Ward Visits Research Articles

Expectant Mother’s Preferences for Services in Public Hospitals of Tamil Nadu, India

Substantial programmatic efforts have been undertaken to improve the access to maternal care services in the public health system of India, yet the service users are often regarded as passive recipients. Limited research is available on the preferences of service users on what they regard the greatest issues in service delivery. A hospital-based discrete choice experiment (DCE) has been conducted in the public health facilities of Tamil Nadu, a southern state of India. This study uses a sample of 261 women who came for antenatal check-ups across six different public hospitals in Tamil Nadu. The DCE technique, which is rooted in random utility theory (RUT), and conditional logit model have been used to analyze the relative importance of health service attributes. The result showed that regular ward visits by specialist doctors like obstetricians and gynaecologists (O&G) and paediatricians were the most preferred attribute of the maternal care service. Expectant mothers are willing to wait the maximum and are prepared to tolerate health service characteristics in public hospitals, such as poor patient amenities, poor staff attitude and lack of privacy maintained during physical examination, provided specialist doctors are available in the hospitals.

Patient and public involvement in data collection for health services research: a descriptive study.

Plain English summaryThere is a consensus that patients and the public should be involved in research in a meaningful way. To date, lay people have been mostly involved in developing research ideas and commenting on patient information but not as much in actual data collection.We have had firsthand experience with lay people helping to conduct a study on how patients in hospital are involved with their medicines. In the first part of this study, we observed doctors’ ward rounds, pharmacists’ ward visits and nurses’ drug administration rounds, to find out if and how healthcare professionals interacted with patients about their medicines. Lay people conducted some of these observations. We wanted to explore the benefits and challenges of having lay people conduct these observations, to tell us more about how lay people can be involved in conducting such research.We interviewed the lay members and researchers involved in this research to find out their views. We also looked at the observation notes to identify what the lay people had noticed that the researchers had not.The lay members and researchers reported that lay members added value to the study by bringing new perspectives. Lay people had noticed some different things to the researchers. We experienced some challenges which need to be addressed. These weregetting the lay observers registered with the hospitals to allow them to be on the wards in this capacitylay observers and researchers having different understanding of research procedures such as patient consenttrying to find lay observers of different backgrounds and ethnic groupsBackground: It is recognised that involving lay people with research in a meaningful rather than tokenistic way is both important and challenging. In a recent health services research study addressing inpatient involvement in medication safety, we sought to overcome this challenge by including lay people in collecting observational data in the hospital setting. The aim of this study was to evaluate lay and researcher perspectives on lay involvement in data collection in order to inform and enhance the future role of lay people in carrying out health services research.Methods: We conducted semi-structured interviews with the lay members who collected observational data in our wider study and the researchers who provided support and/or were involved in their recruitment and training. The interviews were transcribed verbatim and coded using open thematic analysis. In addition, we conducted secondary analysis of the observational data to identify the specific contributions of lay observers.Results: We interviewed the three lay members and the four researchers involved. Both these interviews and the secondary data analysis demonstrated that the lay members added value to the study by bringing additional general perspectives on communication with hospital inpatients.Combined with researchers’ perspectives on interactions more specifically related to medication, this provided a broader answer to our research question of how healthcare professionals facilitate inpatient understanding of their medication and involvement in medication safety. This contrasted to the involvement lay observers reported having in previous research where their role had been more consultative. The lay members all reported that carrying out the observations had been an interesting and informative experience.Some challenges arose including the infrastructure not having been in place to support this specialist lay research role, differing paradigms of research governance held by the public and researchers in relation to consent procedures and difficulties in recruiting a diverse range of members of the public to carry out the role.Conclusions: Lay members can add value to research by being involved in data collection within health services research. There is a need to build infrastructure to better support this involvement.

A guide to a new short course to promote interest and engagement in psychiatry in medical students.

