Person-centred oral hydration care for older people with dementia admitted to acute hospital wards: Empirical research qualitative.

AIMS AND OBJECTIVES: To conduct an in-depth exploration of oral hydration care provided to people living with dementia in acute hospital wards, using a person-centred care framework. BACKGROUND: Oral hydration care is an important, yet rarely explored aspect of fundamental care for people with dementia admitted to acute hospitals. Using person-centred care as a conceptual framework we investigated how oral hydration care is delivered for people living with dementia in acute hospital wards. DESIGN: A qualitative, multiple-case study. The cases were three acute wards in one hospital. METHODS: Direct observation of care for 13 people with dementia (132 h), semistructured interviews with ward staff (n = 28), ward leaders (n = 4), organisational leaders (n = 5), people with dementia (n = 6), their relatives (n = 5), documentary analysis of clinical inpatient records (n = 26) and relevant hospital policies. Data were analysed using framework analysis. RESULTS: Four themes were identified: (1) The acute hospital: oral hydration is obscured and not prioritised (2) Overshadowing of oral hydration at ward level (3) Siloed nature of hydration roles (4) Strategies for, and barriers to, delivering person-centred oral hydration care. CONCLUSIONS: This study combines the concept of person-centred care and oral hydration care for people living with dementia admitted to acute hospital wards, demonstrating that person-centred hydration care was complex and not prioritised. RELEVANCE TO CLINICAL PRACTICE: Nurses should consider means of improving prioritisation and cohesive delivery of person-centred hydration care in acute hospital wards.

End-of-life and immediate postdeath acute hospital interventions: scoping review.

BACKGROUND: Hospital remains the most common place of death in the UK, but there are ongoing concerns about the quality of end-of-life care provision in this setting. Evaluation of interventions in the last days of life or after a bereavement is methodologically and ethically challenging. AIM: The aim was to describe interventions at the very end of life and in the immediate bereavement period in acute hospitals, with a particular focus on how these are evaluated. METHOD: A scoping review was conducted. Studies were restricted to peer-reviewed original research or literature reviews, published between 2011 and 2021, and written in the English language. Databases searched were CINAHL, Medline and Psychinfo. RESULTS: From the search findings, 42 studies were reviewed, including quantitative (n=7), qualitative (n=14), mixed method (n=4) and literature reviews (n=17). Much of the current research about hospital-based bereavement care is derived from the intensive and critical care settings. Three themes were identified: (1) person-centred/family-centred care (memorialisation), (2) institutional approaches (quality of the environment, leadership, system-wide approaches and culture), (3) infrastructure and support systems (transdisciplinary working and staff support). There were limited studies on interventions to support staff. CONCLUSION: Currently, there are few comprehensive tools for evaluating complex service interventions in a way that provides meaningful transferable data. Quantitative studies do not capture the complexity inherent in this form of care. Further qualitative studies would offer important insights into the interventions.

Implementation and perceived impact of the SWAN model of end-of-life and bereavement care: a realist evaluation.

OBJECTIVES: To evaluate the End-of-Life and Bereavement Care model (SWAN) from conception to current use. DESIGN: A realist evaluation was conducted to understand what works for whom and in what circumstances. The programme theory, derived from a scoping review, comprised: person and family centred care, institutional approaches and infrastructure. Data were collected across three stages (May 2021 to December 2021): semi-structured, online interviews and analysis of routinely collected local and national data. SETTING: Stage 1: Greater Manchester area of England where the SWAN model was developed and implemented. Stage 2: Midlands. Stage 3: National data. PARTICIPANTS: Twenty-three participants were interviewed: Trust SWAN leads, end-of-life care nurses, board members, bereavement services, faith leadership, quality improvement, medicine, nursing, patient transport, mortuary, police and coroners. RESULTS: Results from all three stages were integrated within themes, linked to the mechanisms, context and outcomes for the SWAN model. The mechanisms are: SWAN is a values-based model, promoting person/family-centred care and emphasising personhood after death. Key features are: memory-making, normalisation of death and 'one chance' to get things right. SWAN is an enablement and empowerment model for all involved. The branding is recognisable and raises the profile of end-of-life and bereavement care. The contextual factors for successful implementation and sustainability include leadership, organisational support, teamwork and integrated working, education and engagement and investment in resources and facilities. The outcomes are perceived to be: a consistent approach to end-of-life and bereavement care; a person/family-centred approach to care; empowered and creative staff; an organisational culture that prioritises end-of-life and bereavement care. CONCLUSION: The SWAN model is agile and has transferred to different settings and circumstances. This realist evaluation revealed the mechanisms of the SWAN model, the contextual factors supporting implementation and perceived outcomes for patients, families, staff and the organisation.

