Educating tomorrow's clinical researchers: a review of research preparation in undergraduate education.

BACKGROUND: One large health region in England was experiencing difficulties in recruiting to clinical research posts which required registered nurse or allied health professional skills. OBJECTIVES: Pre-registration preparation may influence practitioners' career choices and the study reviewed the research content in pre-registration nurse/AHP degree level programmes in the region to i) describe key features of the modules, and ii) determine the extent to which clinical research featured. DESIGN AND SETTINGS: There are eight universities in the region. We reviewed and analysed 46 research and evidence-based practice module guides from relevant pre-registration degree level programmes. Documentary analysis was used and the findings were reviewed by the project group. RESULTS: Modules aimed to produce practitioners who were aware of the principles of evidence based practice, and who could locate and evaluate research findings. There was some exposure to clinical research, though this was largely indirect, through considering research findings. Therapy students were more likely than nursing students to conduct a small clinical study for their final year assignment. CONCLUSIONS: Pre-registration programmes focused on producing practitioners who were competent users of research evidence to inform practice, rather than clinical researchers, and this was inevitably the focus of the research modules. However, feasible opportunities for increasing students' exposure to clinical research were identified.

A survey of issues of ethnicity and culture in nursing homes in an English region: nurse managers' perspectives.

AIMS: This survey explored issues of ethnicity and culture in nursing homes in one English region. BACKGROUND: The older black and minority ethnic population in the UK is increasing, and this is the first detailed study of numbers of black and minority ethnic residents in nursing homes and of managers' perceptions of their abilities to respond to residents' needs. DESIGN: Mixed methods. METHODS: Date were collected in 2008. A postal survey was sent to all nursing homes in the region. A sub-sample of managers participated in semi-structured telephone interviews. RESULTS: A hundred and one homes responded to the survey, and 13 managers were interviewed. One-third of homes had black and minority ethnic residents, and 95% had staff from these groups. Managers' underlying philosophies of care were to treat each resident individually and not by category. It was felt that individualised care plans resulted in residents' needs being met appropriately. Culturally sensitive care delivery varied. Some homes had established systems that were responsive to residents' diversity, while others responded to the needs of black and minority ethnic residents on an 'as-required' basis. Managers' identified advantages in having staff from diverse backgrounds, although prejudice from residents towards staff emerged as a theme and managers' responses varied. Staff training in the provision of appropriate end-of-life care was identified as a need. CONCLUSION: Black and minority ethnic residents form a small but growing minority of nursing home residents. Predicted increases in this resident group mean that managers must consider the delivery of culturally sensitive services. Future research is needed to explore the perspectives of black and minority ethnic residents. RELEVANCE TO CLINICAL PRACTICE: Nursing homes in England are increasingly diverse communities, and staff training needs must be addressed to promote quality care for all residents.

An evaluation of the impact of the Gold Standards Framework on collaboration in end-of-life care in nursing homes. A qualitative and quantitative evaluation.

BACKGROUND: In the United Kingdom approaching 20% of people aged 85 years and over live in care homes and most will die there. Improving end-of-life care is a government health priority and homes may work with primary care staff and specialist palliative practitioners to provide comprehensive end-of-life care. Consequently effective collaboration between care home and health service practitioners is vital to ensure high quality end-of-life care. OBJECTIVES: To evaluate the impact of a training programme to improve end-of-life care in nursing homes, on collaboration between nursing home staff and other health practitioners. DESIGN: Evaluation using survey methods and qualitative case studies. PARTICIPANTS AND SETTING: All 95 nursing homes in the first national 'Gold Standards Framework in Care Homes' programme in England were invited to participate in the evaluation. METHODS: A survey of homes' characteristics, the approaches to end-of-life care, and liaison with other services, was completed pre and post programme implementation. Case studies were conducted in a sub-sample of 10 homes to provide important context and depth to the evaluation. RESULTS: Pre and post surveys were returned by 49 (52%) homes. Improved collaborations as a result of the programme were anticipated by 31% of managers. Challenges to collaboration included working with large numbers of general practitioners, out-of-hours services and access to specialist practitioners. Improved collaborations between home staff and health service practitioners were identified by 33% of managers as one of the main programme outcomes. Staff reported increased knowledge of end-of-life care, and enhanced confidence, which in turn resulted in improved communication and collaboration. Post-programme, staff felt more confident initiating contact and discussing residents' end-of-life care with general practitioners and those working in specialist palliative care services. CONCLUSIONS: The Gold Standards Framework in Care Homes programme can contribute towards end-of-life care by helping to improve the quality and quantity of communication and collaboration between nursing home staff and primary care and specialist practitioners. Further research is needed to determine why this was not consistent across all homes.

