DIALOR (DIgitAL cOaching for fRailty): protocol for a single-arm mixed-methods feasibility study of a digital health coaching intervention for older people with frailty in primary care.

BACKGROUND: Multidomain interventions in older adults offer the best opportunity to prevent, delay or reverse existing symptoms in the earlier stages of frailty and improve independence but can be costly, and difficult to deliver at scale. However, digital health interventions enable personalised care and empowerment through self-management of long-term conditions, used at any time and when combined with health coaching offer the potential to enhance well-being and facilitate the achievement of health-related goals. We aim to evaluate the feasibility and acceptability of a digital health platform for long-term disease management combined with health coaching for people living with mild-moderate frailty, targeting self-identified goals-activity, nutrition, mood, enhancing social engagement and well-being. METHODS AND ANALYSIS: This is a non-randomised feasibility, single-group, pretest/post-test study, using qualitative and quantitative methods. The digital health coaching intervention (DIALOR-DIgitAL cOaching for fRailty) has been developed for implementation to older adults, aged 65 years or older with mild to moderate frailty and diagnosis of one or more long-term health conditions in the community. Participants will receive 12 weeks of health coaching and have access to a mobile health platform for 6 months. The primary outcome measure is the acceptability and feasibility of DIALOR along with a range of secondary outcome measures (including frailty, functioning measures, quality of life, social engagement, diet quality and self-reported indicators) collected at baseline and at 6 months. The findings will inform whether a wider effectiveness trial is feasible and if so, how it should be designed. ETHICS AND DISSEMINATION: Ethical approval has been granted by the Southeast Scotland Research Ethics Committee 02 (reference: 22/SS/0064). Research findings will be disseminated in a range of different ways to engage different audiences, including publishing in open-access peer-reviewed journals, conference presentations, social media, dissemination workshop with patients, carers, and healthcare professionals and on institution websites.

The changing role of Advanced Clinical Practitioners working with older people during the COVID- 19 pandemic: A qualitative research study.

BACKGROUND: COVID-19 was identified as a pandemic by the World Health Organisation (WHO) in December 2020. Advanced Clinical Practitioners (ACPs) in England working with older people with frailty, experienced their clinical role changing in response to the emergency health needs of this complex population group. In contrast to other countries, in England Advanced Clinical Practitioners are drawn from both nursing and allied health professions. Whilst much of the literature emphasises the importance of ensuring the sustainability of the Advanced Clinical Practitioners' role, the pandemic threw further light on its potential and challenges. However, an initial review of the literature highlighted a lack of research of Advanced Clinical Practitioners' capabilities working with uncertainty in disaster response situations. AIM: To capture the lived experience of how English Advanced Clinical Practitioners working with older people adapted their roles in response to the COVID-19 pandemic (October 2020-January 2021). DESIGN, SETTING AND PARTICIPANTS: A qualitative research design was used. Following ethical approval, 23 Advanced Clinical Practitioner volunteer participants from across England with varied health professional backgrounds were recruited from Advanced Clinical Practitioners' professional and social media networks on Twitter using a snowballing technique. METHODS: Depending on preference or availability, 23 participants (nurses (18), physiotherapists (2), paramedics (2) and a pharmacist (1)) were interviewed singularly (n = 9) or as part of 3 focus groups (n = 14) using Zoom video communication. Audio recordings were transcribed and using qualitative data analysis software, NVivo 12 pro, coded for an essentialist thematic analysis of Advanced Clinical Practitioners' responses using an inductive approach. 27 codes were identified and collated into five themes. For the purposes of this paper, four themes are discussed: experiencing different work, developing attributes, negotiating barriers and changing future provision. FINDINGS: Advanced Clinical Practitioners successfully transferred their advanced practice skills into areas of clinical need during the pandemic. Their autonomous and generic, high level of expertise equipped them for management and leadership positions where speed of change, and the dissolution of traditional professional boundaries, were prioritised. Barriers to progress included a lack of knowledge of the Advanced Clinical Practitioner role and friction between Advanced Clinical Practitioners and physicians. DISCUSSION AND CONCLUSION: The study demonstrated the successful adaption of the Advanced Clinical Practitioner role to enable more creative, personalised and sustainable solutions in the care of older people living with frailty during the pandemic. The potential of Advanced Clinical Practitioner development is in a juxtaposition to the threat of pandemic services being dismantled once the emergency nature of care has passed. Healthcare organisations have a vital part to play in considering the enablers and barriers of Advanced Clinical Practitioner capability-based practice when responding to uncertainty.

