The experiences of cancer nurses working in four European countries: A qualitative study.

PURPOSE: Cancer nurses across Europe are being tasked with delivery of an increasing number of complex treatments and supportive care interventions as a result of ongoing advances in cancer research, and a rise in cancer incidence due to demographic changes. However, all health systems delivering cancer treatment innovations require access to an educated and motivated nursing workforce to meet demand. This study by the European Oncology Nursing Society examines comparative features of cancer nursing in Estonia, Germany, the Netherlands (NL) and the United Kingdom (UK). METHODS: Descriptive qualitative study using focus groups and individual interviews drawing on the views of cancer nurses, managers and stakeholders from four European countries (n = 97). Data collection was designed around national cancer nursing conferences held in Berlin (Germany), Ede (NL), Harrogate (UK) and Tallinn and Tartu (Estonia) between May 2017 and April 2018. Participants included a mix of nursing grades and specialisms. FINDINGS: According to the participants education and career structure for cancer nursing was most well-developed in the Netherlands and the United Kingdom. In Germany and Estonia developments were taking place at Masters level. None of the countries had recordable qualifications in cancer nursing. Variations existed in terms of advanced practice roles and salary. Workload pressures were common, and were rising, and wellbeing initiatives were not identified. Nurses reported gaining positive feedback from caring for patients. DISCUSSION: As demand for cancer treatment continues to grow there is a need to ensure an adequate supply of cancer nurses with the appropriate education and career structure to support patients. This study provides insights from four countries and suggests the need for better recognition as well as working conditions, education and career structures that advance the potential of the cancer nursing role in Europe.

Stress and resilience in a post-Francis world - a qualitative study of executive nurse directors.

AIMS: The aim of this study was to explore the role stressors experienced by executive nurse directors and strategies employed to maintain resilience. BACKGROUND: Recent financial pressures on and care quality scandals in the UK NHS impact on the work of executive nurse directors. The short length of tenure and the high number of vacancies for these posts point to the exacting demands of the role and raise questions about the support mechanisms available for the most senior nurses in NHS organizations. DESIGN: A grounded constructivist study. METHODS: Semi-structured telephone interviews conducted between February-July, 2014. RESULTS: Stressors were both chronic (workload, lack of corporate responsibility for quality, reductions in quality team staffing, tensions between financial solvency and care quality and personal vulnerability) and acute (dealing with complaints and major incidents). Resilience required the support of fellow executives, peers, family and mentors and could be enhanced by self-discipline, good preparation for the post and ongoing coaching. CONCLUSION: Recent fiscal austerity and scandals relating to quality of care have increased pressure on executive nurse directors. Increasing size of organizations, limited resources devoted to quality combined with poorly defined limits of responsibility are all major stressors and executive nurse directors, both in the United Kingdom and internationally, need clear strategies to maintain resilience. Repetitive demands for data by oversight organizations may detract from more important quality assurance strategies.

Giving voice to quality and safety matters at board level: A qualitative study of the experiences of executive nurses working in England and Wales.

BACKGROUND: Recent reports into egregious failing in the quality and safety of healthcare in the UK have focussed on the ability of executive boards to discharge their duties effectively. Inevitably the role of executive nurses, whose remit frequently includes responsibility for quality and safety, has become the object of increased scrutiny. However, limited evidence exists about the experiences of the UK's most senior nurses of working at board level. OBJECTIVE: We aimed to generate empirical evidence on the experiences of executive nurses working at board level in England and Wales. We posed two research questions: What are the experiences of nurse executives working at board level? What strategies and/or processes do nurse executives deploy to ensure their views and concerns about quality and safety are taken into account at board level? DESIGN: Qualitative interviews using semi-structured interviews. SETTING: NHS England and Wales. PARTICIPANTS: Purposive sample of 40 executive board nurses. METHODS: Semi-structured interviews followed by a process of thematic data analysis using NVivo10 and feedback on early findings from participants. RESULTS: Our findings are presented under three headings: the experiences of executive nurses working with supportive, engaged boards; their experiences of being involved with unsupportive, avoidant boards with a poor understanding of safety, quality and the executive nursing role and the strategies deployed by executive nurses to ensure that the nursing voice was heard at board. Two prominent and interrelated discursive strategies were used by executive nurses - briefing and building relationships and preparing and delivering a credible case. Considerable time and effort were invested in these strategies which were described as having significant impact on individual board members and collective board decision making. These strategies, when viewed through the lens of the concept of "groupthink", can be seen to protect executive nurses from accusations by board colleagues of disloyalty whislt also actively restricting the development of "groupthink" within the board. Another finding of note was that executive boards may not be permanently fixed as either unsupportive or supportive as participants described how certain boards that were initially unsupportive adopted a more supportive attitude towards matters of safety and quality. CONCLUSIONS: These highly positioned nurses can provide invaluable advice and support to boards around matters of quality and safety. However, the work of nurse executives remains an under-research area and more work is needed to better understand the ebb and flow of power and influence at play within hospital boards.

