ABSTRACT
Contexte : Le cancer du sein en Afrique subsaharienne et en Côte d'Ivoire en particulier est caractérisé par les stades avancés au diagnostic, rendant la plupart des tumeurs inopérables d'emblée. La microbiopsie n'étant pas pratiquée, le plateau technique d'immunohistochimie n'existant pas, les patientes atteintes de cancer du sein ne bénéficiaient jusque là que d'une cytoponction. Il était alors impossible d'avoir en préthérapeutique leur statut histologique et moléculaire. Pour y remédier, une collaboration interdisciplinaire a débuté entre oncologues, radiologues et pathologistes.Objectif : Déterminer le profil préthérapeutique des récepteurs hormonaux et de HER2 chez les patientes non opérables d'emblée.Patientes et méthodes : Une étude prospective, descriptive, sur 12 mois, a été réalisée au service de Cancérologie du CHU de Treichville à Abidjan (Côte d'Ivoire). Les résultats préliminaires ont porté sur 19 patientes atteintes de cancer du sein localement avancé, inopérable d'emblée ayant toutes bénéficié d'une microbiopsie échoguidée.Résultats : L'âge moyen de nos patientes était de 47 ans. Le délai moyen de consultation était de 10 mois. Huit patientes sur 17 étaient RH + dont une seule patiente ménopausée, 8 patientes sur 17 étaient HER2+ dont 2 ont nécessité une confirmation par le test de FISH.Conclusion : Cette pratique des biopsies percutanées préthérapeutiques devrait progressivement pouvoir remplacer la cytoponction afin de connaitre le statut des récepteurs hormonaux et de HER2 et ainsi améliorer la prise en charge des patientes
Subject(s)
Breast Neoplasms/diagnosis , Breast Neoplasms/therapy , Clinical Protocols , Cooperative Behavior , Cote d'IvoireABSTRACT
"Background: Effective teamwork between doctors and clinical nurse practitioners (CNP) is essential to the provision of quality primary care in the South African context. The Worcester Community Health Centre (CHC) is situated in a large town and offers primary care to the rural Breede Valley Sub-District of the Western Cape. The management of the CHC decided to create dedicated practice teams offering continuity of care; family-orientated care; and the integration of acute and chronic patients. The teams depended on effective collaboration between the doctors and the CNPs.Methods: A co-operative inquiry group; consisting of two facility managers; an administrator; and medical and nursing staff; met over a period of nine months and completed three cycles of planning; action; observation and reflection. The inquiry focused on the question of how more effective teams of doctors and clinical nurse practitioners offering clinical care can be created within a typical CHC.Results: The CHC had established three practice teams; but met with limited success in maintaining the teams over time. The group found that; in order for teams to work; the following are needed: A clear and shared vision and mission amongst the staff. The vision was championed by one or two leaders rather than developed collaboratively by the staff. Continuity of care was supported by the patients and doctors; but the CNPs felt more ambivalent. Family-orientated care within practices met with limited success. Integration of care was hindered by physical infrastructure and the assumptions regarding the care of ""chronics"". Enhanced practitioner-patient relationships were reported by the two teams that had staff consistently available. Significant changes in the behaviour and roles of staff. Some doctors perceived the nurse as an ""assistant"" who could be called on to run errands or perform tasks. Doctors perceived their own role as that of comprehensively managing patients in a consultation; while the CNPs still regarded themselves as nurses who should rotate to other duties and perform a variety of tasks; thus oscillating between the role of practitioner and nurse. The doctors felt responsible for seeing a certain number of patients in the time they were available; while the CNPs felt responsible for getting all the patients through the CHC. The doctors did not create space for mentoring the CNPs; who were often seen as an intrusion and a threat to patient privacy and confidentiality when requesting a consultation. For the CNPs; however; the advantage of practice teams was considered to be greater accessibility to the doctor for joint consultation. The identification of doctors and CNPs with each other as part of a functioning team did not materialise. Effective management of the change process implied the need to ensure sufficient staff were available to allow all teams to function equally throughout the day; to be cognisant of the limitations of the building design; to introduce budgeting that supported semi-autonomous practice teams and to ensure that the staff were provided with ongoing opportunities for dialogue and communication. The implications of change for the whole system should be considered; and not just that for the doctors and nurses.Conclusions: Key lessons learnt included the need to engage with a transformational leadership style; to foster dialogical openness in the planning process and to address differences in understanding of roles and responsibilities between the doctors and the CNPs. The unreliable presence of doctors within the practice team; due to their hospital duties; was a critical factor in the breakdown of the teams.. The CHC plans to further develop practice teams; to learn from the lessons so far and to continue with the co-operative inquiry."
