Primary health care services provided by nurse practitioners and family physicians in shared practice.

BACKGROUND: Collaborative practice involving nurse practitioners (NPs) and family physicians (FPs) is undergoing a renaissance in Canada. However, it is not understood what services are delivered by FPs and NPs working collaboratively. One objective of this study was to determine what primary health care services are provided to patients by NPs and FPs working in the same rural practice setting. METHODS: Baseline data from 2 rural Ontario primary care practices that participated in a pilot study of an outreach intervention to improve structured collaborative practice between NPs and FPs were analyzed to compare service provision by NPs and FPs. A total of 2 NPs and 4 FPs participated in data collection for 400 unique patient encounters over a 2-month period; the data included reasons for the visit, services provided during the visit and recommendations for further care. Indices of service delivery and descriptive statistics were generated to compare service provision by NPs and FPs. RESULTS: We analzyed data from a total of 122 encounters involving NPs and 278 involving FPs. The most frequent reason for visiting an NP was to undergo a periodic health examination (27% of reasons for visit), whereas the most frequent reason for visiting an FP was cardiovascular disease other than hypertension (8%). Delivery of health promotion services was similar for NPs and FPs (11.3 v. 10.0 instances per full-time equivalent [FTE]). Delivery of curative services was lower for NPs than for FPs (18.8 v. 29.3 instances per FTE), as was provision of rehabilitative services (15.0 v. 63.7 instances per FTE). In contrast, NPs provided more services related to disease prevention (78.8 v. 55.7 instances per FTE) and more supportive services (43.8 v. 33.7 instances per FTE) than FPs. Of the 173 referrals made during encounters with FPs, follow-up with an FP was recommended in 132 (76%) cases and with an NP in 3 (2%). Of the 79 referrals made during encounters with NPs, follow-up with an NP was recommended in 47 (59%) cases and with an FP in 13 (16%) (p < 0.001). INTERPRETATION: For the practices in this study NPs were underutilized with regard to curative and rehabilitative care. Referral patterns indicate little evidence of bidirectional referral (a measure of shared care). Explanations for the findings include medicolegal issues related to shared responsibility, lack of interdisciplinary education and lack of familiarity with the scope of NP practice.

Fat-related dietary behaviour: behavioural science concepts for public health practice.

Despite being central to Canadian health objectives, reduction in fat consumption remains a difficult health target to reach. Strong epidemiological data associate high dietary fat intake with cardiovascular disease (CVD). There has been considerable interest in applying concepts from psychosocial models of behaviour change to enhance the effectiveness of CVD prevention programs. This review suggests that the determinants of fat-related dietary behaviours can be integrated within a comprehensive model useful to public health practice. The Transtheoretical Model (TTM) is suggested as an organizing framework for variables empirically related to diet. The TTM holds that dietary change occurs through successive stages, defined according to people's readiness to adopt new behaviours. Furthermore, readiness to change can be explained by variables that are amenable to public health interventions. The integration of important variables within the TTM framework may prove helpful in designing, implementing and evaluating effective dietary change intervention programs in the community.

Health promotion activities in Quebec hospitals: a comparison of DSC and non-DSC hospitals.

In the early 1970s, public health units were introduced to 32 Quebec hospitals. One of the reasons for introducing public health to hospitals was the beneficial influence this new structure, called "Département de santé communautaire" (DSC), was expected to have on the development of health promotion and prevention activities in the hospital. This study compared 19 DSC hospitals with 19 non-DSC hospitals that were matched for mission, size and location. The data came from a larger survey which had been conducted by the Canadian Hospital Association in Canadian hospitals in 1985. According to our results, DSC hospitals differed from their non-DSC counterparts mainly on dimensions related to their public health mandate (e.g. community programs, advocacy). They did not differ greatly on dimensions related to other health promotion and prevention activities within the hospital (e.g. inpatient and outpatient care, employees). These results suggest that while hospitals have not created organizational obstacles to the achievement of public health activities by DSCs, DSCs did not have the expected impact on hospitals.

Facilitating the involvement of Canadian health care facilities in health promotion.

Following a brief background of Canadian health promotion policy efforts, the Canadian health care system, and a discussion of the reasons for increased interest in the area, two health promotion and health care facility initiatives undertaken by the Canadian Hospital Association are presented. The first describes the findings of a 1986 survey of Canadian hospitals (n = 732) in terms of the level of commitment to health promotion, the future priority of health promotion for four target groups, the types of programs and activities, and the perceived obstacles to implementing health promotion. The results suggest that although health promotion is considered an important role for hospitals, most health promotion activities in Canadian hospitals can be classified as ad hoc. The second initiative presents the summary of a focus group meeting which was established to further the organized involvement of health care facilities in health promotion. Findings are described as follows: a shared vision of health and health promotion; the role of health care facilities in health promotion; and the implementation of health promotion in health institutions. These efforts culminated in the striking of a national working group by Health and Welfare Canada to develop a document which will serve as a framework for health promotion in health care facilities.