Nurses', midwives' and key stakeholders' experiences and perceptions on requirements to demonstrate the maintenance of professional competence.

AIM: To present the qualitative findings from a study on the development of scheme(s) to give evidence of maintenance of professional competence for nurses and midwives. BACKGROUND: Key issues in maintenance of professional competence include notions of self- assessment, verification of engagement and practice hours, provision of an evidential record, the role of the employer and articulation of possible consequences for non-adherence with the requirements. Schemes to demonstrate the maintenance of professional competence have application to nurses, midwives and regulatory bodies and healthcare employers worldwide. DESIGN: A mixed methods approach was used. This included an online survey of nurses and midwives and focus groups with nurses and midwives and other key stakeholders. The qualitative data are reported in this study. METHODS: Focus groups were conducted among a purposive sample of nurses, midwives and key stakeholders from January-May 2015. A total of 13 focus groups with 91 participants contributed to the study. FINDINGS: Four major themes were identified: Definitions and Characteristics of Competence; Continuing Professional Development and Demonstrating Competence; Assessment of Competence; The Nursing and Midwifery Board of Ireland and employers as regulators and enablers of maintaining professional competence. CONCLUSION: Competence incorporates knowledge, skills, attitudes, professionalism, application of evidence and translating learning into practice. It is specific to the nurse's/midwife's role, organizational needs, patient's needs and the individual nurse's/midwife's learning needs. Competencies develop over time and change as nurses and midwives work in different practice areas. Thus, role-specific competence is linked to recent engagement in practice.

Nurses' knowledge of pain and its management in older people.

Aim To identify nurses' knowledge of pain and its management in older people in acute hospitals. Method A quantitative, descriptive, cross-sectional design was used to survey a convenience sample of nurses. Data were collected using the Pain in the Elderly Questionnaire. Results The overall mean total score on the questionnaire was 65%, with scores ranging from 7-100%. While there is no recommended score, results indicate lack of nurse knowledge. The four questions with the lowest percentage of correct scores were related to pharmacology. Less than 25% of nurses had recent pain management education. Conclusion These findings indicate a knowledge deficit among nurses regarding pain and its management in older people, particularly in relation to opioid management. To improve pain management, nurses caring for older people would benefit from participation in an education programme with clinical application, such as expert-led, real-life or simulation demonstrations rather than lecture/discussion format only.

The impact of reminiscence on the quality of life of residents with dementia in long-stay care.

BACKGROUND: There is increasing recognition of the potential use of reminiscence in maintaining or improving the quality of life of people with dementia. Despite being used widely in dementia care, evidence on the effectiveness of reminiscence remains uncertain. AIMS: This study aims to evaluate the effectiveness of a structured education-based reminiscence programme-the Dementia Education Programme Incorporating Reminiscence for Staff-for people with dementia residing in long-stay care settings in Ireland. METHODS: Dementia Education Programme Incorporating Reminiscence for Staff is a two-group, single-blind, cluster randomised trial conducted in long-stay residential care settings in Ireland. The primary outcome was the self-rated quality of life of residents as measured by the Quality of Life-Alzheimer's Disease instrument. RESULTS: Using an intention-to-treat analysis, we found that the estimated effect of the intervention on the quality of life of residents was a non-significant 3.54 (p = 0.1; 95% confidence interval -0.83, 7.90), expressed as the difference in mean improvement between the intervention and control groups. However, the per-protocol analysis yielded a significant effect for the intervention on the quality of life of residents of 5.22 (p = 0.04; 95% confidence interval 0.11, 10.34). CONCLUSIONS: Reminiscence may, in certain circumstances, be an effective care option for people with dementia in long-stay settings with potential to impact positively on the quality of life of residents.

'Seeing me through my memories': a grounded theory study on using reminiscence with people with dementia living in long-term care.

