This paper begins by identifying the context and extent of grade-mix changes in the district nursing service, drawing attention to significant dilution in grade mix at a time of considerable organizational change. The paper goes on to argue that there is no easy formula for providing sound evidence on which policy and management decisions about grade mix can be based. It suggests that the focus on tasks in much of the research on district nursing does not offer a sufficient basis for making grade-mix decisions, because nursing skills are not made explicit. The paper then makes reference to one ethnographic research study in order to illustrate and explore some of the methodological difficulties associated with trying to provide evidence of the use of district nursing skills, focusing in particular on the invisible work undertaken by team members. The paper concludes that if differences in the use of skills by different grades of nurse can be identified, then further increases in grade dilution will have consequences for patient care and must therefore address issues of quality in order to comply with the principles of clinical governance.

The aim of this qualitative study was to explore the process of care provided by a community-based geriatric assessment and management team (the elderly resource team or ERT) through a critical incident approach. Cases were discussed both with the ERT alone and in combined discussions with referring primary health care teams, using an external facilitator. Data analysis was based on the critical incident technique and a grounded theory approach. Analysis of 11 cases generated a total of 496 events (a mean of 45 events per case). The numbers of positive events and negative events (areas of concern) were approximately equal (236 and 260, respectively). Certain important themes emerged from the data to describe how the elderly resource team managed their patients. Patients were often referred for covert reasons, such as negative emotions in informal and formal carers and inappropriate demands on them. Integrated multidisciplinary assessment by the team generated a realistic appraisal of the situation. With time, the key worker became a trusted professional, leading to recognition of the patient's poor psychological adjustment to their illness, and unexpected breakthroughs in their management, which previous carers had been unable to achieve. Reflection of these concepts back to informal and formal carers was considered to be supportive. Caring for such complex patients also produced negative emotions in the elderly resource team. Internal support for individuals in such teams can be offered via the concept of role transference. Through further analysis using a grounded theory approach, a conceptual model was developed to describe the process of care delivered. This model requires further testing in order to determine whether it is applicable to other multidisciplinary rehabilitation teams.

Asthma is a common chronic condition which places a considerable burden on patients and NHS resources. The relatively high prevalence, together with its innate variability, makes the provision of care by primary teams an essential and recognized part of overall management which is now generally undertaken by enthusiastic asthma-trained nurses. Despite 10 years of such organized care, there is little evidence of its effectiveness, with few data available on who attends and for what reason. We do not know the views of those for whom the clinics were intended, namely the patients. Here we report the results from two qualitative studies, one using in-depth interviews with individual patients and the other using focus groups on a range of different patients. The first study involved 30 adult patients whose pattern of compliance with inhaled medication allowed categorization of individuals into ‘compliers’ and ‘non-compliers’. The results of this study allowed a typology to be developed which categorized patients into ‘distancers/deniers’, ‘accepters’ and ‘pragmatists’. The focus group involved 70 patients (35 patients on two occasions) from a mixture of practices, and varying age and socio-economic groups. Both studies yielded remarkably similar results, and they show that patients, for a variety of reasons, do not regard asthma clinics as being of relevance to them and generally do not attend. Using the typology that was developed, we present reasons for their non-attendance based on the recurring rich quotes from patients. It is clear from these results that if practices run endless clinics, patients will not attend for the reasons given. Further work involving both quantitative and qualitative techniques is needed to explore who attends asthma clinics and why. Patients' views should now be integrated into future service planning, and the current educational role of the asthma clinic should be replaced by one which more closely reflects patients' needs and expectations.

Little is understood about the patterns in which frequent attenders consult primary care over time, or about the clinical or behavioural reasons for doing so. The aim of this study was to use a sorting task to identify the important features of patterns of attendance to general practitioners generated by frequent attenders over a period of 44 months. A total of 12 experts performed a sorting task on consulting patterns of the 100 most frequent attenders from one general practice in Leeds. A similarity matrix was constructed which was then subjected to cluster analysis. A range and diversity of patterns was clearly demonstrated within the data. The determining factors of the groupings by the experts included frequency, regularity, bursts of consultations, patterns of consulting after bursts, periods of not consulting, and seasonal or annual trends. The cluster analysis provided six final clusters, the largest of which had no fixed or classifiable pattern of attendance. The other five clusters were ‘regular without bursts’, ‘supernovas’, ‘gap and prolonged burst’, ‘bursts and sporadic attending’ and ‘regular as clockwork’. Distinct patterns of frequent attendance exist, and it seems likely that the clinical and behavioural reasons underpinning such behaviours differ. This work furthers our understanding of the way in which frequent attenders consult, and the results have implications both for general practice and for future research. The methodology described may have applications in other areas of primary care and biomedical research.

