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Community nurses provide care to patients in a variety of settings; for example, health centres, community hospitals, patients' homes, and residential and nursing homes. Administering intramuscular (IM)injections to patients in the community is an everyday activity for many nurses in clinical practice. A great deal of problems related to being 'sharps safe' are common to both community nurses and hospital staff. There had been a reported six needlestick injuries (NSIs) from community clinics administering depot IM injections, which required a review. An audit of practice was undertaken in clinics administering depot injections. The audit was undertaken to monitor compliance in sharps management and investigated how community nurses were administering IM injections. The review highlighted a lack of resources, gaps in knowledge and training deficits. The infection prevention and control nurses worked hard to improve practices and procedures. After a year, there had been a significant reduction in NSIs.

Aim: To examine perceptions about how nursing leadership affects quality of care in the community setting., Background: Quality care is considered an essential component of nursing work and recent policy has emphasized the role of leadership in meeting the quality agenda. As shifting the balance of nursing care from the hospital to the community occurs in the UK, there is an imperative to confirm more effectively the quality of care that patients and families receive from nurses working in the community., Methods: A qualitative study involving community nurse leaders (n = 12) and community nurses (n = 27) in semi-structured individual interviews (n = 31) and three focus groups (n = 13)., Results: Tensions exist between 'leading' for quality care and 'delivering' for quality care. Organisational decision making is challenged by limited measures of quality of care in the diverse roles of community nursing., Conclusions: Frontline community nurses and nurse leaders need to articulate how they intend quality of nursing care to be appreciated and actively indicate ways to show this., Implications for Nursing Management: Mechanisms to monitor patient safety, a key aspect of the policy agenda for quality care and other technical aspects of care are important for nurse leaders to develop with frontline community nurses., (© 2011 Blackwell Publishing Ltd.)

Aim: The aim of the study was to identify the impact of a quality register in end-of-life-care, from community nurses' perspective., Background: There is a lack of knowledge about the impact of such a register in end-of-life care., Method: Data were collected by means of focus group interviews with a total of 12 nurses, from two communities in the western part of Sweden. Data analysis was based on grounded theory., Result: Feedback is the core category that influences all other processes. Two main categories emerged: 'Becoming aware of' and 'Acting accordingly'. These influenced the nurses and led to improved quality of care., Conclusion: A quality register gives the users (nurses) feedback on the care provided, which starts a process of change., Implications for Nursing Management: The value of working with a quality register as a feedback system can be applicable to all professions working with quality assurance. The experiences will increase the motivation and understanding the value of using quality registers as a tool for enhanced quality. Further, nurse managers can use such a register as a feedback system, not only as a motivating tool when implementing a quality register, but in the evaluation of its outcomes., (© 2012 Blackwell Publishing Ltd.)

District nurses play a pivotal role in individuals' care pathways by meeting their needs in the community. However, district nurses are frequently referred patients for whom other interprofessional colleagues have more suitable skills to help in achieving their optimum care outcome. Various major reports have identified a clear need to define what district nurses do and how they will respond appropriately to patients' needs. However, there remains only tacit understanding of district nurse referral criteria across the country and within community organizations. This article discusses how a set of facilitative district nurse referral guidelines have been devised to support individuals in achieving their best care outcome. We also debate approaches to managing referrals to district nursing services and the pressing need to ensure these are effectively managed in practice.

Objectives: This study investigated the relationship between patients' self-reported illness, daily afflictions, and the frequency of home nursing care, and whether patients' coping resources influenced the allocation of care. DESIGN, SAMPLE AND MEASUREMENTS: A cross-sectional survey was adopted. Two hundred and forty-two people aged 75 years and above receiving home nursing care participated in the study. Binary logistic regression model was used to test the effects of the independent variables on home nursing care., Results: Poor capacity to perform activities of daily living and high level of education were directly associated with a high frequency of home nursing care. Lack of perceived social support affected the amount of home nursing care allocated only when feelings of loneliness were connected with poor activities of daily living functioning. Interaction effects revealed that perceived social support influenced the amount of home nursing care in persons with higher education, in persons with low education, no such association were found. No associations were found between coping resources and home nursing care., Conclusions: Impaired capacity to perform activities of daily living was the main reason for care allocation. Education was associated with more formal care. Patients with low perceived social support combined with a low education level was a particularly vulnerable group., (© 2010 Blackwell Publishing Ltd.)

