A meta-ethnography of the factors that shape link workers' experiences of social prescribing.

BACKGROUND: Social prescribing is gaining traction internationally. It is an approach which seeks to address non-medical and health-related social needs through taking a holistic person-centred and community-based approach. This involves connecting people with and supporting them to access groups and organisations within their local communities. It is hoped that social prescribing might improve health inequities and reduce reliance on healthcare services. In the UK, social prescribing link workers have become core parts of primary care teams. Despite growing literature on the implementation of social prescribing, to date there has been no synthesis that develops a theoretical understanding of the factors that shape link workers' experiences of their role. METHODS: We undertook a meta-ethnographic evidence synthesis of qualitative literature to develop a novel conceptual framework that explains how link workers experience their roles. We identified studies using a systematic search of key databases, Google alerts, and through scanning reference lists of included studies. We followed the eMERGe guidance when conducting and reporting this meta-ethnography. RESULTS: Our synthesis included 21 studies and developed a "line of argument" or overarching conceptual framework which highlighted inherent and interacting tensions present at each of the levels that social prescribing operates. These tensions may arise from a mismatch between the policy logic of social prescribing and the material and structural reality, shaped by social, political, and economic forces, into which it is being implemented. CONCLUSIONS: The tensions highlighted in our review shape link workers' experiences of their role. They may call into question the sustainability of social prescribing and the link worker role as currently implemented, as well as their ability to deliver desired outcomes such as reducing health inequities or healthcare service utilisation. Greater consideration should be given to how the link worker role is defined, deployed, and trained. Furthermore, thought should be given to ensuring that the infrastructure into which social prescribing is being implemented is sufficient to meet needs. Should social prescribing seek to improve outcomes for those experiencing social and economic disadvantage, it may be necessary for social prescribing models to allow for more intensive and longer-term modes of support.

Applying an equity lens to social prescribing.

BACKGROUND: Social prescribing is often described as an intervention that can help reduce health inequalities yet there is little evidence exploring this. This study aimed to assess the feasibility of accessing and analysing social prescribing (SP) service user data to demonstrate the impact of SP on health inequalities. METHODS: The sample size consisted of records for 276 individuals in Site 1 and 1644 in Site 2. Descriptive analyses were performed to assess the characteristics of people accessing SP, the consistency of data collected and the missingness across both sites. RESULTS: Both sites collected basic demographic data (age gender, ethnicity and deprivation). However, data collection was inconsistent; issues included poor recording of ethnicity in Site 2, and for both sites, referral source data and health and well-being outcome measures were missing. There was limited data on the wider determinants of health. These data gaps mean that impacts on health inequalities could not be fully explored. CONCLUSIONS: It is essential that SP data collection includes information on user demographics and the wider determinants of health in line with PROGRESS Plus factors. Considering equity around who is accessing SP, how they access it and the outcomes is essential to evidencing how SP affects health inequalities and ensuring equitable service delivery.

The Effectiveness of Positive Psychology Interventions for Promoting Well-being of Adults Experiencing Depression Compared to Other Active Psychological Treatments: A Systematic Review and Meta-analysis.

This systematic review assesses if positive psychology interventions (PPI) are more effective than other active psychological interventions for increasing the well-being of depressed adults. A review of randomised trials that compared PPI to other active interventions was conducted. A systematic search was undertaken using PsycInfo, PubMed, EMBASE, Web of Science, Scopus, CINAHL, two trial registries, and a manual search. The outcomes were happiness and depression. Ten studies, totalling 1341 participants, were included in the review. The small effect sizes for depression (Hedge's g = 0.15) and happiness (Hedge's g = 0.20) favoured PPI but were not significant, indicating no difference between PPI and other active interventions for the outcomes. Heterogeneity was high mainly due to differences in trial implementation. Risks of bias ranged from moderate to high. The results should be interpreted with caution because of the small number of included studies, high heterogeneity, and presence of bias. Protocol Registration Number PROSPERO CRD42019152513. Supplementary Information: The online version contains supplementary material available at 10.1007/s10902-022-00598-z.

