Home from home: residents' opinions of nursing homes and long-stay wards.

OBJECTIVE: To compare the levels of satisfaction expressed by residents of nursing homes with those of patients in geriatric long-stay wards. DESIGN: A structured satisfaction questionnaire containing 37 closed and two open questions was used to elicit responses from residents of nursing homes in the former South West Thames Regional Health Authority area. This was compared with a similar survey using the same questionnaire among patients in geriatric long-stay wards surveyed in 1989. SETTING: respondents came from a sample of nursing homes chosen to be representative of both size and geographical location. Nursing homes were stratified by number of beds (1-19, 20-29, 30+) and clustered by location (to reflect the urban, semi-rural and coastal nature of the region). SUBJECTS: A random sample was drawn from each grouping (size and location) to yield a resident sample of 850 in 36 nursing homes. This figure was similar to the number of patients (808) in geriatric long-staywards surveyed in 1989. All eligible nursing home patients were assessed for physical dependency. Mental confusion was ascertained by the Abbreviated Mental Test Score (AMTS). Patients who scored three or less on the AMTS (indicative of severe confusion) or had dysphasia, profound deafness or concurrent serious illness were excluded from further study. RESULTS: 377 nursing home residents were able to complete the questionnaire and their answers were compared with those of 291 long-stay geriatric patients. The responses to the five themes--relations with staff, autonomy, amenities, privacy and social environment-show some minor differences between the two groups but what is more noticeable is the similarity of their views. This is important as much social policy assumes that the more 'homely' atmosphere of the nursing home should elicit higher levels of satisfaction than the 'institutional' setting of the hospital ward. CONCLUSION: We conclude that the difference between nursing homes and hospital wards in terms of their institutionalizing capacities is not as profound as policy-makers believe.

A randomized controlled trial of the cost-effectiveness of a district co-ordinating service for terminally ill cancer patients.

The objective of this paper is to compare the cost effectiveness of a co-ordination service with standard services for terminally ill cancer patients with a prognosis of less than one year. We designed a randomized controlled trial, with patients randomized by the general practice with which they were registered. Co-ordination group patients received the assistance of two nurse coordinators whose role was to ensure that patients had access to appropriate services. The setting was in a South London health authority. Complete service use and outcome data were collected on 167 patients, 86 in the co-ordination group, and 81 in the control group. Our results, as previously reported, show that no differences in outcomes were detected between the co-ordination and control groups; the mean total costs incurred by the co-ordination group were significantly less than those of the control group. The co-ordinated group used significantly fewer inpatient days (mean 24 versus 40 inpatient days; t = 2.4, p = 0.002) and nurse home visits (mean 14.5 versus 37.5 visits; t = 0.3, p = 0.01). Mean cost per co-ordinated patient was almost half that of the control group patients 4774 pounds versus 8034 pounds, t = 2.8, p = 0.006). Although the unit cost data were relatively crude, these cost reductions were insensitive to a wide range of unit costs. These differences persisted when, in order to control for any putative differences in severity between the two groups, the analysis was restricted to patients who had died by the end of the study. The ratio of potential cost savings to the cost of co-ordination service was between 4:1 and 8:1. In conclusion, the co-ordination service for cancer patients who were terminally ill with a prognosis of less than one year was more cost effective than standard services, due to achieving the same outcomes at lower service use, particularly inpatient days in acute hospital. Assuming that the observed effects are real, improved co-ordination of palliative care offers the potential for considerable savings. Further research is needed to explore this issue.

Acceptability and perceived effectiveness of a district co-ordinating service for terminal care: implications for quality assurance.

As part of a randomized controlled trial of a new district co-ordinating service for the care of terminally ill cancer patients, the activities of the nurse co-ordinators and the acceptability and perceived effectiveness of the service were assessed. Co-ordinators' activities were self-recorded; professional caregivers completed a postal questionnaire; and family carers were interviewed at home. Thirty-eight per cent of patients allocated to the co-ordinators were not visited at home. Overall, 41% of professionals had heard of the co-ordinating service and 20% had been contacted. A third of relatives, whether allocated or not to the co-ordinating service, felt that terminal care of their patient was not well co-ordinated and that they did not know how to get the help they needed for their dying relative. It may be that the nurse co-ordinators were unwilling or unable to relinquish their skills in order to provide a 'broker' style of co-ordination. Perhaps less skilled co-ordinators would have been more successful. Moreover, the co-ordinating service had no budgetary responsibility. Those concerned with quality assurance in co-ordination of terminal care might consider the skill mix and professional training of the co-ordinators as well as their budgetary responsibilities and authority.

