Perceptions of the role of the clinical nurse practitioner in the Cape Metropolitan doctor-driven community health centres

Background: The purpose of this study was to evaluate the role of the clinical nurse practitioner (CNP) in a doctordriven primary health care setting. A descriptive study was undertaken, using both a quantitative and a qualitative methodology. The study was undertaken in community health centres (CHC) in the Cape Metropolitan area.Method: A situational analysis was conducted of all 41 CHCs in the Cape Metropolitan area. Three focus group interviews were then undertaken with CNPs, doctors and managers to determine the factors influencing the effective functioning of the CNP. Results: Five-seven percent of the 88 CNPs were totally inactive with regard to consulting patients and only 28% were utilised in a full-time capacity. The major themes to emerge were the factors that determine the effective functioning of the CNP, including self-confidence gained from regular practise, support for their role from doctors and managers, role clarity, and enrolment in the course for the appropriate reason. Conclusions: When enrolling nurses for the CNP course, preference should be given to nurses who will be able to immediately put their training into practise. The managers need to foster a strong CNP identity and ensure maximum opportunities to practise in order for nurses to attain the status of a secure CNP. The doctors need to appreciate the nurses' value in the multidisciplinary team and offer the necessary support. Furthermore, the nurses' role needs to be properly conceptualised by policy makers and contextualised at ground level for them to be effectively utilised in a doctor-driven CHC. SA Fam Pract 2004;46(10): 21-2

Managing chronic conditions in a South African primary care context: exploring the applicability of Brief Motivational Interviewing.

Background: Brief Motivational Interviewing (BMI) is an approach to motivating behaviour change in general health care settings. The relevance and applicability of BMI has not been fully assessed in low- or middle-income country settings. This study explored the application of BMI by general practitioners (GPs) in a public sector primary care setting in Cape Town, South Africa. Methods: How BMI should be adapted and applied was explored by means of a cooperative inquiry group of GPs. This participatory action research involved four action-reflection cycles over a five-month period during which GPs were trained to use BMI skills in their practice and to document and reflect on their experience. Results: GPs found the emphasis on self-evaluation, personal choice and control particularly useful. Skills in open questioning, exchanging information carefully, assessing ambivalence and readiness to change were also helpful. They had mixed experiences with skills for agenda setting and reducing resistance. The use of specific scaling questions and decision balance sheets were not useful. Conclusions: BMI has great potential, as the skills learnt were mostly useful and the process had benefits for the participants. If the full potential of BMI is to be realised, the content will need to be adapted to local clinical conditions. BMI needs to be taught using a participatory educational style and its implementation must be accompanied by support from colleagues and management. Future research on this issue should evaluate the process of implementing BMI skills in different primary care settings and sustaining any positive changes that may occur. SA Fam Pract 2004;46(9): 21-2

An unsuccessful resuscitation: The families' and doctors' experiences of the unexpected death of a patient

Background: The objective was to elicit families' experience of the death of a family member at the Elsies River Community Health Centre, their feelings towards the staff involved in the resuscitation and their opinions about how things could be improved. The study also elicited the doctors' experiences of communicating with the families of patients who had died in the emergency unit. Methods: This was a qualitative study, using free attitude interviews for family members and focus group discussions for doctors. Twelve family members whose loved ones had died in the emergency room and 15 doctors who worked in the emergency room were included. Results: Key themes were identified, relating to issues in the pre-resuscitation period, the resuscitation, breaking the bad news, after breaking the bad news and post-event sequelae. In the pre-resuscitation period, there were problems in admitting, identifying and responding to acutely ill patients. During the resuscitation, the families and staff disagreed about witnessing the resuscitation. Breaking the bad news was often difficult for the doctors and hindered by the physical environment. Afterwards, there were mixed feelings about the quality of emotional support, the use of medication and bereavement counselling. All agreed that viewing the body was helpful and funeral arrangements were not a problem. There was no effective follow-up of the families and the doctors also experienced increased stress following unsuccessful resuscitations. Conclusion: The study found that the role of security staff should be clarified and a better triage system established to enable critically ill patients to be seen promptly. Families should be given the option of viewing the resuscitation and always be kept informed of progress. Doctors need better training in communication skills and breaking bad news, which should be done in a private area. Families should also be given the opportunity to view the body. Families should be assisted with contacting the undertaker and a follow-up visit should be organised after the initial shock, when further questions can be asked and abnormal grief reactions identified. Bereavement counselling should be available and community-based resources should be identified in this regard. Debriefing should also be available for staff involved in unsuccessful resuscitations. SA Fam Pract 2004;46(8): 20-2

Internet-based medical education: a realist review of what works, for whom and in what circumstances

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Neurofeedback training in children with ADHD: 6-month follow-up of a randomised controlled trial

Neurofeedback (NF) could help to improve attentional and self-management capabilities in children with attention-deficit/hyperactivity disorder (ADHD). In a randomised controlled trial, NF training was found to be superior to a computerised attention skills training (AST) (Gevensleben et al. in J Child Psychol Psychiatry 50(7):780–789, 2009). In the present paper, treatment effects at 6-month follow-up were studied. 94 children with ADHD, aged 8–12 years, completed either 36 sessions of NF training (n = 59) or a computerised AST (n = 35). Pre-training, post-training and follow-up assessment encompassed several behaviour rating scales (e.g., the German ADHD rating scale, FBB-HKS) completed by parents. Follow-up information was analysed in 61 children (ca. 65%) on a per-protocol basis. 17 children (of 33 dropouts) had started a medication after the end of the training or early in the follow-up period. Improvements in the NF group (n = 38) at follow-up were superior to those of the control group (n = 23) and comparable to the effects at the end of the training. For the FBB-HKS total score (primary outcome measure), a medium effect size of 0.71 was obtained at follow-up. A reduction of at least 25% in the primary outcome measure (responder criterion) was observed in 50% of the children in the NF group. In conclusion, behavioural improvements induced by NF training in children with ADHD were maintained at a 6-month follow-up. Though treatment effects appear to be limited, the results confirm the notion that NF is a clinically efficacious module in the treatment of children with ADHD

Forum : Clinical Practice - Developing generalism in the South African context.

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Motivational interviewing in Freeman M (Ed) Psychotherapeutic interventions in ARV therapy, 2005, Geneva: 10-18. ISBN 9241493091

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