In this observational study, the perceptions, compliance, techniques, and contextual issues of hand hygiene practices among community clinicians (nurses) during 103 hand hygiene opportunities (based on the World Health Organization "Five Moments for Hand Hygiene") in 40 patient care episodes were examined. Compliance with standard hand hygiene practices was generally poor, with many contextual influences making compliance difficult. Clinician preferences and convenience are important considerations in hand hygiene compliance. Improving home-visiting community clinicians' hand hygiene practices requires addressing contextual issues related to the availability of hand hygiene equipment, such as alcohol-based hand rubs, as well as hand hygiene in-service education to update knowledge on hand hygiene for everyday practice in community settings.

Background: Improving the health of chronically ill older adults is a major challenge facing modern health care systems. A community-based nursing intervention developed by Health Quality Partners (HQP) was one of 15 different models of care coordination tested in randomized controlled trials within the Medicare Coordinated Care Demonstration (MCCD), a national US study. Evaluation of the HQP program began in 2002. The study reported here was designed to evaluate the survival impact of the HQP program versus usual care up to five years post-enrollment., Methods and Findings: HQP enrolled 1,736 adults aged 65 and over, with one or more eligible chronic conditions (coronary artery disease, heart failure, diabetes, asthma, hypertension, or hyperlipidemia) during the first six years of the study. The intervention group (n = 873) was offered a comprehensive, integrated, and tightly managed system of care coordination, disease management, and preventive services provided by community-based nurse care managers working collaboratively with primary care providers. The control group (n = 863) received usual care. Overall, a 25% lower relative risk of death (hazard ratio [HR] 0.75 [95% CI 0.57-1.00], p = 0.047) was observed among intervention participants with 86 (9.9%) deaths in the intervention group and 111 (12.9%) deaths in the control group during a mean follow-up of 4.2 years. When covariates for sex, age group, primary diagnosis, perceived health, number of medications taken, hospital stays in the past 6 months, and tobacco use were included, the adjusted HR was 0.73 (95% CI 0.55-0.98, p = 0.033). Subgroup analyses did not demonstrate statistically significant interaction effects for any subgroup. No suspected program-related adverse events were identified., Conclusions: The HQP model of community-based nurse care management appeared to reduce all-cause mortality in chronically ill older adults. Limitations of the study are that few low-income and non-white individuals were enrolled and implementation was in a single geographic region of the US. Additional research to confirm these findings and determine the model's scalability and generalizability is warranted., Trial Registration: ClinicalTrials.gov NCT01071967. Please see later in the article for the Editors' Summary.

Unlabelled: Scant empirical information exists regarding the quality of district nursing (DN) services. This article reports the testing of 31 quality indicators (QI) in practice., Method: Twelve DN teams provided patient notes for audit. External auditors completed audit forms by cross-referencing between DN office records, patient notes from home, electronic GP records and discussions with DN team leaders. A patient experience questionnaire was piloted., Findings: 277 (77%) patients' records were audited. Access to records was problematic. QIs required further refinement of their wording, modification of inclusion criteria, deletion of some QIs and inclusion of others. Telephone administration of the patient experience questionnaire was not feasible for the DN patient population., Conclusions: QIs can not be used 'off the shelf' and need testing and modification before routine use. Trained, external auditors with clinical backgrounds ensure an informed, uniform, objective approach to data collection, which is desirable as QIs might inform commissioners in a competitive field in future.

Unintentional injury is one of the leading causes of morbidity and mortality in children aged one to 14 and puts more children in hospital than any other cause. The Department of Health (DH) asked the National Institute for Health and Clinical Excellence (NICE) to produce public health guidance on the prevention of unintentional injuries among children and young people aged under 15. This paper, by a member of the NICE programme development group, aims to provide an overview of the recently published guidance. The guidance focuses on strategies, regulation, enforcement, surveillance and workforce development in relation to preventing unintentional injuries in the home, on the road and during outdoor play and leisure. A summary of the main recommendations will be given and those recommendations or considerations directly applicable to community practitioners will be outlined.

This is the second of two papers that examine district nursing within a changing health policy and service environment. The first paper explored the current UK policy context and the way in which district nursing and community nursing services within each country are changing to meet the challenges posed. This article considers the current district nurse (DN) role, which has constantly evolved over the past 150 years, and considers the educational framework that underpins the preparation of these specialist community practitioners in relation to community colleagues such as specialist community public health nurses (SCPHNs). In the context of the current economic climate, there is concern that the apprenticeship model of staff development is replacing specialist practitioner education for DNs, solely on the basis of resource. This article explores the current challenges for DN education within the UK. The underpinning educational preparation of DN programmes is examined and key issues such as safeguarding the public are discussed. The need to develop a cohesive approach to education for post-qualification nurses in the community is advocated. These are important considerations for the future of a discipline which currently feels under threat.