Barriers and enablers to implementing 'DEALTS2' simulation-based train-the-trainer dementia training programme in hospital settings across England: a qualitative study.

BACKGROUND: Despite approaches to provide effective dementia training in acute care settings, little is known about the barriers and enablers to implement and embed learning into practice. We were commissioned by Health Education England to develop and evaluate a new dementia training intervention 'Dementia Education And Learning Through Simulation 2' (DEALTS2), an innovative simulation toolkit to support delivery of dementia training in acute care across England. This study aimed to explore barriers and enablers experienced by trainers implementing DEALTS2 and extent to which it impacted on delivery of training and staff clinical practice. METHODS: We conducted twelve one-day DEALTS2 train-the-trainer (TTT) workshops across England in 2017 for National Health Service Trust staff employed in dementia training roles (n = 199 trainers); each receiving a simulation toolkit. Qualitative data were collected through telephone interviews 6-8 months after TTT workshops with 17 of the trainers. Open ended questions informed by the Kirkpatrick model enabled exploration of implementation barriers, enablers, and impact on practice. RESULTS: Thematic analysis revealed six themes: four identified interrelated factors that influenced implementation of DEALTS2; and two outlined trainers perceived impact on training delivery and staff clinical practice, respectively: (i) flexible simulation and implementation approach (ii) management support and adequate resources (iii) time to deliver training effectively (iv) trainer personal confidence and motivation (v) trainers enriched dementia teaching practice (vi) staff perceived to have enhanced approach to dementia care. Trainers valued the DEALTS2 TTT workshops and adaptability of the simulation toolkit. Those supported by management with adequate resources and time to deliver effective dementia training, were likely to implement DEALTS2. Trainers described positive impacts on their teaching practice; and perceived staff had enhanced their approach to caring for people with dementia. CONCLUSIONS: Trainers explained individual and organisational barriers and enablers during implementation of DEALTS2. The flexible simulation and implementation approach were key to supporting adherence of DEALTS2. To ensure wider implementation of DEALTS2 nationally, Trusts need to allocate appropriate time to deliver effective dementia training. Future research should measure staff behaviour change, patient perspectives of the intervention, and whether and how DEALTS2 has improved health and care outcomes.

Impact of the COVID-19 pandemic on end of life care delivery in care homes: A mixed method systematic review.

BACKGROUND: Current evidence suggests that COVID-19 is having a negative impact on the delivery of end of life care in care homes around the world. There is a need to collate current evidence to provide a comprehensive overview to assess extent of the problem. AIM: To describe and evaluate the impact of the COVID-19 pandemic on end of life care delivery in care homes. DESIGN: Systematic review and narrative synthesis of studies reporting qualitative and quantitative data. DATA SOURCES: The databases MEDLINE, psycINFO, SCOPUS and CINAHL were searched between December 2019 and March 2021. RESULTS: Nine studies were included. For care home staff, challenges included significant increases in responsibility and exposure to death, both of which have taken an emotional toll. Results indicate that staff tended not to be offered adequate emotional support or afforded the time to grieve. For those receiving end of life care, results indicate that the end of life care that they tended to receive, especially in the form of advance planning, was disrupted by the pandemic. CONCLUSION: The effect of the pandemic has been to exacerbate existing problems in the provision of end of life care in care homes for both service providers and users, making that which was previously opaque starkly visible. Future research is needed to explore the effects of the pandemic and its management on those receiving end of life care in care homes and their significant others.

A critical realist evaluation of advance care planning in care homes.

AIMS: To evaluate care planning in advance of end-of-life care in care homes. DESIGN: A qualitative study. METHODS: Qualitative data were collected from January 2018-July 2019 (using focus groups and semi-structured interviews) from three care homes in the South West of England. The data were analysed using thematic analysis followed by Critical Realist Evaluation. RESULTS: Participants comprised of registered nurses (N = 4), care assistants (N = 8), bereaved relatives (N = 7), and domiciliary staff (N = 3). Although the importance of advance care planning was well recognized, the emotional labour of frequently engaging in discussions about death and dying was highlighted as a problem by some care home staff. It was evident that in some cases care home staff's unmet emotional needs led them to rushing and avoiding discussions about death and dying with residents and relatives. A sparsity of mechanisms to support care home staff's emotional needs was noted across all three care homes. Furthermore, a lack of training and knowledge appeared to inhibit care home staff's ability to engage in meaningful care planning conversations with specific groups of residents such as those living with dementia. The lack of training was principally evident amongst non-registered care home staff and those with non-formal caring roles such as housekeeping. CONCLUSION: There is a need for more focused education to support registered and non-registered care home staff to effectively engage in sensitive discussions about death and dying with residents. Furthermore, greater emotional support is necessary to help build workforce resilience and sustain change. IMPACT: Knowledge generated from this study can be used to inform the design and development of future advance care planning interventions capable of supporting the delivery of high-quality end-of-life care in care homes.