The Role and Development of Advanced Clinical Practice Within Allied Health Professions: A Mixed Method Study.

OBJECTIVE: To investigate the profiles of advanced clinical practitioners (ACPs) in the allied health professions (AHPs) and their skills, attributes, experiences and involvement in new models of care. METHODS: A 2 phase, cross sectional, mixed method survey of AHP ACPs across London was conducted in 2018-2019. Online questionnaires were completed by 127 AHP ACPs and then semi-structured interviews were conducted with 15 AHP ACPs. RESULTS: The survey results gave a comprehensive overview of the attributes of AHPs in ACP roles across London. There was considerable variability between role titles, types and levels of qualification, and evolution of the roles. The respondents predominately worked in clinical practice, and less frequently in other ACP domains (research, leadership and management, education). The interview findings provided in-depth insights into the AHP ACP roles within four themes: being advanced, career pathways, outcomes of the advanced practitioner role and influencing and transforming. The "Being advanced" theme highlighted that expert practice comprised confident and autonomous practice, leadership, and applying specialist and expert decision-making skills. "Career pathways" highlighted the diversity within the participants' roles, titles, career opportunities and development. In the "Outcomes of the advanced clinical practitioner role" theme, the ACPs described their services as prompter, more accessible and providing an improved patient journey. The "Influencing and transforming" theme highlighted networking and dissemination and ideas for innovation, influencing and transforming services. CONCLUSION: This is the first comprehensive profile of ACP roles across AHPs and indicates that these roles are already having a positive impact on healthcare services and supporting new models of care. However, establishing the necessary infrastructure, standardization and governance for ACP roles across sectors, along with the career pathways, funding, sustainability and education, could increase impact in the future.

Preparing student nurses to be healthy role models: A qualitative study.

There are national and international expectations for nurses to be healthy role models. This study aimed to investigate student nurses', nurse educators' and registered nurses' experiences and perceptions about being healthy role models and to explore whether nurse education prepares students to become healthy role models. The study used an exploratory qualitative design and was based in the south of England. Participants (n = 39) included student nurses, nurse lecturers and registered nurses. Data collection was conducted through focus groups and data were analysed using thematic analysis. The themes highlighted nurses' understanding of the key features of being a healthy role model, and perceptions that working as nurses does not support individuals to be healthy. Participants had varied views about whether they should be healthy role models or mirror society and share the same struggles with their health. Students and registered nurses reported inadequate understanding of health promotion and that there was a lack of healthy lifestyle content within undergraduate nurse education. Participants also considered that role modelling healthy behaviour would not in itself influence behaviour change. In conclusion, there needs to be preparation and support for student nurses to be healthy role models from the outset of nurse education.

Exchanging focus groups for individual interviews when collecting qualitative data.

BACKGROUND: Focus group data are created through interactions between participants whereas data from individual interviews are created through a dialogue between the participant and researcher, whose questions set the agenda. Focus groups and individual interviews are therefore used for different reasons and produce different data. However, sometimes researchers exchange focus groups for individual interviews when collecting data. AIM: To discuss the rationale for using focus groups, reasons for exchanging focus groups for interviews when collecting qualitative data and any implications for the quality of research in doing so. DISCUSSION: The author first considers the unique features of focus groups and how these contrast with individual interviews. The reasons why individual interviews are added to studies designed for focus groups are then considered, based on the author's experience and a selection of research studies. Researchers showed flexibility, adapting plans to include particular individuals, but they could have provided clearer rationales for using focus groups and changing their designs. CONCLUSION: Researchers should rationalise their choices of research methods and adopt a transparent and systematic approach, with a clear account of the research process and explanations about any changes to their original designs. IMPLICATIONS: for practice Researchers should recognise the differences between focus group and interview data, reflect on their rationales for using each method, and justify their choices. If recruitment is likely to be difficult, researchers intending to use focus groups could nevertheless include individual interviews in their initial design.

