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ROCA HISTORY AND MECHANISMS Brown-Sequard) that the administration of ovarian or testic- ular extracts could treat a variety of mood disorders in hu- Within the past 20 years, the putative role of gender and mans, ranging from depression to the anergy of senescence gonadal steroids in mood regulation has been transformed (3,4). In the 1920s and 1930s, the active gonadal sub- from the staple of stereotype to a critical locus of research stances—testosterone, estradiol, and progesterone—were in clinical neuroscience. This transformation reflects the im- isolated and characterized. Al- cellular hormone-binding protein, the estrogen receptor (a though direct isomorphs between basic mechanisms and concept originally proposed by Langley in 1905), and by clinical observations are for the most part absent, our bur- 1966, the estrogen receptor became the first hormone recep- geoning knowledge of the cellular and central nervous sys- tor to be isolated and identified (6).
Before any nurses were trained to use the PCAM atorlip-10 10mg overnight delivery cholesterol levels in child, they collected data on 113 patients cheap atorlip-10 10 mg fast delivery cholesterol levels fasting, of whom 71 (53%) completed follow-up questionnaires cheap 10 mg atorlip-10 overnight delivery cholesterol medication for diarrhea. Following this cheap atorlip-10 10mg without prescription cholesterol medication affect kidneys, only seven nurses stayed in the study and collected data on 77 patients, with 40 (52%) completing follow-up questionnaires. Patients were not always aware of its use, but most were happy to have their broader needs assessed by the nurse. Conclusions Use of the PCAM tool in primary care shows promise. It seems to be generally acceptable to PNs and patients. However, practice recruitment problems mean that it is not feasible to run a trial at this time in primary care in Scotland (and perhaps in the UK as a whole). This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals xxiii provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. This may be as a result of the limited experience and lack of confidence of primary care nurses who conducted most depression screening as part of routine annual reviews. The tick-box and medicalised nature of the QOF served only to limit these skills even further and contributed to little or no attention being paid in these assessments to the social problems that might contribute to poor physical and mental well-being. The Patient Centred Assessment Method (PCAM) has been developed to enable broad assessment of patient biopsychosocial needs in primary care, and to promote action based on the severity and urgency of needs. The PCAM is an adapted version of the Minnesota Complexity Assessment Method, which was derived from the INTERMED (a method to assess health service needs). The PCAM has previously been evaluated in anticipatory (Keep Well) health check clinics, which were initiated by the Scottish Government for early identification of LTCs, or risk of LTCs, in those aged 40–64 years and living in deprived communities in Scotland. However, the PCAM has neither been evaluated for use by primary care practice nurses (PNs) in regard to its potential value for addressing mental well-being in patients with LTCs nor been subject to clinical trial to determine its impact on nurse behaviour and patient outcomes. Research questions Is it feasible and acceptable to use the PCAM in primary care nurse-led annual reviews for people with LTCs? Is it feasible and acceptable to run a cluster randomised trial of the PCAM intervention in primary care? Aim This research aimed to assess the acceptability and implementation requirements of the PCAM for enhancing the care of patients with LTCs and comorbid mental and social care needs in primary care. It also aimed to assess the fidelity of its implementation/use among nurses (i. Methods Practitioner and patient focus groups were used to assess the views of primary care professionals and people with LTCs about the acceptability and implementation requirements of the PCAM, especially for nurse consultations for LTCs. The PCAM was then tested in a feasibility cluster randomised controlled trial (RCT), which aimed to recruit eight general practitioner (GP) practices and 16 PNs. Four practices (eight nurses) were to be allocated to deliver the PCAM intervention and four practices (eight nurses) would deliver care as usual (CAU). Baseline data collection was to be conducted in all practices with all study nurses prior to randomisation, and consisted of immediate post-consultation data being collected for a cohort of 10 patients per nurse (n = 160 patients), including patient demographics, a patient-completed evaluation of the consultation and patient-completed outcome measures, and any nurse referrals or signposting to services during the consultation. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals xxv provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. SCIENTIFIC SUMMARY by postal questionnaire at the 8-week follow-up. Practices would then be randomised to the PCAM intervention or to deliver CAU. The same data would then be collected for a second cohort of patients in both the intervention and control practices (n = 160 patients), following the introduction of the PCAM in intervention practices. The second cohort would also complete follow-up measures at 8 weeks. Fidelity of implementation and an understanding of how nurses used the PCAM, and whether or not it changed how they engage in assessments, were tested via a sample of audio-recorded nurse-led annual assessments, both before (n = 5) and during the use of the PCAM (n = 4). Follow-up interviews with nurses and patients were conducted to gain their reflections on the use and perceived impact of the PCAM. Outcomes The primary outcome for this study was the comparison of planned recruitment and retention of nurses and patient completion of questionnaires (including follow-up) with actual recruitment and completion rates. The patient outcome measurements tested for use in a future trial were the 12-item General Health Questionnaire, the Short Form questionnaire-12 items and the Warwick–Edinburgh Mental Well-Being Scale. Nurse behaviour was measured via the number and types of referrals/signposting and a patient evaluation of the nurse consultations via the Consultation and Relational Empathy measure and the Patient Enablement Instrument (PEI), and nurse confidence in dealing with mental health issues was assessed using the Depression Attitude Questionnaire. Qualitative focus group, interview and field-note data were used in a process evaluation to identify barriers to, and facilitators of, the use and implementation of the PCAM, as well as the barriers to, and facilitators of, conducting a future trial. Results From approaches to 159 eligible practices, 14 practices expressed an interest in the study and six practices were recruited to take part; five practices accepted the invitation to participate in both phases of the study and one practice agreed to participate in phase 1 only. Of the six participating practices, two had just one PN, resulting in 10 nurses overall. Following the completion of baseline recruitment, the five practices participating in both stages were randomised to either the PCAM arm or the CAU arm in a 2 : 1 ratio. This resulted in three practices (six nurses) being placed in the PCAM arm and two practices (three nurses) in the CAU arm for the second phase of research. Nurse completion Only seven out of the 10 nurses (four practices) provided phase 1 and phase 2 data, including nurse demographic data and nurse outcome data. This would indicate that nurse retention is poor, but, when nurses are committed to participating, data completion can be achieved. Patient recruitment and completion Each nurse was asked to recruit 10 patients in each phase. This was achieved by all nurses in phase 1 (in which 113 patients were recruited and completed questionnaires) and by six nurses in phase 2 (in which 77 patients were recruited and completed questionnaires). Only one nurse who participated in phase 2 failed to recruit the 10 patients required. This suggests that patient recruitment is achievable using the methods proposed in this feasibility trial. Patient follow-up was approximately 60% in phase 1 and just under 50% in phase 2. Reduced follow-up in phase 2 was affected by the delayed study timetable, which did not allow for the follow-up of all participants. Of the remaining two nurses, only one recruited a single patient within the time given for this stage of the study, giving a total sample of nine patients (five before and four after PCAM training). The analysis of recordings suggested that the PCAM does indeed change nurse behaviour in consultations. The use of the PCAM in consultations did not require any more time than usual. Acceptability of the Patient Centred Assessment Method intervention for nurses For nurses, the PCAM was fairly easily integrated into a consultation, although some participants reflected that the process of integration took some time and support. The nurse participants perceived this to be beneficial for both the patient and the nurse, both in relation to the quality of the relationship and the quality of the care provided. Nurses found the resource pack very useful and had been active in signposting patients to various sources of support.
