Bereavement care for older people in healthcare settings: qualitative study of experiences.

AIM: This study aimed to explore the experiences of healthcare staff of caring for bereaved older people, and older people's experiences of bereavement care. BACKGROUND: Loss through death of close family members, partners and friends inhibits the physical, emotional and social well being of older people. The rising population of older people and pressure on healthcare services to reduce costs indicate the necessity of developing strategies that enable coping and independence. DESIGN: A qualitative design drawing on phenomenological methodology was used to understand interactions between healthcare staff and bereaved older people. The study was set in hospital wards, general practice and community nursing teams, and care homes. Healthcare staff and a sample of recently bereaved older people participated. METHODS: Purposive sampling took place to recruit staff with a range of roles, and older people who were 65 years of age or more, and bereaved of a family member or friend for between 6 months and 5 years. Participants took part in in-depth interviews, and data were analysed systematically. RESULTS: Thirty-nine participants were recruited, and three key themes arose from the data: (i) Bereavement care depends on an established relationship between healthcare staff and the patient's relatives; (ii) Preparation for the relative's death may not equate to being prepared for bereavement; (iii) The 'Open Door' to bereavement care is only slightly ajar. CONCLUSIONS: The study identified the interactions of healthcare staff with bereaved older people in terms of the bereavement journey. Staff demonstrated awareness of difficulties the bereaved person may encounter and showed commitment to providing support. However, lack of flexibility in services restricts meaningful interactions. IMPLICATIONS FOR PRACTICE: (i) Healthcare staff may identify gaps in services in terms of preparing relatives and follow-up post-bereavement; (ii) Therapeutic relationships between staff and relatives enable ongoing support; (iii) Development of practice guidelines is a key consideration.

A metasynthesis of qualitative studies regarding opinions and perceptions about barriers and determinants of health services' accessibility in economic migrants.

BACKGROUND: Access to health services is an important health determinant. New research in health equity is required, especially amongst economic migrants from developing countries. Studies conducted on the use of health services by migrant populations highlight existing gaps in understanding which factors affect access to these services from a qualitative perspective. We aim to describe the views of the migrants regarding barriers and determinants of access to health services in the international literature (1997-2011). METHODS: A systematic review was conducted for Qualitative research papers (English/Spanish) published in 13 electronic databases. A selection of articles that accomplished the inclusion criteria and a quality evaluation of the studies were carried out. The findings of the selected studies were synthesised by means of metasynthesis using different analysis categories according to Andersen's conceptual framework of access and use of health services and by incorporating other emergent categories. RESULTS: We located 3,025 titles, 36 studies achieved the inclusion criteria. After quality evaluation, 28 articles were definitively synthesised. 12 studies (46.2%) were carried out in the U.S and 11 studies (42.3%) dealt with primary care services. The participating population varied depending mainly on type of host country. Barriers were described, such as the lack of communication between health services providers and migrants, due to idiomatic difficulties and cultural differences. Other barriers were linked to the economic system, the health service characteristics and the legislation in each country. This situation has consequences for the lack of health control by migrants and their social vulnerability. CONCLUSIONS: Economic migrants faced individual and structural barriers to the health services in host countries, especially those with undocumented situation and those experimented idiomatic difficulties. Strategies to improve the structures of health systems and social policies are needed.

Research to support evidence-based practice in COPD community nursing.

Evidence-based practice (EBP) is a requirement of nurses through the generation of evidence to implementing it, in a bid to to improve clinical practice. However, EBP is difficult to achieve. This paper highlights an approach to generating evidence for enhancing community nursing services for patients with chronic obstructive pulmonary disease (COPD) through a collaborative partnership. A district nurse and two nursing lecturers formed a partnership to devise a systematic review protocol and perform a systematic review to enhance COPD practice. This paper illustrates the Joanna Briggs Institute (JBI) systematic review process, the review outcomes and the practitioner learning. Collaborative partnerships between academics, researchers and clinicians are a potentially useful model to facilitate enhanced outcomes in evidence-based practice and evidence application.

Exploring clinical wisdom in nursing education.

