A review of the literature on family decision-making at end of life precipitating hospital admission.

Around 70% of people would prefer to die at home, yet around 50% die in hospital, according to Dying Matters. In collaboration with a local hospice, a literature review was undertaken to address the question: 'what factors precipitate admission to hospital in the last few days of a person's life for those who had expressed a preference to die at home?' Four electronic databases were searched, with a date range of 2008 to 2018. After 80 articles were screened, 13 were included in the review. The findings identified a number of barriers experienced by people with non-cancer conditions nearing the end of life and their family carers, which inhibit the transition to end-of-life care. The findings suggest that hospice support for non-cancer patients with a deteriorating health trajectory needs to precede patient and family recognition that end-of-life care is needed.

Scoping the role and education needs of practice nurses in London.

Aims To identify education priorities for practice nursing across eight London Clinical Commissioning Groups (CCGs); to identify the education, training, development and support needs of practice nurses in undertaking current and future roles. BACKGROUND: The education needs of practice nurses have long been recognised but their employment status means that accessing education requires the support of their GP employer. This study scopes the educational requirements of the practice nurse workforce and working with educational providers and commissioners describes a coherent educational pathway for practice nurses. METHOD: A survey of practice nurses to scope their educational attainment needs was undertaken. Focus groups were carried out which identified the education, training, development and support needs of practice nurses to fulfil current and future roles. Findings A total of 272 respondents completed the survey. Practice nurses took part in three focus groups (n=34) and one workshop (n=39). Findings from this research indicate a practice nurse workforce which lacked career progression, role autonomy or a coherent educational framework. Practice nurses recognised the strength of their role in building relationship-centred care with patients over an extended period of time. They valued this aspect of their role and would welcome opportunities to develop this to benefit patients. CONCLUSION: This paper demonstrates an appetite for more advanced education among practice nurses, a leadership role by the CCGs in working across the whole system to address the education needs of practice nurses, and a willingness on the part of National Health Service education commissioners to commission education which meets the education needs of the practice nurse workforce. Evidence is still required, however, to inform the scope of the practice nurse role within an integrated system of care and to identify the impact of practice nursing on improving health outcomes and care of local populations.

Engaging patients in pressure ulcer prevention.

As patients increasingly care for themselves at home, they require accessible information to enable informed self-care. This article describes the development of an educational electronic application (app) designed for use by patients at risk of pressure ulcers, and their carers. The app can be downloaded to Windows, Android or Apple smartphones or tablets. The app is based on the current pressure ulcer prevention and management guidelines from the National Pressure Ulcer Advisory Panel and the National Institute for Health and Care Excellence, and is designed to educate patients and carers about how to prevent a pressure ulcer, how to recognise a pressure ulcer, and what to do if they suspect they are developing a pressure ulcer. We hope the app will be used to help with educational conversations among patients, carers and healthcare professionals.

A case study of asthma care in school age children using nurse-coordinated multidisciplinary collaborative practices.

AIM: To describe the role of school nursing in leading and coordinating a multidisciplinary networked system of support for children with asthma, and to analyze the strengths and challenges of undertaking and supporting multiagency interprofessional practice. BACKGROUND: The growth of networked and interprofessional collaborations arises from the recognition that a number of the most pressing public health problems cannot be addressed by single-discipline or -agency interventions. This paper identifies the potential of school nursing to provide the vision and multiagency leadership required to coordinate multidisciplinary collaboration. METHOD: A mixed-method single-case study design using Yin's approach, including focus groups, interviews, and analysis of policy documents and public health reports. RESULTS: A model that explains the integrated population approach to managing school-age asthma is described; the role of the lead school nurse coordinator was seen as critical to the development and sustainability of the model. CONCLUSION: School nurses can provide strategic multidisciplinary leadership to address pressing public health issues. Health service managers and commissioners need to understand how to support clinicians working across multiagency boundaries and to identify how to develop leadership skills for collaborative interprofessional practice so that the capacity for nursing and other health care professionals to address public health issues does not rely on individual motivation. In England, this will be of particular importance to the commissioning of public health services by local authorities from 2015.

SURVEY OF STAFF OPINIONS ABOUT EXTENDED HAEMODIALYSIS TREATMENT TIME AND SERVICE IMPLICATIONS.