AIMS AND OBJECTIVES: To understand people with dementia, staff and relatives perspectives on reminiscence, its impact on their lives and experience of care and care giving. BACKGROUND: The quality of life of people with dementia living in long-term care is an important question for providers and policymakers. Reminiscence is thought to have potential for increasing resident-staff interaction, thereby contributing to enhanced personhood for people with dementia. Relatively little is known about the effects of reminiscence on people with dementia or staff. DESIGN: This is a grounded theory study. This design was chosen because of its focus on understanding people's behaviour, interaction and response to events. METHODS: In-depth interviews were conducted with residents with dementia (n = 11), relatives (n = 5), healthcare assistants (n = 10), nurses (n = 9) and nurse managers (n = 3). RESULTS: Reminiscence enabled staff to see and know the person beneath the dementia. It acted as … a key revealing the person to staff, enabling them to engage with the person with dementia in a different way. Knowing the person enabled staff to understand (through the lens of the person's past) and sometimes to accommodate the person's current behaviour. CONCLUSION: The theory of 'seeing me (through my memories)' was generated from the data. This theory explains that through reminiscing and engaging with the person with dementia, staff begin to see the person (their personhood) through the mirror of their memories. RELEVANCE TO CLINICAL PRACTICE: This study found that reminiscence enhanced the experience of living in long-term care for residents with dementia and working in long-term care settings for staff.

Policy-makers' views on impact of specialist and advanced practitioner roles in Ireland: the SCAPE study.

AIM: To ascertain and explore the views held by key healthcare policy-makers on the impact of clinical specialist and advanced practice nursing and midwifery roles. BACKGROUND: Specialist and advanced practice roles are common world-wide and were introduced in Ireland in 2000. After experiencing these roles for a decade, the views of healthcare policy-makers were sought as part of a national evaluation. METHODS: A qualitative, descriptive design was used. Following ethical approval, 12 policy-makers were interviewed in 2010, using a six-part interview schedule. RESULTS: Policy-makers believed that specialist and advanced practice roles resulted in better continuity of care, improved patient/client outcomes and a more holistic approach. These clinicians were also said to be leading guideline development, new initiatives in care, education of staff, audit and policy development. They lacked administrative support and research time. Budget cuts and a government-applied recruitment moratorium were said to hamper the development of specialist/advanced practice roles. CONCLUSION: Healthcare policy-makers believe that specialists and advanced practitioners contribute to higher quality patient/client care, particularly at a strategic level. IMPLICATIONS FOR NURSING MANAGEMENT: These roles could make an important contribution to future health service developments, particularly in relation to chronic-disease management and community care, where more advanced practitioner posts are required.

The effectiveness of a structured education pulmonary rehabilitation programme for improving the health status of people with moderate and severe chronic obstructive pulmonary disease in primary care: the PRINCE cluster randomised trial.

OBJECTIVE: To evaluate the effectiveness of a structured education pulmonary rehabilitation programme on the health status of people with chronic obstructive pulmonary disease (COPD). DESIGN: Two-arm, cluster randomised controlled trial. SETTING: 32 general practices in the Republic of Ireland. PARTICIPANTS: 350 participants with a diagnosis of moderate or severe COPD. INTERVENTION: Experimental group received a structured education pulmonary rehabilitation programme, delivered by the practice nurse and physiotherapist. Control group received usual care. MAIN OUTCOME MEASURE: Health status as measured by the Chronic Respiratory Questionnaire (CRQ) at baseline and at 12-14 weeks postcompletion of the programme. RESULTS: Participants allocated to the intervention group had statistically significant higher mean change total CRQ scores (adjusted mean difference (MD) 1.11, 95% CI 0.35 to 1.87). However, the CI does not exclude a smaller difference than the one that was prespecified as clinically important. Participants allocated to the intervention group also had statistically significant higher mean CRQ Dyspnoea scores after intervention (adjusted MD 0.49, 95% CI 0.20 to 0.78) and CRQ Physical scores (adjusted MD 0.37, 95% CI 0.14 to 0.60). However, CIs for both the CRQ Dyspnoea and CRQ Physical subscales do not exclude smaller differences as prespecified as clinically important. No other statistically significant differences between groups were seen. CONCLUSIONS: A primary care based structured education pulmonary rehabilitation programme is feasible and may increase local accessibility to people with moderate and severe COPD. TRIAL REGISTRATION: ISRCTN52403063.

Life with chronic obstructive pulmonary disease: striving for 'controlled co-existence'.

