Tracing healthcare organisation integration in the UK using actor-network theory.

PURPOSE: The study presents the findings from a study over a four-year period of the emergence of an integrated healthcare organisation in response to policy changes within the United Kingdom (UK). The aim of the research was to understand the process of healthcare organisation integration through the lens of actor-network theory (ANT). DESIGN/METHODOLOGY/APPROACH: An instrumental case study approach to data collection was selected. Three methods of data collection were used to trace the healthcare organisation integration process: in depth semistructured interviews using a virtual patient journey across services with 36 purposefully selected informants, document analysis and field observations and notes. FINDINGS: The findings of this study suggest that neither the context nor the actors were the sole determinants of the outcome of the integration. Rather it was the dynamic interplay between the actors, their context, the shared agency and the resources available to them as the change emerged shaped the end result. RESEARCH IMPLICATIONS: The findings denote that organisations need to attend to frontline workers as key contributors to change and development that is meaningful for service users. Methodologically, combining the ANT and constructive case study to understand the integration process provided us with new perspective to understand the trajectory of change process. ORIGINALITY/VALUE: This original case study fills a gap in information about the role of healthcare professionals in healthcare policy process and the interactive relationship between all stakeholders of policy process including nonhuman actors.

Climate Change Impact: The Experience of the Coastal Areas of Bangladesh Affected by Cyclones Sidr and Aila.

Bangladesh is considered one of the countries most at risk to the effects of climate change and its coastal area is most vulnerable. This study tries to explore the experiences of cyclones Sidr and Aila affected people living in the coastal areas of Bangladesh. This study was conducted in the cyclone Sidr affected Amtali Upazila of Barguna District and in the cyclone Aila affected Koyra Upazila of Khulna District. Primary data collection was done using Focus Group Interview and then a thematic analysis approach was used for analysis. Three core themes emerged from the analysis and they are, firstly, impacts of climate change on the socioeconomic condition of the people, secondly, the impact on the health status of the population, and finally the impact on vulnerable people. Findings show that the effects of climate change have serious consequences on the livelihood patterns of the affected population and on their overall health status. As a result, the unfavorable health condition of these affected people makes them more vulnerable to various emerging diseases.

'Individualism-collectivism' as an explanatory device for mental illness stigma.

The aim of this study is investigate whether the cross-cultural value paradigm 'individualism-collectivism' is a useful explanatory model for mental illness stigma on a cultural level. Using snowball sampling, a quantitative questionnaire survey of 305 individuals from four UK-based cultural groups (white-English, American, Greek/Greek Cypriot, and Chinese) was carried out. The questionnaire included the 'Community Attitudes to Mental Illness scale' and the 'vertical-horizontal individualism-collectivism scale'. The results revealed that the more stigmatizing a culture's mental illness attitudes are, the more likely collectivism effectively explains these attitudes. In contrast, the more positive a culture's mental illness attitudes, the more likely individualism effectively explains attitudes. We conclude that a consideration of the individualism-collectivism paradigm should be included in any future research aiming to provide a holistic understanding of the causes of mental illness stigma, particularly when the cultures stigmatization levels are particularly high or low.

Developing a framework for critiquing health research: an early evaluation.

A new framework for critiquing health-related research is presented in this article. More commonly used existing frameworks tend to have been formulated within the quantitative research paradigm. While frameworks for critiquing qualitative research exist, they are often complex and more suited to the needs of students engaged in advanced levels of study. The framework presented in this article addresses both quantitative and qualitative research within one list of questions. It is argued that this assists the 'novice' student of nursing and health-related research with learning about the two approaches to research by giving consideration to aspects of the research process that are common to both approaches and also that differ between quantitative and qualitative research.

Older adults experiences of rehabilitation in acute health care.

