Implementing a training intervention to support caregivers after stroke: a process evaluation examining the initiation and embedding of programme change.

BACKGROUND: Medical Research Council (MRC) guidance identifies implementation as a key element of the development and evaluation process for complex healthcare interventions. Implementation is itself a complex process involving the mobilization of human, material, and organizational resources to change practice within settings that have pre-existing structures, historical patterns of relationships, and routinized ways of working. Process evaluations enable researchers and clinicians to understand how implementation proceeds and what factors impact on intended program change. A qualitative process evaluation of the pragmatic cluster randomized controlled trial; Training Caregivers after Stroke was conducted to examine how professionals were engaged in the work of delivering training; how they reached and involved caregivers for whom the intervention was most appropriate; how did those on whom training was targeted experience and respond to it. Normalization Process Theory, which focuses attention on implementing and embedding program change, was used as a sensitizing framework to examine selected findings. RESULTS: Contextual factors including organizational history and team relationships, external policy, and service development initiatives, impinged on implementation of the caregiver training program in unintended ways that could not have been predicted through focus on mechanisms of individual and collective action at unit level. Factors that facilitated or impeded the effectiveness of the cascade training model used, whether and how stroke unit teams made sense of and engaged individually and collectively with a complex caregiver training intervention, and what impact these factors had on embedding the intervention in routine stroke unit practice were identified. CONCLUSIONS: Where implementation of complex interventions depends on multiple providers, time needs to be invested in reaching agreement on who will take responsibility for delivery of specific components and in determining how implementation and its effectiveness will be monitored. This goes beyond concern with intervention fidelity; explicit consideration also needs to be given to the implementation process in terms of how program change can be effected at organizational, practice, and service delivery levels. Normalization Process Theory's constructs help identify vulnerable features of implementation processes in respect of the work involved in embedding complex interventions.

Interdisciplinary health research: perspectives from a process evaluation research team.

BACKGROUND: Interdisciplinary health research (IDHR) is increasingly encouraged and is often a specific requirement for research grants provided by health research funding councils worldwide. There is consensus that research expertise and scholarship from a diverse range of disciplines are necessary to examine questions relating to complex health and social concerns for which single disciplinary approaches have been found inadequate. METHODS: This paper reports on the experiences of an interdisciplinary process evaluation research team working in the field of stroke care. RESULTS: Realising the perceived benefits is less than straightforward; setting up and conducting IDHR can present researchers with a range of challenges at a strategic, practical and individual level. We identify how differences in disciplinary perspectives and skills impacted on our research practice. CONCLUSIONS: Whilst initially challenging, our different approaches to the research problem and the methods to address it, expanded conceptual and methodological understanding and proved of benefit for the research team and the study outputs.

Patients' experience of hospital pharmaceutical services.

OBJECTIVE: This study aimed to investigate inpatients' and outpatients' need for information about medication, to what extent those needs were addressed and patient attitudes regarding pharmaceutical services. METHOD: Self-administered questionnaires were distributed to a sample of outpatients and inpatients in a UK district general hospital. Themes included satisfaction with information given about medication, potential confusion over medication prescribed by the general practitioner and by the hospital, access to a member of the pharmacy team and preferences on how information on medication should be given. KEY FINDINGS: Ninety-one outpatient and 126 inpatient questionnaires were available for analysis. All outpatients who responded acknowledged that they were told how long they might need to wait for their medicines to be dispensed, although approximately one-fifth felt they had to wait a long time. Nearly three-quarters of outpatients felt there was an opportunity to ask medication-related questions of the pharmacy team. Nearly three-quarters of inpatients reported they were encouraged to bring into any hospital any medication they were taking at home. Twenty-eight per cent of 95 inpatients reported that some of their existing medication was stopped while in hospital. For the inpatients who received information about new medication, this was explained to the patient verbally (76%) and both verbally and in writing (22%). Forty-two per cent of inpatients (and 36% of outpatients) expressed a preference to receive information about medication both verbally and in writing. Thirty-five (32%) of 110 inpatients were not aware that a pharmacy team had a presence on the ward. CONCLUSIONS: Overall the majority of both in- and outpatients appeared to be receiving appropriate pharmaceutical services. There is a need to raise the profile of the pharmacy team in regards to provision of medication advice for inpatients. Consideration needs to be given to better provision of written information about medication for patients.

Patient consensus on mode of use of nettle sting for musculoskeletal pain.

