was that professional judgment, rather than guideline recommendations, determined actions. Outcomes of judgments not reported.

3

Aronson J (2003) 'You need them to know your ways': Services users' views about valued dimensions of home care Home Health Care Services Quarterly 22(4) 85-98

Qualitative study of perspectives of users of home care in Canada. Focus is personal care, household help and social support not nursing interventions.

4

Baker D Middleton E (2003) Cervical screening and health inequality in England in the 1990's Journal of Epidemiology & Community Health 57(6) 417-423

Analysis of screening coverage and cervical cancer incidence and mortality in England. No nursing intervention.

5

Barnes M Courtney M (2003) Contemporary child health nursing practice: services provided and challenges faced in metropolitan and outer Brisbane area Collegian 10(4) 14-19

Describes changes in way services are delivered to children (infant welfare service). Unclear what the role of Child Health Nurse is in community. No similarities to enable comparison of services in UK.

6

Bergen A (2003) Care management revisited: A follow-up study British Journal of Community Nursing 8(1) 16-23

Focus is on Mental Health and Learning Disability.

7

Boult C Kane RL Pacala JT Wagner EH (1999) Innovative healthcare for chronically ill older persons: results of a national survey The American Journal of Managed Care Sept 1162-1172

Survey of innovative programmes of community care in Minnesota and a description of different types of care delivery available.

8

Brooks N (2002) Intermediate Care Rapid Assessment Support Service: An Evaluation British Journal of Community Nursing 7(12) 623-633

Evaluation of Multi-professional Delivery of Intermediate Care - Pilot Study.

9

Brookes K Daly J Davidson P Hancock K (2004) Community health nursing in Australia: A critical literature review and implications for professional development Contemporary Nurse 16(3) 195-207

A literature review of community health nurse role internationally. Descriptive account which summarizes role of CHN in Australia.

10

Brown EL Bruce ML McAvay GJ Raue PJ Lachs MS Nassisi P (2004) Recognition of late-life depression in home care: accuracy of the outcome and assessment information set Journal of American Geriatrics Society 52(6) 995-999

Evaluation of the accuracy of home care nurses' rating of the Outcome and Assessment Information Set (OASIS) depression items. Study and tools used are context and culture dependent. OASIS tool only part of assessment used on first visit. Findings based on one agency only.

11

Cranley L Doran D (2004) Nurses' integration of outcomes assessment data into practice outcomes Management for Nursing Practice 8(1) 13-18

Focus of study is acute nursing, although set within larger study incorporating home care nursing. Not possible to extract data relevant to this. Canadian.

12

Deave T (2003) Mothers' views on the First Parent Health Visitor Scheme Community Practitioner 76(7) 251-261.

Longitudinal study to examine First Parent Health Visitor Scheme in one health authority in SW England. Lack of consistency in process of implementation between groups. Unclear in paper how FPHVs differ from generic HVs. Results not consistent with discussion. Relative small sample size with little statistical significance. Authors caution use of findings due to limited sample size.

13

Delasega CA Zerbe TM (2000) A multimethod study of advanced practice nurse post discharge care Clinical Excellence for Practitioners 4(5) 286-293

APN could offer interventions that would fill the gap between hospital and home care in Pennsylvania - context specific study which lacks detail.

14

Ducharme F leVesque L Gendron M Legault A (2001) Development process and qualitative evaluation of a program to promote the mental health of family caregivers Clinical Nursing Research 10(2) 182-201

To develop and evaluate through a participatory approach, an intervention program to promote the mental health of women caregivers in institutions. Only about delivering health care in the community in its broadest sense as based on women caregivers of those institutionalized with dementia.

15

Elkan R Kendrick D Hewitt M Robinson JA Tolley K Blair M Dewey M Williams D Brummell K The effectiveness of domiciliary health visiting: a systematic review of international studies and a selective review of the British literatureHealth Technology Assessment 4(13) 1-339

Systematic review undertaken for NHS. Biased and mostly concerned with cost effectiveness. Keen to demonstrate lack of evidence in many aspects of home visits. Review provided limited information on selection criteria. Outcomes were vague and tried to encompass too many questions. Impossible to make critical judgments on review process. Scant information about inclusions, data extraction and analysis. Not sufficient information to determine effectiveness.

16

Forbes A (2000) A community nurse-led project to tackle health inequalities British Journal of Community Nursing 5(12) 610-618

Evaluation of a community based intervention in a deprived inner-city community. Evaluation focused on simple outcomes, profile of attendees and types of health concerns resulting in a superficial evaluation.

17

Forbes A While A Dyson L (2001) A multi-method examination of the views of community nurses on the core skills of community nurses NT Research 6 (3) 682-695

Exploration of the views of a range of different community nurses working in one inner city community trust regarding the skills and learning needs of community staff nurses. Focused on the skills required by community staff nurses and the education and training needs. Did not examine outcomes for specific interventions.