AIMS AND OBJECTIVES: To understand the meaning of chronic obstructive pulmonary disease (COPD) for people and their response to this disease. BACKGROUND: COPD is a major cause of disability and death. The symptoms of COPD have the potential to impact on every aspect of a person's day-to-day life. To date most published qualitative studies have focused on the 'experience' of breathlessness and its impact on the person. Few studies have sought to 'understand' the meaning of COPD to people and their response to this disease. This study aimed to address this gap. DESIGN: Straussian grounded theory guided study design. Grounded theory was considered appropriate for this study because of its focus on how people respond to and act on the problems they encounter. METHODS: Data were collected through semi-structured interviews with 26 people with COPD. Study participants were recruited from general practices on the western seaboard of Ireland. RESULTS: Two interrelated categories were identified as contributing to 'co-existing with COPD': 'hiding' and 'battling'. 'Co-existing with COPD' was conceptualised as the core category. The potential to 'co-exist' with COPD was influenced by mediating factors. CONCLUSION: The Theory of Co-existing with COPD was generated from the data. This theory explains the delicate balance people with COPD maintain to 'co-exist with COPD'. 'Controlled co-existence' enables the person to feel in control and live life to the optimum. This is a fragile balance however and the unpredictability of COPD can tip the person into 'strained co-existence' or 'uncontrolled co-existence'. RELEVANCE TO CLINICAL PRACTICE: Understanding the experience of living with COPD and the balances involved in 'co-existing with COPD' can help health professionals provide more focused and empowered client care. Enabling people to achieve 'controlled co-existence' with COPD challenges health professionals to educate people with COPD on how to effectively manage their disease.

Developing a structured education reminiscence-based programme for staff in long-stay care facilities in Ireland.

AIMS AND OBJECTIVES: This paper describes the steps used in developing and piloting a structured education programme - the Structured Education Reminiscence-based Programme for Staff (SERPS). The programme aimed to prepare nurses and care assistants to use reminiscence when caring for people with dementia living in long-term care. Reminiscence involves facilitating people to talk or think about their past. BACKGROUND: Structured education programmes are used widely as interventions in randomised controlled trials. However, the process of developing a structured education programme has received little attention relative to that given to evaluating the effectiveness of such programmes. This paper makes explicit the steps followed to develop the SERPS, thereby making a contribution to the methodology of designing and implementing effective structured education programmes. DESIGN: The approach to designing the SERPS was informed by the Van Meijel et al. (2004) model (Journal of Advanced Nursing 48, 84): (1) problem definition, (2) accumulation of building blocks for intervention design, (3) intervention design and (4) intervention validation. METHODS: Grounded theory was used (1) to generate data to shape the 'building blocks' for the SERPS and (2) to explore residents, family and staff's experience of using/receiving reminiscence. RESULTS: Analysis of the pilot data indicated that the programme met its objective of preparing staff to use reminiscence with residents with dementia. Staff were positive both about the SERPS and the use of reminiscence with residents with dementia. CONCLUSIONS: This paper outlines a systematic approach to developing and validating a structured education programme. Participation in a structured education programme is more positive for staff if they are expected to actively implement what they have learnt. Ongoing support during the delivery of the programme is important for successful implementation. RELEVANCE TO CLINICAL PRACTICE: The incorporation of client and professional experience in the design phase is a key strength of this approach to programme design.

An overview of interpretive phenomenology as a research methodology.

AIM: To provide an overview of interpretive phenomenology. BACKGROUND: Phenomenology is a philosophy and a research approach. As a research approach, it is used extensively in nursing and 'interpretive' phenomenology is becoming increasingly popular. DATA SOURCES: Online and manual searches of relevant books and electronic databases were undertaken. REVIEW METHODS: Literature review on papers on phenomenology, research and nursing (written in English) was undertaken. DISCUSSION: A brief outline of the origins of the concept, and the influence of 'descriptive' phenomenology on the development of interpretive phenomenology is provided. Its aim, origins and philosophical basis, including the core concepts of dasein, fore-structure/pre-understanding, world view existential themes and the hermeneutic circle, are described and the influence of these concepts in phenomenological nursing research is illustrated. CONCLUSION: This paper will assist readers when deciding whether interpretive phenomenology is appropriate for their research projects. IMPLICATIONS FOR RESEARCH/PRACTICE: This paper adds to the discussion on interpretive phenomenology and helps inform readers of its use as a research methodology.

COPD in primary care settings in Ireland: stories from usual care.