This article describes a new course for preclinical medical undergraduates designed to promote interest and engagement in psychiatry. The course employed a range of innovative teaching techniques alongside ward visits to provide students with early clinical experience. Unusually, assessment for the course involved the production of creative works as well as reflective writing about students' experiences. We collected a variety of feedback from participants showing that they found the course enjoyable and educational. We conclude that, overall, the course had a positive effect on student perceptions of psychiatry.

Impact of continuing nursing care on anticoagulation therapy after heart valve replacement

Objective To explore the continuing nursing care effect on anticoagulation therapy after heart valve replacement patients. Methods A total of 153 patients after heart valve replacement between September 2012 to August 2013 were randomly divided into the control group (77 cases) and intervention group (76 cases) by convenient drawing method. All patients in two groups during hospitalization received regular hospital health education and discharge education, and the patients of control group complete the telephone follow-up in 1 week after discharge, while the patients of intervention group received telephone follow-up ward visit, lectures for group and individual explanation at 1 week, 1 month, 3 months, 6 months, 1 year after discharge. 1 year later, the evaluation of patients′ medical compliance and anticoagulation effect were carried out between two groups. Results 1 year later, the recognition of anticoagulation therapy among intervention group patients obtained 89.04%, part of recognition 9.59%, far from recognition 1.37%, better than 70.27%, 20.27%, 9.46% of the control group (χ2=8.847, P=0.012); the complete, part and none medication compliance of intervention group were 97.26%, 1.37% and 1.37 better than 86.49%, 10.81%, 2.70% of the control group; return visit on time was 97.26% in the intervention group while 87.84% in the control group (χ2=6.134, 4.713; P<0.05); 87.67% patients achieved INR standard in the intervention group comparing with 70.27% in the control group, the complication of anticoagulant therapy dramatically decreased to 6.85%, lower than 18.92% of the control group (χ2=6.686, 4.757; P<0.05). Conclusions Continuing nursing care can improve patient′s cognition and medication compliance of the anticoagulation therapy after heart valve replacement, improve the INR success rate, and reduce the anticoagulant therapy related complications. Key words: Heart valve replacement; Continuing nursing care; Anticoagulant therapy

AN OBSERVATIONAL STUDY OF THE ROLE OF THE PAEDIATRIC CLINICAL PHARMACIST

Aim Only three UK studies have previously described the role of the paediatric clinical pharmacist in reducing risk to patients1. These involved chart review, medication reconciliation and incident reporting to collect data. Pharmacists are recognised to make regular interventions to reduce or prevent medication errors but these are usually not documented due to time/workload constraints. We wished to describe contributions to patient care/safety made by pharmacists using direct observation to gain a comprehensive overview. Method Fourteen pharmacists were shadowed during 197 ward visits (Jun 2012–Jul 2013) on 15 paediatric wards in two UK NHS Trusts, one secondary and one tertiary care hospital. No widely accepted classification system of pharmacists9 interventions is available, therefore we used the following: Interventions medication error was identified and pharmacist intervened to prevent further doses reaching patient. Definition adapted from the American Society of Hospital Pharmacists,2 Pharmaceutical Care Network Europe Foundation3 and interventions from a previous systematic review.1 Contributions other pharmacist activities to enhance patient care. Definitions were adapted from the hospital medicines codes, NHS careers website4 and from a previous systematic review.1 Results Pharmacists were observed reviewing 6,034 prescriptions for 1,371 patients. They made 3311 contributions (54.8% of prescriptions overall) and 505 interventions (8.4% of prescriptions overall). Similar rates of interventions were identified in the two Trusts (8.7% vs 7.6% of all prescriptions). More pharmacists9 contributions were identified in the secondary care than the tertiary care Trust (62.7% vs. 36.8% of all prescriptions). The acceptance rate of pharmacists9 recommendations by doctors was 99.5%. The most common errors intercepted included: Omission error (28% all errors), e.g. omission of medication on admission (15.2% new patients) and omission of dose. Wrong dose (24% all errors) e.g. overdose (e.g. ten-fold error (1400 mg cefuroxime instead of 140 mg) and misplacing of numbers (gentamicin 210 mg instead of 120 mg)). Illegible prescribing (19% all errors), e.g. unclear drug name or dose. Wrong frequency (5.7% all errors), e.g. prescribing paracetamol five times daily instead of four times daily. The most common contributions included: annotating prescriptions with information (19.2% all prescriptions), e.g. rate of administration for IV drug; drug history and allergy status checking in 97% and 100% of new patients respectively and supplying medications (10% all prescriptions), mostly ready to administer IV doses from aseptic units. Conclusion To our knowledge this is the first study to observe paediatric clinical pharmacists in their daily activities to document their role. They were shown to play an important role in improving healthcare services provided to patients and intercepting medication errors. The acceptance rate of pharmacists9 recommendations by doctors was high.

