How has your training prepared you for a nursing career?

Also known as a heart attack, myocardial infarction (MI) is a dramatic and life changing event. The victim does not know how to resume a normal life post MI, so the nurse plays a pivotal role as an educator regarding the resumption of a normal lifestyle. However, much controversy exists in the literature as to best practice guidelines, and when the appropriate time frame is for teaching. This paper will explore the best practice guidelines and time frame for post-MI education, exercise, proper diet, and resumption of sexual activity.

Education is a vital component of care for patients after myocardial infarction. By informing patients about the disease process of MI, it helps to reduce anxiety and aid recovery, as the underlying cause of MI is related to lifestyle. Nurses need to provide education on lifestyle change with regards to minimizing the reoccurrence of MI. A change in diet is one of the most important aspects of nursing teaching for post MI patients. A heart healthy diet is recommended to reduce LDL and blood pressure. Heart healthy diet guidelines include limiting total calories from fat less than 30%, limiting total calories from saturated fats to 8-10 % and limiting cholesterol to intake to less that 300mg per day. According Grundy (2003) in a diet and re infraction trial carried on 2033 men who had suffered from MI. They were divided into two groups. Half were advised to reduce fat intake, increase dietary fiber, increase fatty fish intake. The other half received no dietary advice. The prescribed diet was reported to provide about 500-800mg/d of every long chain N-3 fatty acids. Patients who received the prescribed amount of fatty fish had a 29% reduction in all cause mortality over the period of study. Much of the benefit was attributed to diet’s higher content of N-3 fatty acids. Nurses need to educate patients based on patients’ unique concerns, thus, standard protocol regarding post-MI teaching need to be tailored to each individual patient. Every patient has various experiences and a wide range of emotions, and needs the appropriate methods pertaining to teaching the client when he/she is ready to listen. Bores & Sinclair (2009) mention how crucial it is to have post-MI education and programs individualized to each patient’s specific needs, and to examine the organizational factors influencing their performance on the patient teaching role.

Thompson & Lewin (2000) describe how exercise may have significant protective effects in post-MI patients. As a nurse, it is important to encourage the client to identify what they felt may have been the cause of their MI and if the client is associating this as psychological distress. Thompson & Lewis (2000) also mention that initial distress predicts outcomes for return to work and for some other aspects of quality of life outcome, lifestyle changes, and compliance with medical care. Every patient should be helped to develop an individualized and concrete plan for recovery in the weeks following the MI (Thompson & Lewis, 2000). It is also important that the patient’s partners be advised to alter family routines as little as possible except for lifestyle changes, such as smoking or diet, which should begin immediately (Thompson & Lewis, 2000). The patient and partner’s understanding of the advice should be checked during the course and at the end of each session, by asking them to summarize the advice imparted, it may be helpful if information provided was written or tape recorded for review throughout the rehabilitation phase.

There is a strong correlation between proper diet, exercise and improving post-MI outcomes. According to Skinner, Cooper, & Feder (2007), who have summarized some recommendations from the National Institute for Health and Clinical Experience (NICE) on effective secondary prevention in patients with post-MI, nurses can utilize this information, by taking into account the recommendation of lifestyle advice that should be consistent and take into consideration the patients’ current habits. Patients should be advised to increase physical activity, quit smoking, eat a Mediterranean-style diet, consume at least seven grams of omega 3 fatty acids a week, keep weekly alcohol consumption within safe limits, achieve and maintain a healthy weight if obese, and advise patients against taking supplements containing carotene, vitamin E or C supplement and folic acid supplements (Skinner, et. al, 2007).

Education about exercise post-MI is vital to relieving anxiety and resumption of activity. Another recommendation by NICE regarding exercise is to advise patients to return to work and to get involved in activities of daily living while taking into account the his/her physical and psychological status, and the nature of his/her work. Exercise has been shown to increase myocardial oxygen delivery, and improvements are seen on changes in the oxygen utilization of the peripheral skeletal muscles, resulting in decreased demand placed on the myocardium at any given workload (Nolewajka, Kostuk, Rechnitzer, & Cunningham, 1979). Furthermore, Luszczynska (2006) found that the promotion of an active lifestyle after eight months post-MI can help patients to increase their sessions of moderate physical activity.

The resumption of sexual is an area of great concern for post MI patients. Often, patients are more preoccupied and greatly concerned with feelings of inadequacy and disempowerment due to their compromised physiological condition. Nurses often feel awkward addressing the issue, and are not sure how to begin the education process. Fortunately, the literature for the past two decades has shown the positive effects of counseling and education. It is interesting to note that the exertion required for sex is only equivalent to climbing up two flights of stairs (Steinke, 2000). With this kind of information at hand, the nurse can easily use a conversation on exercise as a spring board for a discussion of the resumption of sexual activity.

Research by Steinke & White (2006) reveals attention to sexual concerns of MI patients before and after hospital discharge results in improved patient outcomes. There is a strong link between heightened anxiety and decreased sexual satisfaction with post MI patients. Therefore nurses, in particular coronary care nurses, play an important role in counseling patients in this area (Crumlish, 2004). However, Crumlish (2004) asserts this is a frequently neglected area. It seems logical that there is a strong link between anxiety and feelings of sexual inadequacy post MI, which brings the question as to whether there are also gender and cultural differences. Research by Moser, Dracup, McKinley, Yamasaki, Kim, Riegel, Ball, Doering, An, & Barnett (2003) demonstrate that although women have higher levels of anxiety post MI, this relationship is independent of age, education level, marital status, or presence of co-morbidities. Whether these variables influence the effectiveness of post MI teaching remains to be investigated.

The best practices in sex education post MI have changed over the past two decades. In the early 1990s, research and education was focused on dispelling the myths and fears of sexual dysfunction (Boone & Kelley, 1990), whereas in the 2000s the focus has changed to the effects of anxiety (Steinke & White, 2006). Both decades show the need for counseling, however in the 2000s, the nurse is the key educator, rather than the physician. Fortunately, there are several approaches to post MI sex education that can be used by the nurse to decrease anxiety. For instance, the hypothesis that MI patients who receive both written instructions and a videotape to view at home about sex education will resume sexual activity more quickly than the patients who receive only written instructions was tested in a two group randomized clinical trial (Steinke & Swan, 2004). They found significant improvements in the experimental group after only one month, indicating that video tape intervention is an effective means of providing post MI sex education. The nurse who incorporates these teaching approaches can address the sensitive topic of resumption of sexual activity in an appropriate and effective manner.