Changing from 12-hr to 8-hr day shifts: A qualitative exploration of effects on organising nursing care and staffing.

AIMS AND OBJECTIVES: To investigate (a) How nursing care is organised on wards where nursing staff work different lengths of day shifts, and (b) How length of day shift affects the staffing of wards. BACKGROUND: Twelve-hour shifts have become increasingly common worldwide but there are concerns about impact on care quality and safety. Eight-hour shifts, and how day shift length affects how nurses organise their work, and staffing, have been little studied. DESIGN: Case study. METHODS: The setting was two older people's wards in an acute hospital in England. Nursing staff on one ward continued to work 12-hr day shifts; staff on the other ward worked 8 hr late and early day shifts, with an afternoon overlap, for 6 months. Qualitative interviews were conducted with 22 nursing staff. Semi-structured observations were conducted from 12-15.00 (5 × 3 hr episodes on each ward). Data analysis was conducted using the Framework approach. RESULTS: Theme 1: Organising nursing care and staff activities, (sub-themes: Care delivery across a 12 hr shift; Care delivery on early and late 8 hr shifts; Staff communication and documentation; Staff breaks; Teaching, supervision and staff development); Theme 2: Staffing wards with different length of day shift (sub-themes:: Adequacy of staffing and use of temporary staff; Recruitment and retention of staff after introducing 8 hr shifts). CONCLUSION: Nursing staff organised care on 8-hr shifts similarly to 12-hr shifts but then felt dissatisfied with their care delivery and handovers. Nursing staff on both wards approached care in a task-focused way. There were concerns that adopting an 8-hr shift pattern negatively affected recruitment and retention. RELEVANCE TO CLINICAL PRACTICE: Changing from 12 hr to 8 hr day shifts may affect nursing staff satisfaction with their care delivery and handovers, and have a negative effect on staffing wards.

Development of tools to measure dignity for older people in acute hospitals.

BACKGROUND: Dignity is a concept that applies to all patients. Older patients can be particularly vulnerable to experiencing a loss of dignity in hospital. Previous tools developed to measure dignity have been aimed at palliative and end-of-life care. No tools for measuring dignity in acute hospital care have been reported. OBJECTIVES: To develop tools for measuring patient dignity in acute hospitals. SETTING: A large UK acute hospital. We purposively selected 17 wards where at least 50% of patients are 65 years or above. METHODS: Three methods of capturing data related to dignity were developed: an electronic patient dignity survey (possible score range 6-24); a format for nonparticipant observations; and individual face-to-face semi-structured patient and staff interviews (reported elsewhere). RESULTS: A total of 5,693 surveys were completed. Mean score increased from 22.00 pre-intervention to 23.03 after intervention (p < 0.001). Staff-patient interactions (581) were recorded. Overall 41% of interactions (239) were positive, 39% (228) were neutral, and 20% (114) were negative. The positive interactions ranged from 17%-59% between wards. Quality of interaction was highest for allied health professionals (76% positive), lowest for domestic staff (22% positive) and pharmacists (29% positive), and intermediate for doctors, nurses, healthcare assistants and student nurses (40%-48% positive). A positive interaction was more likely with increased length of interaction from 25% (brief)-63% (longer interactions) (F[2, 557] = 28.67, p < 0.001). CONCLUSIONS: We have developed a simple format for a dignity survey and observations. Overall, most patients reported electronically that they received dignified care in hospital. However, observations identified a high percentage of interactions categorised as neutral/basic care, which, while not actively diminishing dignity, will not enhance dignity. There is an opportunity to make these interactions more positive.

The views of older people and health professionals about dignity in acute hospital care.