PATIENTS' AND RELATIVES' EXPERIENCES OF PERITONITIS WHEN USING PERITONEAL DIALYSIS.

BACKGROUND: Internationally, increasing numbers of patients are requiring treatment for end-stage kidney disease and greater use of peritoneal dialysis is thus being promoted. However, peritonitis can be a significant problem in this population. It is the leading cause of technique failure in patients using peritoneal dialysis and results in considerable morbidity and mortality. There is a dearth of research exploring patients' and their families' experiences of peritonitis. OBJECTIVES: The aim of this paper is to explore patients' and their families' perspectives and experiences of peritonitis. DESIGN: An ethnographic study was conducted in 2011 in the United Kingdom. PARTICIPANTS: Sixteen patients and nine of their relatives were recruited through purposive and convenience sampling. APPROACH: In-depth interviews were undertaken with patients and their families, who were also observed using peritoneal dialysis in their homes. The data were analysed thematically using Wolcott's (1994) three-stage approach. RESULTS: This article describes four themes: learning about the risk of peritonitis; measures taken to prevent the infection; how participants monitored continuously for signs and symptoms of the infection; how they then identified and intervened once peritonitis was suspected. Overall, peritonitis was associated with fear and uncertainty, pain and learning from episodes of the infection. CONCLUSIONS: Overall, peritonitis was a distressing experience that participants sought to prevent. However, there was some confusion amongst participants about the signs and symptoms of the infection and further education for patients and their families is thus crucial.

Patient and family perspectives on peritoneal dialysis at home: findings from an ethnographic study.

AIMS AND OBJECTIVES: To discuss findings from an ethnographic study, considering the experiences of patients and families, using peritoneal dialysis at home in the United Kingdom. BACKGROUND: Peritoneal dialysis is a daily, life-preserving treatment for end-stage renal disease, undertaken in the patient's home. With ever-growing numbers of patients requiring treatment for this condition, the increased use of peritoneal dialysis is being promoted. While it is known that quality of life is reduced when using dialysis, few studies have sought to explore experiences of peritoneal dialysis specifically. No previous studies were identified that adopted an ethnographic approach. DESIGN: A qualitative design was employed, utilising ethnographic methodology. METHODS: Ethical and governance approvals were gained in November 2010 and data were generated in 2011. Patients (n = 16) and their relatives (n = 9) were interviewed and observed using peritoneal dialysis in their homes. Thematic analysis was undertaken using Wolcott's (1994) three stage process: Description, Analysis and Interpretation. RESULTS: This article describes four themes: initiating peritoneal dialysis; the constraints of peritoneal dialysis due to medicalisation of the home environment and the imposition of rigid timetables; the uncertainty of managing crises and inevitable deterioration; and seeking freedom through creativity and hope of a kidney transplant. CONCLUSIONS: This study highlights the culture of patients and their families living with peritoneal dialysis. Despite the challenges posed by the treatment, participants were grateful they were able to self-manage at home. Furthermore, ethnographic methods offer an appropriate and meaningful way of considering how patients live with home technologies. RELEVANCE TO CLINICAL PRACTICE: Participants reported confusion about kidney transplantation and also how to identify peritonitis, and ongoing education from nurses and other healthcare professionals is thus vital. Opportunities for sharing experiences of peritoneal dialysis were valued by participants and further peer-support services should thus be considered.

Minimising pain response during routine infant immunisation.

By the time a child in the UK reaches 13 months of age he or she should have received nine vaccinations. Therefore, it is important to look at interventions to decrease pain associated with receiving vaccines and to examine the evidence base for current clinical practice. This study (sample 72 babies randomly allocated to one or other treatment) was a small randomised, controlled trial to determine whether, when immunising babies aged two to six months, there is any difference in the perceived level of pain and distress experienced by babies when given two injections at the same time (simultaneous technique) as compared to giving them one injection after the other (sequential technique). Both practices are currently widespread. The study has shown that there is no difference in parents' perceptions of the distress experienced by babies receiving either simultaneous or sequential vaccinations. Preliminary findings of the observed measure of pain behaviour in babies report statistically significant differences in distress behaviours at four time points after vaccination between the sequential and simultaneous vaccinations, further research in a larger study is required to confirm these findings.

Perspectives on peritoneal dialysis at home: implications for the management of a chronic condition. A study protocol.