Tailoring cultural offers to meet the needs of older people during uncertain times: a rapid realist review.

BACKGROUND: Non-medical issues (e.g. loneliness, financial concerns, housing problems) can shape how people feel physically and psychologically. This has been emphasised during the Covid-19 pandemic, especially for older people. Social prescribing is proposed as a means of addressing non-medical issues, which can include drawing on support offered by the cultural sector. METHOD: A rapid realist review was conducted to explore how the cultural sector (in particular public/curated gardens, libraries and museums), as part of social prescribing, can support the holistic well-being of older people under conditions imposed by the pandemic. An initial programme theory was developed from our existing knowledge and discussions with cultural sector staff. It informed searches on databases and within the grey literature for relevant documents, which were screened against the review's inclusion criteria. Data were extracted from these documents to develop context-mechanism-outcome configurations (CMOCs). We used the CMOCs to refine our initial programme theory. RESULTS: Data were extracted from 42 documents. CMOCs developed from these documents highlighted the importance of tailoring-shaping support available through the cultural sector to the needs and expectations of older people-through messaging, matching, monitoring and partnerships. Tailoring can help to secure benefits that older people may derive from engaging with a cultural offer-being distracted (absorbed in an activity) or psychologically held, making connections or transforming through self-growth. We explored the idea of tailoring in more detail by considering it in relation to Social Exchange Theory. CONCLUSIONS: Tailoring cultural offers to the variety of conditions and circumstances encountered in later life, and to changes in social circumstances (e.g. a global pandemic), is central to social prescribing for older people involving the cultural sector. Adaptations should be directed towards achieving key benefits for older people who have reported feeling lonely, anxious and unwell during the pandemic and recovery from it.

Understanding the role of the paramedic in primary care: a realist review.

BACKGROUND: Since 2002, paramedics have been working in primary care within the United Kingdom (UK), a transition also mirrored within Australia, Canada and the USA. Recent recommendations to improve UK NHS workforce capacities have led to a major push to increase the numbers of paramedics recruited into primary care. However, gaps exist in the evidence base regarding how and why these changes would work, for whom, in what context and to what extent. To understand the ways in which paramedics impact (or not) the primary care workforce, we conducted a realist review. METHODS: A realist approach aims to provide causal explanations through the generation and articulation of contexts, mechanisms and outcomes. Our search of electronic databases was supplemented with Google and citation checking to locate grey literature including news items and workforce reports. Included documents were from the UK, Australia, Canada and the Americas-countries within which the paramedic role within primary care is well established. RESULTS: Our searches resulted in 205 included documents, from which data were extracted to produce context-mechanism-outcome configurations (CMOCs) within a final programme theory. Our results outline that paramedics are more likely to be effective in contributing to primary care workforces when they are supported to expand their existing role through formal education and clinical supervision. We also found that unless paramedics were fully integrated into primary care services, they did not experience the socialisation needed to build trusting relationships with patients or physicians. Indeed, for patients to accept paramedics in primary care, their role and its implications for their care should be outlined by a trusted source. CONCLUSIONS: Our realist review highlights the complexity surrounding the introduction of paramedics into primary care roles. As well as offering an insight into understanding the paramedic professional identity, we also discuss the range of expectations this professional group will face in the transition to primary care. These expectations come from patients, general practitioners (family physicians) and paramedics themselves. This review is the first to offer insight into understanding the impact paramedics may have on the international primary care workforce and shaping how they might be optimally deployed.

Social Prescribing in National Health Service Primary Care: What Are the Ethical Considerations?

Policy Points Social prescribing is proposed as a way of improving patients' health and well-being by attending to their non-clinical needs. This is done by connecting patients with community assets (typically voluntary or charitable organizations) that provide social and personal support. In the United Kingdom, social prescribing is used to improve patient well-being and reduce use of National Health Service resources. Although social prescribing schemes hold promise, evidence of their effects and effectiveness is sparse. As more information on social prescribing is gathered, it will be important to consider the associated ethical issues for patients, clinicians, link workers, and community assets.

Supporting social prescribing in primary care by linking people to local assets: a realist review.