AIMS AND OBJECTIVES: To report the findings from interviews conducted as part of a wider study on interventions to support dignified care in older people in acute hospital care. The data in this study present the interview data. BACKGROUND: Dignity is a complex concept. Despite a plethora of recommendations on how to achieve dignified care, it remains unclear how to attain this in practice and what the priorities of patients and staff are in relation to dignity. DESIGN: A purposive sample of older patients and staff took part in semi-structured interviews and gave their insight on the meaning of dignity and examples of what sustains and breaches a patient's dignity in acute hospital care. METHOD: Thirteen patients and 38 healthcare professionals in a single metropolitan hospital in the UK interviewed. Interviews were transcribed verbatim and underwent a thematic analysis. RESULTS: The meaning of dignity was broadly agreed on by patients and staff. Three broad themes were identified: the meaning of dignity, staffing level and its impact on dignity, and organisational culture and dignity. Registered staff of all healthcare discipline and student nurses report very little training on dignity or care of the older person. CONCLUSION: There remain inconsistencies in the application of dignified care. Staff behaviour, a lack of training and the organisational processes continue to result in breaches to dignity of older people. Clinical nurses have a major role in ensuring dignified care for older people in hospital. RELEVANCE TO CLINICAL PRACTICE: There needs to be systematic dignity-related training with regular refreshers. This education coupled with measures to change the cultural attitudes in an organisation towards older peoples' care should result in long-term improvements in the level of dignified care. Hospital managers have an important role in changing system to ensure that staff deliver the levels of care they aspire to.

Nurses as role models in health promotion: a concept analysis.

There are national and international expectations that nurses are healthy role models; however, there is a lack of clarity about what this concept means. This study used concept analysis methodology to provide theoretical clarity for the concept of role models in health promoting behaviour for registered nurses and students. The framework included analysis of literature and qualitative data from six focus groups and one interview. Participants (n=39) included pre-registration students (adult field), nurse lecturers and registered nurses (RNs), working in NHS Trusts across London and South East London. From the findings, being a role model in health promoting behaviour involves being an exemplar, portraying a healthy image (being fit and healthy), and championing health and wellness. Personal attributes of a role model in health promoting behaviour include being caring, non-judgemental, trustworthy, inspiring and motivating, self-caring, knowledgeable and self-confident, innovative, professional and having a deep sense of self.

How does the length of day shift affect patient care on older people's wards? A mixed method study.

BACKGROUND: Internationally, studies have focused on whether shift length impacts on patient care. There are also ongoing concerns about patient care for older people in hospital. The study aim was to investigate how length of day shift affects patient care in older people's hospital wards. OBJECTIVES: 1) To explore how length of day shift affects patient care in older people's wards; 2) To explore how length of day shift affects the quality of communication between nursing staff and patients/families on older people's wards DESIGN: A mixed method case study. SETTINGS: The study was based on two older people's wards in an acute hospital in England. One ward was piloting two, overlapping 8h day shifts for 6 months while the other ward continued with 12h day shifts. PARTICIPANTS AND METHODS: Qualitative interviews were conducted with 22 purposively recruited nursing staff (17 registered nurses; 5 nursing assistants). An analysis of patient discharge survey data was conducted (n=279). Twenty hours of observation of nursing staff's interactions with patients and families was conducted, using an adapted version of the Quality of Interaction Schedule (301 interactions observed), with open fieldnotes recorded, to contextualise the observations. RESULTS: There were no statistically significant differences in patient survey results, or quality of interactions, between the two wards. There were three overall themes: Effects of day shift length on patient care; Effects of day shift length on continuity of care and relationships; Effects of day shift length on communication with patients and families. Nursing staff believed that tiredness could affect care and communication but had varied views about which shift pattern was most tiring. They considered continuity of care was important, especially for older people, but had mixed views about which shift pattern best promoted care continuity. The difficulties in staffing a ward with an 8h day shift pattern, in a hospital that had a 12h day shift pattern were highlighted. Other factors that could affect patient care were noted including: ward leadership, ward acuity, use of temporary staff and their characteristics, number of consecutive shifts, skillmix and staff experience. CONCLUSIONS: There was no conclusive evidence that length of day shift affected patient care or nursing staff communication with patients and families. Nursing staff held varied views about the effects of day shift length on patient care. There were many other factors identified that could affect patient care in older people's wards.