Rehabilitation is a key component of nursing and allied healthcare professionals' roles in most health and social care settings. This paper reports on stage 2 of an action research project to ascertain older adult's experience of rehabilitation. Twenty postdischarge interviews were conducted and the interview transcripts were analysed using thematic content analysis. All older adults discharged from an acute older acute rehabilitation ward to their own homes in the community were eligible to participate. The only exclusion criterion was older adults who were thought to be unable to give consent to participate by the nurse in charge and the researcher. Whilst 92 older adults were eligible to participate in this research study, only 20 were interviewed. The findings from this study suggest that older adults valued communication with health professionals but were aware of their time constraints that hindered communication. This study suggests that both nurses and allied health professionals are not actively providing rehabilitative services to promote health and well-being, which contradicts the focus of active ageing. Furthermore, there was evidence of unmet needs on discharge, and older adults unable to recall the professions that were involved in their interventions and the rationale for therapy input. It is suggested that further research is needed to explore the effectiveness of allied health rehabilitation in the acute setting. This study highlights the need for further research into older adults' perceptions of the rehabilitation process in the acute setting.

Preparation for cancer care: perceptions of newly qualified health care professionals.

The present paper is derived from a larger survey which examined the perceptions of recently qualified health care professionals' experience on evidence-based practice, team working and cancer care. This study reports solely on the findings relating to cancer care. The perceptions of recently qualified professionals in relation to their initial educational input on issues such as confidence, anxiety, communication skills and practice in cancer care as well as adequacy of support, professional supervision and use of reflection were gathered using a cross-sectional postal survey design. A total of 50 graduates from each professional category in nursing, occupational therapy, physiotherapy, and social work were sampled yielding a total sample of 200. Eighty-five questionnaires were returned yielding a response rate of 43%. Twenty-eight (33%) respondents stated that they were currently involved in working with people with cancer. These were as follows: 5 nurses, 8 physiotherapists, 9 occupational therapists and 6 social workers. Despite the low response rate, the findings suggest that health care professionals' educational input and experiences of working with people with cancer were overall positive; for example, in the respondents' confidence, communication skills, decrease in anxiety and application of knowledge gained in classroom to professional practice. Moreover, most respondents learnt about caring for cancer patients through practice rather than classroom teaching. A high percentage (i.e. 64%;18) across all groups felt supported when caring for people with cancer and reported receiving professional supervision as well as being able to actively reflect on their practice. The implications for education and practice were discussed particularly as there have been few studies conducted in relation to the specific needs and collaborative learning of these health care professional groups.

Preparing for professional practice: how well does professional training equip health and social care practitioners to engage in evidence-based practice?

This paper reports on the findings of a study that aimed to explore how relevant initial training is in relation to evidence-based practice, and explore the perceptions of recently qualified practitioners about their confidence to engage in evidence-based practice. A cross-sectional postal survey was used to ascertain the views of nurses, social workers, occupational therapists and physiotherapists who had been qualified no longer than two years prior to the survey, and had qualified at one of three London Universities. Fifty questionnaires were sent out to each professional group (a sample of 200 overall) and there was a 43% response rate achieved. The results show a clear discrepancy between what are generally positive attitudes towards evidence-based practice and the value of research evidence and the infrequency with which they actually do make use of research resources and engage in evidence-based practice. A number of constraints to engagement in accessing and utilising evidence were identified.

Nurses' perceptions of multidisciplinary team work in acute health-care.

Multidisciplinary teamwork is viewed as one of the key processes through which care is managed in the British National Health Service, and yet is often viewed as one of the most problematic. Working in a multidisciplinary team requires many skills, which involves understanding not only one's own role but also the role of other professionals. The aim of this study was to explore nurses' perceptions of multidisciplinary teamwork in acute health-care. Nineteen nurses were interviewed using the critical incident approach to obtain their perceptions of multidisciplinary teamwork. Direct observation was conducted to record interactions between nurses and health-care professionals in multidisciplinary teams. In total, 14 meetings were attended in elder care and orthopaedics and seven in acute medicine. The findings of this study identified three barriers that hindered teamwork: (i) differing perceptions of teamwork; (ii) different levels of skills acquisitions to function as a team member; and (iii) the dominance of medical power that influenced interaction in teams. Thus, education establishments and nursing managers need to ensure that the acquisition of team-playing skills is an integral part of continued professional development.