BACKGROUND: We explored the potential impact of staff opinions and service provision upon patient's willingness to recruit to a clinical trial studying the effects of extended treatment time (TT) on haemodialysis (HD), six hours versus four hours for a period of twenty-four weeks. METHODS: We conducted a local survey of dialysis nurses and a national survey of multidisciplinary HD staff opinions to extended TT including clinical benefits, tolerance to, prescription and ability to accommodate extended TT on in-centre HD programmes. RESULTS: The survey was completed by 56/134 (42%) local nurses and the national survey by 15/72 (21%) of dialysis providers across the UK (35% nurses and 75% other healthcare professionals). The majority of respondents felt extended TT was clinically beneficial but only 42% of nurses would recommend extended TT compared to 95% of non-nursing healthcare professionals (p < 0.0001). Although 45% of nurses felt that it was well tolerated, non-nursing healthcare professionals suggested this was significantly higher at 75% (p < 0.05). The negative impact on service provision was agreed by 83% of nurses with the need to facilitate shifts within a finite time period and pressure to find session spaces being cited. CONCLUSION: There is conflict between the understanding that extended TT is clinically beneficial and its prescription & delivery to patients. Enrolment to studies examining HD delivery strategies may be influenced by service provision and staff attitudes. In centre HD has been designed to maximise patient throughput and we may need to consider more flexible settings in which to deliver longer treatment time: Home HD maybe a solution.

Success and failure in integrated models of nursing for long term conditions: multiple case studies of whole systems.

BACKGROUND: Current projections indicate that the UK faces a 252% increase in people aged over 65 with one or more long term conditions (LTC) by 2050. Nurses, managing their own caseloads and clinics, working across sectors and organisational boundaries and as part of a wider multi-disciplinary team, are frequently seen as key to managing this growing demand. However, the evidence base informing the nursing role in managing LTC, the most effective configuration of the multi-disciplinary team and the policy evidence relating to the infrastructure required to support cross organisational working, remains weak. OBJECTIVES: To explore, identify and characterise the origins, processes and outcomes of effective chronic disease management models and the nursing contributions to such models. DESIGN: Case study whole systems analysis using qualitative interview methods. SETTINGS: Two community matron services, two primary care (GP) practice nursing services, two hospital based specialist nursing services were purposefully sampled from across England and Wales. PARTICIPANTS: Selection criteria were derived using a consensus conference. The nurses in the service, all patients and carers on the caseload, members of the multi-disciplinary team and stakeholders were invited to participate. METHODS: Semi-structured interviews with all participants, thematic analysis within a whole system framework. RESULTS: The study found high levels of clinical nursing expertise which in the case of the community matrons was meeting the aim of reducing hospital admissions. Both the primary care and hospital nurse specialist indicate similar levels of clinical expertise which was highly valued by medical colleagues and patients. Patients continued to experience fragmented care determined by diagnostic categories rather than patient need and by the specific remit of the clinic or service the patient was using. Patient data systems are still organised around the impact on services and prevalence of disease at an individual level and not around the patient experience of disease. CONCLUSION: Nurses are making a major contribution to meeting the policy objectives for long term conditions. Primary care nurses and hospital nurse specialists do broadly similar roles. The scope of the nursing roles and services studied were idiosyncratic, opportunistic and reactive, rather than planned and commissioned on an analysis of local population need.

The nursing contribution to chronic disease management: a case of public expectation? Qualitative findings from a multiple case study design in England and Wales.

BACKGROUND: The global response to the rise in prevalence of chronic disease is a focus on the way services are managed and delivered, in which nurses are seen as central in shaping patient experience. However, there is relatively little known on how patients perceive the changes to service delivery envisaged by chronic care models. OBJECTIVES: The PEARLE project aimed to explore, identify and characterise the origins, processes and outcomes of effective chronic disease management models and the nursing contributions to the models. Design, settings and participants Case study design of seven sites in England and Wales ensuring a range of chronic disease management models. Participants included over ninety patients and family carers ranging in age from children to older people with conditions such as diabetes, respiratory disease, epilepsy, or coronary heart disease. METHODS: Semi-structured interviews with patients and family carers. Focus groups were conducted with adolescents and children. A whole systems approach guided data collection and data were thematically analysed. RESULTS: Despite nurses' role and skill development and the shift away from the acute care model, the results suggested that patients had a persisting belief in the monopoly of expertise continuing to exist in the acute care setting. Patients were more satisfied if they saw the nurse as diagnostician, prescriber and medical manager of the condition. Patients were less satisfied when they had been transferred from an established doctor-led to nurse-led service. While nurses within the study were highly skilled, patient perception was guided by the familiar rather than most appropriate service delivery. Most patients saw chronic disease management as a medicalised approach and the nursing contribution was most valued when emulating it. CONCLUSIONS: Patients' preferences and expectations of chronic disease management were framed by a strongly biomedical discourse. Perceptions of nurse-led chronic disease management were often shaped by what was previously familiar to the patient. At a strategic level, autonomous nursing practice requires support and further promotion to wider society if there is to be a shift in societal expectation and trust in the nurse's role in chronic disease management.

Streaming primary urgent care: a prospective approach.