An exploration of the 6Cs as a set of values for nursing practice.

In 2012, after several high-profile cases of poor quality care in England and concerns about a lack of compassion and a need to refocus on values, the Department of Health in England published a new strategy for nursing, midwifery and care staff: Compassion in Practice. The strategy included the 6Cs (care, compassion, courage, communication, competence and commitment) and in the follow-on framework, produced by NHS England in 2016, the 6Cs were included again. This article explains the background to the 6Cs and highlights the other values frameworks that nurses and midwives must work within too. Nursing theorists have studied caring extensively and the earlier set of 6Cs, produced by a Canadian nurse Sister Simone Roach, is explained in the article. The meaning of the DH's 6Cs is then explored in detail with reference to previous research and nursing theory.

Enhancing Care Transitions for Older People through Interprofessional Simulation: A Mixed Method Evaluation.

INTRODUCTION: The educational needs of the health and social care workforce for delivering effective integrated care are important. This paper reports on the development, pilot and evaluation of an interprofessional simulation course, which aimed to support integrated care models for care transitions for older people from hospital to home. THEORY AND METHODS: The course development was informed by a literature review and a scoping exercise with the health and social care workforce. The course ran six times and was attended by health and social care professionals from hospital and community (n = 49). The evaluation aimed to elicit staff perceptions of their learning about care transfers of older people and to explore application of learning into practice and perceived outcomes. The study used a sequential mixed method design with questionnaires completed pre (n = 44) and post (n = 47) course and interviews (n = 9) 2-5 months later. RESULTS: Participants evaluated interprofessional simulation as a successful strategy. Post-course, participants identified learning points and at the interviews, similar themes with examples of application in practice were: Understanding individual needs and empathy; Communicating with patients and families; Interprofessional working; Working across settings to achieve effective care transitions. CONCLUSIONS AND DISCUSSION: An interprofessional simulation course successfully brought together health and social care professionals across settings to develop integrated care skills and improve care transitions for older people with complex needs from hospital to home.

Realising dignity in care home practice: an action research project.

BACKGROUND: More than 400,000 older people reside in over 18,000 care homes in England. A recent social care survey found up to 50% of older people in care homes felt their dignity was undermined. Upholding the dignity of older people in care homes has implications for residents' experiences and the role of Registered Nurses. AIMS AND OBJECTIVES: The study aimed to explore how best to translate the concept of dignity into care home practice, and how to support this translation process by enabling Registered Nurses to provide ethical leadership within the care home setting. DESIGN: Action research with groups of staff (Registered Nurses and non-registered caregivers) and groups of residents and relatives in four care homes in the south of England to contribute to the development of the dignity toolkit. METHODS: Action research groups were facilitated by 4 researchers (2 in each care home) to discuss dignity principles and experiences within care homes. These groups reviewed and developed a dignity toolkit over six cycles of activity (once a month for 6 months). The Registered Nurses were individually interviewed before and after the activity. RESULTS: Hard copy and online versions of a dignity toolkit, with tailored versions for participating care homes, were developed. Registered Nurses and caregivers identified positive impact of making time for discussion about dignity-related issues. Registered Nurses identified ongoing opportunities for using their toolkit to support all staff. CONCLUSIONS: Nurses and caregivers expressed feelings of empowerment by the process of action research. The collaborative development of a dignity toolkit within each care home has the potential to enable ethical leadership by Registered Nurses that would support and sustain dignity in care homes. IMPLICATIONS FOR PRACTICE: Action research methods empower staff to maintain dignity for older people within the care home setting through the development of practically useful toolkits to support everyday care practice. Providing opportunities for caregivers to be involved in such initiatives may promote their dignity and sense of being valued. The potential of bottom-up collaborative approaches to promote dignity in care therefore requires further research.

Working in partnership with patients and carers.

Health policy and healthcare professional guidelines promote patient and carer involvement, which includes working in partnership with service users in all aspects of healthcare provision, research and education. This article explores the expectations for nurses to work in partnership with patients and carers, examines the definitions and theories of working in partnership and related concepts, as well as considering examples of partnership working in nursing practice.