Leading end-of-life care: an action learning set approach in nursing homes.

If the end-of-life care needs of people living in nursing homes are to be met, effective leadership is necessary. This in turn requires that appropriate training and support are provided for nursing home managers. To meet this need, an action learning set (ALS) involving nursing home managers was developed, and as a result of the continuous process of learning and reflection that characterizes ALS work the managers brought about a number of improvements in end-of-life care. These included more consistent use of care plans, increased involvement of clients and their families in planning end-of-life care, more training for staff, and the use of events and techniques to create opportunities for discussing the end of life. The managers set specific individual objectives focused on improving end-of-life care and were supported in meeting them through their membership of the set.

Delivering 'Gold Standards' in end-of-life care in care homes: a question of teamwork?

AIM: This paper reports findings from a study which investigated the introduction of the Gold Standards Framework for improving end-of-life care into care homes in England. BACKGROUND: The Gold Standards Framework was developed in primary care to improve the care provided for people at the end-of-life. Following its successful introduction to this setting it was adapted and implemented in care homes. DESIGN: A case study approach was appropriate for this study of a care programme into a 'real life' setting. METHOD: Fourteen managers participated in an initial telephone interview. Ten of these homes participated in the case study phase and 61 staff participated in individual or group interviews. Seven residents and three relatives participated in face to face interviews. Qualitative data were analysed in line with the template approach. Survey data were also analysed and a validated Teamworking Questionnaire was used. RESULTS: It was found that teamwork is central to the successful introduction of the Gold Standards Framework in Care Homes. Good staffing levels and management support were also perceived to be key factors in homes where the Framework became established. CONCLUSION: Effective teamwork was necessary for changes in end-of-life care to be achieved in the care homes. If end-of-life care and other improvements in practice are to continue, teamwork will need to be supported and developed. RELEVANCE TO CLINICAL PRACTICE: Effective teamwork appears to be a pre-requisite for successful implementation of new programmes of care. Organisations wishing to implement such programmes should assess the quality of teamwork and may need to address this first.

Use of information feedback and attentional focus of feedback in treating the person with a hemiplegic arm.

BACKGROUND AND PURPOSE: Feedback about motor performance can induce either an internal focus of attention (about body movement) or an external focus of attention (about the effects on the environment) in the learner. The main aim of this pilot study was to examine the attentional focus of feedback given by physiotherapists during treatment of the hemiplegic arm. A second aim was to examine the frequency of feedback about motor performance during treatment. METHOD: A multi-methods design was used (quantitative and qualitative). Eight physiotherapists and eight patients with stroke were recruited from two hospitals. Data were collected by video recordings of treatment, interviews (both therapists and patients) and questionnaire (therapists). Information feedback, instructions and motivational statements were identified from the video recordings. Feedback and instructions were further grouped into internal focus, external focus or mixed focus of attention. Themes were drawn from the interview transcripts. Triangulation was used to provide corroborating information from the different data sets. RESULTS: Two hundred and forty-six of the total 1914 statements identified in the videos were feedback, the rest comprising instructions and statements of motivation. Of the feedback statements, 236 of the total 247 identified had an internal focus. Therapist interviews and questionnaires revealed more external focus communication than actual treatment. CONCLUSIONS: Physiotherapists used instructions and statements of motivation more than feedback and directed the patient's attention more to body movement than movement effects. The outcome of this study may prompt clinicians' to examine the amount and the attentional focus of the feedback they use in their clinical practice, and to consider whether it is a most effective approach in light of current evidence.

A phase II exploratory cluster randomized controlled trial of a group mobility training and staff education intervention to promote urinary continence in UK care homes.