18

Hallett C E Pateman B D (2000) The 'invisible assessment': the role of the staff nurse in the community setting Journal of Clinical Nursing 9(5) 751-762

Perceptions of D grade staff nurse of their role in the community nursing team. Examines and describes issues in role clarification and lack of development within staff nurse role. Does not explore interventions.

19

Head, B.J. Maas, M. Johnson, M. (2003) Validity and community-health-nursing sensitivity of six outcomes for community health nursing with older clients Public Health Nursing 20(5) Sept/Oct 385-398

Assessed the importance, sensitivity to nursing interventions and content validity of six client-centered outcomes from the Nursing Outcomes Classification (NOC) and recommend that the NOC is tested in community nursing practice.

20

Houck G M King M K Tomlinson B Vrabel A Wecks K (2002) Small group intervention for children with attention disorders The Journal of School Nursing 18(4) 196-200

Describes 2 practice improvement projects that provided group experiences for child with ADHD symptoms, including disruptive behaviour. Not research.

21

Irvine F (2005) Exploring district nursing competencies in health promotion: the use of the Delphi technique Journal of Clinical Nursing 14(8) 965-975

Aims to establish a consensus view about competencies that district nurses need in order to fulfill an effective health promotion role. Technique used open to criticism. Identifies the knowledge, skills and attitudes required but does not link these to any specific health promotion interventions. Too general to inform current review.

22

Kearne M York R Deatrick JA (2000). Effects of home visits to vulnerable young families. Journal of Nursing Scholarship 32(4) 369-376.

A systematic review of qualitative studies - restricted to US and Canada. Inclusion criteria were: home based, nurse delivered preventative work to families with pre-term and full term babies. However, included experimental and quasi-experimental. Review process weakened results and restricted to the US.

23

Kemp L Anderson T Travaglia J Harris E (2005) Sustained nurse home visiting in early childhood: exploring Australian nursing competencies Public Health Nursing 22(3) 254-259

Describes home visiting nurses but discusses differences between specialist and generalist. No similarities to enable comparison of services in UK.

24

Kneafsey R Long AF Ryan J (2003) An exploration of the contribution of the community nurse to rehabilitation Health & Social Care in the community 11(4) 321-328

Community Nurses' perceptions of their role and potential contribution to rehabilitation. Focuses on subsection of data relating to community nurses collected as part of a wider, 2-year, qualitative study. Descriptive of role rather than evaluative of interventions.

25

Koch T Kralik D (2001) Chronic illness: reflections on a community based action research programme Journal of Advanced Nursing 36(1) 23-31

Focus is on understanding the experiences of living with chronic illness. No nursing intervention.

26

Lewin SA Dick J Pond P Zwarenstein M Aja G van Wyk B Bosch-Capblanch X Patrick M Lay health workers in primary and community health care The Cochrane Database of Systematic Reviews 2005 Issue 1 Art. No: CD004015. DOI: 10.1002/14651858.CD004015.pub2

Cochrane Systematic Review focusing on effects of Lay Health Workers (LHW's) interventions in primary and community health care on health care behaviours, patients' health and well being, and patients' satisfaction with care.

27

Lowe C Raynor D Teale C Lubgan G (2000) Can nurses identify medication problems using over-75 health check? Journal of Clinical Nursing 9(5) Sept 816-817

Pilot Study

28

Luker K A Wilson K Pateman B Beaver K (2003) The role of district nursing: perspectives of cancer patients and their carers before and after hospital discharge European Journal of Cancer Care 12(4) 308-316

Identified the roles of district nurses and community services as perceived by patients with cancer and their carers before and after hospital discharge.

Sampling discussed but not justified, interview guide mentioned but not described. Examines perceptions of role and no specific interventions are explored.

29

McCarthy MC (2003) Detecting acute confusion in older adults: comparing clinical reasoning of nurses working in acute, long-term, and community healthcare environments. Research in Nursing and Health 26 203-212

Exploratory study. Demonstrates community environment influences clinical reasoning. States explicitly that the results don't allow for definitive predictions about associated patient outcomes.

30

McCaughan D Thompson C Cullum N Sheldon T Raynor P (2005) Nurse practitioner and practice nurses' use of research information in clinical decision making: findings from an exploratory study Family Practice 22(5) 490-497

Descriptive study of decisions made by primary care nurses and information sources used. No evaluation of outcomes of decisions.

31

McCorkle R Strumpf N Nuamah IF Adler DC Cooley ME Jepson C Lusk E Torosian M (2000) A specialized home care intervention improves survival among older post surgical cancer patients Journal of American Geriatrics Society 48(12) Dec 1707-1713

Focuses on post surgical cancer patients.

32

Mignor D (2000) Effectiveness of use of home health nurses to decrease burden & depression of elderly caregivers Journal of Psychosocial Nursing & Mental Health Services 38(7) 34-41

Investigation of the impact of home health nursing intervention on burden and depression of elderly care givers who were caring for an ill relative in their home.

Comparative descriptive quantitative study from USA. Not all variables examined. Discussion rather superficial.