G25 Communicating with parents following a suspected adverse drug reaction in a child: who says what and when?

Aim To pilot a prompt guide to support discussions between clinicians and parents following a suspect adverse drug reaction in a child. Method We designed the prompt guide in response to the findings from the Adverse Drug Reactions in Children: Qualitative study (ADRIC: QUAL) that identified parents unmet information and communication needs following a suspected ADR in their child. The prompt guide was developed by the ADRIC: QUAL and wider ADRIC study team; reviewed by parent expert advisory groups and expert advisory groups at the Medicines and Health care products Regulatory Agency (MHRA) and the Royal College of Paediatrics and Child Health (RCPCH) medicines committee before being finalised. The prompt guide was piloted at a regional children’s hospital and it is the findings of the pilot study that are reported here. We identified suspected ADRs in children through daily ward visits. Treating clinicians used the prompt guide during routine conversations with parents about that suspected ADR. Clinicians then took part in a short structured interview. Results The prompt guide was used 17 times by nurses (n = 9), specialist nurses (n = 4), and doctors (n = 4). Clinicians who used the prompt guide felt it was easy to use; was helpful in structuring and pacing the discussion; ensured all relevant topics were covered,; and empowered parents. An unexpected finding was confusion about whether a child had experienced a suspected ADR and this influenced whether discussions with families took place. Where discussions did take place, there was confusion about who communicated with parents. While doctors felt nurses were often the first to recognise, and therefore communicate with parents about suspected ADRs, few nurses recognised their role in this process and their accounts suggest that they are poorly supported in this role. Conclusion Optimal communication with parents about suspected ADRs in children depends on clinicians recognising a suspected ADR. Nurses potentially play an important role in communicating with families in such situations but they do not always recognise their role and there maybe unmet training needs.

ELECTRONIC PRESCRIBING: FRIEND OR FOE? AN AUDIT OF PRESCRIBING ERRORS AFTER THE INTRODUCTION OF AN ELECTRONIC PRESCRIBING SYSTEM IN NEONATES AND CHILDREN

ObjectiveTo compare the rate, nature and clinical significance of prescribing errors, before and after the introduction of electronic prescribing, in neonates and children.MethodsThe study was conducted at a large teaching...

Intervention of ward visits by an endocrine nurse specialist and a protocol and in the management of hyponatraemia

Intervention of ward visits by an endocrine nurse specialist and a protocol and in the management of hyponatraemia

Welche Erwartungen stellen Schwangere an eine ideale Entbindungsklinik?

The aim of this study was to evaluate expectations of pregnant women on an ideal maternity hospital. We prospectively performed a survey among 566 pregnant women with regard to their expectations on a perfect hospital for obstetrics. Data collection was accomplished in 3 obstetrical departments in Mannheim, Germany. The questionnaire contained 23 general questions about sociodemographic characteristics and 34 specific questions about the anticipated childbirth. Women who were less than 20 weeks pregnant and women who did not speak German fluently were excluded from this study. In our survey the possibility to get to know midwifes and doctors at information evenings and a guided delivery room tour were defined as very important factors by the interviewed women. Of particular importance was a continuous care by a single midwife and the physical attendance of a family member during childbirth. Furthermore, friendliness of the staff and medical care by paediatricians after childbirth were identified to be important. To some extent, a modern appearance of the ward was also a matter of importance. The medical treatment of mother and the newborn child and the friendliness of the staff have been identified as the most important factors with regard to the expectations of women on an ideal maternity hospital. In addition, a pleasant ambiance of the ward and regular visits by a lactation specialist were named as important.