OBJECTIVES: To assess feasibility, acceptability and potential efficacy of group exercise and staff education intervention to promote continence in older people residing in care homes. To establish measures and information to inform a larger trial. DESIGN: Phase II pilot exploratory cluster randomized controlled trial. SETTING: Six purposely selected care homes in the West Midlands, UK. SUBJECTS: Thirty-four care home residents (mean age 86, 29 female), 23 with cognitive impairments. INTERVENTION: Physiotherapy-led group exercise and staff continence and mobility facilitation training. MAIN OUTCOME MEASURES: Reported continence status, Rivermead Mobility Index. Feasibility was assessed by uptake and compliance, and acceptability by verbal feedback. A staff knowledge questionnaire was used. RESULTS: Thirty-three residents, cluster sizes from 3 to 7. The number of residents agreeing with the statement 'Do you ever leak any urine when you don't mean to?' in the intervention group decreased from 12/17 at baseline to 7/17 at six weeks in the intervention group and increased from 9/16 at baseline to 9/15 at six weeks. The Rivermead Mobility Index scores were better in the intervention group (n=17; baseline: 6.1, six weeks: 6.2) compared with controls (n=16; baseline: 5.9, six weeks: 4.75). The intervention was feasible, well received and had good compliance. CONCLUSIONS: Group mobility training and staff education to promote continence is feasible and acceptable for use with care home residents, including those with cognitive impairment.

Use of self-chosen therapies by depressed people in primary care.

AIMS: This paper focuses on attitudes towards and use of self-chosen treatment among people prescribed antidepressants and discusses the implications for practitioners involved in medicines management. BACKGROUND: In the wide-ranging debate around the extension of non-medical prescribing in the UK the relationship between complementary and alternative therapies and prescribed medication has received little attention. Research indicates that self-treatment, including use of complementary and alternative therapies is burgeoning, yet there is uncertainty about the degree to which practitioners should be knowledgeable about therapies or be capable of advising clients on their use. Complementary and alternative therapy use is common among people with depression and greater knowledge of their use may be appropriate if health practitioners are to be able to support and inform people with depressive symptoms. METHODS: Qualitative methodology was adopted and 60 people from four primary care practices in the West Midlands, UK were interviewed individually and their self-reported treatment journeys documented. RESULTS: Almost two-thirds of participants had attempted to use self-chosen therapies during their recent illness though few had discussed their use with health service practitioners. Use of a range of self-chosen therapies was supported by a belief that they were natural, combined with a desire to avoid consulting health practitioners. Reasons for non-use of such therapies included confidence in health practitioners and caution about the possibility of drug interactions. CONCLUSIONS: Health practitioners require an awareness that people with mental health problems are using a range of self-chosen treatments and might consider the appropriateness of initiating discussions on self-chosen treatments with clients. This area requires greater debate and if necessary identification of an appropriate knowledge base. RELEVANCE TO CLINICAL PRACTICE: Assessment of common mental health problems should include discussion of patients' previous and current self-treatment. Such discussions will assist in identifying attitudes and beliefs towards health service treatment and provide a basis for selecting appropriate interventions.

Attributing recovery from depression. Perceptions of people cared for in primary care.

AIMS AND OBJECTIVES: The aim of the study was to understand how people treated for depression in primary care perceived the care they received. The focus was specifically on ascertaining their perceptions of what had helped during their treatment, their understanding of the factors to which they attributed their recovery, and their reflections on their experience of depression. BACKGROUND: Although knowledge of the factors that promote recovery from depression is growing, personal accounts of attributions of recovery are largely absent from the literature. Identifying and understanding people's accounts of their recovery is particularly important for practitioners involved in medication management and prescribing. METHOD: A purposeful sample of 60 people who had accessed primary care and been prescribed medication because of depressive symptoms was interviewed using a semistructured approach. Interviews explored people's experiences of accessing and using primary care, their assessments of care offered, experiences of medication management and their attributions of recovery. RESULTS: Recovery from depression was characterized by its multifactorial nature, and two-thirds of the participants felt that medication had contributed to their recovery. Factors in recovery changed with the passage of time and many perceived personal strengths as important to recovery. Practitioners who acknowledged and encouraged people's roles in recovery and supported multifaceted care were perceived by users as caring and offering holistic, individualized care. CONCLUSION: People with depression are keen to regard their recovery as multifactorial and to have their own roles in recovery acknowledged. Preferences for a 'portfolio' of care, the components of which change as recovery progresses, were evident. RELEVANCE TO CLINICAL PRACTICE: Practitioners involved in prescribing and medication management for depression must aim to explore patients' beliefs about appropriate treatments and recovery. Addressing these can potentially promote treatment concordance and enhance recovery from depression by establishing and sustaining therapeutic relationships.