Home oxygen therapy costs millions of pounds every year and demand for the service is growing. As part of the Department of Health's respiratory programme, NHS Improvement--Lung works with several clinical teams in England to address variations in patient care. This article discusses how oxygen service assessment and review can save money and raise the quality of care.

Background: Healthcare professionals working in the community do not always prescribe oral nutritional supplements (ONS) according to best practice guidelines for the management of malnutrition. The present study aimed to determine the impact of a community dietetics intervention on ONS prescribing practices and expenditure 1 year later., Methods: The intervention involved general practitioners (GPs), practice nurses, nurses in local nursing homes and community nurses. It comprised an education programme together with the provision of a new community dietetics service. Changes in health care professionals' nutrition care practices were determined by examining community dietetics records. ONS prescribing volume and expenditure on ONS were assessed using data from the Primary Care Reimbursement Service of the Irish Health Service Executive., Results: Seven out of 10 principal GPs participated in the nutrition education programme. One year later, screening for malnutrition risk was better, dietary advice was provided more often, referral to the community dietetics service improved and ONS were prescribed for a greater proportion of patients at 'high risk' of malnutrition than before (88% versus 37%; P < 0.001). There was a trend towards fewer patients being prescribed ONS (18% reduction; P = 0.074) and there was no significant change in expenditure on ONS by participating GPs (3% reduction; P = 0.499), despite a 28% increase nationally by GPs on ONS., Conclusions: The community dietetics intervention improved ONS prescribing practices by GPs and nurses, in accordance with best practice guidelines, without increasing expenditure on ONS during the year after intervention., (© 2011 The Authors. Journal of Human Nutrition and Dietetics © 2011 The British Dietetic Association Ltd.)

Aim: To field test an objective evaluation tool consisting of process-oriented quality indicators for pressure ulcer care, using nursing charts of homecare nurses. These quality indicators were developed by the authors., Background: Most Japanese homecare nursing agencies are small and to use much of their human and economic resources to improve the care quality is not realistic. A simple and effective system for quality assurance/improvement needs to be considered., Design: Descriptive study design, using the chart reviews of 34 homecare nursing clients from two homecare nursing agencies., Methods: Nursing charts were evaluated using our quality indicators for pressure ulcer care, and whether the charts pass or not in terms of the practices described in the quality indicator was rated. The pass rates by chart and nurses' self-evaluation were compared, and pass rates by charts were examined. Results.  The evaluation by chart review generally matched with self-evaluations. The pass rates by charts were higher for indicators related to wound treatment than those related to preventive care., Conclusions and Implications for Practice: Home healthcare nurses could give more attention to pressure ulcer prevention. Regular self-checks of quality indicators may remind the nurses of the importance of prevention., (© 2010 Blackwell Publishing Ltd.)

Cultural competence is best understood by assessing provider and client perspectives. In this descriptive quantitative study, clients assessed dimensions of nurses' cultural competence including communication, decision-making, and interpersonal style. Nurses in 7 county health departments in North Carolina assessed their own cultural competence. Sixty-nine clients completed the Interpersonal Processes of Care and 71 nurses completed the Cultural Competence Assessment. Clients perceived their nursing care to contain key components of cultural competence. Nurses rated themselves as moderate to high cultural competence. Consistencies were noted between the clients' and nurse perceptions of cultural competence. These findings contribute to the enhancement of cultural competence among community nurses.

Professor Alan Glasper discusses the Department of Health's plans to expand health visiting services in England, in an initiative which aims to support families and address public health issues such as childhood obesity.

For people with chronic obstructive pulmonary disease (COPD), hospital admission can be associated with a poor prognosis. Consequently, the end-stage of the illness needs to be recognized for timely palliative care to be initiated. Tools to enhance the palliative phase, such as the Gold Standards Framework and the Liverpool Care Pathway, rely on the recognition of the final phase of a person's life. The illness trajectory of cancer makes this recognition far easier than for COPD, and as a result, many patients and their families manage at home with limited support. The Lincolnshire Respiratory Network has developed criteria to help recognize the end stage of COPD, which correlate well with recommendations from the Consultation on a Strategy for Services for COPD in England (Department of Health, 2010). However, there needs to be appropriate training to assist practitioners in their confidence to refer patients with end-stage COPD to palliative care providers.

