Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Nurse practitioners - its the time that matters.
- Peter Brindle (17 April 2000)
-
Confirming the Obvious
- Moy Coomer (17 April 2000)
-
Proving the obvious
- Martyn Lobley (17 April 2000)
-
Practice Nurses give patient satisfaction but are still prevented from prescribing.
- Maresah Haines (17 April 2000)
-
Role of nurse practitoners in treating minor illness
- Peter Leman, Jane Terris (17 April 2000)
-
Re-defining role of GP and Practice nurse
- Michael Strachan (21 April 2000)
-
Minor illness - GP or not GP?
- James Wilson (12 May 2000)
-
Nurse management of patients
- E P L Turton (12 May 2000)
-
Minor Problem
- M Mahendran (30 May 2000)
-
Synergy
- Michael P Sheehan (24 June 2005)
|
|
|||
|
Peter Brindle, locum GP Bristol
Send response to journal:
|
EDITOR The take-home message from the three papers by Shum et al., Kinnersley et al., and Venning et al. is the same: Patients express greater satisfaction with practitioners, whether nurses or doctors, who spend longer over their consultations and give them more information. The cost effectiveness of nurse practitioners seeing minor illness is yet to be established. The real issue is the length of the consultation, not that suitably trained nurses can see minor and largely self limiting conditions as well as a GP. Presumably this new work takes these scarce and highly skilled professionals away from other work that they are already good at and diverts them to something which GPs can do already. About 20% of cases seen by the nurses had to be seen by a GP at the same visit anyway so why not 'cut out the middle man'? Keep the doctors seeing the acute illnesses but use the resources which might be used on training these nurses to increase consultation time of GPs who have already been trained. It is however, worth considering the related point that spending longer on minor illnesses at the expense of something else might not be an appropriate use of scarce resources anyway. References: Shum et al. BMJ p1038, Kinnersley et al. BMJ p1043 and Venning et al. p1048. All in BMJ No 7241, 15 April 2000 |
|||
|
|
|||
|
Moy Coomer, Practice Nurse Manager RGN Medway Doctors on Call
Send response to journal:
|
Practice Nurses' roles have evolved and expanded in the last 10 years and we have been forging ahead with our professional developments quietly in the background, working collaboratively with our GPs as an integrated team player. Dr Shum's research findings just put us firmly on the map and raising general practice nurses' profile. - Thank you. Having said that, I think the Nursing profession has to ask itself how it sees its role in the delivery of primary healthcare, and must be cautious that we are are not manipulated by political manoeuvres to be a 'substitute' for general practitioners. |
|||
|
|
|||
|
Martyn Lobley, GP Gallions Reach Health Centre, London SE28 8BE
Send response to journal:
|
Shum et al should have been streetwise enough not to warn their patients that a study was in progress until after the randomisation process had been completed. It would have been quite simple and much more appropriate to randomise patients at the moment the same day appointment was agreed, rather than at a later stage. Any patient entering the surgery who had made his or her mind up that they wished to consult a doctor rather than a nurse that day simply had to nominate themselves into one of the exclusion groups offered to them as the means to that end. Thus, any patient with influenzal symptoms who wished to engineer a consultation with a GP merely had to check the box labelled "severe difficulty in breathing" and take a seat. Most trivial illnesses could be and very probably were exaggerated in a similar fashion with bouts of D&V expressed as "severe stomach pain" or dry tickly coughs classified as "chest pain". It's always entertaining to rummage through other people's dustbins and I can't help thinking that the patients who selected themselves out of the study group and ended up in the trash can labelled "Exclusions" would have been a richer vein of research gold to mine. All Shum et al have shown is that, when a self-selected population who didn't mind whether they saw a doctor or nurse were asked whether they preferred to see a doctor or nurse, they didn't seem to mind much whether they saw a doctor or a nurse. No amount of statistical software or intention to treat analysis after the event could have rescued this particular voyage of discovery. |
|||
|
|
|||
|
Maresah Haines, Practice Nurse General Practice
Send response to journal:
|
This article is a welcome confirmation to practice nurses of the high level of satisfaction they demonstrate in patient care. Many practices nationally are now providing practice nurse led minor illness services and it is comforting to note that the trial demonstrated that this is seen to be an effective service. What a pity that practice nurses are still excluded in being able to prescribe for the patients that they consult with minor illness. If the government is intent on developing nurse led services, then it needs to ensure that practice nurses have equal access to prescribing. It is a total anomaly that within general practice that district nurses and health visitors are allowed to prescribe and yet practice nurses are excluded. It is time that the "rubber stamping" of prescriptions by GPs for their practice nurse colleagues comes to an end and practice nurses be able to prescribe in their own right. |
|||
|
|
|||
|
Peter Leman, A&E Consultant St Thomas' Hospital, London, Jane Terris
Send response to journal:
|