Controversy exists as to when the best timing is for patient teaching about the resumption of sexual activity. For example, some researchers recommend waiting until the patient is psychologically ready. Others believe it is dependent on the physician’s assessment of the degree of readiness. While Gentz (2000) asserts that it is actually safe to resume sexual activity after only seven to ten days post-MI. Regardless of the controversy, it is obvious that the nurse plays a key role as the patient educator to provide counseling on the best practice guidelines to assist the patient to safely resume sexual activity.

The future practice in nursing about education in secondary prevention of MI should focus on the discharge planning of the client. Effective communication between the acute care nurses and the community nurses can bridge the gaps when transferring the clients from hospital to home or long term care setting and can ensure the clients are receiving excellent nursing care in services across setting. Also, nurses should ensure interpreters are used and translated written materials are available when conducting family meeting about discharge, teaching with clients and family members. This can ensure that information is delivered to clients correctly and the clients will understand the purpose and meaning of the teaching. Moreover, the hospital can implement a telephone system for follow up to discharge clients to reinforce the teaching especially the detail of medication and plan of emergency incident. At last, nurses should integrate cultural-ethical content into teaching and provide holistic care which can help the health care providers to work effectively with diverse populations.

Although controversy exits in the literature regarding when to begin post MI teaching, it is evident that the nurse plays a critical role in education. Post-MI teaching needs to be individualized to meet the needs, goals, hopes and values of each patient. Education regarding lifestyle modification, diet, exercise, anxiety, and resumption of sexual activity has been show to be beneficial to assist the patient to adjust to his/her new lifestyle. Although the resumption of sexual activity is associated with anxiety and fear of coital death, according to best practice guidelines, patients can resume within seven to ten days post-MI. Overall, the role of the nurse is to educate the patient about MI and its treatment, lifestyle changes (drugs, diet, exercise), self-monitoring and management (especially the early detection and treatment of chest pain), coordination of care with other health care providers, and provide rehabilitation support. By educating the clients about secondary preventions such as pharmacotherapy, health education and psychological support in developing lifestyle medications, clients are able to develop coping strategies for treating and preventing MI and ultimately yield to better health outcome and restore their function in normal daily living activities.

A nurse’s role focuses on the help, care and support given to their patients whilst treating people as individuals and upholding their dignity (The NMC code, 2015). In this essay I will discuss the ways in which nurses can ensure that patients with dementia receive individualised patient care. The aim of this essay is to demonstrate how care is implemented to

patients with dementia

and how nurses ensure care is individualised to meet the

patients’ needs and wants

.

Nurses can identify the individual needs of the patient by
following the nursing process.  The
nursing process is a series of stages intended for nurses to demonstrate
excellent care. It consists of five phases: Assessing, diagnosing, planning,
implementing and evaluating.  This
process is client centred. These stages mean that nurses should individualise
what is needed for one patient.  A
patient needs, and problems is identified through these steps. The Assessment
phase is the first step in which it allows nurses to identify what the patient’s
needs are. The nurse collects information from the patient by asking them
questions and running physical examinations. They dissect the information that
is gathered in this stage in which it is further analysed which requires in
dept thinking. The Diagnosing Phase is the next phase in which the nurses make
an overall diagnosis about the information that was collected in the assessment
phase (Gardner, 2003). It is stated that patients tackle a medical diagnosis
with what mental health professionals name an anticipatory anxiety. They are
nervous and scared as to what they are told and how it may change their day to
day life for them and their close ones (McClain and Buchman, 2011).  The diagnosis of dementia entails of
examination, cognitive testing and assessment. Nurses informing patients that
their memory and cognitive function is beginning to change can be challenging and
difficult to hear hence it is crucial that nurses should uphold their dignity
and inform them of the treatment that will be applied and to give them the help
and support they need. (Prince and Martin, 2016). The planning phase lets the
nurses create a plan of action in which ongoing treatment will be discussed.
This phase allows the nurses to address patient’s needs. The implementing phase
is when nurses carry out the plan of action. For dementia patients their
symptoms tend to go worse. It is vital that nurses demonstrate great care in
which they can them support with daily activities e.g. washing and dressing
them. They should also monitor the patient and focus on the improvements made
by the patients. It is vital that the nurses care, monitor and support that is
given to the patients is continuous. The care that is received by the patients
with dementia is much lower as to those patients without dementia hence it is
fundamental that the nurses ensure that care is individualised to the patients’
needs and wants.  For the last evaluation
phase, it is crucial that nurses complete an evaluation to see if the treatment
that was carried out is working and if any changes happen. If the treatment
isn’t working nurses can support the client, analyse and understand as to why
it didn’t work (Gardner, 2003).

Nurses should respect the patient’s beliefs and prevent
making assumptions mainly grounded on their appearance or other personal
quality. They must listen and consider patient concerns. It is vital that the
nurse is non-judgmental and open minded towards the patient. Nurses can ensure
care is individualised when it comes to fulfilling the nutrition, pain
management and personal needs of the patient. If the patient cannot manage or
is unable to regulate their nutrition, then the nurse should support and
encourage the patient by placing food within their reach (Kaplan, 1996).

Providing care to a patient who suffers from dementia is
vital as the patient does not have the ability fully understand their
diagnosis. As a nurse, it is encouraged to introduce yourself to the patient to
create a therapeutic relationship during treatment. Patients who have dementia
are no longer able to maintain their individuality and personhood hence why it
is important that nurses can try and uphold and preserve it for them. Patients value
nurses recognizing their individuality. Nurses reassure patients that one is
not living a horrible and unhappy life by implementing the worth and value to
their life by trying to get to know the person behind the patient. Nurses can
ensure that care is individualised as they could get to know the individual,
their values, likes and dislikes and hobbies as this gives the patient an individuality
whilst always showing compassion and respect (Collins and Hughes, 2014). This
is most valued and appreciated by patients as it allows the nurses to know the
characteristic and the personality of the patient.  Nurses can show
recognition to the patient by acknowledging their needs and wants and providing
care that is customized and adapted to it. It is important that nurses try and
build an insight of the patient’s world and how to bond with them. When
communicating and engaging with them they must always say their name unless the
patient wishes a different way of being addressed.  Nurses can consider the patients perspective
when demonstrating care that is exclusively personalised to their needs.  Giving recognition to the patient allows the
relationship to build much stronger as you are giving your attention and time
to them.  Nurses would give the patients the choice and responsibility to
make their own decisions when it comes to their choice of food, clothes they
want to wear, getting involved in activities etc. Allowing the patients to make
decision like this lets them know that they are comfortable. It also gives them
a sense of involvement and participation to express their qualities and
personality. However, when the discussion of making clinical discussions arises
and the patient is unable to make the decisions due to cognitive abilities
declining, the family and doctors will be more involved. Nurses should allow
the patients to create their own pace in which you shouldn’t push the patients over
their limits. It would be much of a benefit to focus on the improvements made
by the patients even if it’s something small. This would motivate and drive the
patient building their self-esteem. When a nurse is caring for a patient who
has dementia it is important that you do not patronise them. Respect for the
patient is a main aspect nurses must implement in their duty of care. Nurses can
ensure that the care and treatment given to the patients is with both respect
and compassion (The NMC code, 2015). Socialisation and interaction is
fundamental for patients as it allows the patients to maintain a social life
and form relationships. Allowing the patients to experience and be around
company will progress their communication skills. Nurses should recognise that
all patients including people with dementia is built in relationships and that
dementia patients require a healthy social environment to promote opportunities
for personal and mental progress.  Dementia affects the way a patient
communicates. People suffering from dementia can find difficulties responding
back to question (NICE, 2012).