The recent interest in wisdom in professional health care practice is explored in this article. Key features of wisdom are identified via consideration of certain classical, ancient and modern sources. Common themes are discussed in terms of their contribution to 'clinical wisdom' itself and this is reviewed against the nature of contemporary nursing education. The distinctive features of wisdom (recognition of contextual factors, the place of the person and timeliness) may enable their significance for practice to be promoted in more coherent ways in nursing education. Wisdom as practical knowledge (phronesis) is offered as a complementary perspective within the educational preparation and practice of students of nursing. Certain limitations within contemporary UK nursing education are identified that may inhibit development of clinical wisdom. These are: the modularization of programmes in higher education institutions, the division of pastoral and academic support and the relationship between theory and practice.

Support for Older People with COPD in Community Settings: A Systematic Review of Qualitative Research.

BACKGROUND: There are an estimated three million people affected by Chronic Obstructive Pulmonary Disease (COPD) in the UK with only about 900,000 of these being diagnosed according to the Healthcare Commission, and prevalence is increasing. Significant progress has been made in respect of treatment and management of the disease. However, there is limited evidence related to the perspective of those with COPD despite an acknowledgement that lung function, as determined by spirometry, does not necessarily equate with pulmonary disease and subsequent functional level or disability. The impact of COPD on patients, their family, carers and healthcare services demands that better ill health prevention and disease maintenance strategies be employed. OBJECTIVE: The objective was to explore the common and shared experiences of those in caring partnership for patients with COPD receiving care and support in their community. CONCEPT OF SUPPORT: For this review, the definition of support takes the view that support relates to 'any activity or intervention aimed at improving or maintaining the health status of a patient with COPD'. INCLUSION CRITERIA: The review focused on the experiences of patients, carers, family members, nurses and doctors involved in providing support to patients with COPD in their own home. Patients aged 65 years and over were included.The review considered studies that represented patient, carer, nursing and medical staff experiences and perceptions of support relating to COPD.The review considered evidence from qualitative research including phenomenology, grounded theory, and descriptive studies, where support for COPD in a community context was the focus. SEARCH STRATEGY: The search set out to find published studies in English from 1990-2010. METHODOLOGICAL QUALITY: The studies were appraised and findings extracted using the JBI critical appraisal tool for qualitative research. Three reviewers appraised the studies independently. 72 studies were critically appraised and 39 met the inclusion criteria. DATA SYNTHESIS: Findings from included papers were aggregated, categorised and synthesised. RESULTS: If those with COPD received more consistent support in relation to information, rehabilitation, end of life care and other service provision then their quality of life could be enhanced.Better planned and more integrated support for home based care around self-care/management and in managing exacerbations can reduce patient and carer anxiety and distress related to COPD.Individualisation of care, which is not based on the patient's 'disease state' (i.e. physical parameters) but on assessed need, is a necessary part of care for those with COPD.

Inconsistencies in guidelines for visual health surveillance of VDT workers.

OBJECTIVES: In Europe, 25% of workers use video display terminals (VDTs). Occupational health surveillance has been considered a key element in the protection of these workers. Nevertheless, it is unclear if guidelines available for this purpose, based on EU standards and available evidence, meet currently accepted quality criteria. The aim of this study was to appraise three sets of European VDT guidelines (UK, France, Spain) in which regulatory and evidence-based approaches for visual health have been formulated and recommendations for practice made. METHODS: Three independent appraisers used an adapted AGREE instrument with seven domains to appraise the guidelines. A modified nominal group technique approach was used in two consecutive phases: first, individual evaluation of the three guidelines simultaneously, and second, a face-to-face meeting of appraisers to discuss scoring. Analysis of ratings obtained in each domain and variability among appraisers was undertaken (correlation and kappa coefficients). RESULTS: All guidelines had low domain scores. The domain evaluated most highly was Scope and purpose, while Applicability was scored minimally. The UK guidelines had the highest overall score, and the Spanish ones had the lowest. The analysis of reliability and differences between scores in each domain showed a high level of agreement. CONCLUSIONS: These results suggest current guidelines used in these countries need an update. The formulation of evidence-base European guidelines on VDT could help to reduce the significant variation of national guidelines, which may have an impact on practical application.

Determining factors required for a holistic approach to weight management of those with obesity.

A prospective 6-month longitudinal survey was carried out to ascertain the extent of relationships between weight beliefs, expectations of weight loss; physical, social, emotional, and well-being; and weight management from the perspective of obese individuals who did not have an identified eating disorder. Physical, social, and emotional factors in weight management show interrelationship and are associated with weight change. Therefore, understanding the relationships between physical, social, and emotional factors of obese individuals would facilitate a holistic, person-centered approach and, it is suggested, have an impact on achieving weight loss and thereby reduce considerable detrimental health effects.