Exploring the facets of continence care: a continence survey of care homes for older people in Birmingham.

AIMS: This study aimed to explore continence prevalence, knowledge and care in Birmingham care homes, UK. BACKGROUND: There is an increasing need to respond to rising numbers of care home residents suffering from incontinence in the UK. A lack of staff knowledge, training and treatment options can make this problematic. METHOD: A survey was developed and sent to 186 care homes in Birmingham catering for those 65 years old and over. A freepost envelope was provided for return of the completed form. RESULTS: Sixty-six (35%) surveys were returned providing a representative sample. Eighty per cent of nursing home residents and 49% of residential home residents were reported incontinent. Half of the staff (53%) had some form of qualification in caring/nursing. Absorbent products were used to manage incontinence in over 50% of homes. Advanced age was cited as the main cause of incontinence. Sixty-eight per cent of homes used the continence advisory service and/or district nursing services. CONCLUSIONS: While results proved encouraging in relation to numbers of qualified staff there is a need for improved continence awareness. Focus on aetiology, assessment procedures and treatment options are needed. While external service use levels were encouraging there appeared to be a need for an exchange of knowledge between services to optimize care. RELEVANCE TO CLINICAL PRACTICE: While there is an existing body of knowledge relating to continence prevalence and management in nursing homes this research base is lacking for residential care settings. This survey addresses this imbalance by combining information from both settings. This paper also provides an insight into the components that have an impact upon continence promotion, prevention and management. By establishing a picture of current practice an indication of areas for improvement can be exposed.

Aggression and violence towards staff working with older patients.

AIM: To investigate the incidence of violence and aggression towards staff working in elderly care wards and to consider the factors that influence the risk of experiencing such an incident. METHOD: Questionnaires were administered to 287 nursing and therapy staff within a community health NHS trust in the West Midlands. A response rate of 34% (96) was achieved. RESULTS: Fifty one per cent (49) of staff had experienced an incident of violence or aggression. There was a significant difference between the probability of experiencing violence and the occupation of the participant (chi2 = 0.035), with 65% (31 of 48) of nurses having experienced an incident, compared to only 42% (10 of 24) of occupational therapists and 27% (4 of 15) of physiotherapists. CONCLUSION: This study should be replicated in a wider geographical area and apparent anomalies in frequency of assault by occupation need to be considered in future research.

Concordance with antidepressant medication in primary care.

AIM: To identify how depression is managed in primary care settings and examine patients' perspectives on their care and the impact medication had on their recovery. This article specifically addresses patients' accounts of the influences on medication concordance. METHOD: A total of 60 patients from four primary care centres who had a recent episode of depression were interviewed using a semi-structured questionnaire and a framework analysis to identify recurring themes. Participants had largely recovered from their illness. FINDINGS: Many factors influenced patients' decisions to take and continue prescribed antidepressants and four broad themes were identified. These were: the role and relationship with health practitioners; factors related to the illness; beliefs about and experiences of medication for depression; and the wider context of depression. CONCLUSION: Concordance with antidepressants is multifactorial and may change over time in the same patient. Influences on concordance may be positive or negative and the combined effects are highly individual and dependent on circumstances. Nurses involved in medication management should encourage discussion of the likely impact of, and patients' attitudes toward, medication.

Room for improvement? Reporting response rates and recruitment in nursing research in the past decade.