When conversing with patient
with dementia they may also find problems to maintain the information during a
discussion. Nurses must validate and shouldn’t dismiss what is said by the
patient. They must try to understand and take notice of what the patient
expresses to them.  Nurses can
communicate in a calm and respectful way in which they should speak directly to
the patient. It can be frustrating for a patient with dementia to communicate
their needs and wants hence it is vital that nurses are supposed to remain calm
and patient if the patient becomes agitated (Ellis and Astell, 2017).  When a patient’s conditions begin to deteriorate,
health and social care needs begin to increase causing them to require more
help and personal care. When nurses are relaying information to a patient they
should give the patient both oral and written information, so it can be fully
understood and so it can encourage and boost their communication skills in
their care and treatment. When released from hospital, people with dementia are
likely to suffer a serious loss of individuality, and increased needs for help
and support. So, it is important that the care is demonstrated to patients not
only during hospital but when they arrive home.  Nurses can try and view the world from the viewpoint
of the person with dementia, distinguishing that everyone’s experience has its
own psychological validity, that people with dementia act from this outlook
(Brooker, 2007).

The ageing population is
exponentially increasing resulting in challenges to nurses in coping and
treating the conditions and health needs that arise with old age (Bhardwa,
2015). These barriers that I will be explaining are obstacles that prevent the
pace of excellent care being demonstrated by nurses. The barriers to
demonstrating care to dementia patients is that they receive poor quality in
which nurses tend to focus on other patients with severe illness and diseases.  Another barrier would be ineffective advance
care planning. Some people with dementia receive a delayed diagnosis which can
result in them not having the mental capacity to attain decisions. A lot of
patients find it difficult to vision their self-getting better due to their
current state. Nurses can ensure that the care that is provided to people with
dementia is quality care during the duration of their treatment. Hospice use is
incredibly low for dementia patients. The people with dementia that get transferred
to a hospice can result in confusion and distress at a state in which the person
is unable to handle change. Also, they have completely different needs compared
to cancer patience’s. It is crucial that both staff and nurses have the
training required to deliver care to individuals with dementia. Age
discrimination is also a barrier that elderly patients face in which the
symptoms demonstrated to doctors and nurses is referred to a getting old. Nurses
are failing to spot and notice the symptoms of dementia in a lot of patients
which creates a poor rate of diagnosis (Collins and Hughes, 2014). The
organization like the National Health Service also create barriers resulting in
patients not receiving the care they need. They have limited access to
resources, lack of time, heavy patient workloads and insufficient staffing. Nurses
have a contribution when it comes to the barriers of providing care to
patients. Some nurses have a lack of interest, lack of confidence in critical
appraisal skills, lack of knowledge and them feeling overwhelmed (CAN, 2018). Dementia
patients experience behavioural and personality changes. Patients that
specifically have advances dementia tend to be physically aggressive, have
hallucination and get agitated. These symptoms can result physical and
emotional distress to both the patient and the nurse. There is also hostile
treatment for dementia patients that is very familiar in which it consists of
tube feeding and antibiotic treatment for infections. This treatment is known
to be wrong and does not improve survival. Families of the patient shows great
dissatisfaction against the aggressive treatment that is demonstrated to the
patients. Nurses can implement excellent care by concentrating on improving
patients comfort and increase in advance care planning (Collins and Hughes,
2014).

The points I explained in this essay show how providing and
offering care to people with dementia can be complex and there can be a lot of
boundaries that come along with it however when the when the needs, wants,
choices and problems is focused and centred around the patient that’s when care
is at its best. Nurses should always put the patient first. Nurses can value
patients with dementia by promoting their self -worth and treating them as
individuals.

References

The Code, 2015)

Your Bibliography: The Code. (2015). [ebook] Nursing and
Midwifery Council. Available at:
https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf
[Accessed 26 Apr. 2018].(McClain and Buchman, 2011)

McClain, G. and Buchman, M. (2011). After
the diagnosis. [Clifton Park, N.Y.]: Delmar Cengage Learning.

Gardner, P. (2003). Nursing process in
action. Australia: Thomson, Delmar Learning.

Prince, Martin, Comas-Herrera, Adelina, Knapp, Martin,
Guerchet, Maëlenn and Karagiannidou,

Maria (2016) World Alzheimer report 2016: improving
healthcare for people living with dementia:

coverage, quality and costs now and in the future. Alzheimer’s Disease International (ADI), London, UK

(Kaplan, 1996)  Kaplan, M. (1996). Clinical practice with caregivers of dementia patients. Washington, D.C.: Taylor & Francis.

(Patient experience in adult NHS services: improving
the experience of care for people using adult NHS services, 2012) Patient
experience in adult NHS services: improving the experience of care for people
using adult NHS services. (2012). NICE.

Ellis, M. and Astell, A. (2017). Adaptive interaction and
dementia.

Brooker, D. (2007). Person-centred dementia care. London:
Jessica Kingsley Publishers.

(Bhardwa, 2015) Bhardwa, S. (2015). Barriers to dementia care. Independent Nurse.

(Cna-aiic.ca, 2018)Cna-aiic.ca. (2018).
Barriers to Nursing. [online] Available at:
https://cna-aiic.ca/en/nursing-practice/evidence-based-practice/barriers-to-nursing
[Accessed 26 Apr. 2018].

Collins, J. and Hughes, J. (2014). Living and dying with
dementia in England: Barriers to care. London.

Introduction

Diabetes is a disease which has a significant impact on individuals, family and society (DH, 2002). It affects 1.4 million people across the UK (Hilton and Digner, 2006). Such is the significance of the disease for the National Health Service (NHS) and other resources and services, that the Department of Health published the National Service Framework (NSF) for Diabetes in 2002, setting standards for the diagnosis and management of diabetes (DH, 2002).