BACKGROUND: Social prescribing is a way of addressing the 'non-medical' needs (e.g. loneliness, debt, housing problems) that can affect people's health and well-being. Connector schemes (e.g. delivered by care navigators or link workers) have become a key component to social prescribing's delivery. Those in this role support patients by either (a) signposting them to relevant local assets (e.g. groups, organisations, charities, activities, events) or (b) taking time to assist them in identifying and prioritising their 'non-medical' needs and connecting them to relevant local assets. To understand how such connector schemes work, for whom, why and in what circumstances, we conducted a realist review. METHOD: A search of electronic databases was supplemented with Google alerts and reference checking to locate grey literature. In addition, we sent a Freedom of Information request to all Clinical Commissioning Groups in England to identify any further evaluations of social prescribing connector schemes. Included studies were from the UK and focused on connector schemes for adult patients (18+ years) related to primary care. RESULTS: Our searches resulted in 118 included documents, from which data were extracted to produce context-mechanism-outcome configurations (CMOCs). These CMOCs underpinned our emerging programme theory that centred on the essential role of 'buy-in' and connections. This was refined further by turning to existing theories on (a) social capital and (b) patient activation. CONCLUSION: Our realist review highlights how connector roles, especially link workers, represent a vehicle for accruing social capital (e.g. trust, sense of belonging, practical support). We propose that this then gives patients the confidence, motivation, connections, knowledge and skills to manage their own well-being, thereby reducing their reliance on GPs. We also emphasise within the programme theory situations that could result in unintended consequences (e.g. increased demand on GPs).

The lived experience of working with people with eating disorders: A meta-ethnography.

OBJECTIVE: Working with people with eating disorders (EDs) is known to elicit strong emotional reactions, and the therapeutic alliance has been shown to affect outcomes with this clinical population. As a consequence, it is important to understand healthcare professionals' (HCPs') experiences of working with this client group. METHOD: A meta-synthesis was conducted of qualitative research on HCPs' lived experiences of working with people with EDs. The results from the identified studies were analyzed using Noblit and Hare's meta-ethnographic method. Data were synthesized using reciprocal translation, and a line of argument was developed. RESULTS: Thirty-seven studies met the inclusion criteria. Reciprocal translation resulted in a key concept: "Coping with caring without curing." This was underpinned by the following third-order concepts: (a) "The dissonance and discomfort of being a helper struggling to help," (b) "Defending against the dissonance," and (c) "Accepting the dissonance to provide safe and compassionate care." These concepts were used to develop a line-of-argument synthesis, which was expressed as a new model for understanding HCPs' experiences of working with people who have an ED. DISCUSSION: Although the conflict associated with being a helper struggling to help led some HCPs to avoid and blame people with EDs, others adopted a compassionate stance characterized by humanity, humility, balance, and awareness.

Proof of concept trial for a new theory-based intervention to promote child and adult behavior change.

Interventions to change children's behavior typically target adults or children, but rarely both. The aims were to: (a) evaluate acceptability and feasibility of an innovative theory-based intervention designed to change both child and adult behavior, and (b) generate effect sizes for a definitive randomized controlled trial. The oral health of sixty children aged 5-9 years with a repaired cleft lip and/or palate was assessed before randomization to one of three conditions: (a) control group, (b) intervention group in which children and adults were asked to form implementation intentions, or (c) intervention plus booster group in which adults were additionally sent a reminder about the implementation intentions they and their children formed. Oral health assessments were repeated at 6-month follow-up alongside exit interviews. The procedures proved popular and participants exposed to the intervention additionally reported believing that forming implementation intentions was effective. Descriptive statistics generally showed oral health improvements across all conditions, although the effects were more marked in the intervention plus booster condition, where plaque improved by 44.53%, gingivitis improved by 20.00% and free sugar consumption improved by 8.92% (vs. 6.43% improvement, 15.00% deterioration and 15.58% improvement in the control group, respectively). Data collection procedures were acceptable and the intervention feasible. The effect sizes suggest that the intervention plus booster condition has sufficient promise to proceed to a fully-powered randomized controlled trial. The intervention has the potential to be adapted to tackle other child health behaviors and to be deployed at scale.