Background: Quality indicators exist for the acute and primary care sectors in the National Health Service (NHS), but until recently little attention has been given to measuring the quality of community services. The innovative project described in this paper attempted to address that gap., Objectives: To produce a framework for developing quality indicators for Bristol Community Health services. To develop a set of initial indicators for Bristol Community Health services using the proposed framework., Method: After familiarising ourselves with community services and NHS policy, gathering the views of stakeholders and consulting the literature on quality indicators, we designed a framework for indicator development, using the 'test' case of the district nursing service. The long list of possible indicators came from best practice guidelines for wound, diabetes and end of life care, the three conditions most commonly treated by district nurses. To narrow down this list we surveyed and held workshops with district nurses, interviewed service users by telephone and met with commissioners and senior community health managers., Results: The final set of quality indicators for district nurses included 23 organisational and clinical process and outcome indicators and eight patient experience indicators. These indicators are now being piloted, together with two potential tools identified to capture patient reported outcomes., Conclusion: Developing quality indicators for community services is time consuming and resource intensive. A range of skills are needed including clinical expertise, project management and skills in evidence-based medicine. The commitment and involvement of front-line professionals is crucial.

Objectives: Difficulties in recruiting nurses into public health settings threaten the public's health. Gaps in existing data make determining the health impact of workforce changes numbers difficult to perform. Public health practice leaders are left to make difficult staffing and program decisions without knowing how the health of their vulnerable populations will be affected. The objective of this study was to identify indicators that could be used to document the effect of the shortage of public health nurses (PHNs) on the health of a population., Design and Sample: A consensus-building process was used. Nursing directors from 6 local health departments (LHDs) in 2 states participated along with 3 public health system researchers., Results: The findings from this collaborative process suggest that it is possible to identify outcome indicators across states and multiple LHDs that may be sensitive to PHN staffing levels and interventions. Possible connections between PHN staffing and each population-patient care indicator (rates of Chlamydia, first trimester prenatal care, early childhood immunization) are presented., Conclusions: The process used here in identifying these indicators and the proposed nursing-sensitive population outcome indicators themselves provide a template for the development and analysis of additional outcome indicators sensitive to the quality of nursing and other health care., (© 2010 Wiley Periodicals, Inc.)

Learning needs assessment is an important stage of every educational process that aims to inform changes in practice and policy for continuing professional development. Professional competencies have been widely used as a basis for the development of learning needs assessment. The Canadian Community Health Nursing Standards of Practices (CCHN Standards) were released in 2003. However, it is not known whether community health nurses (CHNs) have the educational background to enable them to meet these standards. This article reports on the development of a learning needs assessment questionnaire for CHNs. Exploratory and confirmatory factor analyses were conducted to examine the consistency of factors underpinning the CCHN Standards. Also, validity and reliability of the questionnaire were evaluated using appropriate techniques. This process resulted in a valid and reliable CHN learning needs assessment questionnaire to measure learning needs of large groups of practitioners, where other forms of measurement cannot be feasibly conducted.

Aim: To explore the nature of relationships between nurses and older people within the home and to illuminate the nature and quality of caring boundaries within this setting., Background: Older people are increasingly receiving nursing care in the home. There has been little exploration of the nature of the nurse-older patient relationship within this setting., Methods: An ethnographic approach using semi-structured interviews with 16 community nurses and 13 older patients (aged 65 years and over), were undertaken to explore the nature of care relationships within the home setting., Findings: The study has highlighted the centrality of the location of care and the concept of 'the home' in terms of geographical and metaphorical meanings. Moreover, the study has clearly illuminated the complex nature of relationships and boundary construction from a number of perspectives., Conclusion: As the location of care for older people continues to move closer to home it is crucial that the implicit qualities that are valued within nurse-patient relationships within this context of care, and which contribute to the quality of care, are recognized and made more explicit at the organizational and policy level., Practice Implications: For nurses working within the home there is a clear impetus to clearly define and articulate the full breadth of their role, the nature of relationships and issues surrounding professional boundary construction within this environment. There is also a need for the core qualities that underpin the receipt of care within the home and the facets of the nurse-patient relationship valued by older people to be fully recognized and accounted for., (© 2009 Blackwell Publishing Ltd.)

This article introduces a four-part series on the future of community services in England. The series will explore different models of delivery.