Diabetes is separated into different types and presentations of the disease. Diseases are characterised by high blood glucose due to a lack of insulin or impaired response to insulin (DH, 2002). In Type 1 Diabetes, the pancreas does not produce insulin because the cells which produce it, Beta cells in the Islets of Langherhans, have been destroyed by the body’s own immune system (DH, 2002; Watkins, 2003). This is the form of diabetes which will be dealt with in this case study. Type 2 diabetes is associated with older age of onset, and is characterised by reduction in insulin production and a degree of insulin resistance (Watkins, 2003).

Case History

The patient, G, presents at 4am via paramedic ambulance at the Accident and Emergency department following collapse at her place of work. G is 23 years old, and was diagnosed with Type 1 Diabetes 8 months ago. She has been prescribed twice-daily insulin and diet modifications but is known to be non-compliant with this regime and has presented previously to diabetic clinic with worsening complications including loss of vision due to diabetic retinopathy. This is due to her commitment to maintaining her pre-diagnosis body image and also due to lifestyle factors. She studies health and beauty at a local college, and also works late nights at a gentleman’s club. She has not coped well with her diagnosis of Type 1 diabetes, being a hitherto independent young woman who travelled the world.

On admission, G is unconscious, and her hospital record identifies her as diabetic. Her symptoms suggest either acute hypoglycaemia or Diabetic Ketoacidosis (DKA). Hypoglycaemia in Type 1 Diabetes is usually due to an overdose of insulin, lack of carbohydrate intake, excessive exercise, or a combination of any of these factors. DKA is a potentially life-threatening condition caused by an inadequate concentration of insulin in the blood (DH, 2002; Hankin, 2005). As a result, the body’s cells cannot use glucose for energy and instead draw on the body’s fat reserves, causing blood glucose to rise but also causing an increase in ketone bodies, the by-products of fat metabolism (DH, 2002).

Care Needs

There are two distinct sets of clinical needs in this case. Watkins (2003) states that the needs of the diabetic patient are: save life; alleviate symptoms; prevent long-term complications; reduce risk factors such as smoking, hypertension, obesity and hyperlipidaemia; educate patients and encourage self-management. Initially, G needs immediate resuscitation, stabilisation of her diabetes and diagnosis and treatment of all aspects of her current condition.

While it is logical to assume from her past history that this is DKA related to insulin omission, DKA could also be precipitated by other conditions such as infections or myocardial infarction (DH, 2002). This is due to the body response to physical or biological stress, resulting in, for example, a hypermetabolic state with alterations in carbohydrate metabolism (Turina et al, 2006). Endocrine reactions to stress cause increased levels of catecholamines and glucocorticoids, both of which precipitate hyperglycaemia (Turina et al, 2006). Therefore the diagnostic phase must include investigation for concomitant or precipitating illness, because the cause must be treated in order to achieve full glycaemic control.

The initial findings are more suggestive of DKA. An immediate blood glucose test is carried out on admission using a standard Glucometer, and is found to be 1.3 mmols. The normal range of blood glucose is 4-7 mmols. This finding is consistent with hypoglycaemia. The risk of severe hypoglycaemia is higher in patients receiving insulin therapy (DH, 2002). The brain is dependent on a constant supply of glucose as its main source of energy, and so hypoglycaemia can affect brain function, leading to confusion, fits, coma and even death (DH, 2002). G’s pallor is consistent with hypoglycaemia (Guthrie and Guthrie, 2004). Blood pressure is elevated at 150/90 mmHg, pulse is strong and rapid at 110 bpm, and pupils are dilated, all symptoms consistent with hypoglycaemia (Guthrie and Guthrie, 2004).

Immediate Care

Diagnosis of coma is achieved through use of the Glasgow coma score – which on admission is 3. G is unresponsive to pain. Immediate resuscitation involves the following distinct phases and should be in line with an evidence-based hypoglycaemic management protocol (DH, 2002; Edge et al, 2005; Hankin, 2005; Hilton and Digner, 2006):

Immediate Resuscitation

The immediate treatment is the introduction of glucose, either by intravenous bolus injection of 50% glucose or by intravenous injection of glucagon. Both work by raising blood glucose, thus reversing the neurological effects of hypoglycaemia.

Observations and diagnostic tests

Blood pressure, temperature, pulse and respiration rate are recorded via continuous telemetry. And ECG is taken to rule out myocardial infarction. Blood tests include Full Blood Count, Liver Function Tests, Urea and Electrolytes (Hankin, 2005). Prothrombin Time and Clotting Factors may also be tested, due to the risk of disseminated intravascular coagulation. The following will also be tested:Glucose (blood, urine); HbA1c; Fructosamine; Ketones (urine); Urinary albumin excretion; Creatinine / urea; Proteinurea; Plasma lipid profile (Reinauer, 2002). The simplest indicator of the adequacy of carbohydrate metabolism of a patient is the blood glucose Concentration, but glucose is rapidly metabolized in the body (Reinauer, 2002). This suggests that blood glucose reflects the immediate status of carbohydrate metabolism, but does not allow a retrospective or prospective evaluation of glucose metabolism (Reinauer, 2002). Neurological observations should be carried out regularly and trends monitored alongside other vital observations (Guthrie and Guthrie, 2004).

Oxygen therapy

A Guedel airway has been inserted during transit, but the client is otherwise not in respiratory distress. Oxygen saturation is measured via digital probe and is found to be 100% on 2L Oxygen via facemask. Intubation is not considered at this point.

Intravenous Access

Immediate intravenous access with two large-bore IV cannulae is necessary. Depending on G’s condition and peripheral vascular status, it may be necessary to insert a central line, which would serve the dual purpose of allowing accurate blood pressure measurement and the introduction of fluids and medication.

Insulin therapy

Continuous IV insulin has been found to be the most effect means of maintaining glycaemic control in the setting of the often variable clinical and metabolic status (Watkins, 2003). Continuous intravenous insulin is commenced utilising a standard solution of 100 unit human insulin to 100 ml saline delivered by a syringe driver. The solution is mixed and checked by two qualified staff prior to commencement. The rate is set at mls/hr dependent upon hourly blood glucose measurement with glucometer.

IV Fluid Therapy

IV fluid therapy needs to be strictly monitored, and for this reason, fluid balance must be accurately measured. A urinary catheter (indwelling) is be inserted. Urine may be sent for microscopy, culture and sensitivity at this point as hyperglycaemia may result in pyuria due to the presence of glucose allowing rapid proliferation of bacteria. A urinary tract infection could be a precipitating disease and so must be tested for, and given G’s non-compliance with disease management it is likely she may have periods of hyperglycaemia leading to such complications. At the same time, a urine specimen is tested by ‘dipstick’. IV fluids may be both hydrating 0.9% Saline and an infusion of 5% or 10% glucose via infusion pump to allow titration of insulin therapy on an hourly basis. The hydration regime should be managed in conjunction with close monitoring of electrolyte levels (Guthrie and Guthrie, 2004).