The aim of the PRINCE study was to determine the effectiveness of a structured education pulmonary rehabilitation programme for those living with COPD in primary care in Ireland. This qualitative element of the larger PRINCE trial aims to describe the constituents of 'usual care' for patients allocated to the control arm of the study. A descriptive qualitative study was used to explore the constituents of usual care. A convenience sample of participants (n=20) allocated to the usual care group were interviewed. Three main themes arose from the study: experiences of having and managing COPD, lifestyle advice, and factors that helped or hindered self-management. Usual care left many people grappling in the dark trying to manage their COPD. It was found that usual care was not at its optimum for people with COPD in the control arm of the PRINCE study.

Research approaches related to phenomenology: negotiating a complex landscape.

AIM: To provide a comprehensive overview of the many research approaches related to phenomenology and their philosophical underpinnings. BACKGROUND: Phenomenological research approaches are varied and often difficult to apply appropriately. Some researchers persist in labelling their studies as examples of Heideggerian or Husserlian phenomenology without fully understanding the implications of the underpinning philosophical assumptions. DATA SOURCES: Methodological sources related to phenomenology as a philosophy and phenomenology as a research approach are used to illustrate the range of phenomenological methods and their philosophical underpinnings. DISCUSSION: The origins of phenomenology are the writings of Husserl and the advancement of his thoughts by Merleau-Ponty, Heidegger, Gadamer and Ricoeur. The importance of fully understanding a methodology and its philosophical underpinnings before using it, or claiming to use it, is emphasised. In addition, the variety of phenomenological research approaches that have evolved over the past 50 years are explored and placed in the context of their philosophical underpinnings. CONCLUSION: There is no single way to conduct a phenomenological study. There are many approaches from which researchers can choose. This has resulted in a range of labels and often in different descriptions for the same approach. IMPLICATIONS FOR RESEARCH/PRACTICE: It is essential that researchers planning to use phenomenology are familiar with the many approaches available. This knowledge will help researchers choose the approaches that best suit the aims of their studies.

A cluster randomised controlled trial evaluating the effectiveness of a structured pulmonary rehabilitation education programme for improving the health status of people with chronic obstructive pulmonary disease (COPD): The PRINCE Study protocol.

BACKGROUND: A key strategy in improving care for people with chronic obstructive pulmonary disease (COPD) is the provision of pulmonary rehabilitation programmes. Pulmonary rehabilitation programmes have been successful in improving patients' sense of dyspnoea and Health Related Quality of Life. However, the effectiveness of structured education pulmonary rehabilitation programmes delivered at the level of the general practice on the health status of people with COPD remains uncertain and there is a need for a robust and fair assessment of this. The PRINCE study will evaluate the effectiveness of a Structured Education Pulmonary Rehabilitation Programme (SEPRP), delivered at the level of the general practice, on the health status of people with COPD. METHODS/DESIGN: The PRINCE Trial is a two-armed, single blind cluster randomised trial conducted in the primary care setting in Ireland. Randomisation to control and intervention is at the level of the General Practice. Participants in the intervention arm will receive a SEPRP and those allocated to the control arm will receive usual care. Delivery of the SEPRP will be by a practice nurse and physiotherapist in the General Practice (GP) site. The primary outcome measure of the study will be health status as measured by the Chronic Respiratory Questionnaire (CRQ). Blinded outcome assessment will be undertaken at baseline and at twelve-fourteen weeks after completion of the programme. A comparison of outcomes between the intervention and control sites will be made to examine if differences exist and, if so, to what extent between control and experimental groups. Sample size calculations estimate that 32 practices with a minimum of 10 participants per practice are required, in total, to be randomised to control and intervention arms for power of at least 80% with alpha levels of 0.05, to determine a clinically significant change of 0.5 units in the CRQ. A cost effectiveness analysis will also be conducted. DISCUSSION: The results of this trial are directly applicable to primary care settings in Ireland. Should a SEPRP delivered by practice nurses and physiotherapists in primary care be found to be effective in improving patients' sense of dyspnoea and HRQoL, then the findings would be applicable to many thousands of individuals in Ireland and beyond.

Rigour and grounded theory.