The development and assessment of a scale to measure the experience of an anorexic voice in anorexia nervosa.

The anorexic voice (AV) is defined as a critical internal dialogue, which has been implicated in the development and maintenance of anorexia nervosa (AN). Systematic research to explore this further requires a valid and reliable measurement tool. This study aimed to develop and assess the validity of the Experience of an Anorexic VoicE Questionnaire (EAVE-Q). EAVE-Q items were developed and checked for face and content validity through cognitive interviews with seven individuals diagnosed with AN. Participants with a diagnosis of AN (N = 148) completed the EAVE-Q, sociodemographic questions and measures of mood and quality of life to assess internal consistency and construct validity. Forty-nine participants completed the EAVE-Q twice more to assess test-retest reliability. The EAVE-Q had good face and content validity and good acceptability. Principal axis factoring resulted in an 18-item scale organized into five domains with high internal consistency (α = 0.70 to α = 0.85). Domains correlated significantly with eating disorder symptoms, psychological distress, and quality of life. The EAVE-Q did not discriminate between participants on the basis of body mass index. Test-retest reliability was moderate. Although the factor structure of the EAVE-Q requires replication in other AN samples, the EAVE-Q is the first measure of a critical internal dialogue in AN. It is hoped that it will aid future research to increase understanding of AN and the continued development of person-centred treatments.

Compassion in nursing: Solution or stereotype?

Compassion in healthcare has received significant attention recently, on an international scale, with concern raised about its absence during clinical interactions. As a concept, compassionate care has been linked to nursing. We examined historical discourse on this topic, to understand and situate current debates on compassionate care as a hallmark of high-quality services. Documents we looked at illustrated how responsibility for delivering compassionate care cannot be consigned to individual nurses. Health professionals must have the right environmental circumstances to be able to provide and engage in compassionate interactions with patients and their relatives. Hence, although compassionate care has been presented as a straightforward solution when crisis faces health services, this discourse, especially in policy documents, has often failed to acknowledge the system-level issues associated with its provision. This has resulted in simplistic presentations of 'compassion' as inexpensive and the responsibility of individual nurses, a misleading proposal that risks devaluing the energy and resources required to deliver compassionate care. It also overlooks the need for organisations, not just individuals, to be charged with upholding its provision.

Perceptions of the "anorexic voice": A qualitative study of health care professionals.

People with anorexia nervosa (AN) often report experiencing a highly critical inner voice (AV) focused on their eating, shape, and weight. There are promising preliminary findings for its role in the treatment of AN, and the support of staff is vital for the AV to be embedded in treatment, but their views remain unknown. The aims of this study were to undertake a qualitative exploration of the perceptions of the AV among health care professionals (HCPs) in specialist eating disorder services. A thematic analysis was applied to interviews with 15 HCPs, including nurses, therapists, psychiatrists, health care assistants, psychologists, and dietitians. Two overarching themes were identified: "The AV is a vehicle for increasing compassion" and "It's not a one-size-fits-all." The AV was seen as a means of developing and sustaining compassion, but participants noted that it does not resonate for all clients. All HCPs in this study believed that there was potential benefit in utilizing the AV in their work with people with AN, and it is likely that doing so would help to reduce burnout and frustration within clinical teams.

Why I eat at night: A qualitative exploration of the development, maintenance and consequences of Night Eating Syndrome.

Night Eating Syndrome (NES), as a diagnosis, presents as a combination of disordered eating, sleep and mood. Patients identified as having both NES and obesity demonstrate poorer outcomes in terms of weight loss compared to those with NES only. However, research focusing on psychological factors associated with NES remains relatively underdeveloped. This study aimed to explore the relationship between NES and the experience of emotion from the perspective of patients accessing a weight management service. Ten adults who met diagnostic criteria for moderate or full NES took part in a semi-structured interview. Data were analysed using a constructivist approach to grounded theory. A core concept to emerge from the analysis was termed 'emotional hunger'; reflecting an urge or need to satiate a set of underlying unmet emotional needs. It was underpinned by the following interrelated themes: (1) Cultivating a dependency on food; (2) Relying on food to regulate emotions; (3) Understanding the significance of night-time; (4) Acknowledging the consequences of night eating. This study provides an in-depth understanding of the relationship between NES and the experience of emotion from the perspective of patients attending a weight management service. Results have potential to inform future service development, particularly around the adoption of a more holistic approach to night eating behaviours.