Place of Care

The first 48 hours should be managed in a critical care facility. Whilst in the intensive or high dependency unit, G’s condition should be approached using an integrated, holistic approach, focusing on maintaining homeostasis and blood glucose (Place and Phillips, 2005). Following this, G should be transferred to a medical ward under the care of a diabetes specialist for ongoing monitoring, health education and treatment. Once neurological status has been established, a full history should be taken (Krentz, 2004).

Ongoing Care

Care should be managed by a specialist team in line with established, agreed care pathways (Pollom and Pollom, 2004). If all professionals within the team and those in liaison with the team follow the National Service Framework, the implementation of an integrated approach across hospital and community services should be achievable (O’Brien and Hardy, 2003).

Monitoring

Once stabilised, G should be returned to her normal insulin regimen with balanced dietary intake. Blood glucose monitoring and insulin administration will be carried out by healthcare staff initially. A plan of care should be developed to address G’s need holistically (Collis, 2005), with the specific aim of improving her current condition and instigating programmes to improve future glycaemic control, concurrently reducing her risk of long-term complications of her condition (Watkins, 2003).

Complications of diabetes in the long term are life threatening and associated with serious morbidity. Macrovascular complications, such as atherosclerosis increase the risk of coronary artery disease and cardiovascular accident (Guthrie and Guthrie, 2004; Bloomgarden, 2005; Soedmah-Muthu, 2006). Diabetic retinopathy can lead to blindness (Guthrie and Guthrie, 2004). Neuropathy can lead to gastrointestinal disturbance, peripheral vascular disease, ulceration and erectile dysfunction in males (Guthrie and Guthrie, 2004). Glycolysation in the kidney leads to glomerular damage and eventually irreversable kidney failure (Guthrie and Guthrie, 2004).

Condition Management Review

Given G’s history and a recent diabetic emergency, the diabetic team may decide to review their management of G’s diabetes. There may be alternative treatments which could enhance her quality of life and reduce the risk of recurrent diabetic emergencies. She may be a candidate for a continuous subcutaneous insulin pump or for even more controversial therapies such as nasal insulin (Snow, 2006). While the National Institute for Health and Clinical Excellence (NICE) has not approved inhaled insulin for general use, pilot studies demonstrate its efficacy in some cases of both Type 1 and Type 2 diabetes (Snow, 2006). However, this therapy may not be suitable for G’s busy lifestyle as she would still need to take regular injected insulin combined with this therapy, and also because her issue is not hyperglycaemia in this instance, but hypoglycaemia.

Therefore, a continuous subcutaneous insulin infusion pump may be the solution (NICE, 2007). Lee et al (2004) demonstrate that this approach is both safe and effective in achieving better glycaemia control for clients with ‘fragile’ diabetes. The pump system provides the closest approximation of natural insulin secretion by providing a continuous rate of infusion which can be adjusted by the client throughout the day, based on self-assessment of blood glucose, diet and activity levels (Lee et al, 2004). The pump infuses insulin over 24 hours with facilities for preprandial boosts (Watkins, 2003). Pump therapy allows clients to achieve not only better glycaemic control, but the ability to lead a more normal life, providing flexibility of, for example, mealtimes (Lee et al, 2004).

In considering a holistic approach, this therapy is particularly suitable for G’s lifestyle as it would allow the flexibility she needs. Lee et al (2004) cite some of the reasons for initiating the system, including poor glycaemic control, a need for flexibility and lifestyle and a history of hypoglycaemic events requiring assistance. The system is associated with high rates of satisfaction and compliance (Lee et al, 2004). However, this therapy is not always available in every NHS trust in the UK, and G will need to be educated in its use, for example in rotating cannula sites, and also given ongoing support to ensure proper self-management and compliance. Research has demonstrated that training in intensive insulin management improves both glycaemic control and quality of life for patients with Type 1 diabetes (DAFNE, 2002), and it would be logical to assume that if the multi-disciplinary team can demonstrate to G some improvements in her quality of life, she might be more likely to be compliant with diet and insulin regimes.

Another component of the condition review is liaison with ophthalmic services and review, assessment and management of her diabetic retinopathy. In diabetic retinopathy, vascular damage weakens the walls of the blood vessels causing microaneurysms and leakage of protein into the retina (Guthrie and Guthrie, 2004). This leads to blockage of the retinal vessels, and eventually retinal ischaemia (Guthrie and Guthrie, 2004). In response, the retina stimulates growth of new vessels, which are thin and friable and prone to breakage, causing micro-haemorrhage into the retina and vitreous humour, affecting vision (Guthrie and Guthrie, 2004). Ultimately, scar tissue forms which leads to blindness (Gurthrie and Guthrie, 2004).

Health Promotion and Education

It is vital to implement a programme of education to support G in developing not only the skills to properly monitor her condition but also to motivate her to accept and engage with her disease. There is evidence from clinical trials that lifestyle modifications and effective health education contributes to a reduction in the risk of diabetic comllications (Anthony et al, 2004). Skinner et al (2003) draw attention to the differences between programmes which are based on ensuring patient compliance with healthcare professional-designed management, and programmes which focus on a client-centred approach. A client-centred approach might be the more appropriate in this instance given G’s previous non-compliance with insulin and diet regimes. The literature on diabetes unequivocally demonstrated that diabetic clients must understand their disease and be empowered to avoid unhealthy behaviour ssuch as smoking and unhealthy diets, and be encouraged to exercise and control blood glucose (Anthony et al, 2004). G’s lifestyle appears healthy in terms of exercise, but it is glycaemic control which must be addressed here.

It is also vital to employ a multi-disciplinary approach with collaborative care co-ordinated by diabetic specialists – both medical and nursing (NSF). It has been found that seamless care of the diabetic client can result in a shortened length of stay in hospital, and can help prevent recurrent admissions due to poor self-management (Pollom and Pollom, 2004). Research continues to demonstrate that such services are still falling short of the published standards (Edge et al, 2005). Keen (2005) argues that there is still a need for an integrated approach to diabetes with close collaboration and sharing between primary and secondary care providers. There should be networks of diabetes specialists traversing the boundaries of acute and community sectors, for example, to support an ongoing integrated service that allows client needs to be met appropriately (Keen, 2005). However, having a lead professional (ie nurse) who coordinates such a programme is also important (Scott, 2006).