33

Mitchell E Sullivan F (2001) A descriptive feast but an evaluative famine: systematic review of published articles on primary care computing during 1980-1997 British Medical Journal 322(7181) 279-282

Review aims to establish impact of computers on primary care consultations. In descriptions of individual studies, nursing involvement is evident, but no detail on extent or effectiveness of contribution is offered.

34

Naylor MD Bowles KH Brooten D (2000) Patient problems and advanced practice nurse interventions during transitional care Public Health Nursing 17(2) 94-102

A secondary analysis of patient records written by advanced practice nurses using the Omaha system. This resulted in an increased understanding of problems seen by APNs and of the interventions carried out but no indication of effectiveness

35

Page P Lengacher C Holonsback C Himmelgreen D Pappalardo L Lipana M Lein K (1999) Quality of care-risk adjustment outcomes model: testing the effects of a community-based educational self-management program for children with asthma Nursing Connections 12(3) 47-58

Discussion of a community-based educational self-management program for children with asthma. Not research, describes an outcomes model incorporating adjustment for patients' risks for various outcomes of care.

36

Philp I Newton P McKee KJ Dixon S Rowse G Bath PA (2001) Geriatric assessment in primary care: formulating best practice British Journal of Community Nursing 6(6) 290-295

Development of best practice model for standardized assessment of older people in primary care, and to evaluate the costs and perceptions of the benefits of the model. Results descriptive of use of EASY-care. No evaluation of outcomes of using tool.

37

Plew C Billingham K Rowe A (2000). Public health nursing: Barriers and opportunities. Health and Social Care in the Community 8(2) 138-14

Qualitative study. To identify understanding and practice of public health nursing in one area. Health authority and senior trust nurses only were investigated. Does not explore community nursing but rather senior nurses' understanding of public health nursing and focuses on collaboration within organizations.

38

Plews C Bryar R Closs J (2005). Clients' perceptions of support received from health visitors during home visits. Journal of Clinical Nursing 14(7) 789-797

Primary qualitative study with limited relevance. Clients interviewed by a number of HVs - only those who were supported were included. Information collected on level of support was only related to one HV visit so methodologically unsound.

Small and homogenous sample. Limited explanation about decisions made in recruitment, and data collection to make a judgment on credibility of findings.

39

Pritchard JE (2005) Strengthening women's health visiting work with women Journal of Advanced Nursing 51(3) 236-244

Qualitative feminist study exploring health visitors' interactions with women clients. Limited applicability. Focus of findings is on health visitors' personal feelings and beliefs about life events and their impact on their interactions with female clients. Further focus is on understanding women in a 'gendered society' and suggested ways to enhance HV practices from a feminist perspective. Does not fully address nursing in the community specifically.

40

Redsell SA Hastings AM Cheater FM Fraser RC (2003) Devising and establishing the face and content validity of explicit criteria of consultation competence in UK primary care nurses Nurse Education Today 23 299-306

Devise criteria for consultation in primary care and determine face and content validity. Focus is on criteria.

41

Robinson A Street A (2004) Improving networks between acute care nurses and an aged care assessment team Journal of Clinical Nursing 13(4) 486-496

Investigated the possibilities for facilitating the transition of older people from hospital to home through improving the working relationships between nurses and members of a multidisciplinary aged care assessment team. This is not specifically about nursing in the community.

42

Sahlberg-Blom E Ternestedt BM Johansson JE (2000) Patient participation in decision making at the end of life as seen by a close relative Nursing Ethics 7(4) 296-313

Description of variations in patient participation in decisions about care planning during final phase of life for a group of gravely ill patients. Interviews from part of larger study. Patients were cared for in hospital during final stages of life, not cared for in the community.

43

Sawtell M Jones C (2002) Time to listen: an account of the role of 'support' health visitors Community Practitioner 75(12) 461-464

An RCT of three different forms of support for families with infants in deprived inner city area. This paper however reported 2 case studies with the results of the RCT to be published elsewhere. Anecdotal evidence so far that community specialist HVs were beneficial in providing effective support in home visits.

44

Schoneman D (2002) Surveillance as a nursing intervention: use in community nursing centers Journal of Community Health Nursing 19(1) 33-47

Description of nature of surveillance as nursing intervention in USA but no discussion of outcomes. Tools used are context and culture dependent.

45

Soini H Valimaki M (2002) Challenges faced by employees in the home care of elderly people British Journal of Nursing 11(2) 100-110

A questionnaire in Finland to find out the problems and interventions and support needs of homecare employees identified that training and clinical supervision was needed. Not a nursing intervention.

46

Thompson C McCaughan D Cullum N Sheldon T Raynor P (2005) Barriers to evidence-based practice in primary care nursing - Why viewing decision making as context is helpful Journal of Advanced Nursing 52(4) 432-444

Descriptive study aims to identify barriers to primary care nurses' use of research to inform decision making. Identifies need to explore nature of community nurse decision making for future research. No links made between intervention and outcome.