Developing a support group for carers of people living with dementia.

Significant numbers of people in the UK care for someone living with dementia. Providing support for carers is socially and economically important, enabling them to continue in their caring role and improving their day-to-day experience of caring. This article comprises a reflection by one dementia nurse specialist who ran a six-week educational support group for carers of people living with dementia. It describes the development of the group and the challenges faced, as well as discussing the future of the group, including the need to ensure its sustainability through collaborative working. The article also details some of the positive outcomes described by carers who attended the group.

Impact of 'DEALTS2' education intervention on trainer dementia knowledge and confidence to utilise innovative training approaches: A national pre-test - post-test survey.

BACKGROUND: Gaps in acute care staff knowledge, skills, and attitudes towards dementia exist. Innovative training approaches that improve the delivery of care for people with dementia are needed. We were commissioned by Health Education England to develop and evaluate a new dementia education intervention 'Dementia Education And Learning Through Simulation 2' (DEALTS2), a simulation toolkit to enhance delivery of dementia training nationally across England. OBJECTIVES: Evaluate differences in trainer dementia knowledge scores pre and post training, satisfaction with DEALTS2 Train-The-Trainer (TTT) workshops and simulation toolkit, confidence to use training approaches, and spread of implementation. DESIGN: A questionnaire survey using a pre-test - post-test design with measures completed: before (pre-test); after (T1); and 12 months post training (T2). SETTING: Twelve one-day DEALTS2 TTT workshops delivered across England in 2017. PARTICIPANTS: National Health Service Trust staff employed in dementia training roles (n = 199 trainers). METHODS: Trainers attended DEALTS2 TTT workshops and received the simulation toolkit. Data were collected between 2017 and 2018 using a questionnaire capturing differences in dementia knowledge scores, Likert scales and closed-ended questions measured satisfaction, confidence and implementation. Data were analysed using quantitative methods. RESULTS: Response rate was 92% (n = 183) at pre-test/T1 and 26% (n = 51) at T2. Trainer dementia knowledge scores increased from pre-test to T1 (p < 0.001) and were retained after 12 months in 5 of the 6 areas measured (pre-test to T2, p < 0.002); largest gains in 'humanised approaches to dementia care'. 96% (n = 176/183) were satisfied with DEALTS2 TTT workshops and simulation toolkit; 66.7% (n = 34/51) felt confident to deliver dementia training informed by DEALTS2. Adherence rates were good with 45% (n = 23/51) using the innovative training approaches within twelve months. CONCLUSIONS: The results show DEALTS2 effectively increased trainer dementia knowledge and confidence to utilise innovative dementia training approaches. Implementation of DEALTS2 varied across organisations, therefore further research should explore factors determining successful implementation.

Design and evaluation protocol for 'DEALTS 2': a simulation-based dementia education intervention for acute care settings.

BACKGROUND: There is a paucity of simulation-based dementia education programmes for acute care settings that support the development of interpersonal skills pertinent to good care. Moreover, few studies measure the effectiveness of such programmes by evaluating the persistence of practice change beyond the immediate timeframe of the workshops. We were commissioned by Health Education England (HEE) to develop and evaluate 'DEALTS 2', a national simulation-based education toolkit informed by the Humanisation Values Framework, developed at Bournemouth University and based on an experiential learning approach to facilitate positive impacts on practice. This paper describes the process of developing DEALTS 2 and the protocol for evaluating the impact of this intervention on practice across England. METHODS: Intervention development: Following an initial scoping exercise to explore the barriers and enablers of delivering the original DEALTS programme, we developed, piloted, and rolled out DEALTS 2 across England through a Train the Trainer (TTT) model. Key stakeholders were asked to critically feedback during the development process. EVALUATION DESIGN: Mixed methods approach underpinned by Kirkpatrick Model for evaluating effectiveness of training; assessing reaction, learning, behaviour, and results. Evaluation forms and telephone interviews (quantitative and qualitative) with trainers that attended TTT workshops (n = 196) and, once implemented in individual Trusts, the staff that the trainers train. CONCLUSIONS: Evaluation of implementation and impact on care delivery for people with dementia will provide evidence of effectiveness. This will support the future development of simulation-based education programmes, amidst the current complexity of pressure in resource limited healthcare settings.