The relationship between severe asthma and social class.

Asthma is one of the few diseases which has been reported to be common in the higher social classes. In order to assess the relationship between severe asthma and social class we analysed a national study of disabled adults undertaken by the Office of Population Censuses and Surveys (OPCS). The study estimated that there were 5.8 million people over 16 years with some degree of disability living in private households in England and Wales. Thirteen percent of disabilities were due to respiratory disease: 6% chronic bronchitis and emphysema, 3% asthma and allergy, and 4% other respiratory diseases. Among 10,000 individuals interviewed, 338 disabled adults reported asthma as a contributing cause of their disability. Of 291 cases with social class recorded, 41 (14%) were in social classes 1 and 2, 128 (44%) in social class 3, and 122 (42%) in social classes 4 and 5. An estimate of the relationship between social class and adult asthma in the general population was derived by calculating a morbidity ratio for the different social classes. The morbidity ratio for all social classes combined equals 100: for social classes 1 and 2 it was 63 (95% confidence intervals 48, 91); 93 (95% confidence intervals 77, 109) for social class 3; and 131 (95% confidence intervals 108, 153) for social classes 4 and 5. Adults in social classes 4 and 5 were approximately twice as likely to have severe asthma as those in social classes 1 and 2. This could be as a result of differences in the prevalence or treatment of asthma among the social classes.

Randomised controlled trial of effects of coordinating care for terminally ill cancer patients.

OBJECTIVES: To measure effects on terminally ill cancer patients and their families of coordinating the services available within the NHS and from local authorities and the voluntary sector. DESIGN: Randomised controlled trial. SETTING: Inner London health district. PATIENTS: Cancer patients were routinely notified from 1987 to 1990. 554 patients expected to survive less than one year entered the trial and were randomly allocated to a coordination or a control group. INTERVENTION: All patients received routinely available services. Coordination group patients received the assistance of two nurse coordinators, whose role was to ensure that patients received appropriate and well coordinated services, tailored to their individual needs and circumstances. MAIN OUTCOME MEASURES: Patients and carers were interviewed at home on entry to the trial and at intervals until death. Interviews after bereavement were also conducted. Outcome measures included the presence and severity of physical symptoms, psychiatric morbidity, use of and satisfaction with services, and carers' problems. Results from the baseline interview, the interview closest to death, and the interview after bereavement were analysed. RESULTS: Few differences between groups were significant. Coordination group patients were less likely to suffer from vomiting, were more likely to report effective treatment for it, and less likely to be concerned about having an itchy skin. Their carers were more likely to report that in the last week of life the patient had had a cough and had had effective treatment for constipation, and they were less likely to rate the patient's difficulty swallowing as severe or to report effective treatment for anxiety. Coordination group patients were more likely to have seen a chiropodist and their carers were more likely to contact a specialist nurse in a night time emergency. These carers were less likely to feel angry about the death of the patient. CONCLUSIONS: This coordinating service made little difference to patient or family outcomes, perhaps because the service did not have a budget with which it could obtain services or because the professional skills of the nurse-coordinators may have conflicted with the requirements of the coordinating role.

Responses to the institution among elderly patients in hospital long-stay care.

The theory of the 'total institution' argues that institutions deliberately create dependency in individuals who would otherwise be self-determining. We examine the significance of this concept for patients in long-stay geriatric wards. All such patients in the South West Thames Region (808) were located and assessed for levels of physical dependency and mental confusion. 87% were profoundly disabled, 53% were severely confused and 23% were seriously ill or unable to communicate. Those capable of responding (291) were interviewed. Three quarters or more were satisfied with 'staff relations', 'autonomy', 'amenities' and 'privacy' and three fifths were satisfied with the 'social environment'. Results suggest that: (a) patients in long-stay geriatric wards who were not severely confused were able to make realistic assessments of their situation and (b) the majority were not passively institutionalized. In terms of institutionalization theory, it is their physical frailty that appears to differentiate this group from other categories of 'inmates'. We conclude that appropriate policy for the long-term ill necessitates consideration of the actual as well as the attributed needs of patients.

Marital status: association with social and economic circumstances, psychological state and outcomes of pregnancy.