Having the "Headspace" for Compassion Toward Self and Others: A Qualitative Study of Medical Students' Views and Experiences.

Phenomenon: Debate about compassion exhibited by healthcare professionals has escalated, following a perceived decline over recent years. At the same time, a growing interest in self-compassion has emerged, which is seen as facilitating compassion toward others. Little research has explored, in depth, what compassion to self and others means to medical students. Therefore, a study was designed to address this gap in knowledge. APPROACH: A qualitative study was conducted, involving students from all 4 years of a graduate-entry medical school in the United Kingdom. Focus groups were used to obtain the views of students on compassion for self and others (patients). Care was taken to achieve variation within the sample in terms of age, gender, and year of study. Focus groups were completed between September and October 2016. An inductive thematic analysis was performed. FINDINGS: A total of 31 students participated in 4 focus groups, each lasting between 60 and 90 minutes. Having the cognitive freedom-"headspace"-to be aware of and respond to one's own and others' difficulties and distress was identified as an overarching theme within the data. This was underpinned by the themes developed during analysis: (a) bringing humanity into the workplace; (b) compassion as a variable, innate resource; (c) zoning into an individual's current needs; and (d) collective compassion. Students talked about the importance of being adaptable and responsive to situational factors in relation to self-compassion and compassionate care. They also highlighted the contribution of role models in promoting compassion to self and others. Insights: It is important for medical educators to explore ways of enhancing students' compassion to self and others during their training and beyond. Integrating approaches to "well-being" into the curriculum can create opportunities for self-compassion development, but rigid protocols could derail these efforts.

Enabling the flow of compassionate care: a grounded theory study.

BACKGROUND: Compassion has become a topic of increasing interest within healthcare over recent years. Yet despite its raised profile, little research has investigated how compassionate care is enacted and what it means to healthcare professionals (HCPs). In a grounded theory study, we aimed to explore this topic from the perspective of people working with patients with type 2 diabetes - a long-term condition that involves repeated interactions with HCPs. METHODS: Semi-structured interviews and focus groups were conducted between May and October 2015 with 36 participants, selected from a range of roles within healthcare. Data collection explored their understanding of compassionate care and experiences of it in practice. Analysis followed the constructivist approach of Charmaz, which recognises meaning as being created by the interaction of people working under specific sociocultural conditions. It moved from open to focused coding, and involved the development of memos and constant comparison. RESULTS: Our analysis revealed that wishing to provide compassionate care, on its own, was insufficient to ensure this transpired; HCPs needed to work in a setting that supported them to do this, which underpins our core concept - the compassionate care flow. Data suggested that to be sustained, this flow was energised via what participants described as 'professional' compassion, which was associated with the intention to improve patient health and participants' role within healthcare. The compassionate care flow could be enhanced by defenders (e.g. supportive colleagues, seeing the patient as a person, drawing on their faith) or depleted by drainers (i.e. competing demands on time and resources), through their impact on professional compassion. CONCLUSIONS: This paper presents a model of compassionate care based on the notion of flow. It looks at processes associated with this concept and how compassionate care is delivered within health settings. Our new understanding of this phenomenon will help those working in healthcare, including managers and policy makers, to consider and potentially offset disruption to the compassionate care flow.

A qualitative evidence synthesis to explore healthcare professionals' experience of prescribing opioids to adults with chronic non-malignant pain.