Premature infants: the impact of environmental stimuli on lung development in early life

exposure assessment on particulate matter (Han X, 2006), several respiratory outcomes have been associated with air pollution exposure in children. Since lung development continues through adolescence and because of higher minute ventilation and higher levels of physical activity, children are more vulnerable to the adverse effects of air pollution than are adults. The respiratory effects of air pollution can be divided into three major areas: respiratory symptomatology and disease, pulmonary function and airway reactivity. Some contaminants (e.g., benzene, carbon dioxide, carbon monoxide, lead, nitrogen oxide, particulate matter and sulfur dioxide) can cause cancer, birth defects, brain and nerve damage and long term injury to the lungs and airway passages. When certain concentrations and durations are exceeded, these can cause severe injury and even death. Respiratory symptoms associated with air pollution exposure in children include burning eyes and nose, recurrent colds, itchy irritated throat, chronic cough and difficulty breathing. Also noted is increased prevalence of chest wheezing apart from colds or of wheezing most days or nights, of chest tightness, and of cough/phlegm production requiring medical attention. Air pollution is also associated with increased incidence of chest illness and of acute upper and lower respiratory tract infections. Furthermore, increased frequency of symptomatic asthmatic attacks, of exacerbations in persons with chronic cardiopulmonary or other disease, of emergency ward or physician visits, and increased frequency and duration of hospitalization for respiratory conditions have been observed. A meta-analysis showed 1.8 times risk of pneumonia in young children due to exposure to unprocessed solid fuel (Dherani M, 2008). Reductions in pulmonary function such as FEV1 or FVC associated with clinical symptoms have been reported with air pollution. Children may fail to maintain their predicted FEV1 growth curve. Further associations include increase in use of asthma medication and enhanced bronchial reactivity (AAP, 2004; ATS, 2000; Ackermann-Liebrich U, 1992; Braun-Fahrlander C,

Traditional Religion on the Site of Modern Medical Treatment : A Ward Visit of Angels(The Practice of Women Overcoming &quot;Tradition&quot; and &quot;Modernity&quot;: From the Viewpoint of Gender,Panels,THE PROCEEDINGS OF THE SEVENTIETH ANNUAL CONVENTION OF THE JAPANESE ASSOCIATION FOR RELIGIOUS STUDIES)

Traditional Religion on the Site of Modern Medical Treatment : A Ward Visit of Angels(The Practice of Women Overcoming &quot;Tradition&quot; and &quot;Modernity&quot;: From the Viewpoint of Gender,Panels,THE PROCEEDINGS OF THE SEVENTIETH ANNUAL CONVENTION OF THE JAPANESE ASSOCIATION FOR RELIGIOUS STUDIES)

Including pharmacists on consultant-led ward rounds: a prospective non-randomised controlled trial

This study aimed to compare interventions made by pharmacists attending consultant-led ward rounds in addition to providing a ward pharmacy service, with those made by pharmacists providing a word pharmacy service alone. A prospective non-randomised controlled study on five inpatient medical wards was carried out at two teaching hospitals. A mean of 1.73 physician-accepted interventions were made per patient for the study group, compared to 0.89 for the control (Mann Whitney U, p < 0.001) with no difference between groups in the nature or clinical importance of the interventions. One physician-accepted intervention was made every eight minutes during the consultant-led ward rounds, compared to one every 63 minutes during a ward pharmacist visit. Pharmacists attending consultant-led ward rounds in addition to undertaking a ward pharmacist visit make significantly more interventions per patient than those made by pharmacists undertaking a ward pharmacist visit alone, rectifying prescribing errors and optimising treatment.