Dietician involvement is vital in this instance, as both an immediate form of intervention and in the promotion of long-term optimisation of health (Pollom and Pollom, 2004). It is also important to involve community services at this stage, as it has been demonstrated in the literature that community support programmes are effective in promoting healthy lifestyles for diabetic clients (Robinson, 2006). Watkins (2003) states that much great finesse is needed in design of diabetic diets, because if they eat too much, diabetic control deteriorates, and if they eat too little, they become hypoglycaemic. The important principle is that carbohydrate intake should be steady from day to day (Watkins, 2003).

In terms of health education, G needs to be re-educated in calibration and monitoring of her glucose testing equipment, reinforcing the importance of good glycaemic control (Reinauer, 2002). This needs to be assessed by a healthcare professional (Reinauer, 2002). G also needs to be reminded that the strips need to be stored in an airtight container and kept upright (Reinauer, 2002). However, it is also vitally important to address the psycho-social aspects of G’s condition or the behaviours or emotional response which may be affecting her engagement with the management of her condition (Watkins, 2003). Emotional, social and psychiatric disorders can underlie disruptive diabetes (Watkins, 2003). Ongoing social and psychiatric support may be appropriate in this instance. This kind of support may be particularly important in supporting G to prevent the inevitable long-term health problems caused by poor glycaemic control.

Diabetes UK, the leading UK charity for people with diabetes, recommends the implementation of a structured education programme (Diabetes UK, 2006). Taking into account the emotional, social and lifestyle implications, such programmes aim to empower people with diabetes to achieve true self-management (Diabetes UK, 2006; NICE, 2003). The programmes need to have a curriculum, be implemented by trained educators, and be audited (Diabetes UK, 2006). They need to be locally accessible, ongoing and suited to the needs of the individual, either in group formats or on a 1-1 basis (Diabetes UK, 2006; NICE, 2003: Skinner et al, 2003). Whether or not G will have access to such a programme remains a postcode lottery, despite the recommendations of the NICE guidelines (NICE, 2003; DH, 2002; Diabetes UK, 2006). Therefore a realistic assessment of available continuing care facilities for G is vital for her future health and wellbeing. It may also help in keeping her motivated and compliant (Funnell, 2004). Diabetes UK (2006) assert that ‘structured education can help people to engage more effectively with their healthcare professional and this, in turn, enables them to make better informed choices about their individual healthcare.’ Telephone or video-link support may also be of some benefit (Bowles and Dansky, 2003).

Conclusion

As can be seen from this case, presentation of Type 1 Diabetes in the young adult can be a challenge for the client and for those charged with treating and supporting them. G’s case demonstrates the need for acute and ongoing healthcare services to work collaboratively and consistently, providing continuity of support that is locally based and tailored to meet individual needs. This support could be vital to minimise the long-term complications of diabetes, improving individual quality of life and reducing the future demands on the already over-stretched UK health service.

Critical analysis of research studies is one of the most important steps towards incorporation of evidence into practice (Burns & Grove, 2007). This paper is an attempt towards achieving this goal. The paper critically analyzes the article “Group prenatal care and preterm birth weight: Results from a matched cohort study at public clinics” by Ickovics et al.(2003). This aim will be achieved by sequentially critiquing the research problem, the literature review, principles of research ethics employed in the study, the underlying theoretical framework, the research hypothesis, the sampling technique, the research design, data collection methods, the analysis, and the recommendation proposed by the authors. Finally, the paper will end with an overall appraisal of the strength and limitations of the study.

Rationale:

This particular research paper was analyzed as the concept of group prenatal care has not been investigated in detail yet. While reviewing the literature on the stated topic the limited supporting evidences for group prenatal care was found. Only 01 RCT (Ickovics et al.2007), 01 matched cohort study (Ickovics et al.2003), and 03 pilot studies with descriptive analysis were found (Baldwin, 2006; Grady and Bloom, 1998; Rising, 1998). The comparative analysis of all 05 studies is shown in appendix 1. Chosen study is the only one which examined the impact of group versus individual prenatal care on birth weight and gestational age.

DISCUSSION

The problem:

The problem studied by Ickovics et al. (2003) is that, whether group prenatal care has a significant impact on the perinatal outcome like birth weight, and gestational age. This problem is extremely significant to nursing, for a number of reasons. The first reason as described by Ickovics el al. (2003), is the significant relationship of these perinatal outcomes with “neonatal morbidity and mortality” (p. 1052). Neonatal mortality is one of the areas of concern for nursing due to high mortality rates around the world and especially in developing countries (Straughn et al.,2003).

Purpose:

The purpose for conducting the study has been explicitly stated by Ickovics et al. (2003). The stated purpose can be accomplished very well because both the outcomes that are birth weight and gestational age, are measureable and thus the research problem is testable (Haber & Cameon, 2005). A quantitative approach is suitable for this study as the variables are quantifiable and can be described objectively in numbers. Ickovics et al. (2003) have introduced the problem statement after giving a brief background of the importance of the adequate prenatal care, and the factors that determine the adequate prenatal care. They then introduce the subject of group prenatal care as a “structural innovation” in the domain of prenatal care (Ickovicd et al., 2003, p. 1052), and then share the problem statement that this innovative method of provision of prenatal care has not been tested yet.

The authors have stated the underlying assumptions of the study. Ickovics et al.(2003) believe that more time the pregnant women spent together, the better will be their understanding of the health behaviors, and they will receive more social support from each other. This will reduce their risk behaviors for instance smoking leading to low birth weight. The limitations of the study have also been discussed explicitly in the article Ickovics et al. (2003) admit that their study is limited because of non-random selection of the women for group prenatal care. The limitation is realistic because the practice was already in place and researchers wanted to observe the outcomes in relation to the two different approaches to care. Moreover, this is an inherent feature of the cohort design that the groups are selected on the basis of their exposure or non-exposure to a particular phenomenon which is not controlled by the researcher, rather the choice is made by the subject themselves. This feature of the cohort design makes it prone to “selection bias.”(Rochon et al., 2005).

Review of Literature

The review of the literature presented by Ickovics et al., (2003) is comprehensive. It starts by emphasizing the importance of adequate prenatal care in terms of perinatal outcomes. It then focuses on the factors that make the prenatal care adequate. The authors then describe the group prenatal care as a structure innovation designed to make the prenatal care adequate, and they appreciate that this new approach has not been tested yet for its efficacy in improving prenatal outcomes. The review then proceeds with a brief description of Centering Pregnancy Program and its components, which finally leads to the statement of purpose of the study. The review ends with a rationale for the selection of study population that is black and Latinas women who are vulnerable for adverse perinatal outcomes. There is an evident relationship of the review with the purpose of study in that the authors have presented only those studies that are pertinent to perinatal care and that have established the efficacy of group care in other population. The review includes a mix of recent and old studies. As this study was accepted for publication in 2003, most of the studies cited in the review were not current, that is those studies were not published in the last five years of the date when this study was accepted for publication (Burns & Groove, 2007); and there are only 10 out of 26 studies, that were current and were published in the last five years of the date of acceptance of the study under consideration, for publication. The review clearly indicates that the other interventions that have been planned to augment prenatal care were not found to be effective in improving the women’s perinatal outcome.