Multidisciplinary perceptions of the role of nurses and healthcare assistants in rehabilitation of older adults in acute health care.

AIM: This paper describes the perceptions of nurses, healthcare assistants, doctors and therapists of rehabilitation and the role of nurses and healthcare assistants on an acute older adults ward in a London teaching hospital. BACKGROUND: The role perception, education and training and attitudes towards the older adults have been identified as barriers that have an impact upon the nurses' role within rehabilitation. However, little is known about the role of nurses and healthcare assistants in rehabilitation of older adults in acute health care. DESIGN: Action research study. METHOD: Twenty-four semi-structured interviews were conducted and audio recorded about healthcare professionals' understanding of rehabilitation, the type of skills needed and their perceptions of the role of nurses and healthcare assistants in rehabilitation. The interview transcripts were analysed using the thematic content analysis. RESULTS: The findings suggest that the therapists relied on nurses and healthcare assistants for therapy carry-over. Healthcare assistants were perceived as the professional group who could deliver therapy carry-over. There was an evidence of role hierarchy as healthcare assistants perceived that they were not actively involved in decision-making or discharge planning. CONCLUSION: This paper suggests that healthcare assistants and nurses are viewed as the professional group best placed to deliver therapy carry-over. However, whilst there is an acknowledgement of their role, there remains a reluctance to acknowledge healthcare assistants as a professional group and to involve them within decision-making and discharge planning. RELEVANCE TO CLINICAL PRACTICE: Employers must be seen to advocate, support and implement education and training programs for healthcare assistants. However, whilst nurses and healthcare assistants have an integral role in rehabilitation, there needs to be more research into the how they are supported by therapy professionals.

Involving users in service planning: a focus group approach.

This paper outlines the way in which a focus group approach was used to involve service users in the possible reconfiguration of follow-up services for breast cancer patients at a North London hospital. The focus group was used to identify the priority issues for users and the development of an objective questionnaire, to survey all current service users. Within the National Health Service (NHS) the concept of user involvement has been embodied in contemporary health policy, and has become an important constituent of current policy direction. This study was the first stage of a larger stakeholder project that aimed to involve service users and clinicians in developing a new model of breast cancer follow-up service. From the focus group emerged five key themes around breast cancer follow up. They were: The need for reassurance after the diagnosis of cancer. Continuity of care. Privacy and dignity and other elements of the examination technique. Information and the detection of new symptoms. The opportunity to discuss feelings and worries. In this paper, the nature of breast cancer follow-up services is outlined, and the difficulties associated with such services are discussed. The background to user involvement within the United Kingdom is explored, and the strategies that have previously been used are considered. The practical issues involved in using the focus group approach are examined, and the experience of using such an approach is outlined in this study. The involvement of service users as a key stakeholder in the process of planning change, through a participatory research strategy, ensured that their voices were heard alongside those of both hospital and primary care staff.

Preparing for practice: how well are practitioners prepared for teamwork.

This article reports on the findings of a study that aimed to explore how relevant initial training is in relation to teamwork, and to explore the perceptions of newly qualified practitioners about their confidence to work as a member of a team. A cross-sectional postal survey was used to ascertain the views of nurses, social workers, occupational therapists and physiotherapists who had been qualified between six months and two years prior to the survey, and had qualified at one of three London universities. Fifty questionnaires were sent out to each professional group (a sample of 200 overall) and there was a 43% response rate. Findings revealed that respondents reported positive experiences of team working, with only one area--equality of status within teams--being highlighted as problematic. While no other area generated this level of disagreement, there were two other areas in which respondents felt unsure: cooperation within the team and conflict resolution within the team.

Do all health and social care professionals interact equally: a study of interactions in multidisciplinary teams in the United Kingdom.