BACKGROUND: Many patients with musculoskeletal pain prefer topical treatments because they consider them safer than oral drugs. There is a long history of topical use of nettle sting for pain, but no standard method of application. Our objective was to develop a consensus of the experiences of nettle sting users. METHODS: A consensus study was conducted using the expert panel method. Media articles resulted in 16 responses and nine users attended a meeting. Participants first responded to questions on how they chose the leaf and how they applied the nettle sting; then discussed their individual responses; and finally responded once more to the same questions. Consensus was defined as 70% agreement. Participants' consensus was developed from the responses and discussions, and modified in response to repeated feedback and to comments of seven other nettle users. RESULTS: Consensus was present initially on three questions: 'Important to feel a good strong sting', 'Immediately sting the area again' and 'Sting once a day'. Opinions on the method and site of application, and format of a course of treatment varied. This range of advice was incorporated into a treatment consensus document acceptable to all users in the study. CONCLUSIONS: The users' consensus document for the use of nettle sting for musculoskeletal pain is published for anyone who wishes to use this self-care approach to treating their pain. The user's consensus document represents an essential step in undertaking further research into the effectiveness of nettle sting as a treatment for musculoskeletal pain.

British pain clinic practitioners' recognition and use of the bio-psychosocial pain management model for patients when physical interventions are ineffective or inappropriate: results of a qualitative study.

BACKGROUND: To explore how chronic musculoskeletal pain is managed in multidisciplinary pain clinics for patients for whom physical interventions are inappropriate or ineffective. METHODS: A qualitative study was undertaken using semi-structured interviews with twenty five members of the pain management team drawn from seven pain clinics and one pain management unit located across the UK. RESULTS: All clinics reported using a multidisciplinary bio-psychosocial model. However the chronic pain management strategy actually focussed on psychological approaches in preference to physical approaches. These approaches were utilised by all practitioners irrespective of their discipline. Consideration of social elements such as access to social support networks to support patients in managing their chronic pain was conspicuously absent from the approaches used. CONCLUSION: Pain clinic practitioners readily embraced cognitive/behavioural based management strategies but relatively little consideration to the impact social factors played in managing chronic pain was reported. Consequently multidisciplinary pain clinics espousing a bio-psychosocial model of pain management may not be achieving their maximum potential.

Community pharmacists' perceptions of medicines use reviews and quality assurance by peer review.

OBJECTIVES: To explore existing mechanism to ensure quality assurance of medicine use reviews (MURs), and to identify those parameters of an MUR that community pharmacists consider as indicators of quality. SETTING: Community pharmacists undertaking MURs in Cornwall, United Kingdom. METHOD: A questionnaire was developed to investigate pharmacists' attitudes towards MURs and towards quality assurance of MURs. Questionnaires were distributed during December 2008 to a sample of pharmacists in Cornwall accredited to provide the service. Main outcome measures Community pharmacists' attitudes towards quality assurance of MURs. RESULTS: Fifty completed questionnaires were returned, a third of which were from locum pharmacists. The most frequently reported determinant for undertaking an MUR was the pharmacist's judgement. Company policy to deliver MURs was acknowledged as a potential indicator of a sub-optimal MUR. Pharmacists shared a common sense of what constitutes a "poor" MUR but not what defines a quality one. CONCLUSION: For peer review to operate as an effective mechanism to assure quality of MURs, pharmacists need to develop an effective forum to share their practice experiences.

'It got right to the spot' The patient experience of primary angioplasty: a qualitative study.

BACKGROUND: Primary angioplasty is becoming an established treatment for myocardial infarction. Yet we have a limited understanding of patients' attitudes toward this treatment and their experiences of receiving it in practice. AIMS: Exploration of patients' experiences and perceptions of primary angioplasty as treatment for their heart attack. METHODS: Qualitative study of a purposive sample of patients admitted to a tertiary cardiology unit in east London, UK. Participants were interviewed either in their own homes or in hospital. Recruitment continued until no new substantial themes emerged. Eleven men and four women aged 35 to 74 years who had sustained a myocardial infarction were interviewed 13 to 90 days after primary angioplasty. We used the framework method of analysis to identify and explore emerging themes. RESULTS: Informants were expecting open-heart surgery as treatment for their heart attack. They were impressed by the service they actually received. They were generally not engaged in decisions about their treatment in the acute setting and this passivity sometimes persisted after discharge. Expectations of follow up in primary care were not often met. CONCLUSIONS: Patients are satisfied with the primary angioplasty as treatment for acute myocardial infarction but have poor understanding of the management of this condition.

'Am I going to see the next morning?' A qualitative study of patients' perspectives of sleep in COPD.

AIM: To investigate patients' perspectives of sleep in COPD. METHOD: Patients with moderate to severe COPD underwent semi-structured interviews about their sleep experiences. Contextual questionnaire data were collected. RESULTS: Ten patients were studied. Six reported bad sleep, but all described some sleep problems. Nocturnal anxiety and fears of breathlessness and dying were common features; these impacted on existing sleep problems related to exacerbations, medications, and habitual behaviours that can disrupt sleep. Poor sleep was associated with poorer health status. Patients reported a lack of support from their GPs and few had received advice for sleep problems. CONCLUSION: Anxiety about breathlessness affects the sleep experience of patients with COPD, and sleep quality impacts on physical and emotional functioning. Education about behaviours that can disrupt sleep offers potential benefits to the patient. COPD patients' sleep issues are complex and should be addressed at the clinical consultation.