Patients' participation in and evaluation of a follow-up program following intensive care

Patients' difficulties following critical illness and the willingness of intensive care units (ICU) to take an expanded responsibility during the recovery period have led to the development of different follow-up programs. The aim of this study was to explore and describe patients' participation in and evaluation of a follow-up program at a nurse-led clinic (NLC). Patients with a length of stay ≥72 h, discharged from the ICU, participated in a follow-up program based on three contacts, as a visit to the NLC, telephone contact, ward visit or as an indirect contact, during a 6-month period. A specially developed database recorded information regarding patients' participation and questionnaires were used to obtain patients' views of the follow-up program. Of 96 study patients, 51% visited the NLC once or twice. These patients were younger (P<0.001) and had lower Acute Physiology and Chronic Health Evaluation II (P=0.017) compared with those who did not visit the clinic. The most common reason for not visiting the clinic was not enough strength, chiefly physical. In the evaluation, patients answered that they received advice and information, an opportunity to talk, increased knowledge and re-evaluated memories and experiences from the ICU stay. Patients appreciated the follow-up and expressed gratitude to the competent and obliging staff. The current follow-up program, adjusted to individual patients' conditions and needs in terms of different types of contacts and continuity, was found to be of great value. Effects of the program other than the patient perspective are also relevant to evaluate.

Ward pharmacy services — is a once daily visit less efficient than a twice daily visit?

Abstract Ward pharmacy services are widely provided in hospitals throughout the United Kingdom. The objective of this study was to compare the efficiency of once daily with twice daily ward visits. Over a two week period, eight matched wards — four providing a twice daily service and four a once daily service — were assessed in three areas: time taken to provide the service, clinical pharmacy activity, and supply of non-stock items. A total of 120 ward pharmacy visits occurred during the 10 day study period. The mean total daily ward visit time was 55 minutes in the twice daily group compared with 40 minutes in the once daily group, a difference of 15 ± 7.6 minutes/ward/day. Pharmacists in the once daily group spent 52 per cent of time on clinical pharmacy activities and recorded 169 prescription monitoring incidents (PMIs). In comparison, pharmacists in the twice daily group spent proportionally less time on clinical pharmacy activities (42 per cent) and recorded significantly fewer PMIs (107). The proportion of non-stock items originating from the ward pharmacy service was similar in both groups. This study found a once daily ward pharmacy service more efficient than a twice daily service, saving an average of 15 minutes/ward/day.

Fully Automated Surveillance of Healthcare-Associated Infections with MONI-ICU: A Breakthrough in Clinical Infection Surveillance.

Expert surveillance of healthcare-associated infections (HCAIs) is a key parameter for good clinical practice, especially in intensive care medicine. Assessment of clinical entities such as HCAIs is a time-consuming task for highly trained experts. Such are neither available nor affordable in sufficient numbers for continuous surveillance services. Intelligent information technology (IT) tools are in urgent demand. MONI-ICU (monitoring of nosocomial infections in intensive care units (ICUs)) has been developed methodologically and practically in a stepwise manner and is a reliable surveillance IT tool for clinical experts. It uses information from the patient data management systems in the ICUs, the laboratory information system, and the administrative hospital information system of the Vienna General Hospital as well as medical expert knowledge on infection criteria applied in a multilevel approach which includes fuzzy logic rules. We describe the use of this system in clinical routine and compare the results generated automatically by MONI-ICU with those generated in parallel by trained surveillance staff using patient chart reviews and other available information ("gold standard"). A total of 99 ICU patient admissions representing 1007 patient days were analyzed. MONI-ICU identified correctly the presence of an HCAI condition in 28/31 cases (sensitivity, 90.3%) and their absence in 68/68 of the non-HCAI cases (specificity, 100%), the latter meaning that MONI-ICU produced no "false alarms". The 3 missed cases were due to correctable technical errors. The time taken for conventional surveillance at the 52 ward visits was 82.5 hours. MONI-ICU analysis of the same patient cases, including careful review of the generated results, required only 12.5 hours (15.2%). Provided structured and sufficient information on clinical findings is online available, MONI-ICU provides an almost real-time view of clinical indicators for HCAI - at the cost of almost no additional time on the part of surveillance staff or clinicians.