Subject(s)
Cooperative Behavior , Delivery of Health Care , Hospitals, Public , Nursing, Team , Physician-Patient Relations , Physicians , Primary Health Care , Public SectorABSTRACT
This synopsis seeks to highlight and promote the enormous potential that exists between these two initiatives that seek to address closely related issues and targeting the same populations at risk within a fairly well defined geographical setting. It also attempts to argue that malaria control; just like HIV-Aids control be given high priority in the New Partnership for Africa's Development (NEPAD) health agenda; as current statistics indicate that malaria is again on the rise. While much attention and billions of dollars have rightly been given to HIV-Aids research; treatment and prevention; malaria; and not Aids; is the region's leading cause of morbidity and mortality for children under the age of five years. This is the bad news. The good news is that unlike Aids; malaria treatment and prevention are relatively cheap. In addition; there is a payback to fighting malaria; support aimed directly at improving health; rather than poverty reduction; may be a more effective way of helping Africa to thrive. Robust and sustained growth may come to Africa through a mosquito net; Artemisinin-based Combination Therapies (ACTs) or a malaria vaccine; rather that a donor's cheque for economic development initiatives
Subject(s)
Cooperative Behavior , Malaria/prevention & control , Public-Private Sector PartnershipsABSTRACT
"Background: Primary health care; which was the domain of the nursing profession; was popularised by the introduction of free health services by the South African legislature. In addition; the district health system was developed with the aim of keeping people healthy by creating small management systems adapted to cater for local needs. These measures increased public access to healthcare centres; leading to an increased workload at primary health level. The government; being a large organisation; relies on groups that include doctors and nurses to accomplish its goals; and the governess of these groups plays a major role in determining the effectiveness of the overall organization. ""The nurse has an ethical responsibility in the interest of the welfare of her patient to be a loyal and petent colleague to the doctor. The nurse and the doctor must be able to rely on each other. Mutual respect is vital."" Nurses have dependent; independent and interdependent roles in their interaction with doctors; and both professions should embrace the Patient's Rights Charter; which requires a good standard of practice and care of patients. International journals have published numerous letters citing doctor-nurse disagreements in their interactions. Historically; the doctor-nurse relationship is an unequal one characterised by the dominance of the doctor; with nurses assuming a position of lower status and dependence on physicians. One qualitative study showed that nurses perceive the quality of communication with doctors as being poor. Lack of teamwork in the relationship resulted from different expectations and a confusion of roles. Both professions have however demonstrated a willingness to promote teamwork in hospitals. A journal review on interventions to promote collaboration between nurses and doctors showed positive gains once collaboration was embraced.Method: This was a descriptive qualitative study in which the experiences of Kwa-Nobuhle general practitioners and professional nurses were explored. An equal number of nurses and doctors (five each) were purposefully selected; for the free-attitude interviews used for data collection. All interviews were analysed using the thematic analysis method. Themes were integrated into a single Model.Results: Majority of respondents experienced a relatively good relationship. The positive factors were balanced by negative experiences by almost all respondents. The positives were personal growth; efficiency at work; opportunity for education and learning at the primary healthcare level. The negatives were doctors' inconsistent clinic visits; role confusion (with doctors being confused with policymakers); dominance of the doctor in the relationship; and lack of doctor-nurse forums for communication; with subsequent suspicion and tension. The impact of the conflicts was neutralised by the track record of the relationship and the behaviour of the participants towards each other.Conclusion: This study showed congruence with other studies; where the doctor-nurse relationship was influenced by a power differential; collaboration; role confusion; impact of the respondents' competence; the significance of recognising the nurses' hierarchy and continuity of the care they provide at the primary health level. Maximum variation; strict admission criteria and data validation through a member check addressed issues of bias in this study. The exploration of relationships is a sensitive issue and a different methodology may produce different results. The environment where this research was conducted may differ from others; leading to discrepancies in findings. Future research could further focus on team building and the essential elements to sustain the doctor-nurse-patient team."
Subject(s)
Cooperative Behavior , Ethics , Physician-Nurse Relations , Primary Health CareABSTRACT
Background: The primary healthcare system was adopted as the vehicle of healthcare delivery and a means of reaching the larger part of the population in South Africa in 1994. One of the strategies employed in providing a comprehensive service is the incorporation of visits to clinics by doctors in support of other members of the primary healthcare team; particularly nurses. A successful collaboration at this level brings benefit to everyone involved; particularly patients. Clear expectations and a confusion of roles leads to lack of teamwork; thus it is important to have clearly established models for such involvement. Doctors working in district hospitals mostly visit clinics; but their workload; staff shortages and transport often interfere with these visits. As a form of private-public partnership; local GPs are sometimes contracted to visit the clinics. Very little is known about this practice and problems are reported; including the perception that GPs do not spend as much time in the clinics as they are paid for10.Understanding the practice better may provide answers on how to improve the quality of primary care in the district health system. The aim of this study was to describe the experiences of local GPs visiting public clinics regularly over a long period of time.Methods: A case study was undertaken in the Odi district of the North West Province in three primary care clinics visited by GPs. The experiences of the doctors; clinic nurses; district managers and patients regarding the GP's visits were elicited through in-depth interviews. Details of the visits with regard to patient numbers; lengths of the visits; remuneration and preferences were also sought. The data were analysed using different methods to highlight important themes.Results: The visits by the GPs to the clinics were viewed as beneficial by the patients and clinic staff. The GPs were often preferred to government doctors because of their skills; patience and availability. The visits were also seen as a gesture of patriotism by the GPs. There were constraints; such as a shortage of medicines and equipment; which reduce the success of these visits.Conclusion: The involvement of GPs in primary care clinics is beneficial and desirable. It enhances equity in terms of access to services. Addressing the constraints can optimise the public-private partnership at this level