The influence of patients' and primary care practitioners' beliefs and expectations about chronic musculoskeletal pain on the process of care: a systematic review of qualitative studies.

OBJECTIVES: To review qualitative, empirical studies exploring the influence of patients' and primary care practitioners' beliefs and expectations on the process of care for chronic musculoskeletal pain. METHODS: A multidisciplinary review group searched 9 bibliographic databases. The group worked in pairs to screen titles and abstracts for relevance, to quality appraise relevant studies, to extract data from high-quality studies and to undertake a thematic analysis of this data. RESULTS: We identified 12,994 abstracts from our searches, of which we obtained 113 full-text articles as their abstracts contained insufficient information for us to decide on their eligibility. We appraised 22 qualitative studies, 15 of which were included in the analysis. Themes identified included; (1) beliefs about pain, (2) expectations of treatment, (3) trust, and (4) patient education. Both patients and practitioners wanted clear communication within the consultation and to be respected, but conflicts existed on nearly all other aspects of the consultation, some of which at present may seem insurmountable and may lead to difficulties in achieving positive outcomes. DISCUSSION: To tackle the challenges and conflicts identified within the review, change may have to occur, not just in individual patient and practitioner beliefs and behavior, but also at an organizational and system level, for example, changes in undergraduate and postgraduate education and changes in the organization and availability of health services.

"It struck me that they didn't understand pain": the specialist pain clinic experience of patients with chronic musculoskeletal pain.

OBJECTIVE: To explore the experiences of diagnosis and management among patients who attended a specialist musculoskeletal pain clinic and the factors influencing their interpretation of these experiences. METHODS: A postal questionnaire was sent to potential participants 6-20 months after their first clinic attendance. Data were collected on pain presence, severity, and location; health-related quality of life; psychological distress; and care-seeking behavior. Questionnaire data were used to inform combined purposive and theoretical sampling. In-depth interviews were conducted that probed participants' understanding of their chronic musculoskeletal pain and its management in a specialist musculoskeletal pain clinic. RESULTS: Fifteen patients were interviewed. Four main themes were identified: spoiled identity (pain limited patients' activities so extensively that it affected their sense of self); diminishing faith in medicine (patients were disappointed with aspects of their care-seeking experience); making sense of pain (patients made sense of their pain by locating their pain within the context of their lives); and learning to live with the pain (an issue for all patients was whether or not their pain would stop or whether they had to learn to live with it). CONCLUSION: Developing, implementing, and evaluating approaches to address patients' spoiled identities might allow us to improve patient-centered outcomes in chronic musculoskeletal pain.

Homelessness: a problem for primary care?

Homelessness is a social problem that affects all facets of contemporary society. This paper discusses the concept of homelessness in terms of its historical context and the dominance of the pervasive 'victim blaming' ideologies, which, together with the worldwide economic changes that have contributed to a fiscal crisis of the state, and the resultant policies and circumstances, have led to an increase in the number of 'new homeless' people. This paper attempts to challenge the dominant political discourse on homelessness. The widespread healthcare problems and heterogeneity of homeless people have a particular impact on health services, with many homeless people inappropriately accessing local accident and emergency (A&E) departments because of barriers inhibiting adequate access to primary care. A number of primary care schemes have been successfully implemented to enable the homeless to have better access to appropriate care. However, there is no consistency in the level of services around the United Kingdom (UK), and innovations in service are not widespread and by their nature they are ad hoc. Despite the successes of such schemes, many homeless people still access health care inappropriately. Until homeless people are fully integrated into primary care the situation will not change. The question remains, how can appropriate access be established? A start can be made by building on some of the positive work that is already being done in primary care, but in reality general practitioners (GPs) will be 'swimming against the tide' unless a more integrated policy approach is adopted to tackle homelessness.

An evaluation of personal medical services: the times they are a changin'.

The Personal Medical Services (PMS) pilot sites, launched in England in 1997 by the Secretary of State for the then Conservative government, introduced a local contract for primary care, aimed at promoting flexibility, innovation and policy participation. As part of the National Evaluation of PMS, this paper considers the professional and organisational relationships established between service providers working in those PMS sites which specifically set out to address inequalities in access to primary care for vulnerable populations. The introduction of PMS enabled a change of cultural values in primary care, particularly regarding GPs' relationships with nurses and practice staff. However, PMS has not necessarily led to equal partnerships within primary care teams. Rather,in the selected sites evaluated new interprofessional relationships emerged. There was evidence of intra and interprofessional partnerships being forged, providing the basis for further improved intersectoral collaboration. There was also evidence that the GP based medical model made way for a community oriented/public health model with emphasis on health maintenance for the vulnerable.