Clinical governance issues arising from the Mental Health and Learning Disabilities Pharmacy Workforce Survey (England) 2006

In the last 10 years changes in the Government's agenda for medicines management and improved patient safety have resulted in unprecedented calls for the provision of mental health pharmacy services. This has not been reflected in pharmacy workforce planning or budgets. We aim to ascertain pharmacy staffing levels in Mental Health Trusts and whether supply of medicines and delivery of clinical pharmacy services are at an appropriate level. All Chief/Lead Pharmacists for Mental Health Trusts in England were sent a questionnaire. Follow-up was done twice by e-mail at 2-week intervals. The response rate was 48% (n = 38 usable questionnaires), and results showed that many Trusts were providing little more than a basic supply service. Pharmacy services equating with risk-management were often provided on an ad hoc basis. Staffing levels were reported as insufficient, with mainly part-time staff. A basic pharmacy ward visit was only offered by 60.8% (n = 14/23; not all participants answered all questions) of respondents, at the 100% level (i.e. a daily service). Six of 31 respondents receiving pharmaceutical services from external organisations reported no formal signed agreements with the external provider. The increasing emphasis on community-based mental health teams, while still retaining on-site provision and Department of Health initiatives to improve patient safety via medicines management, has placed great strain on mental health pharmacy services. The resultant pharmaceutical input from external drivers is not reflected in appropriate pharmacy staffing levels. The results raise some serious governance issues.

Accompanied ward visit

Accompanied ward visit

A nurse‐led intensive care after‐care programme – development, experiences and preliminary evaluation

The benefits of critical care follow-up services include increased understanding of the long-term consequences of intensive care and entail helping patients and their next of kin to come to terms with their problems and distress following critical illness and intensive care treatment. To establish an intensive care after-care programme and to conduct a preliminary evaluation of the follow-up service from the patients' and relatives' perspectives in a general intensive care unit (ICU) in Sweden. A descriptive and evaluative design was used, and data from the first year of the after-care programme were collected. The final programme was nurse led and included five main points; a patient diary with colour photographs, ward visits, a patient information pamphlet, a follow-up consultation 2-3 months after intensive care discharge and feedback to the ICU staff. An evaluation questionnaire was handed out to patients and next of kin attending the follow-up clinic, e.g. asking the respondents to rate their satisfaction of the consultation on a visual analogue scale (VAS). The first year of after-care statistics showed that 170 survivors with a stay of 48 h or more were discharged from the ICU, resulting in 190 ward visits and 79 follow-up consultations. The preliminary evaluation revealed that the 2-month follow-up consultation achieved a median VAS rating of 9.8 (ranging from 1 to 10, poor to excellent) from both patients and next of kin. The development and preliminary evaluation of this nurse-led intensive care programme resulted in a feasible programme, requiring modest resources, with a high level of patient and relative satisfaction. This paper attempts to share with professional colleagues important steps during the developmental process of establishing an intensive care follow-up service and presents the content and preliminary evaluation of a nurse-led intensive care after-care programme focusing on the patients' and relatives' perspectives.