AIM: To identify the appropriate service provider attendees of emergency departments (EDs) and walk-in centres (WiCs) in North East London and to match this to local service provision and patient choice. DESIGN: An anonymous patient survey and a retrospective analysis of a random sample of patient records were performed. A nurse consultant, general practitioner (GP) and pharmacist used the presenting complaints in the patients' records to independently stream the patient to primary care services, non-National Health Services or ED. Statistical analysis of level of agreement was undertaken. A stakeholder focus group reviewed the results. SUBJECTS AND SETTING: Adult health consumers attending ED and urgent care services in North East London. RESULTS: The health user survey identified younger rather than older users (mean age of 35.6 years--SD 15.5), where 50% had not seen a health professional about their concern, with over 40% unable to obtain a convenient or emergency appointment with their GP. Over a third of the attendees were already receiving treatment and over 40% of these saw their complaint as an emergency. Over half of respondents expected to see a doctor, one-quarter expected to see a nurse and only 1% expected to see a pharmacist across both services, although WiCs are nurse-led services. More respondents expected a prescription from a visit to a WiC, whereas in the ED a third of respondents sought health advice or reassurance. CONCLUSION: A number of unscheduled care strategies are, or have just been, developed with the emphasis on moving demand into community-based services. Plurality of services provides service users with a range of alternative access points but can cause duplication of services and repeat attendance. Managing continued increase in emergency and unscheduled care is a challenge. The uncertainties in prospective decision making could be used to inform service development and delivery.

Unscheduled care: learning from video-recorded consultations.

One aspect of the implementation of patient-centred care is the improvement of consultations between service users and practitioners, and this can be done through 'communicative action'. This article explains how observing video recordings of consultations in a walk-in centre can help service users and practitioners better understand each other's conversations and interactions.

Assume leadership in the delivery of top quality home healthcare

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The process of hospital discharge for medical patients: a model.

BACKGROUND: The 1990 NHS Community Care Act established a requirement for hospital discharge policies and procedures in the United Kingdom to be developed in collaboration with local government authorities in order to ensure supported discharge for those in need. AIMS: The aim of the study reported in this paper was to track decisions about hospital discharge in relation to outcomes for a sample of medical patients and their carers, identified as at risk of experiencing unsuccessful discharge processes. METHODS: Themed unstructured interviews were conducted in three different hospitals with 30 patients identified as at risk of unsuccessful discharge and their carers pre- and postdischarge. Hospital, community and social care staff involved in the care of the patient were also interviewed. FINDINGS: Patients and carers were constantly negotiating their social roles, seeking to juggle appropriate identities and limited resources to maintain their own and each others' dignity and quality of life. When the negotiation process was destabilized (for example, by exacerbation of chronic disease, withdrawal of some resource, or the experience of additional stressors - not necessarily health-related), then either or both parties sought a way out. In all the cases examined the result was admission to hospital - usually, but not always, mediated by community professionals. CONCLUSIONS: The effective discharge of patients from hospital needs to move from a functional focus on symptom management to a negotiation of quality of life that seeks to promote health for all parties involved.

Using randomised controlled trials (RCTs) to test service interventions: issues of standardisation, selection and generalisability.

The commissioning of healthcare services is increasingly linked to the availability of rigorous evidence of clinical and cost effectiveness. In the current climate, 'rigorous evidence' is synonymous with the randomised controlled trial (RCT). Consequently, health technologies are often funded in preference to service developments due to an imbalance in the availability of strong evidence to support service developments. Simultaneously, there is an increasing policy emphasis on patient choice and individualized care in the NHS. In this paper Bill Watson, Susan Procter and Wendy Cochrane discuss the implications of using experimental methods in service development research, with reference to an ongoing RCT evaluating the component parts of pulmonary rehabilitation in people with chronic obstructive pulmonary disease (COPD).

A community outreach service for people with COPD.

This paper describes the development and evaluation of a nurse-led interagency community outreach service for patients with chronic obstructive pulmonary disease. The service improved the quality of life of the patients who accessed it. However, difficulties in maintaining the service arose from the historical structure of care delivery and policy frameworks.

Implementation of clinical guidelines for female urinary incontinence: a comparative analysis of organizational structures and service delivery.

The aim of the study was to explore and compare the development of continence services in two contrasting trusts. The first was a community trust which had initiated a top-down purchaser-led continence service. The second was a combined acute and community trust which had introduced a bottom-up, organic continence service based on staff development. The research used a qualitative, interpretative design. Evidence-based guidelines for female urinary incontinence (FUI) were analysed and key organizational features elicited. These were used to frame and analyse 20 semi-structured interviews with a range of community-based professionals who provided a service to women suffering from urinary incontinence. The interviews identified practitioner knowledge and awareness of the evidence pertaining to the management and treatment of FUI and also the features of the organizational structure of service provision in their locality which facilitated or constrained the implementation of evidence-based treatment in this area. The findings suggest that evidence-based guidelines were more closely adhered to in practice, in the trust using organic approaches to service development. Top-down, purchaser led approaches were more prescriptive and circumscribed the scope of professional practice. This adversely affected access to services for women suffering from urinary incontinence. Organic approaches to service development produce more flexible, responsive services. It is difficult, however, to integrate this approach with strategic planning as the flexibility required maybe incompatible with managerial responsibilities for defining roles and organizational functions.