Developing a holistic approach to obesity management.

The aim of this paper is to discuss the theoretical background and relevance of a holistic approach to obesity management by nurses. There is a global rise in the number of people with obesity, such that it now represents one of the major health challenges. However, nurses are often influenced by physical and dietetic focused approaches and could fail to acknowledge a range of other factors that can impact on weight management. As part of the development of a holistic approach to obesity a literature search was undertaken to establish relevant theoretical perspectives that underpin practice in physical, psychological and social aspects of care (focused on the period 1995-2005). In addition, experiences of working in a secondary care weight management clinic were also drawn upon. Psychobiological, attribution and social support theories were identified that could contribute to a better understanding of obesity. If these theoretical perspectives and supporting evidence can be integrated in a holistic approach to care and management it might be possible to promote better health and well-being in those with obesity. Creating a greater understanding of the range of theoretical perspectives and supporting evidence related to obesity could, it is argued, provide enhanced care and management.

Roles and systems for routine medication administration to prevent medication errors in hospital-based, acute care settings: a systematic review.

BACKGROUND: Levels of medication administration error have been reported as accounting for 38% of all adverse drug events and have been calculated as occurring in 3-8% of all administrations. The majority of these will occur as part of "routine" administration. OBJECTIVES: To undertake a systematic review of roles and systems for preventing medication error during routine medication administration in hospital-based acute care settings and of perceptions of causes of error. INCLUSION CRITERIA: Types of participants- Participants were nurses, pharmacists, pharmacy technicians, medical and surgical staff and adult patients in hospital-based, acute care settings.Types of intervention/Phenomena of interest- Intervention related to administration systems and related to roles of those who administer medicines were considered. The perceptions of causes of error was the phenomena of interest.Types of outcomes- 1) Number of medication administration errors, and 2) Nurses and patients' perceptions of causes of medication errorTypes of studies- Quantitative studies of medication error rates for differing medication systems and roles of those administering medications. Qualitative and descriptive studies of perceived causes of errors. SEARCH STRATEGY: The review sought studies published in English from 1990 to December 2008. 23 databases, websites and search engines were searched. METHODOLOGICAL QUALITY: Critical appraisal tools from Joanna Briggs Institute were used. Two reviewers appraised studies independently. 35 studies out of 1004 identified papers were critically appraised. 19 studies met the inclusion criteria. DATA EXTRACTION: Data were extracted using standardised extraction forms. DATA SYNTHESIS: It was not possible to undertake meta-analysis due to lack of studies in all categories and lack of similarity between studies. Quantitative results were combined in a narrative summary. Qualitative studies were synthesised accordingly using a meta-aggregative approach. RESULTS: Nurses perceptions of medication administration errors suggest that ineligible prescriptions and distractions/interruptions (external factors) are perceived as key causes of error. Limited evidence on patient perceptions, suggest that their inclusion in routine medication administration may reduce errors.Studies related to routine medication administration roles and systems are small and lack power and generalisability to all acute care contexts. What evidence exists suggests routine medication that is individualised to the patient and administered close to the bedside, reduces error.There is equivocal evidence related to differing roles of nurses. The use of dedicated medication nurses and primary administration (nurse administers "own" patient medications) are inconclusive. Equivocal evidence related to three system types was identified: self administration; trolley, bay and bedside systems; individualised and unit dose medications.There is no evidence of effectiveness related to one or two nurse checking or related to the use of devices to reduce distractions, such as signs or tabards. CONCLUSIONS: Administration from individually labelled medication, administered close to the patient, appear to be the most significant factors in reducing errors during routine medication rounds. Nurses' perspectives on causes of medication errors, may differ from those recorded. There is no conclusive evidence that manipulating the nursing role has any impact on errors.Implication for practice- Individual or patient dose systems used with administration occurring as close to the patient as possible. Including the patient more fully in the administration process through self administration or involvement in the checking process has some potential for reducing errors.Implication for research- The review identifies the need for rigorous large scale further research.

Bereavement and bereavement care in health and social care: provision and practice in Scotland.