Ethical Consideration:

The study has been designed in a manner that there are minimum risks to the subjects. Since this is a non experimental study and only intends to observe the impact of an intervention that is already in progress without manipulating any of the variables, therefore there are minimal risks associated with it (Rochon et al, 2005). However, the researchers have not made any extra effort to maximize the benefits for the subjects. There is no mention of how and when informed consent was attained from the subjects, but this may have not been reported as it was an observational study and most likely was related to quality improvement and do not need consent. The researchers have obtained the approval of research from institutional review boards at these clinics. Also, at one point, the authors have described their efforts to maintain anonymity of the subjects. The authors explained that while selecting matched cohort for the study they entered all the information needed to select the cohort, except for the patient identification information.

Theoretical/Conceptual Framework:

The study is based on an underlying framework that is the centering pregnancy model. The underlying assumptions of the study are derived from the model that includes the belief that learning in groups promote shared support, change in behavior, and problem solving skills and it has significant impact on the birth outcome (Rising, 1998). The rationale for the use of the framework is evident from the fact that the entire concept of group prenatal care is based on this model and underlying assumptions. In fact, the research problem and the purpose are also derived from the same model, because the purpose of the study is to examine the impact of group prenatal care.

Hypothesis:

The hypothesis to be tested by the study is formally stated in the article. The hypothesis is derived from the research problem and hence predicts that “infants of women in group prenatal care would have significantly higher birth weight and be less likely to be delivered preterm compared with those who received individual prenatal care” (Ickovics et al, 2003, p. 1052). This is a complex hypothesis as it predicts the relationship between one independent variable (provision of group prenatal care), and two independent variables (birth weight and gestational age). The hypothesis can also be categorized as directional hypothesis, as it predicts the expected direction of the relationship between provision of group prenatal care, birth weight, and gestational age. According to Polit & Beck (2008) “a directional hypothesis indicates that the researcher has intellectual commitment to the hypothesized outcome, which might result in bias.” (p.99).

Haber & Cameron (2005) therefore suggest that directional hypothesis should only be formed on the basis of sound literature evidences and theoretical basis. In this case, Ickovics et al (2003) have got sound literature support, and since group prenatal care is one of the ways to augment the content of prenatal care; therefore, the authors have hypothesized that group prenatal care will lead to improved birth weight and gestational age. Also, there is sound theoretical base to this hypothesis, as it is based on the centering pregnancy model. The hypothesis is spelled out clearly and it objectively describes the outcome variables (Polit & Back, 2008), that is perinatal outcomes have been quantified and objectively described as birth weight and gestational age.

Sampling:

Ickovics et al (2003) clearly described the population as “Black and Hispanic pregnant women of low socioeconomic status, entering prenatal care at 24 or less weeks of gestation.” (p.1051).The authors have also described in detail the characteristics of the sample such as race, age, parity, and city of residence. The detailed and comprehensive description of the sample gives an in depth understanding of the sample’s characteristics and determines the generalization of the findings to a specific population based on these characteristics (Haber & Singh, 2005). In this case, looking at the characteristics of the sample, the findings can be generalized to black and Hispanic pregnant women of low socioeconomic group, aged 25 or younger, as more than 85% of the sample consisted of black women who were 25 years old or younger. Sample’s characteristics help in determine heterogeneity or homogeneity of the sample (Haber & Singh, 2005). In this case, some of the sample’s characteristics that had the potential to act as cofounders, for instance age, race, parity, history of preterm labor and total number of visits were matched in both the groups. This resulted in homogeneity among the two groups in terms of the above mentioned characteristics. The matching of the two groups on the basis of these characteristics also reduced the potential sampling bias that could have resulted if the groups would’ve been different in terms of these characteristics and the resulting health behaviors. If the groups were not matched, these differences in groups could have accounted for the differences in outcomes, rather than intervention itself.

Ickovics et al (2003) have described the sample selection process in detail. They have also indicated the potential sampling bias due to lack of randomization while enrolling subjects in group prenatal care. Women, who voluntarily enrolled themselves in the group prenatal care programme at the clinics, were recruited as participants in the group that received group prenatal care. Ickovics et al (2003) have also comprehensively described the controls that they have utilized to minimize sampling error or sampling bias, that is, they have randomly selected the comparison group through a computer programme on the basis of first available patient with closest delivery date, by matching some of the characteristics of the treatment group.

The clinics from where the subjects were recruited were also selected by non probability sampling method, selecting only those clinics that served minority women from low socio economic background. The non probability sampling method employed in the study fits well with the level of inquiry and design of the study as Haber & Singh (2005) supported “non experimental studies usually use non probability, purposive sampling method.” (p. 53)

The sample size taken by Ickovics et al (2003), that is N=458 is sufficiently large. Each group had 229 research subjects. The sufficiency of the sample size was assured by conducting a power analysis that “229 pairs had a power of 0.80 to detect a small effect…reflecting the ability to detect a difference between the two treatment groups of 155 g.” (p. 1053). According to Burns & Groove (2007) the power of 0.8 is the minimum acceptable level of power for any study.

Research Design:

Ickovics et al (2003) have used cohort design, which is also known as longitudinal prospective design. The cohort design, which is a non experimental design, is appropriate for the level of inquiry of the study. In this the researchers intended to examine the difference between the outcomes of the women who received group perinatal care versus who received individual care. LoBiondo-Wood, Haber & Singh (2005) supported that longitudinal design is quite appropriate for testing the difference between the two groups in terms of outcomes variables. However, Ickovics et al (2003) could have used an experimental design for this study, if they wanted to determine the cause and effect relationship between the group prenatal care and perinatal outcomes. This would also have assured randomization of subjects into intervention and control group and would have given a higher level of evidence. However, they may have chosen non experimental study design rather than experimental design to study the impact of group prenatal care in a natural setting, and not in a control study setting. As discussed in the sampling section, potential effects of unwanted variables like race, age, parity, city of residence, history of preterm labor, and total number of prenatal visits have been controlled by Ickovics et al (2003) by matching the cohorts on the basis of these characteristics, in order to ensure significant internal validity of the study (Polit & Beck, 2008). Also, Ickovics et al (2003) have recruited a large sample to ensure a power of 0.8 for the study, which is also one of the ways to maximize the internal validity of the study (Polit & Beck, 2008).