AIMS: This paper reports an analysis of recruitment and response rates in published nursing research in three peer reviewed nursing journals in 2002. We wished to establish if the deficits in reporting nursing research identified a decade earlier had been addressed. BACKGROUND: This analysis was informed by our personal experiences of research which produced widely differing response rates. An examination of the literature revealed a lack of consensus on desirable response rates in nursing research. Previous analyses have shown deficits in describing participants, sampling methods and reporting recruitment. METHODS: Papers reporting empirical research in three nursing journals in 2002 were reviewed in terms of a number of variables including research methodology, respondent type, recruitment method, response rate, location, and data collection method. Nominal coding was used as necessary. Data were analysed using the Statistical Package for Social Sciences and a variety of descriptive statistics were employed. RESULTS: Half of the papers did not report a response rate. Of those which did, over three-quarters of both qualitative and quantitative studies had response rates of 60% or more. Research conducted in hospital and educational settings produced higher response rates than those in community settings. Studies with response rates of less than 60% did not always refer to their rates in the study limitations, and low response rates do not appear to be a barrier to publication. CONCLUSION: Reporting of sampling, recruitment and response rates in nursing research must be improved to support nursings' claim to be an evidence-based profession and to underpin clinical governance requirements. Only through improvements in the quality of nursing research publications can knowledge be extended and a better-informed research community be created.

Aggressive and violent incidents: perceptions of training and support among staff caring for older people and people with head injury.

BACKGROUND: Reported rates of workplace violence are increasing and studies of violence and aggression to health service staff in the United Kingdom have largely focused upon mental health and accident and emergency units. The study of violence and aggression in other specialties has been neglected. This paper reports the findings from a survey of staff perceptions of training and support in an elderly care and head injury unit. AIMS AND OBJECTIVES: Staff in a care of older people and head injury unit, half of whom were nurses, were surveyed to identify their experiences of violence and aggression in the workplace, their receipt of training, the relevance of training and knowledge of support services. METHODS: An anonymous semi-structured questionnaire was sent to all nursing, therapy and psychology staff in the unit. Quantitative data were analysed by SPSS and content analysis was adopted for the qualitative data. RESULTS: Just over half the participants had experienced an incident of violence or aggression in the past 12 months. Training was judged to be relevant by almost 90% of respondents but was not always delivered in line with trust guidance. Staff who had been involved in incidents were more likely to identify training needs. A higher percentage of nurses than other professions were involved in incidents, but they were not as aware of the staff support department as other professional groups. CONCLUSIONS: The findings indicate that care of older people and head injury units should examine more closely the delivery of staff training on violence and aggression, and invite staff to identify their training needs. A national survey of approaches to staff support may be worthwhile. RELEVANCE TO CLINICAL PRACTICE: Staff who had received training judged it to be relevant to their working situations, but outstanding training needs should be identified and addressed. Confidential staff support facilities should be well publicized.

The pharmacist's role in the medicinal management of depression.

AIM: To elicit pharmacists' perceptions of medication management for people who have been prescribed medication for depression. METHOD: A questionnaire survey of 103 mainly community pharmacists was used. RESULTS: People frequently approached pharmacists for information about a range of issues concerning antidepressant medication. Although pharmacists were knowledgeable about all aspects of pharmacological interventions, many felt their location in the commercial sector inhibited the amount of assistance they could provide. Barriers to providing information were identified, and the paucity of pharmacists' links with primary care teams exposed. CONCLUSION: The survey supports other studies that have suggested pharmacists could provide considerable assistance in helping people to understand their medication and its benefits. There is also discussion of the ways in which the future role of pharmacists could be developed so that they collaborate more closely with other healthcare professionals.

Caring for people with depression.

BACKGROUND: Mental health care has recently become a government priority, and depression is a very common mental health problem. Many people feel that the mode of treatment used is less important than the effective delivery of care and intensity of follow up. The authors of this study devised a questionnaire to elicit the views of a small sample of mental health professionals and service users on the quality of current services. CONCLUSION: Most respondents felt that there is room for improvement in mental health services. Perceptions of the needs of people with depression focused on care, rather than on specific interventions. The voluntary sector was rated highly in caring for people with depression. Greater awareness among professionals of self-help organisations was seen as beneficial.