Problems around deficits in interprofessional collaboration have been identified since the National Health Service (NHS) was introduced. It is within the context of the current policy focus on improving collaborative working that this study was undertaken. A direct observational study using the Bales' Interaction Process Analysis tool was carried out in two older persons teams to explore patterns of interaction in the multidisciplinary team meetings. Analysis revealed some key differences in the way in which different professions interacted. Occupational therapists, physiotherapists, social workers (SW) and nurses rarely asked for opinions and for orientation. The consultant (the individual in charge of the medical team) tended to have high rates for asking for orientation, giving opinions and giving orientation. Although some nurses did have high individual rates for the giving of orientation. The data from the research has highlighted that therapists, SWs and nurses are reluctance to voice their opinions in multidisciplinary teams and thus conformity may dominate its culture. It is suggested that therapists, SWs and nurses need to cite their opinions in teams more effectively if they are to be competent and committed patient-centred practitioners.

Supportive care: experiences of cancer patients.

The aim of this study was to explore how cancer patients with progressive disease perceived and experienced supportive care at the different stages of their cancer journey and to compare this to the perceptions of health care professionals. It was a single centre study using qualitative data obtained from two focus group interviews in an independent centre for specialist palliative care. Eight patients attending the centre were interviewed in two focus groups to ascertain their views on the supportive care that they had experienced during the course of their illness, focusing on: time of diagnosis, acute treatment phase and palliative care phase. Themes that emerged from the analysis of the interview transcripts using the QSR NUD*IST (version 4) software package included the following: manner in which diagnosis was revealed, information made available to family and friends, patients' acceptance of cancer; service provision such as a named contact person, choices in treatment and care, problems of limited resources; feelings of being unsupported, and ways in which supportive care could be improved.

Non-participant observation: using video tapes to collect data in nursing research.

Observation is a highly valued and effective research method, as well as being an essential part of nursing practice. The authors explore the way in which non-participant observation as a research method might be enhanced by the use of video recording. The utility, ethical considerations and constraints of video recording as a data collection tool are discussed, with examples from a research study. The authors argue that the use of videos can enhance the credibility of non-participant observation studies through the minimisation of selectivity and bias and the opportunity to employ more rigorous strategies for ensuring reliability.

The problems of interprofessional healthcare practice in hospitals.

This article outlines the problems of interprofessional practice in the hospital setting. It examines the difficulties associated with competing ideologies and aims, inequalities in power relations, communication and role confusion and overlap. Within the hospital setting such problems often arise although the roots of the problem may go unacknowledged. The ways in which the problems occur in the hospital setting are considered, as is the underlying cause of such problems. Case studies will be used to analyse how the problems arise and ways in which they might be addressed.

Do multidisciplinary integrated care pathways improve interprofessional collaboration?

This paper reports on the evaluation stage of an action research project on interprofessional collaboration in discharge planning. Findings from interviews with health care professionals working in the acute sector had revealed concerns about discharge planning and multidisciplinary teamwork. In the United Kingdom the National Health Service (NHS) Plan has reinforced the need for an integrated approach to health care. Effective health care integration requires effective communication, teamwork and the commitment to deliver integrated care. Integrated documentation is a key strategy for enhancing interprofessional collaboration and reducing the isolation of professionals, and has been successfully implemented in a range of health care settings. Presented with the concerns about the collaborative process in discharge planning, an action research strategy was chosen to bring about change in an orthopaedic ward in one London teaching hospital. This paper will evaluate the implementation of an integrated care pathway with fractured neck of femurs in one London teaching hospital. Care pathways facilitate the management of defined patient groups using interdisciplinary plans of care. The emphasis will be on understanding whether integrated care pathways enhance and develop interprofessional collaboration and enable effective information access and flow across the professions and the organization. The criteria for evaluation, forming the hypotheses of the study, were that interprofessional nonverbal and verbal communication would be enhanced and that interprofesisonal collaboration would increase. Methods of evaluation used were: (i) stakeholder interviews, (ii) interprofessional audit and (iii) analysis of the variances from the integrated care pathway. The evaluation revealed that although integrated care pathways led to improved outcomes for the health care trust there was little evidence to suggest that interprofessional relationships and communication were enhanced. Furthermore, key factors in discharge delays appeared to be organizational rather than professional.

Correspondence.

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