Data Collection:

Before data collection the researchers have to operationalize the variables of interest (Sullivan-Bolyani, et al 2005). Ickovics et al (2003) have operationalized gestational age as term or preterm based on the weeks of gestation as measured by the last menstrual period and ultrasound.

Subjects’ demographics information and the number of prenatal visits were obtained from the medical records of the clinic. It has not been mentioned that who determined gestational age through ultrasound, who measured the neonate’s weight, and who retrieved data from medical records. It is really important to know who collected data in order to establish its accuracy, as the expertise and training of the data collector has significant impact on the correctness and precision of data (Sullivan-Bolyai et al, 2005).

Quantitative Analysis:

Ickovics et al (2003) have used both descriptive and inferential statistics to examine the data. Since the purpose of the study was to examine the differences between the two groups, therefore the inferential statistics was used that is McNemar test, which is appropriate to the level of inquiry due to matched groups. It is also appropriate to the cohort design as this design also intends to measure differences between the two groups, in terms of outcome variables (Polit & Beck, 2008). The other inferential statistical test used is paired t-test which is also appropriate for the study as it is used to test differences between the means of two groups that are matched or paired with each other on the basis of certain characteristics (Polit & Beck, 2008).

Another statistic used in the study is the F statistic. It appears as if the authors have used F statistic when applying multiple linear regression because F statistic has been used while indicating the interaction effect between birth weight and preterm delivery (p. 1054). Linear regression is used to explain how much variability in outcome variable is attributable to the independent variable (Burns & Groove, 2007).

The authors have used descriptive statistic to describe the distribution of demographic variables among the subjects like age, race and parity. They also have used descriptive analysis to describe the distribution of demographic variables among the distribution of outcomes variables (birth weight and gestational age) among the sample.

Ickovics et al (2003) have used parametric as well as non parametric statistics, for instance t-test for matched pairs is a parametric test while McNemar test is a non parametric test. As few variables have been measured on the ratio level of measurement, for instance number of prenatal visits, therefore Ickovics et al (2003) had the liberty to apply parametric statistic. Ickovics et al (2003) had measured the outcome variables of birth weight and gestational age on nominal level. The birth weight was categorized as low birth weight (less than 2500 g), and very low birth weight (less than 1500 g) and the gestational age was categorized as term or preterm (less than 37 weeks of gestation). Therefore, researchers were also able to apply non parametric statistic that is McNemar test (Polit & Beck, 2008).

The consistency in the results of descriptive and inferential statistics confirms the correctness of the findings (Polit & Beck, 2008). There is a logical link between the statistical analysis and the findings of the study. Also, there is consistency in the results presented in numbers and result presented in text, for instance in the above example, the statistical result shows p<0.01 which is statistically significant, and this is well supported by the explanation that is birth weight was greater in infants of women who received group prenatal care versus individual prenatal care. However, Ickovics et al (2003) have not explicitly stated whether they have taken uniform level of significance for all the statistical tests performed or are different for each test, and if so then what is the level of significance for each test.

The graphical and tabular presentations are accurate and appropriate and matches with the findings presented in text (Sullivan-Bolyayi, et al, 2005). The statistics presented in these tables and the graphs are according to their appropriate level of measurement. For instance in table 2, mean and standard deviations have only been calculated for the birth weight which is the only ratio level data in that table, the other variables that are at nominal level of measurement were calculated in percentages (Sullivan-Bolyayi, et al, 2005). The authors have not only established the significance of findings, but they have also described the clinical significance of the results.

Conclusion and Recommendations:

The results derived from data analysis are clearly stated and explained with reference to the research question and hypothesis. The findings are stated succinctly and the authors have related their findings with the research purpose and its underlying assumptions. Ickovics et al (2003) have discussed that the findings can be generalized among women who are vulnerable for preterm births. This seems to be an overgeneralization beyond the study population, because the study sample and the target population was black and Hispanic women who were high risk for preterm birth and were of low socioeconomic status. These findings may not be applicable to all the women who are at risk of preterm births without specifying their ethnicity and socioeconomic status. Ickovics et al (2003) have also discussed the potential benefits of implementing the findings. The authors have also recommended that further research needs to be done for determining the exact mechanisms involved in group prenatal care that results in improved perinatal outcome. Another recommendation is to widely apply group prenatal care in future, however, the authors also appreciate that it is not easy to introduce such big structural changes.

Strengths and limitations of the study:

Overall, the study is a good effort in examining the impact of group prenatal care on perinatal outcomes. A well formulated hypothesis, relevant and comprehensive literature review, an in depth account of sample’s characteristics, well thought research design and statistical analysis are strengths of the study. However, randomization of subjects at the time of recruitment, employment of research ethics such as voluntary participation and realistic generalization of the findings would have added more strength to it.

Appendix 1

Pregnancy outcomes: Group vs individual prenatal care

STUDY

Study Design

Outcomes: Group Vs Individual Prenatal Care

OR (95% CI)

NNT

Ickovics JR et al (2007).

RCT N=1047

Preterm births

0.67 (0.44-0.98)

25

Preterm births in African American women

0.59 (0.38-0.92)

17

Breastfeeding initiation

1.73 (1.28-2.35)

8

Less-than-adequate prenatal care*

0.68 (0.50-0.91)

16

RESULTS (P VALUE)

Ickovics JR et al (2003).

Matched cohort N=458

Birth weight (g)

3228 vs 3159 (P<.01)

–

Preterm birth weight (g)

2398 vs 1990 (P<.05)

–

Grady MA et al (2004).

Cohort study with clinic comparison N=124 (intervention)

Preterm births <37 wk (%)

10.5 vs 25.7 (P<.02)

7

Low birth weight <2500 g (%)

8.8 vs 22.9 (P<.02)

7

Breastfeeding at hospital discharge (%)

46 vs 28 (P<.02)

6

Rising (1998)

Descriptive analysis N=111

3rd trimester emergency room visits (%)

26 vs 74 (P=.001)

2

Baldwin (2006)

2-group pre-/post-test design N=98

Change in prenatal knowledge scoresâ€

0.98 vs 0.4 (P=.03)

–

CI, confidence interval; NN T, number needed to treat; OR, odds ratio.

*Kotelchuck Adequacy of Prenatal Care Utilization Index, a validated scoring scale encompassing timing of initiation of care, number of visits, and quality and content of prenatal care. Kotelchuck M. An evaluation of the Kessner Adequacy of Prenatal Care Index and the proposed Adequacy of Prenatal Care Utilization Index. Am J Public Health. 1994;84:1414-1420.

Ref: Williams, K.J and Kaufmann, L (2009) The journal of family practice , 58, (7)