We examined the association of marital status with economic, social and psychological factors and with the outcomes of pregnancy (defined as onset of labour, type of delivery, live and still births and birthweight). The study population was 1431 white women consecutively booking for antenatal care. Birth registrations were inspected. Of 278 women who were unmarried during pregnancy, 61 per cent were cohabiting, 26 per cent were living with adults other than the father and 13 per cent were living alone. Compared with the married women, unmarried women overall were, on average, younger, less educated, of lower social class, in poorer economic circumstances, more dependent on state support and less satisfied with their living arrangements. Irrespective of age and social class, they were less likely to have planned the pregnancy, more likely to smoke and drink, to book later for antenatal care and to miss more appointments. In general, unmarried women were more likely to have some indication of depression and to experience more serious life events during the pregnancy. Controlling for age and social class, the categories 'married', 'cohabiting' and 'on their own' showed significant trends from best to worst. Those living with adults other than the father showed intermediate results. There were no significant effects of marital status, controlled for age and social class, and associated social, economic and psychological circumstances on outcomes of pregnancy. Forty-one per cent of births to women on their own, 35 per cent to women living with other adults and 11 per cent to women cohabiting during pregnancy were registered by only one parent.(ABSTRACT TRUNCATED AT 250 WORDS)

PIP: The authors examined the association of marital status with economic, social, and psychological factors and with the outcomes of pregnancy (defined as onset of labor, type of delivery, live and stillbirths, and birthweight). The study population comprised 1431 white women who were consecutively booked for antenatal care. Birth registrations were inspected. Of 278 women who were unmarried during pregnancy, 61% were cohabiting, 26% were living with adults other than the father, and 13% were living alone. Compared with the married women, unmarried women overall were, on the average, younger, less educated, of lower social class, in poorer economic circumstances, more dependent on state support, and were less satisfied with their living arrangements. Regardless of age and social class, they were less likely to have planned the pregnancy, were more likely to smoke and drink, to book later for antenatal care, and to miss more appointments. In general, unmarried women were more likely to have some indication of depression and to experience more serious life events during the pregnancy. Controlling for age and social class, the categories "married", "cohabiting", and "on their own" showed significant trends from best to worst. Those living with other adults other than the father showed intermediate results. There were no significant effects of marital status controlled for age and social class, and associated social, economic, and psychological circumstances on pregnancy outcomes. 41% of births to women on their own, 35% to women living with other adults, and 11% to women cohabiting during pregnancy were registered by only 1 parent. It is possible that a continuation of the poor quality of life observed among unmarried women during pregnancy could affect the later wellbeing of their children.

The role of the specialist in community nursing: perceptions of specialist and district nurses.

We investigated the management of specialist nurses and how district and specialist nurses perceived themselves and each other, in terms of responsibility, autonomy, skills and training, communication, role conflicts and job satisfaction. All locality and neighbourhood nurse managers, all specialist nurses, and all district and community staff nurses in one Health Authority were interviewed and surveyed. There was little disagreement about the role of the specialist nurse. District nurses were largely positive about specialist nurses, but the area of "hands-on" care was difficult for both groups of nurses. Communication between district and specialist nurses needed to be improved. Both specialist nurses and their managers believed that specialists were inappropriately managed.

Effects of reduction of acute hospital services on district nursing services: implications for quality assurance.

Two questions of importance to those concerned with maintaining standards and increasing the efficiency of Community Nursing are: (1) does reducing hospital provision alter the number of patients referred for Community Nursing or the type of care provided; (2) are Community Nursing Services directed towards those who most require them? A base-line study was carried out in the first quarter of 1988, before the closure of one of two general hospitals in an inner London Health Authority and was replicated in the same quarter of 1989, after all acute inpatient services had been transferred to the other hospital. Comparison of patients discharged before and after closure showed no significant differences in patients' age, sex, proportion living alone, length of stay in hospital, readmissions or deaths within one month of discharge. There was some decline in general nursing care. Total discharges declined by 20% while the number of referrals remained the same, indicating that proportionately more patients were discharged with a referral. Comparing referred and unreferred patients showed that Community Nursing Services were already being directed towards those most in need both before and after hospital closure. Results suggest that Community Nursing helps to maintain patients in the community.

Can the Spitzer Quality of Life Index help to reduce prognostic uncertainty in terminal care?