Students′ feedback concerning the IMNCI strategy

Sir, The government of Gujarat (GOG) has implemented an Integrated Management of Neonatal and Childhood Illness (IMNCI) Strategy under Reproductive and Child Health (RCH) II. A step was taken, perhaps for the first time in India, to sensitize undergraduate (UG) students during their third M.B.B.S. (III/I batch/7th clinical term) by conducting a short training daily during their morning posting to preventive and social medicine for 3 hours over 10 days. Modules and physician chart books were provided to each UG free of cost by the GOG. In the Department of Community Medicine, Government Medical College, Surat Department of Pediatrics, pre-service IMNCI training for 127 students from batch 78 was conducted jointly in 2007. A self-administered questionnaire containing closed and a few open-ended questions was used to obtain feedback. Although it started with students, it was declared that this training will be a part of the internal assessment. Out of 127 students, 115 (90.5%) were present when evaluation forms were completed. All of the 115 students attended the training. A total of 91 (79.1%) students attended for all 10 days. Thirteen students (11.3%) were absent for 1 day and the remaining 11 students (9.6%) were absent for 2 days. None of the students were absent for 3 or more days. A total of 60 students (52.2%) found the training to be good; the remaining 55 students (47.8%) thought it was excellent. Students found the training oriented them towards clinical diagnosis as well as the management of pediatric illnesses. They felt that such training is needed by everyone as it teaches home-based care and is an easy way to reduce morbidity and mortality among children. It provided primary knowledge about child health as well as enhanced their ability to identify serious patients and provide emergency treatment and referral. They valued ward visits and algorithms to classify and manage the pediatric patient. Training methods were interactive and such practical approaches kept the students attentive. The method of teaching and training and the contents were found by the students to be logical and sequential. Contents were very clear and the method of delivery was lucid. IMNCI training involved mother or parents in treatment, which was beneficial for disease management. A total of 53 students (46.1%) found the training appealing as it used audio-visual aids for demonstration. Fourteen students (12.2%) found the training remarkable because it used disease classification. A majority (72.2%) of the students felt that it improved both their knowledge and skill regarding pediatric practice while 25 of the students (21.7%) thought it improved only their knowledge. The remaining 7 students (6.1%) felt it helped improve only their skill. A large number of students appreciated all components of the training. They suggested that this training should be given to all categories of health workers throughout India. Two studies that assessed the performance of health workers who had been trained in the full case management process(1,2) showed substantial success in their communication with mothers and in teaching them how to administer treatments at home. One student felt that it was oversimplification for medical students. IMNCI training should be made complex and the time duration should also be increased. Additional visits to wards should be planned and real cases should be given for assessment instead of hypothetical situations. When asked about the differences between conventional teaching and IMNCI training, students expressed that this is an excellent form of integrated teaching. A different modality of presentations is not seen during the usual teaching of pediatrics and preventive medicine. Active interest was created during this training, which reinforced their existing knowledge. Most of the opinions from students suggest that it was useful to them but will be more important and meaningful for health workers. The methodology was impressive and the whole program can increase the confidence of undergraduates in managing common pediatric morbidity and promoting positive behavioral changes. It will be premature to generalize the observations as it has just been started in Gujarat but students' perceptions and opinions can be of great help in organizing future IMNCI trainings.

Enhancing patient care by the professional development of clinical staff: A self-directed educational manual for staff working with parents with advanced cancer

The paper by Turner and her colleagues published in this issue is a welcome example of the way in which an educational programme for staff can not only increase their knowledge but also develop skills and professional confidence in a challenging clinical situation. The manual they have produced is based on their earlier work assessing the educational needs of nursing staff supporting parents with advanced cancer. This self-directed educational programme is designed to enable oncology nurses to receive additional training but the model has wider relevance both for other healthcare professions and for other serious illnesses such as degenerative neurological disease. There can be few clinicians who have not been asked for guidance by parents on supporting their children understand that their illness is progressing to its final phase. Some parents will state their children are unaware of the severity of their illness but observation of the children at home or on the ward may suggest the opposite. It is understandable that parents in a distressing situation will wish to protect their children from unnecessary worries but often the children have realised something is amiss. The children are concerned even if they are not informed. Children find out about their parent’s cancer from overheard phone-calls, leaflets left in the home or by noticing posters during ward visits. Their awareness and knowledge of the potential implica-