Editor, We currently work alongside a large group of emergency nurse practitioners in a positive relationship and read with interest the paper by Shum, et al [1] on the use of nurse practitioners in treating minor illness. The authors conclude that practice nurses offer an effective service for minor illnesses, unfortunately the data provided doesn't support this. Almost the entire effect seen (2.2 points out of 100) is due to the greater length of time that the nurses spent with the patients. The multiple regression leaves an almost negligibly significant difference (p=0.047) in scores once this is taken into account. Furthermore the authors state that they used an intention to treat analysis, however it doesn't seem to include the large number of patients who did not wish to see a nurse in the first place (n=206). This allows for selection bias, as those who entered the study had already formed a subset of patients who may prefer a nurse consultation. It is of interest that despite their possible equal satisfaction with the consultation, only 7.5% of those that saw a nurse wanted to see a nurse again, and five times as many (31.5%) would rather see the GP next time. In contrast, of those patients that saw the GP half would still rather see the GP and only 2% wanted to see a nurse next time. This data sits uncomfortably with the satisfaction scale results, and the validity of this questionnaire is open to question, as it was originally developed to compare satisfaction within GPs [2] not between different types of health care providers; "Comparison between health professional groups should be undertaken with caution".[3] Whilst it is clear that information bias distorts many of the findings of the study, i.e. the lack of blinding of the intervention style (GP or nurse) to the observer (patient). We should also consider that the number of subjects in the study was in fact just the 24 individuals being assessed (5 nurses and 19 GPs). It is very easy to obtain p values of <0.05 if large groups of patients are recruited, but as each intervention was by an individual practitioner and outcome was satisfaction with that individuals style of consultation, the true sample size was actually much smaller. On a final note, we agree that the study was greatly underpowered to predict safety of nurse vs. GP consultation. The authors should take into account that a "clinically effective service" that they conclude is offered by nurses needs to detect the rare life threatening illness as well as generate satisfaction with outcome in self-limiting illness. The future of nurses in managing minor illness is uncertain and may well include the nurse practitioner, however this paper has contributed little evidence to support such a change in practice. Dr Peter Leman Dr Jane Terris A&E Department St Thomas' Hospital [1] Shum C, Humphreys A, Wheeler D, Cochrane M, Skoda S, Clement S. Nurse management of patients with minor illnesses in general practice: multicentre, randomised controlled trial. BMJ 2000; 320: 1038-1043. [2] Baker R. Consultation satisfaction questionnaire: development of a questionnaire to assess patients' satisfaction with consultations in general practice. Br J Gen Pract 1990; 40: 487-490. [3] Poulton B. Use of the consultation satisfaction questionnaire to examine patients' satisfaction with general practitioners and community nurses: reliability, replicability, and discriminant validity. Br J Gen Pract 1996; 46: 26-31. |
|||
|
|
|||
|
Michael Strachan, general practitioner College Practice 50 College Rd Maidstone ME15 6SB
Send response to journal:
|
This article focuses on what is the role of the GP and that of the practice nurse in the area of managing minor illness General Practitioners need to ask themselves are they satisfied in seeing patients with minor illness or is this an area we can now safely delegate ? Many in the profession seem protective of our role. Under the current pressures of the NHS our practice has instituted a similar system in order to save ourselves (in part) from this increasingly burdensome workload. GPs can be available for more substantive cases which may reqire onward referral after evaluation by practice nurses This leads to greater satisfaction from patients (viz this study), nurses (who I believe enjoy a widening of their role ) and doctors. It seems sensible that patients should obtain help at appropriate skill level be that nurse, GP, or specialist, as long as we all recognise our strengths and limitations. |
|||
|
|
|||
|
James Wilson, Medical student Newcastle University Medical School
Send response to journal:
|
Dear Editor, Shum et al conducted a multicentre randomised control trial assessing the acceptability and safety of a minor illness service led by practice nurses in general practice. While this study goes a long way to meeting its aims and objectives we feel that certain aspects have been overlooked. Firstly, although the age and previous experience of each of the nurses was stated by the authors, this was not the case for the GPs. We feel that these are important factors that may affect patients’ opinions of the consultation and the enthusiasm with which GPs treat cases of minor illnesses. This information would have helped in the interpretation of the results. Before beginning the study these nurses had specific training in the management of minor illnesses. As this is a new role for them, we would expect their levels of enthusiasm to be greater than that of the doctors. This may affect the outcome measures of patient satisfaction. It remains to be seen whether this quality of service can be maintained. A longer follow up period would have been useful. Although the patient satisfaction results look convincing, some evidence in the paper contradicts the conclusion that patients were equally satisfied with doctor or nurse led care. For example, of those who expressed a preference, most would still prefer to see a GP rather than a nurse in both intervention groups. This was not highlighted in the study. Also, the authors fail to give the reasons for 10% of eligible patients declining to take part in the study. It may have been that these people were not prepared to see a nurse. This may skew the satisfaction results in the nurses favour, and suggests that for a proportion of the population nurse consultation is not acceptable. Finally, the average consultation length for nurses was longer than for the doctors. Could the level of satisfaction be more related to consultation time than to which practitioner is seen? Analysis using data on mean consultation time and patient satisfaction for individual practitioners is required in order to determine whether this is the case. James M. Wilson