Data from an on-going trial of co-ordinating care for terminally ill cancer patients are used to investigate whether the Spitzer Quality of Life (QL) Index can be used to reduce prognostic uncertainty in terminal care. Four questions are addressed. First, can doctors and nurses distinguish between patients with a prognosis of more or less than 1 year? Second, do the medical and nursing staff differ in their ability to estimate prognosis? Third, are there differences in the length of life remaining between groups of patients with different QL Index scores? Fourth, how well does the QL Index predict the likelihood of individual patients dying within 6 months of assessment? Doctors and nurses assigned between 17 and 25% of patients to the wrong prognostic group and were as likely to over-estimate as to under-estimate life expectancy. Medical and nursing staff did not differ in their ability to make prognostic judgements. Patients with a low QL Index score were more likely to die within 6 months than those with higher scores, but scores on the Index were not strong predictors of 6-month survival in individual patients. The Index is not accurate enough to be used to predict what sort of treatment terminally ill patients will require in the future and for how long. Nevertheless, it may prove valuable for those planning services for terminally ill cancer patients who require information on the levels of need in a population.

The practice of traditional birth attendants in Zululand.

PIP: Approximately 60% of births in the Mseleni area of South Africa's Kwa Zulu province were home deliveries in 1984. Home deliveries in the area are generally attended by members of the pregnant woman's family. If difficulties are encountered during labor, the family will call upon a midwife, or Traditional Birth Attendant (TBA) for assistance. 14 TBAs from the Mseleni area were interviewed in 1984, about their technics and beliefs with regard to childbirth, and how they had acquired them. Most of the women reported that they had learned their technics from their mothers, who had also been TBAs. But TBAs from Mseleni District, where the local hospital was situated, had apparently learned from women working at the hospital that eggs and milk were valuable foods for their patients. The traditional beliefs and practices that the TBAs reported varied depending on the particular district they were from. Judged by the standards of modern medicine, some of these traditional practices appeared to be useful, while others seemed counterproductive. All of the interviewers expressed a willingness to participate in a training program at the hospital. It is recommended that such a program be conducted.^ieng

The health of rectal cancer patients in the community.

Surviving rectal cancer patients living in five health districts were identified through cancer registrations. Four hundred and twenty (91%) were interviewed at home by health visitors to assess their physical, social and psychological health. In most respects, the health of rectal cancer patients overall was similar to that of the general population of the same age, sex and social circumstances. However, those with a colostomy (63%) were more likely to be severely depressed, socially isolated and stigmatized. They also suffered more from physical problems, particularly urinary symptoms, flatus and offensive bowel motions. The pressure of a colostomy was associated with reduced sexual capacity, though not with lack of sexual interest. The results confirm the high psychological and social costs of a permanent colostomy.

Stigma in patients with rectal cancer: a community study.

A self-rating measure of stigma and several supplementary questions were devised in order to assess perceived stigma in a community survey of the quality of life in 420 rectal cancer patients, of whom 265 had a permanent colostomy. Half the patients felt stigmatised, higher proportions being observed among younger patients and among those with a colostomy. Feelings of stigma were associated with poor health, particularly emotional disorders, with the presence of other medical problems, and with disablement. Patients who perceived stigma made more use of medical services but were less satisfied with them, particularly with regard to communication with health professionals. Socio-economic factors, such as employment status, higher income, and higher social and housing class, did not protect patients against feeling stigmatised by cancer or by colostomy. Most patients, with or without stigma, enjoyed close relationships with intimates, but the stigmatised were more likely to have withdrawn from participation in social activities. Assessing stigma by self-rating gives information which adds to that obtained by the usual methods of assessing quality of life.

Changes in hair zinc and copper concentrations of breast fed and bottle fed infants during the first six months.

A longitudinal study of 35 full term breast fed (20 males and 15 females; mean birthweight = 3540 g) and 25 full term bottle fed infants (14 males and 11 females; mean birthweight = 3466 g) was carried out to compare the effect of method of feeding on hair zinc and copper concentrations. Hair samples were collected at 30 +/- 2, 90 +/- 4 and 180 +/- 4 days of age and analysed for zinc and copper by instrumental neutron activation procedures. Mean daily zinc and copper intakes were calculated at monthly intervals using three day diet records and test weigh data for the breast fed group. Only the male bottle fed infants showed a significant decline in hair zinc concentration (p less than 0.01) during the six-month study period. These results support the suggestion that male infants have a higher requirement for zinc than females in early infancy. No comparable systematic decline in hair zinc levels was evident in the female bottle fed infants or the male and female breast fed infants. The absence of any fall in hair zinc concentrations in the breast fed infants, despite their significantly lower (p less than 0.01) dietary zinc intakes compared to the bottle fed group, is attributed to the superior bioavailability of zinc from breast milk. Hair copper levels rose during the first three months in both groups, subsequently declining between 3-6 months. These changes were not significantly related to sex or method of milk feeding, but are associated with the redistribution of copper which occurs during early infancy.