Compassionate care in the community: reflections of a student nurse.

Reflecting on practice and analysing situations when compassionate care has been delivered can be a valuable way of helping student nurses develop their understanding of humanising care. This exemplar showcases a scenario when a second-year student nurse studying for a BSc (Honours) in adult nursing explored an experience while working in the community. She critically reflected on an incident highlighting a simple yet powerful example of how she helped an older couple manage an aspect of their care. This exercise helped the student to explore and understand what compassionate care means and highlighted how the value of reflection can be used to gain new insights to enhance the care of older people in her future practice in the community.

Systematic critical realist review of interventions designed to improve end-of-life care in care homes.

The demand for high-quality end-of-life care is rising. Frequently evidenced concerns about the provision of end-of-life in care homes relate to inter-disciplinary communication and engagement in advance care planning. A number of interventions employing different mechanisms have been designed to address these issues. Therefore, the aim of this systematic critical realist review was to describe and explain the effectiveness of interventions designed to improve end-of-life care in care homes. Electronic searches were conducted in ScienceDirect, MEDLINE, PubMed, PsychINFO, and CINAHL from January 2000 to August 2018. Forty one studies were included in the review. While most of the evidence identified in this review was not strong, there was evidence to suggest that education and inter-professional collaboration can be effective intervention mechanisms for improving end-of-life care in care homes. High staff turnover was a significant contextual mechanism impacting on the sustainability of interventions. In terms of human agency, it is important to note a consistent finding related to the dedication and enthusiasm of care home staff who deliver end-of-life care.

What is an older husband's experience of caring for his wife who has dementia?

A significant number of informal carers look after people who have dementia. Women's caring experiences are well documented. However, a substantially smaller amount of research exists specifically investigating the male carer perspective. This literature review explores older husbands' experiences of caring for their wives who have dementia. The findings suggest that husbands are committed to their caring role but can feel socially isolated. The caring role of older men has altered the dynamic in the marriage. Husbands continue to show commitment towards their spouses but feel that male-only support groups could offer some respite from their responsibilities. Nurses need to take time to listen to husbands' experiences, offering emotional support and signposting them to other services. Further research on the long-term effects and support needs of older male carers is needed.

Influences on clinical decision-making during a community placement: reflections of a student nurse.

High quality care is dependent on good clinical judgement and often-complex decision making. Nurses need to be able to justify and defend their clinical decisions. In this article, a third-year nursing student reflects on an incident from a community placement involving a collaborative clinical decision. Carper's (1978) four fundamental patterns of knowing are used to analyse the decision-making process. It is shown that influences on decision-making include prior knowledge and expertise, law and accountability, and ethical principles such as respect for autonomy and beneficence. Good communication, interpersonal skills and a person-centred approach have a bearing on decision-making. It is argued that intuition also has a place and may be increasingly used with experience.

Exploring the meaning of home and its implications for the care of older people.

AIMS AND OBJECTIVES: To explore the meaning of home for six baby boomers and consider how this insight can be used when caring for older people in hospital or residential settings. BACKGROUND: Feeling at home is important to help retain a sense of autonomy, security and well-being, but home is a complex concept to understand. The baby boomers are a large cohort entering later life and understanding their sense of home is not only an example of anticipatory gerontology but it could also provide the tools to explore home with the current older population, who may be in a variety of care settings. DESIGN AND METHODS: A qualitative hermeneutic approach was adopted to explore the meaning of home of six baby boomers. The participants were asked to take photographs showing what home meant to them and interpret these in a recorded photo-elicitation interview. Small teams then reviewed the images to provide further insight. Finally, all the data were reviewed to provide an overall analysis of the revealed meaning of home. RESULTS: Having possessions or stuff was important for the meaning of home; being familiar with the local environment was also "homely," as well as certain textures and familiar sounds and smells; relationships with others and the ability to have choice in where and how the participants live were also significant for their meaning of home. CONCLUSIONS: The meaning of home is complex. Nevertheless, in this study, an evocative sense of home was revealed and these insights could be used in discussions with older people in care settings to help increase their sense of autonomy, security and well-being. Furthermore, these insights could also be used to develop a framework to help nursing staff guide these discussions. RELEVANCE TO CLINICAL PRACTICE: By considering the multisensory nature of the meaning of home, nurses can create a sense of home for patients. Feeling at home can improve the well-being and a sense of autonomy for patients. Enabling patients to feel more autonomous recognises the importance of a person-centred approach to care.