Background: Unplanned readmissions of recently discharged patients impose a significant burden on hospitals with limited bed capacity. Deficiencies in discharge processes contribute to such readmissions, which have prompted experimentation with multiple types of peridischarge interventions., Objective: To determine the relative efficacy of peridischarge interventions categorised into two groups: (1) single component interventions (sole or predominant) implemented either before or after discharge; and (2) integrated multicomponent interventions which have pre- and postdischarge elements., Design: Systematic metareview of controlled trials., Data Collection: Search of four electronic databases for controlled trials or systematic reviews of trials published between January 1990 and April 2009 that reported effects on readmissions., Data Synthesis: Among single-component interventions, only four (intense self-management and transition coaching of high-risk patients and nurse home visits and telephone support of patients with heart failure) were effective in reducing readmissions. Multicomponent interventions that featured early assessment of discharge needs, enhanced patient (and caregiver) education and counselling, and early postdischarge follow-up of high-risk patients were associated with evidence of benefit, especially in populations of older patients and those with heart failure., Conclusion: Peridischarge interventions are highly heterogenous and reported outcomes show considerable variation. However, multicomponent interventions targeted at high-risk populations that include pre- and postdischarge elements seem to be more effective in reducing readmissions than most single-component interventions, which do not span the hospital–community interface.

The delivery of an effective community nursing workforce relies on competent staff. Commissioners will need to be assured that their providers employ competent, efficient staff who give value for money. The Knowledge and Skills Framework (KSF) was introduced as part of Agenda for Change to identify the competences required, but competency testing using the KSF has not been fully implemented across the UK, and measuring competency, using the KSF indicators, still leaves much room for variation and a non-standardized approach. In the first of this two-part article, the authors discuss the process through which the provider services of one London PCT developed standardized competences using the KSF which were linked to staff performance and which provided clear areas for individual development.

Aim: This study is a report of the development and testing of the Satisfaction Scale for Community Nursing for measuring patient satisfaction with community nursing., Background: Measuring patient satisfaction with a psychometrically sound instrument is important if patient judgment is used as a quality indicator to evaluate the quality of the service., Methods: Service users and providers participated in generating items for a questionnaire related to the concept of patient satisfaction. A convenient sample of 121 patients receiving care from the Community Nursing Service was recruited to pilot the questionnaire for its initial validation in 2005. Content validity and factor analysis of the draft questionnaire were assessed. Psychometric properties of the final questionnaire were assessed using data from 80 patients in a validation study conducted during 2006., Results: A 17-item satisfaction questionnaire with a five-point Likert scale measuring three quality domains was developed: technical competence, coordination of services and interpersonal relationships in community nursing. Cronbach's alpha was 0.90. Principal component analysis with varimax rotation yielded three factors with eigenvalues >1; these accounted for 76.6% of the total variance. The factor loadings of the items ranged from >0.64 to 0.84. The concurrent validity of the scale associated with two conceptually related variables was 0.61 (P < 0.05) and 0.66 (P < 0.05)., Conclusion: The questionnaire may be valuable for assessing the satisfaction level of clients with community nursing service in meeting their expectations, and thus for enhancing treatment adherence and improving the quality of care., (© 2010 The Authors. Journal of Advanced Nursing © 2010 Blackwell Publishing Ltd.)

Health is understood as a complex phenomenon, related to multiple causes linked to factors which have diverse biological, psychological, economic and social natures. Among these and individuals' behavior a causal relationship is established, converting those individual decision-making processes into fundamental health which bears evidence on the necessity for health professionals to be prepared for this new reality. Community nursing clinical contexts comprise the first line of priorities to deal with this problem. The objective of this article is to comprehend how the process to prepare nursing professionals for clinical practice in community nursing occurs in a Superior School of Nursing in Portugal. This study is of an exploratory and descriptive nature. Interviews were carried out and later their content was analyzed. Based on the results, the authors noticed the need to redirect teaching in order to form professionals who attend to the needs of the population, who work in teams, and who, mainly succeed in dialoging according to the Paulo Freire perspective. The authors conclude that it is necessary to create a greater coherence between what is taught and what occurs in the context of clinical practice, in other words, that the school world carries on a dialogue with the working, clinical practice world and vice versa.

This article, the first in a series on the NHS Institute for Innovation and Improvement's eight high impact actions, presents three case studies of how senior nurses in acute and community settings have developed hospital discharge arrangements to improve patient flow and ensure more effective use of bed capacity.