The interview study described here aimed to explore current views of and practice in bereavement care and identify priorities for service development in Scotland. Fifty-nine participants who worked with the bereaved in some way, or whose interest was in bereavement or bereavement care, were interviewed. They represented National Health Service organizations, chaplaincy departments, educational institutions, academic departments, voluntary groups, and other related bodies, such as funeral directors. Transcripts were read repeatedly and initial emerging themes were identified, coded and shared between research team members to reach a consensus for key themes. Priority areas for development were related to raising public awareness, coordination of services, guidance, and professional education.

Tracing and identifying the impact of evidence-use of a modified pipeline model.

AIM: This paper opens up a discussion about effective ways of tracing and identifying impact of evidence implementation in the field of nursing, through the use of Nutley et al.'s concept of an impact continuum, and Glasziou's Pipeline Model. APPROACH: Work to date on improving and evaluating the use of evidence in health care settings has tended to focus on evidence implementation as an endpoint or entity, often seen and measured in terms of change in practice. However, the direct application of evidence to practice is not straightforward. Glasziou's Pipeline Model of the different stages through which evidence flows, in the process of implementation, is critically reviewed in relation to five key issues: the type of evidence entering the pipeline; the linearity of the model; leakages and blockages in the pipeline; levels of impact; and impact measurement. The Pipeline Model is then combined with Nutley et al.'s continuum of impacts in order to present a Modified Pipeline Model. DISCUSSION AND CONCLUSIONS: The Modified Pipeline Model enables evidence implementation to be viewed as a process rather than an entity in itself, which in turn enables longitudinal assessment of barriers and facilitators to evidence "flow." By flow we mean the way in which evidence is transferred from reporting or publication stages to patient outcomes. It also allows identification of the multiple impacts that can occur through the process of evidence implementation, which may be impact on the way the nurse thinks about practice to the healing rate of a leg ulcer. Finally, the Modified Model raises the issue of impacts beyond the pipeline, that is, those outcomes for patients that result from adherence to evidence-based care. This Modified Pipeline Model thus has the potential to support individuals and organizations in enhanced implementation planning, evaluation and management.

Using Qualitative Assessment and Review Instrument software to synthesise studies on older people's views and experiences of falls prevention.

Aim To report on the experiences of using software (Qualitative Assessment and Review Instrument (QARI)) specifically designed to synthesise qualitative research studies. Background The synthesis of qualitative research using a systematic review process is somewhat contentious and at present a variety of approaches exists. One approach is the QARI tool from the Joanna Briggs Institute (JBI) which provides a structured process to qualitative synthesis for appraising, extracting and synthesizing qualitative research that is considered more aggregative than interpretative. The process shares similarities with the methods of quantitative systematic review although the analysis stage is grounded in qualitative methodology. QARI provides a means for accumulating and synthesizing qualitative-based knowledge on the view and experiences of healthcare users and staff that can be used alongside systematic reviews of effectiveness to supply information on barriers and facilitators to adopting an intervention. The synthesis of qualitative research on older people's experiences of falls is used as the focus in this paper. Conclusions In common with other qualitative synthesis methodologies, there remain important areas for debate. These relate to the process and outcomes of: quality assessment, extracting findings from primary studies, the creation of categories (themes, metaphors), the expression of the synthesis and the credibility of an iterative review process.

Appraising and comparing pressure ulcer guidelines.

BACKGROUND: Whilst considerable activity has been related to guideline development for nurses regarding pressure ulcer prevention and management, no attempt has been made to comparatively evaluate these guidelines against some form of quality indicators. AIM: To compare and contrast four national pressure ulcer guidelines, and identify similarities and differences in their quality and content. METHODS: An international comparative appraisal method, using the AGREE (Appraisal of Guidelines Research and Evaluation) instrument, was undertaken to appraise four published pressure ulcer guidelines. Two further domains were added to the AGREE instrument to assess comparability of the guidelines and their perceived contribution to practice. An international group undertook the comparative appraisal. RESULTS: The domain scores for each guideline show some but not total agreement among reviewers. One particular set of guidelines was identified as scoring highest in a majority of AGREE domains. Overall, evidence of variability exists between pressure ulcer guidelines and common areas of development to consider for all guidelines. IMPLICATIONS FOR PRACTICE: The results raise many questions concerning the "best" pressure ulcer guideline to use, particularly related to the AGREE scoring. Some notable shortcomings exist in all the pressure ulcer guidelines reviewed and these shortcomings need to be addressed from a quality perspective. However, other issues such as style of reporting and potential contribution to practice might more fully affect choice by practitioners as opposed to guideline developers. CONCLUSIONS: Notable differences exist among the four guidelines that are possibly explained by different approaches to development and also because of different cultural factors and intentions for use. Whilst the AGREE tool identifies the quality of the guideline development process it still requires local engagement with practitioners to determine which guideline should be implemented.