|
|||
|
|
|||
|
E P L Turton
Send response to journal:
|
EDITOR- The design and conclusions of the study by Shum et al1 of their trial on nurse management of patients in general practice, gives me concern. Their objective was to assess the acceptability and safety of a service led by practice nurses in general practice. Patients were recruited who initially sought a same day appointment, and didn't mind seeing a nurse. Satisfaction with a nurse-led consultation is therefore likely to be generally high especially in patients with trivial problems. Patients were also able to excluded themselves at the reception desk if they said their symptoms matched any on a list. We are not told how many patients were excluded on this account, or how many of these turned out infact to have trivial illnesses, but simply wanted to see a doctor. Despite this selection of patients with minor illnesses, the nurse was unable to deal completely with the problem in nearly 30% of cases, which led to patient delay while being seen by or discussed with a doctor. Regression analysis demonstrated that patients were less satisfied when this occurred. We are told that the nurses had 10-minute appointment slots, but nothing about the "intensity" of appointments or other work- load throughout the day between the two groups. The nurses took 23% longer for consultations. Emphasis is made that nurses gave more advice on self- medication and self-management, and that patients expressed greater satisfaction with them. No benefit of that extra advice is shown in this study. Just 2% of patients who saw a doctor said they would prefer to see a nurse next time with the same problem whereas 31.5% of those seeing a nurse said they would want to see a doctor the next time. This is despite the nurse taking longer, discussing self medication more, and the self selected nature of this study. Detecting differences in clinical outcome from a nurse led practice is important but the study lacked sufficient power for this. We do not know from this study whether clinical symptoms and signs were properly elicited, investigations appropriately and cost- effectively ordered or correct treatment instituted. This study did not have the design to test whether nurses are able to achieve this. I dispute that the study has been of adequate design to suggest that nurses offer a clinically effective or safe service. The study concludes that a same day appointment service led by a practice nurse is acceptable to patients. But the study does not tell us whether this practice is acceptable for patients. EPL Turton 1. Shum C, Humphreys A, Wheeler D, Cochrane M, Skoda S, Clement S. Nurse management of patients with minor illnesses in general practice: multicentre, randomised controlled trial. BMJ 2000;320:1038-43. |
|||
|
|
|||
|
M Mahendran, General Practitioner Milton Keynes
Send response to journal:
|
This is a study that contributes nothing at all to General Practice. The patients who come with minor ailments to the Doctor are not uncommonly diagnosed of having a co-existing condition. The years of training and experience which has helped some of us to pick up some rare conditions. We all do admit that there will be a small minority of Doctors who do "look" at the patient with minor illnesses with a quick fix attitude. On issues such as this patient satisfaction surveys alone will never tell us the whole story. As Nurses and Doctors we should always try and do what we set out to do better rather than trying to find economically better options which are not in the patient's interst. |
|||
|
|
|||
|
Michael P Sheehan, NP student Stanford, 94025
Send response to journal:
|
Thank you for your time. I am currently researching some of these same issues for my thesis. I enjoyed your research and agree that there are limitations present in design (several posters before me have very accurately and eloquently pointed these out). I would just like to post for everyone reading that the answer to our questions is already present in our own responses. Synergy is the key. The side by side care in practice will be the new paradigm for primary care. I know that there are those that feel NP's as primary care providers are an affront or taking away jobs. I know that there are those that want to point out that NP's are better for cost containment etc...However, I think the synergistic care provided by the two will be the key to success. Consider it for future research projects. It will be important to use specialized nursing care. The NP's provided longer consultations for minor illnesses. We don't know why they had longer but I would suspect that it is because of other duties. GP's have a lot more to accomplish in their practice. Utilize the fact that NP's provide longer consults. Use them for cases that require more teaching/talking. GP's can be great diagnosticians and it is important to use their strengths and experience in the clinical setting as guidance. I hope that when I am able to practice I will be able to work alongside a GP that can provide guidance and experience. I hope that (s)he will utilize my desire to deliver high quality, cost efficient care. I hope that I will be a tool of the GP in providing care that will lead to higher patient satisfaction. The synergy between a GP and NP can produce higher satisfaction with both the NP (b/c of time or other factors) and the GP in that the GP's practice will produce the most complete and comprehensive care available. In todays health care system where profit and satisfaction must coexist, the synergistic care of the NP and GP is paramount. Competing interests: None declared |
|||