Background: People with severe mental illnesses (SMI) are at increased risk of cardiovascular disease (CVD). Clinical guidelines recommend regular screening for CVD risk factors. We evaluated a nurse led intervention to improve screening rates across the primary-secondary care interface., Methods: Six community mental health teams (CMHTs) were randomised to receive either the nurse led intervention plus education pack (n = 3) or education pack only (n = 3). Intervention (6 months): The nurse promoted CVD screening in primary care and then in CMHTs. Patients who remained unscreened were offered screening by the nurse. After the intervention participants with SMI were recruited from each CMHT to collect outcome data., Main Outcome: Numbers screened during the six months, confirmed in General Practice notes., Results: All six CMHTs approached agreed to randomisation. 121 people with SMI participated in outcome interviews during two waves of recruitment (intervention arm n = 59, control arm n = 62). Participants from both arms of the trial had similar demographic profiles and rates of previous CVD screening in the previous year, with less than 20% having been screened for each risk factor. After the trial, CVD screening had increased in both arms but participants from the intervention arm were significantly more likely to have received screening for blood pressure (96% vs 68%; adjusted Odds Ratio (OR) 13.6; 95% CI: 3.5-38.4), cholesterol (66.7% vs 26.9%, OR 6.1; 3.2-11.5), glucose (66.7% vs 36.5% OR 4.4; 2.7-7.1), BMI (92.5% vs 65.2% OR 6.5; 2.1-19.6), and smoking status (88.2% vs 57.8% OR 5.5; 3.2-9.5) and have a 10 year CVD risk score calculated (38.2% vs 10.9%) OR 5.2 1.8-15.3). Within the intervention arm approximately half the screening was performed in general practice and half by the trial nurse., Conclusions: The nurse-led intervention was superior, resulting in an absolute increase of approximately 30% more people with SMI receiving screening for each CVD risk factor. The feasibility of the trial was confirmed in terms of CMHT recruitment and the intervention, but the response rate for outcome collection was disappointing; possibly a result of the cluster design. The trial was not large or long enough to detect changes in risk factors., Trial Registration: International Standard Randomised Controlled Trial Registration Number (ISRCTRN) 58625025.

Aim: This paper is a report of a study to develop a grounded theory to explain how district nurses meet the emotional needs of dying patients in the community., Background: There has been a policy commitment internationally to improve community services and enable people with terminal illnesses to die in their own homes. This increasing trend towards home deaths in the United Kingdom (UK) makes more demand on district nurses to provide emotional support for dying patients., Methods: A 'classic' grounded theory study was conducted in the UK between 2002 and 2005. Unstructured observations and semi-structured interviews were conducted with a purposive sample of nine district nurses, nine patients and four family carers. A further theoretical sample of five books of authors' accounts of their dying experiences and three district nurses who were advanced practitioners were selected., Findings: Five categories were identified in the data: 'outside world', 'dying world', 'entering dying world', 'maintaining connections' and the core category 'bridging worlds'. The theory of 'bridging worlds' indicated that dying patients experienced 'dying world' and 'outside world'. District nurses met dying patients' emotional needs by acting as a bridge between their two worlds, encouraging them to maintain connections with the outside world so that they did not become isolated in their dying world., Conclusion: District nurses should ensure that they meet both the physical and emotional needs of dying patients. Nursing education and literature need to concentrate on raising awareness of nurses' role in providing emotional support.

Little has been reported regarding the nature of home visits by palliative care specialist physicians to assist in the management of complex cases. We determined the characteristics, actionable clinical findings and recommendations made during consecutive home visits conducted by a specialist physician for patients registered with a community palliative care service. Patient demographic information and clinical records were reviewed. Ninety-one patients received a total of 104 home and residential facility visits. Median patient age was 59 (Q1-Q3, 43-72). Ten children (under the age of 14) received a total of 15 visits. Seventy-three patients (80%) had a cancer diagnosis. Median visit duration was 60 min (Q1-Q3, 45-60). The major actionable clinical findings were pain (120), gastrointestinal (115), neuropsychiatric (58), mouth and skin (33) and respiratory (29). One-third of recommendations involved changes in analgesia regimen (opioids 67, adjuvants 44). The specialist physician home visit resulted in multiple patient care recommendations. This information may help palliative care programmes improve their care for patients and families in the community.