End-of-life care in UK care homes: a systematic review of the literature.

BACKGROUND: The number of people requiring end-of-life care provision in care homes has grown significantly. There is a need for a systematic examination of individual studies to provide more comprehensive information about contemporary care provision. AIM: The aim of this study was to systematically review studies that describe end-of-life care in UK care homes. METHOD: A systematic PRISMA review of the literature published between 2008 and April 2017 was carried out. A total of 14 studies were included in the review. RESULTS: A number of areas of concern were identified in the literature in relation to the phases of dying during end-of-life care: end-of-life pre-planning processes; understandings of end-of-life care; and interprofessional end-of-life care provision. CONCLUSIONS: Given that the problems identified in the literature concerning end-of-life care of residents in care homes are similar to those encountered in other healthcare environments, there is logic in considering how generalised solutions that have been proposed could be applied to the specifics of care homes. Further research is necessary to explore how barriers to good end-of-life care can be mitigated, and facilitators strengthened.

Widening participation in nurse education: An integrative literature review.

BACKGROUND: Widening participation into higher education is espoused within educational policy in the UK, and internationally, as a mechanism to promote equality and social mobility. As nurse education is located within higher education it has a responsibility to promote widening participation within pre-registration educational programmes. It could also be argued that the profession has a responsibility to promote equality to ensure its' workforce is as diverse as possible in order to best address the health needs of diverse populations. OBJECTIVES: To undertake an integrative review on published papers exploring Widening Participation in undergraduate, pre-registration nurse education in the UK. DESIGN: A six step integrative review methodology was utilised, reviewing papers published in English from 2013-2016. DATA SOURCES: Search of CINAHL, Education Source, MEDLINE, PsychINFO, SocINDEX, Science Direct, Business Source Complete, ERIC, British Library ETOS, Teacher Reference Centre, Informit Health Collection and Informit Humanities and Social Science Collection which highlighted 449 citations; from these 14 papers met the review inclusion criteria. REVIEW METHODS: Both empirical studies and editorials focusing upon widening participation in pre-registration nurse education in the UK (2013-2016) were included. Papers excluded were non UK papers or papers not focussed upon widening participation in pre-registration nursing education. Research papers included in the review were assessed for quality using appropriate critical appraisal tools. RESULTS: 14 papers were included in the review; these were analysed thematically identifying four themes; knowledge and identification of WP, pedagogy and WP, attrition and retention and career prospects. CONCLUSIONS: Whilst widening participation is a key issue for both nurse education and the wider profession there is a lack of conceptualisation and focus regarding mechanisms to both encourage and support a wider diversity of entrant. Whilst there are some studies, these focus on particular individual widening participation groups rather than a wider strategic focus across the student lifecycle.

Does nurses' vulnerability affect their ability to care?

Recent reports from the Department of Health (2008), the Parliamentary and Health Service Ombudsman (2011) and the Commission on Dignity in Care for Older People (2012) have been highly critical regarding the care that some patients have experienced. They have highlighted that fundamental aspects of care are missing resulting in a lack of high quality individualised nursing care, which is in contrast with holistic nursing philosophy. We have to ask ourselves what is happening within nursing, as many enter the profession owing to a desire to 'make a difference'. Drawing on focus group data exploring perceptions of caring for residents with dementia in a care home setting, the authors found that nurses and healthcare assistants experience a mutual vulnerability with patients. This paper explores whether this mutual vulnerability could lead to nurses focusing on the clinical aspects of their role to the detriment of the compassionate, caring components of nursing.

How education can improve care for residents with dementia.

Meeting the needs of people with dementia is topical in health and social care. However, the care of older people, including those with dementia, has received much negative media coverage over the past few years. Colten Care, a care home group in the south of England, asked staff from the School of Health and Social Care at Bournemouth University to develop and deliver an educational programme to 20 staff working at three of the group's care homes. The programme adopted a person-centred approach to residents and staff and focused on empowering staff to influence practice in the homes where they worked. This article explores the content of the programme and how aspects of it were incorporated in participants' care homes. The programme was positively evaluated and formed the basis for the development of Colten Care's inhouse two-and-a-half day education programme.

Ask the experts.

Although UK healthcare spending is now close to the European average( Organisation for Economic Co-operation and Development 2008 ), older people still receive inadequate services ( Healthcare Commission 2008 ). The recession is a time of great peril and great opportunity: there is the risk of savage funding cuts and falling quality; but there is also the opportunity to integrate our fragmented healthcare system and harness the skills of nurses to drive up quality.