AIM: This paper explores ways to enhance and demonstrate rigour in a grounded theory study. BACKGROUND: Grounded theory is sometimes criticised for a lack of rigour. Beck (1993) identified credibility, auditability and fittingness as the main standards of rigour for qualitative research methods. These criteria were evaluated for applicability to a Straussian grounded theory study and expanded or refocused where necessary. The author uses a Straussian grounded theory study (Cooney, In press) to examine how the revised criteria can be applied when conducting a grounded theory study. REVIEW METHODS: Strauss and Corbin (1998b) criteria for judging the adequacy of a grounded theory were examined in the context of the wider literature examining rigour in qualitative research studies in general and grounded theory studies in particular. A literature search for 'rigour' and 'grounded theory' was carried out to support this analysis. CONCLUSION: Criteria are suggested for enhancing and demonstrating the rigour of a Straussian grounded theory study. These include: cross-checking emerging concepts against participants' meanings, asking experts if the theory 'fit' their experiences, and recording detailed memos outlining all analytical and sampling decisions. IMPLICATIONS FOR RESEARCH PRACTICE: The criteria identified have been expressed as questions to enable novice researchers to audit the extent to which they are demonstrating rigour when writing up their studies. However, it should not be forgotten that rigour is built into the grounded theory method through the inductive-deductive cycle of theory generation. Care in applying the grounded theory methodology correctly is the single most important factor in ensuring rigour.

Developing a structured education programme for clients with COPD.

This article describes the development of a Structured Education Pulmonary Rehabilitation Programme (SEPRP), for the PRINCE (Pulmonary Rehabilitation In Nurse-led Community Environments) study. This process involved a literature review of existing PR programmes, a content analysis of national and international PR programmes and a concept analysis of empowerment. Secondly, two small descriptive qualitative studies were undertaken to further inform programme content exploring the views of health professionals and clients on programme content, as well as their perceptions of living with COPD. The findings of these two stages led to the development of the eight-week PRINCE SEPRP, based on a philosophy of empowerment and the SEPRP was underpinned by the Transtheoretical model (TTM) of behaviour change. Programme content included managing medications and managing breathlessness, knowing and managing symptoms, recognizing and managing acute exacerbations as well as an individualized exercise programme. Participants' experiences of self management following participation in the SEPRP were also examined. The findings indicate that nurses working in primary care have an important role in informing the development of SEPRP as well as having a key role in their delivery. They have the potential to work in empowering ways with COPD clients and the PRINCE SEPRP is just one example of how this can be put into practice.

Personhood and Dementia Care: A Qualitative Evidence Synthesis of the Perspectives of People With Dementia.

BACKGROUND AND OBJECTIVES: Personhood is considered the cornerstone of person-centered care for people with dementia. However, there is little research on personhood in dementia care from the perspective of the person with dementia themselves. This article presents a qualitative evidence synthesis of the experiences and perceptions of people with dementia on personhood in dementia care. RESEARCH DESIGN AND METHODS: A systematic search of nine databases was conducted. In addition to initial screening, CART analysis was used to determine the most relevant papers. Thematic synthesis was conducted on 20 papers. The CASP tool was used to examine the quality of the included papers. GRADE CERQual analysis examined confidence in the review findings. RESULTS: People with dementia experience many changes due to the disease and the experience of being cared for in different settings. Personhood is affirmed through personal interactions with family, friends, other care recipients, and formal caregivers, as well as through continued engagement in social and occupational roles. DISCUSSION AND IMPLICATIONS: The review has important implications for practice, regulation, and policy. The person and their personhood should be protected rather than undermined, and relationships should be enhanced not diminished by the formal care process. The focus should be on creating and amplifying opportunities for people with dementia to affirm the self through interactions with others and engaging in occupational and social roles to ensure continuity of self.

Choosing between Glaser and Strauss: an example.

Choosing between Glaserian and Straussian grounded theory when selecting a methodological approach can be challenging, but few papers consider this decision-making process. This paper explores the Glaser-Strauss debate using an example of a study which explored whether older people experience a sense of home in residential settings.

Telling a 'good or white lie': The views of people living with dementia and their carers.