Objectives: 1) To describe the community health nursing workforce in Canada; 2) To compare, across political jurisdictions and community health sectors, what helps and hinders community nurses to work effectively; 3) To identify organizational attributes that support one community subsector--public health nurses--to practise the full scope of their competencies., Methods: Our study included an analysis of the Canadian Institute for Health Information nursing databases (1996-2007), a survey of over 13,000 community health nurses across Canada and 23 focus groups of public health policy-makers and front-line public health nurses., Results: Over 53,000 registered and licensed practical nurses worked in community health in Canada in 2007, about 16% of the nursing workforce. Community nurses were older on average than the rest of their profession. Typical practice settings for community nurses included community health centres, home care and public health units/departments. To practise effectively, community nurses need professional confidence, good team relationships, supportive workplaces and community support. Most community nurses felt confident in their practice and relationships with other nurses and professionals, though less often with physicians. Their feelings about salary and job security were mixed, and most community nurses would like more learning opportunities, policy and practice information and chances to debrief about work. They needed their communities to do more to address social determinants of health and provide good quality resources. Public health nursing needs a combination of factors to succeed: sound government policy, supportive organizational culture and good management practices. Organizational attributes identified as supports for optimal practice include: flexibility in funding, program design and job descriptions; clear organizational vision driven by shared values and community needs; coordinated public health planning across jurisdictions; and strong leadership that openly promotes public health, values their staff's work and invests in education and training., Conclusion: The interchangeable and inconsistent use of titles used by community nurses and their employers makes it difficult to discern differences within this sector such as home care, public health, etc. Our studies also revealed that community nurses: thrive in workplaces where they share the vision and goals of their organization and work collaboratively in an atmosphere that supports creative, autonomous practice; work well together, but need time, flexible funding and management support to develop relationships with the community and their clients, and to build teams with other professionals; could sustain their competencies and confidence in their professional abilities with more access to continuing education, policies, evidence and debriefing sessions.

The swine flu pandemic has gripped the headlines over the summer and its management in the UK is proving to be controversial. The government's advice to issue anti-virals to people of all ages with flu-like symptoms runs contrary to World Health Organisation advice. The benefits of anti-virals for children has been called into doubt because of the risk of severe side effects. Concern over adverse drug reactions has prompted the Medicines and Healthcare products regulatory agency to urge health professionals and the public to assist its monitoring of the drug by reporting adverse drug reactions. It is essential that district nurses have up-to-date knowledge of the adverse reactions of the commonly used anti-virals in order to exercise a duty of care to their patients by giving appropriate advice and ensuring adequate monitoring and early detection of unwanted side effects. This article makes recommendations to district nurses for improving patient concordance with prescribed medicines, reporting adverse drug reactions via the swine flu ADR portal and how to obtain up-to-date information on unwanted side effects.

Objective: To present preliminary evidence for the reliability and validity of the Dual Protection Counseling Checklist (DPCC), an instrument designed to evaluate nurses' fidelity to high quality dual protection counseling in a family planning setting., Methods: During a trial comparing a dual protection (DP) nurse counseling intervention to standard of care (SOC), client-counselor sessions were audiotaped. Following good inter-rater reliability, 78 audiotaped interviews were coded from the two conditions using the DPCC. We constructed indices from a subset of codes to capture three domains: Promotion of DP (PDP), Relapse prevention counseling (RPC), and Quality of Nurse-Client Interaction (QNCI). The association between scores on these indices and client outcomes was evaluated using logistic regression., Results: The DPCC and indices were reliable. Construct validity of indices was supported by greater frequency of target behaviors by the DP nurse. Validity of the QNCI was further supported by its association with clients' sexual risk reduction 6 months post-counseling., Conclusion: The DPCC and indices hold practical utility for evaluation, monitoring, and supervision of nurse-client counseling sessions., Practice Implications: The Dual Protection Counseling Checklist provides a user-friendly tool for assessing nurses' and other providers' counseling behaviors in dual protection.

Objectives: I explored the underutilization of the community/public health nursing (C/PHN) credential by examining the individual characteristics of public health nurses, the value these nurses perceive for certification, the barriers they perceive to obtaining or maintaining a C/PHN credential, and their credential status., Methods: I surveyed a national sample of 655 public health nurses regarding this more than 20-year-old credential. I analyzed variables related to perceived value, barriers, and characteristics of public health nurses., Results: The perceived value of credentialing did not differ among public health nurses relative to whether they had ever had a C/PHN credential. The C/PHN credential, however, was obtained significantly more often by public health nurses in academic settings than by those working in practice settings., Conclusions: The C/PHN credential appears to be disproportionately underutilized and unknown to public health nurses in the practice community. Findings suggest, however, that utilization could be improved by increasing the credential's visibility outside of academic environments and by establishing system-level changes that provide external recognition, such as salary increases and career advancement, for specialty credentials.