AIM: This article is a report of a study protocol designed to explore the experience of home peritoneal dialysis from the perspectives of individuals, their families and healthcare professionals in the United Kingdom. BACKGROUND: Peritoneal dialysis is an established life-saving treatment for end-stage renal disease. This daily treatment is undertaken at home, and nurses play a key role in supporting people with their dialysis and monitoring their condition. Although peritoneal dialysis is known to have an impact on peoples' quality of life, few studies have explored peoples' experiences of undertaking this treatment at home, nor investigated their families' and health professionals' perspectives. DESIGN: An ethnographic study is proposed, which will use in-depth interviews and non-participant observations with people who are undertaking peritoneal dialysis at home in the United Kingdom. Family members and healthcare professionals closely involved with these individuals will also be interviewed. The local ethics and governance committees approved this study in November 2010. DISCUSSION: It is anticipated that the study's findings will provide a detailed insight into the impact of peritoneal dialysis on individuals and their families. The findings will inform local strategies and/or interventions that could improve peoples' experiences of undertaking this treatment. Furthermore, the appropriateness of ethnographic methodology to examine individuals' and families' experiences of home treatments will be considered.

An assessment of the quality and impact of NPSA medication safety outputs issued to the NHS in England and Wales.

OBJECTIVES: To assess the quality and impact of medication safety outputs issued by the National Patient Safety Agency (NPSA) to the NHS in England and Wales. METHODS: A multi-method study comprising (1) focus groups and interviews with NHS Chief Pharmacists and (2) an electronic survey of medical, nursing and clinical governance directors. RESULTS: Acute sector respondents agreed that the medication outputs had a major impact on patient safety. Pharmacists welcomed national support for medication safety improvement, despite the resulting workload. Medical Directors were much less likely to be aware of alerts and Rapid Response Reports (RRRs) than their nursing and clinical governance colleagues. One key finding was the inability of around half of NHS trusts to communicate effectively and reliably with their junior doctors. CONCLUSION: Medication alerts issued by the NPSA have stimulated significant work to improve medication safety and are believed to have had an important impact on patient safety.

A baseline study of anticoagulant management in UK hospitals.

OBJECTIVES: To undertake a baseline study of the management of anticoagulants in order to allow later comparison of the impact of the National Patient Safety Agency (NPSA) patient safety alert (including a new patient held record) published in April 2007. METHODS: A multimethod study comprising semistructured interviews in 20 acute trusts and a telephone/email survey of general practitioners (GPs). RESULTS: The authors found a high degree of consensus concerning a number of problems in the management of anticoagulation services. Consultant haematologists and chief pharmacists expressed concern about the level of competence of junior medical and nursing staff and the quality of patient discharge from general inpatient wards. Patients were regularly discharged before being stabilised on Warfarin, pre-discharge information was not always given, patient-held records were not reliably completed nor follow-up arrangements made. At the ward level, there was some confusion about the responsibility for completing the yellow book on discharge and little awareness of the role of GPs in providing a monitoring service. GPs were largely dissatisfied with the quality of discharge information. CONCLUSION: The baseline data present a significant cause for concern in the management of warfarin prior to the publication of the NPSA safety alert.

Safe practice for patients receiving anticoagulant therapy.

Venous thrombolembolism, although largely preventable, continues to be a major cause of death in hospitalised patients. The anticoagulant drugs used to prevent and treat this condition require careful and knowlegeable management. Nurses working in acute and community settings have an important role in this process.

What work has to be done to implement collaborative care for depression? Process evaluation of a trial utilizing the Normalization Process Model.

BACKGROUND: There is a considerable evidence base for 'collaborative care' as a method to improve quality of care for depression, but an acknowledged gap between efficacy and implementation. This study utilises the Normalisation Process Model (NPM) to inform the process of implementation of collaborative care in both a future full-scale trial, and the wider health economy. METHODS: Application of the NPM to qualitative data collected in both focus groups and one-to-one interviews before and after an exploratory randomised controlled trial of a collaborative model of care for depression. RESULTS: Findings are presented as they relate to the four factors of the NPM (interactional workability, relational integration, skill-set workability, and contextual integration) and a number of necessary tasks are identified. Using the model, it was possible to observe that predictions about necessary work to implement collaborative care that could be made from analysis of the pre-trial data relating to the four different factors of the NPM were indeed borne out in the post-trial data. However, additional insights were gained from the post-trial interview participants who, unlike those interviewed before the trial, had direct experience of a novel intervention. The professional freedom enjoyed by more senior mental health workers may work both for and against normalisation of collaborative care as those who wish to adopt new ways of working have the freedom to change their practice but are not obliged to do so. CONCLUSIONS: The NPM provides a useful structure for both guiding and analysing the process by which an intervention is optimized for testing in a larger scale trial or for subsequent full-scale implementation.

Making patients safer: nurses' responses to patient safety alerts.