OBJECTIVE: A common symptom of cognitive decline in people living with dementia, or people with memory problems, the cause of which has not yet been diagnosed, is the person repeatedly asking for loved ones who are deceased or making statements that are incorrect. Carers are then faced with a dilemma, do they avoid and distract or 'correct' the person and tell the 'truth', or tell a lie. This paper explores the concept of lying from the perspective of people living with dementia in the community and their informal/unpaid carers. METHODS: A descriptive qualitative study utilising focus groups to collect the data was conducted. Three focus group's with a purposive sample of people with memory problems (n = 14) and three focus group's with informal/unpaid carers (n = 18) were undertaken. Qualitative content analysis was used to analyse the data. RESULTS: All participants considered that blatant lying with the intention to deceive and do harm is not acceptable. However, telling a 'good lie' or 'white lie' to alleviate distress was in certain circumstances considered acceptable. The intention behind the 'lie' in their view had to be to do good, and the informal/unpaid carer telling the lie had to really 'know the person' and be cognisant of family preferences. Some informal/unpaid carers acknowledged that it may be acceptable for health care professionals to tell a 'good lie' or 'small lie' in certain circumstances. However, health professionals need to 'know the person' and need to consider informal/family caregivers' wishes. CONCLUSION: Lying was only considered acceptable in the context of knowing the person and when done with the intention not to harm or deceive, undertaken with empathy, and only for the purpose of mitigating the person living with dementia's distress.

Resident perspectives of the determinants of quality of life in residential care in Ireland.

AIM: This paper is a report of a study conducted to identify the determinants of quality of life for older people living in residential care, including exploration of mediating factors at personal and institutional levels and to construct a model of these. BACKGROUND: The quality of life of older people living in residential care is an under-researched area. The focus in the gerontology literature has been on quality of care rather than quality of life for these people. There is emerging consensus, however, that quality of life for older people is a complex, multidimensional concept, incorporating both subjective and objective elements, whether people live at home or in residential care. METHOD: A grounded theory study was conducted in 2005-2006. A total of 101 interviews were undertaken with older people across 12 sites, representing different types of residential care in Northern Ireland. The constant comparative technique was used to analyse data. FINDINGS: Four themes having an impact on the quality of life of residents were identified: ethos of care; sense of self and identity; connectedness; and activities and therapies. Mediating and facilitating and/or constraining factors for quality of life were also identified. The core category was conceptualized as 'maximizing potential'. CONCLUSION: Achieving optimal quality of life for older people in residential care will remain elusive unless all the factors which affect on it are taken into account by practitioners and policy-makers. Improving the quality of life of older people in residential care will require action in respect of all of the domains identified in this paper.

Determinants of quality of life for older people living with a disability in the community.

AIM: This paper is a report of a study conducted to identify the determinants of quality of life for older people with a disability living in the community and to construct a model to explain these. BACKGROUND: There is no consensus in the literature as to the meaning of quality of life. Few studies have focused on the determinants of quality of life for people with a disability. METHODS: A grounded theory study was conducted between 2005 and 2006, using semi-structured interviews to collect data. The constant comparative technique was used to analyse data. The sample comprised 122 older people with one of six disabilities: stroke (n = 20), arthritis (20), depression (20), vision and hearing deficits (20), learning disability (24) or dementia (18) who were living in the community. FINDINGS: A model of the factors that determine quality of life of older people with a disability was developed. 'Living well' was conceptualized as the core category. The potential to 'live well' was influenced by foundation, mediating and facilitating/constraining factors. Quality of life of older people with a disability was revealed as a complex mix of these factors. CONCLUSION: Quality of life cannot be fully understood unless the totality of factors that have an impact on and shape perceptions are taken into account. The model implies that good support from nurses, a focus on a person's abilities and access to information and connectedness to others can make a difference and may help people cope in a better way.

Older Women's Experiences of Aging and Health: An Interpretive Phenomenological Study.

Objective: This interpretive phenomenological study explored older Irish women's experiences of aging and health related issues. Method: Data were collected using in-depth interviews with 23 older women (coresearchers). Data analysis followed the "Vancouver school of doing phenomenology" framework and included a meta-synthesis of individual case constructions. Results: "Retaining autonomy within a process of adaptation and continued engagement" describes the essential meaning of coresearchers' experiences. Four themes were identified: "Being in control: Balancing needs and supports," "Navigating a changing world," "Being connected and involved," "Trying to stay well." Discussion: Gender shapes older women's experience of aging, health, and ill health. Three major factors moderate their experience: autonomy and control, proactivity and adaptability, and staying engaged with life. The study concludes that aging, gender, and health are intrinsically linked and collectively shape older women's experience. This is an important consideration when planning gender-appropriate health care services for older women.