Teaching and learning about culture: a European journey.

UNLABELLED: This paper explores the evolving nature of an understanding of culture through attendance on an Intensive Programme (IP) funded by ERASMUS-SOCRATES. AIMS: The purpose of this paper is to report a journey of learning about culture through attendance on a ERASMUS-SOCRATES funded Intensive Programme (IP) for nurses in Hasselt, Belgium. METHOD: This paper seeks to describe the process and experience of our involvement through an examination of the authors' participation as teachers and students. This was undertaken using serial taped group and individual interviews. The metaphor of the IP as a journey is described and used as the vehicle for data collection and analysis. FINDINGS: The key findings were the development of key themes relating to: Personal Values and Culture, Engagement and Culture, Personality and Culture and Physicality and Culture. Discussion of these findings raises issues of language and language skill, communication and listening skills, stereotyping, personal awareness, cultural awareness, sensitivity and competence. CONCLUSIONS: It is proposed that direct engagement through programmes, such as the reported IP, with other nurses and nurse educationalists in Europe is an essential part of any modern nursing curriculum and aids the development of internationalisation. Without such direct engagement there is potential for a narrower, limited view of culture and a lack of sensitivity in understanding our own and other cultures.

Skin problems in people with obesity.

AIM: To establish the level and type of skin problems in people with obesity and the extent to which they sought advice on their problem. METHOD: A self-report survey was carried out in a specialist nutrition clinic in Scotland during 2001. A convenience sample of 100 patients was selected. RESULTS: A majority (n = 75, 75 per cent) of respondents had some type of skin problem. The main problems identified were itchiness and dry skin. The sites for skin problems varied although groin, limbs and beneath the breasts were the most prevalent areas. The two main causes of perceived skin problems were perspiration and friction. Forty four (59 per cent) had seen a doctor about their skin problem, but few (n = 12, 16 per cent) had consulted other healthcare professionals and some (25 per cent) had not sought any advice. CONCLUSION: There is a considerable level of skin problems in this patient group, which has not previously been reported or identified as a significant potential co-morbidity. Therefore, nurses and other healthcare professionals should incorporate some form of skin assessment into any assessment of patients with obesity. Further research is needed to determine the specificity and degree of skin problems in those who are diagnosed as obese and the impact it has on their life and their weight management.

Continuing professional development: a review.

In the UK health sector, continuing professional development for nurses is now clearly identified as necessary to the continued improvement of clinical services. The clinical governance movement that is driving this improvement has had a great effect on the NHS and it is now necessary to demonstrate service maintenance and improvement. Lifelong learning and the enhancement of skills through training or self-development are mentioned as ways of providing staff governance (DoH 1999, SEDH 1999).

The meaning of models of nursing to practising nurses.

BACKGROUND: It is contended that models of nursing have lost the momentum and challenge that they promised the profession. Their use, value and purpose have been seriously questioned and new perspectives on their use and implementation in practice, education and research are required. In addition, limited evidence exists on the implementation of models into clinical areas. AIM: To explore the meaning of models of nursing to practising nurses. METHODS: Serial interviews with qualified nurses who were undertaking an educational programme or module that explored and examined models of nursing. FINDINGS: The outcome reveals that the use of the terms, models of nursing or nursing model, are limited and confusing as the terms can encompass a range of meanings. It is suggested that a three-model typology exists that clarifies more fully the present position of nursing models. The three models are Theoretical Model, Mental Model and Surrogate Model. LIMITATIONS: The focus on data collection through serial interviews with qualified practitioners could have been broadened to include a range of data sources such as teachers and clinical areas, which could have enriched the phenomenon of models of nursing. CONCLUSIONS: There is a greater need to understand nursing models within the framework of the three-model typology and to reconsider their introduction and use in this context.