Aims and Objectives: To explore through literature review the appropriateness of three common tools for use by community nurses to screen war veteran and war widow(er) clients for depression, anxiety and post-traumatic stress disorder., Background: War veterans and, to a lesser extent, war widow(er)s, are prone to mental health challenges, especially depression, anxiety and post-traumatic stress disorder. Community nurses do not accurately identify such people with depression and related disorders although they are well positioned to do so. The use of valid and reliable self-report tools is one method of improving nurses' identification of people with actual or potential mental health difficulties for referral to a general practitioner or mental health practitioner for diagnostic assessment and treatment. The Geriatric Depression Scale, Depression Anxiety Stress Scales and Post-traumatic Stress Disorder Checklist are frequently recommended for mental health screening but the appropriateness of using the tools for screening war veteran and war widow(er) community nursing clients who are often aged and have functional impairment, is unknown., Design: Systematic review., Conclusions: Current literature informs that the Geriatric Depression Scale accurately predicts a diagnosis of depression in community nursing cohorts. The three Depression Anxiety Stress Scales subscales of depression, anxiety and stress are valid; however, no studies were identified that compared the performance of the Depression Anxiety Stress Scales in predicting diagnoses of depression or anxiety. The Post-traumatic Stress Disorder Checklist predicts post-traumatic stress disorder in community cohorts although no studies meeting the selection criteria included male participants., Relevance to Clinical Practice: This review provides recommendations for the use of the Geriatric Depression Scale, Depression Anxiety Stress Scales and The Post-traumatic Stress Disorder Checklist based on examination of the published evidence for the application of these screening tools in samples approximated to community nursing cohorts. Findings and recommendations would guide community nurses, managers and health planners in the selection of mental health screening tools to promote holistic community nursing care.

Aim: This review seeks to identify the most effective hand-washing and hand-cleansing practice that could be used in primary care., Background: Healthcare associated infection is a major problem in the UK causing 5000 deaths every year. Current guidelines indicate expert opinion is the level of evidence for hand washing as an activity to reduce infection., Design: Systematic review., Method: Publications on hand-washing, hand-cleansing studies, policy and practice-based documents were sought by searching several databases. Terms used included hand washing, hand cleansing, hand hygiene, hand decontamination, infection control and primary care., Results: Few articles described the hand-washing technique in detail and some publications simply referred to either the European and British Standards or the Centre for Disease Control statement on hand washing. Major discrepancies in hand position and water flow direction were found. Several methodological problems were also identified and few studies were undertaken in primary care., Conclusion: This review has found a lack of evidence for hand-washing techniques being undertaken in practice today. Findings from hand-washing technique studies were inconclusive and methodological issues exist resulting in sparse reliable evidence. There is an urgent need to undertake methodologically sound studies of hand-washing techniques for use in the ever expanding scope of primary care practice., Relevance to Clinical Practice: Evidence for hand-washing and hand-cleansing techniques will inform healthcare professional practice, and contribute to the overall management of infection control in primary care.

Aim: This paper is a report of a study to describe venous leg ulcer care regarding compression, pain management and lifestyle advice in community settings and to identify factors that predict the provision of lifestyle advice by nurses., Background: Incongruence between evidence and practice in leg ulcer care has been reported. Little is known about predictive factors related to the provision of lifestyle advice., Method: Two focus interviews and a Delphi procedure were used to develop a self-administered questionnaire based on the Graham questionnaire. Nurses employed by community healthcare organizations and independent nurses in private practices participated (n = 789). The data were collected in 2006., Findings: Compression was applied in 58.7% of patients with venous ulcers. Pain was present in 82.9%. A third of patients with pain received analgesics, but half of these patients (52.1%) took analgesics as prescribed. Half of the nurses (50.8%) gave lifestyle advice related to the leg ulcer. It was mainly instructions about leg elevation (68.3%), promoting physical activity (39.8%) and optimizing nutrition (16.7%) that were provided. Nurses who perceived themselves to have adequate leg ulcer knowledge and skills were 3.75 times more likely to provide lifestyle advice compared with those lacking such knowledge and skills. Nurses who found leg ulcer care not rewarding, rarely successful or difficult gave statistically significantly less lifestyle advice than those who found it rather rewarding, successful and not difficult., Conclusion: Patients with leg ulcers receive less than optimum care and patient education. A particular challenge lies in leg ulcer education programmes and pain management.