AIM: This paper is a report of a study to determine whether action required by patient safety alerts was effectively taken. BACKGROUND: Over the last 10 years, there has been a growing awareness of the number of patients unintentionally harmed in the course of their treatment. Safety alerts are designed to reduce the incidence of adverse events by removing these predisposing factors. METHOD: A multi-method study was carried out in 20 acute, two mental health, four ambulance and 15 primary care provider organizations in the United Kingdom in 2006-2007 using surveys, interviews with senior managers and front-line staff, collection of documentary evidence and equipment audit. The implementation of three safety alerts for nursing action is reported. FINDINGS: Most staff were aware of the dangers posed by gloves to staff with latex allergy, but only 20% were aware of the types of common equipment that posed a danger to sensitive patients. Almost 40% of nurses were unable to give a correct acidity value to allow nasogastric feeding to commence. One alert, on needle-free intravascular connectors, was distributed in only a few organizations as the term used was unfamiliar at all levels of the organization. CONCLUSION: Healthcare providers have succeeded in setting up successful systems to disseminate alerts to middle management level, but there is evidence that implementation of recommendations by nurses is sub-optimal.

Developing a U.K. protocol for collaborative care: a qualitative study.

OBJECTIVE: This study aimed to explore the views of stakeholders including patients, general practitioners (GPs) and mental health workers on the feasibility, acceptability and barriers to a collaborative care model for treatment of depression within the context of U.K. primary health care. METHOD: We used semistructured interviews and focus groups with a purposive sample of 11 patients and 38 professionals from a wide selection of primary and secondary care mental health services, as well as framework analysis using a "constant comparative" approach to identify key concepts and themes. RESULTS: Regular contact for patients with depression is acceptable and valued by both patients and professionals. However, patients value support, whereas professionals focus on information. To be acceptable to patients, contacts about medication or psychosocial support must minimize the potential for patient disempowerment. The use of the telephone is convenient and lends anonymity, but established mental health workers think it will impair their judgments. While patients merely identified the need for skilled case managers, GPs preferred established professionals; however, these workers did not see themselves in this role. All involved were cautious about deploying new workers. Additional barriers included practical and organizational issues. CONCLUSIONS: Although a telephone-delivered mix of medication support and low-intensity psychological intervention is generally acceptable, significant issues to be addressed include the values of the current mental health workforce, fears about new workers' experience and competence, the balance of face-to-face and telephone contacts and case manager education in nonspecific skills necessary to develop a therapeutic alliance, as well as the knowledge and skills required for education, medication support and behavioral activation. Qualitative research can add value to careful modeling of collaborative care prior to international implementation.

Nurse staffing and healthcare outcomes: a systematic review of the international research evidence.

The relationship between quality of care and the cost of the nursing workforce is of concern to policymakers. This study assesses the evidence for a relationship between the nursing workforce and patient outcomes in the acute sector through a systematic review of international research produced since 1990 involving acute hospitals and adjusting for case mix. Twenty-two large studies of variable quality were included. They strongly suggest that higher nurse staffing and richer skill mix (especially of registered nurses) are associated with improved patient outcomes, although the effect size cannot be estimated reliably. The association appears to show diminishing marginal returns.

What's the evidence that NICE guidance has been implemented? Results from a national evaluation using time series analysis, audit of patients' notes, and interviews.

OBJECTIVES: To assess the extent and pattern of implementation of guidance issued by the National Institute for Clinical Excellence (NICE). DESIGN: Interrupted time series analysis, review of case notes, survey, and interviews. SETTING: Acute and primary care trusts in England and Wales. PARTICIPANTS: All primary care prescribing, hospital pharmacies; a random sample of 20 acute trusts, 17 mental health trusts, and 21 primary care trusts; and senior clinicians and managers from five acute trusts. MAIN OUTCOME MEASURES: Rates of prescribing and use of procedures and medical devices relative to evidence based guidance. RESULTS: 6308 usable patient audit forms were returned. Implementation of NICE guidance varied by trust and by topic. Prescribing of some taxanes for cancer (P < 0.002) and orlistat for obesity (P < 0.001) significantly increased in line with guidance. Prescribing of drugs for Alzheimer's disease and prophylactic extraction of wisdom teeth showed trends consistent with, but not obviously a consequence of, the guidance. Prescribing practice often did not accord with the details of the guidance. No change was apparent in the use of hearing aids, hip prostheses, implantable cardioverter defibrillators, laparoscopic hernia repair, and laparoscopic colorectal cancer surgery after NICE guidance had been issued. CONCLUSIONS: Implementation of NICE guidance has been variable. Guidance seems more likely to be adopted when there is strong professional support, a stable and convincing evidence base, and no increased or unfunded costs, in organisations that have established good systems for tracking guidance implementation and where the professionals involved are not isolated. Guidance needs to be clear and reflect the clinical context.