Policy initiatives increasingly emphasise the importance of breaking down organizational and professional barriers in order to achieve the delivery of effective mental health services. In this context, joint commissioning is seen as providing a way forward, and GPs are now identified as having a key role to play, alongside other professionals and agencies. However, there is evidence that joint commissioning is not yet well established, and a number of barriers to its development have been identified. The study reported here aimed to inform the development of joint commissioning between primary health care and social care in Wales by first mapping progress to date and then exploring the issues involved in more detail through three case studies. After the methods used for each stage have been described, the results are presented and discussed in relation to the problems identified and potential approaches to their resolution.

The purpose of this study was to analyse and describe the experiences of adolescents who had been maltreated by their parents in childhood. Child maltreatment was defined as physical, psychological or sexual abuse or neglect caused by parents or other primary caregivers of the child. Data were collected from seven adolescents, aged 14–19 years, who had been maltreated within their family of origin for many years. Interviews employed broad themes pertaining to family life, maltreatment experiences and the family's strengths and problems. The data were analysed by qualitative content analysis. The analysis resulted in a description of the adolescents' experiences of maltreatment and of the consequences of maltreatment as perceived by the young people themselves. The consequences included connections between maltreatment and family life and direct consequences for the adolescents themselves. These results aid our understanding of child maltreatment and its manifestations from the viewpoint of adolescents within the family. An improved understanding of their views should make it possible to develop nursing care of these children and their families as part of multidisciplinary work. The role of nursing is central to this work, because one of the goals of nursing is to improve the well-being of families and individuals. However, further research is still needed to add to our knowledge of child maltreatment from the adolescents' viewpoint.

Interviewing can provide unique opportunities for professionals to gain some understanding of the child's subjective experience, where other means of data collection are inappropriate and other sources of data are less valid. This article is concerned with the principles and practicalities of interviewing children for the purposes of health-related research. It draws on the knowledge gained from three decades of research involving interviewing young people in many contexts, including health care, social welfare and child protection. A conceptual framework is presented to illustrate the interactive and iterative processes that occur between interviewer and interviewee, and the pivotal importance of context in shaping any interaction. The influences of the young person's linguistic, cognitive and social skills are discussed. The effects of the gender and ethnicity of both the researcher and the researched are considered in relation to the conduct of the interview, and the influence of adult biases and perspectives on the evaluation and interpretation of data is explored.

Nurses are increasingly being employed instead of doctors in some areas of work. This article examines this phenomenon in relation to a ‘nurse-led’ Personal Medical Services Primary Care Act pilot scheme. As part of an evaluative project, we examined the way in which patients understood and constructed nursing roles in the context of their use of primary care services in a socially deprived area. Whilst professional roles are established to some extent as the result of negotiation between and within professions and with government policymakers, patients' perceptions also affect whether or not changes are accepted, and the extent to which new roles gain legitimacy. Our evaluation took the form of a case study with questionnaires, in-depth interviews and observations. This particular paper is based mainly on data obtained from interviews with patients who had experienced the nurse-led service. The results showed that some patients attributed high status to the nurse by emphasizing that the nurse leading the practice was highly qualified, and other patients reconstructed the role and thought of the nurse as a doctor. This latter interpretation was derived from the patients' descriptions of core activities such as diagnosis and treatment, and other factors such as an absence of uniform. However, the most important factor that affected whether or not patients accepted a ‘nurse-led service’ related to the way in which the service met their needs. This seemed to be more important than perceptions of professional identity. The nurse-led service continued to provide the social support and continuity of care that the patients valued, and which had been provided by their previous general practitioner. The provision of these aspects of care appeared to be more important than whether or not the service was nurse-led or doctor-led. It is important to consider patients' perceptions of policy innovation when establishing new services.

The concept of burnout among health care professionals involved in AIDS care has been well documented in hospital and hospice settings, but no empirical research has been conducted among practitioners working with AIDS patients in the community setting. This study used a burnout measurement tool, namely the Maslach Burnout Inventory (MBI), to measure the level and components of burnout in a sample of 47 community HIV/AIDS nurse specialists. The study also explored the under-researched relationship between different elements of the MBI. The main finding of the study was a high level of burnout among these practitioners, with over 50% of participants scoring as burnout ‘cases’. There was no link between burnout and caseload and length of time in practice, and female respondents rated marginally higher with regard to the number of burnout cases. There was also a close relationship between the intensity and frequency scales on the MBI. The importance of utilizing both a supportive model of clinical supervision and also the development of less formal peer support systems is suggested as a way forward in addressing burnout prevention in this group of practitioners.