BACKGROUND: Despite recent guidelines suggesting that patients with chronic non-malignant pain might not benefit, there has been a significant rise in opioid prescription for chronic non-malignant pain. This topic is important because an increasing number of HCPs are prescribing opioids despite very limited evidence for long-term opioid therapy for chronic non-malignant pain outside of end-of-life care. To better understand the challenges of providing effective treatment, we conducted the first qualitative evidence synthesis to explore healthcare professionals' experience of treating people with chronic non-malignant pain. We report findings that explore healthcare professionals' experience of prescribing opioids to this group of patients. METHODS: We searched five electronic bibliographic databases (Medline, Embase, CINAHL, PsychINFO, AMED) from inception to November 2015 and screened titles, abstracts and full texts of potential studies. We included studies in English that explored healthcare professionals' experience of treating adults with chronic non-malignant pain. Two reviewers quality appraised each paper. We used the methods of meta-ethnography developed and refined for large reviews, and the GRADE-CERQual framework to rate confidence in review findings. RESULTS: We screened 954 abstracts and 184 full texts, and included 77 studies in the full review. 17 of these 77 studies included concepts that explored the experience of prescribing opioids. We abstracted these concepts into 6 overarching themes: (1) Should I, shouldn't I? (2) Pain is Pain; (3) Walking a fine line; (4) Social guardianship; (5) Moral boundary work; (6) Regulations and guidelines. We used the GRADE-CERQual framework to evaluate confidence in findings. A new overarching concept of 'ambiguity' explains the balancing required around the factors taken into account when prescribing opioids. Managing this ambiguity is challenging and these findings can inform healthcare professionals dealing with these decisions. CONCLUSIONS: This conceptual model demonstrates the complexity of making a decision to prescribe opioids to someone with chronic non-malignant pain. Although opioid prescription is underpinned by the therapeutic aim of alleviating pain, this aim may be misplaced. This has implications for education in light of the new regulations for opioid prescription. Findings also demonstrate that the decision is influenced by intra- and interpersonal factors and broader external concerns.

Development and Validation of the Pride in Eating Pathology Scale (PEP-S).

There is a growing body of theoretical and clinical literature highlighting the role of pride in maintaining eating disordered behaviours. Despite its clinical importance, there are no measures to assess feelings of pride associated with eating psychopathology. This study describes the development and validation of the Pride in Eating Pathology Scale (PEP-S), a self-report questionnaire that examines feelings of pride towards eating disordered symptoms (e.g., pride in food restriction, thinness and weight loss). Participants were 390 females, recruited from university and community populations, whose mean age was 26.99 years. Respondents rated pride in eating pathology on a 7-point Likert-scale. Principal Component Analysis indicated that the 60-item scale comprised a four component structure: (1) pride in weight loss, food control and thinness, (2) pride in healthy weight and healthy eating, (3) pride in outperforming others and social recognition and (4) pride in capturing other people's attention due to extreme thinness. These four components explained a total of 65.31% of the variance. The PEP-S demonstrated very good internal reliability (α ranging from 0.88 to 0.98) and very good test-retest reliability over a 3-week time-span (r ranging from 0.81 to 0.93). The PEP-S also showed excellent convergent and discriminant validity. Furthermore, the scale discriminated between women with high and low levels of eating psychopathology. The PEP-S is a psychometrically robust measure of pride in eating pathology. It has the potential to advance theoretical understanding and may also be clinically useful. Copyright © 2015 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: The PEP-S is a valid, reliable, quick and easy to administer self-report questionnaire that measures pride related to eating pathology. The PEP-S assesses four clinically relevant dimensions: (1) pride in weight loss, food control and thinness, (2) pride in healthy weight and healthy eating, (3) pride in outperforming others and social recognition and (4) pride in capturing other people's attention due to extreme thinness. The PEP-S has very good internal and test-retest reliability, and very good convergent and discriminant validity. The PEP-S distinguishes between women with higher and lower levels of eating psychopathology. The PEP-S makes an important contribution to understanding pride in eating psychopathology, which is essential from both clinical and theoretical perspectives.

Measuring compassionate care: views of healthcare staff.

Aim To explore healthcare professionals' views of measuring compassionate care. Method As part of a grounded theory study participants, who were healthcare professionals involved in the care of patients with type 2 diabetes, were invited to discuss the topic of compassionate care measurement through semi-structured interviews and focus groups. Results Measuring compassionate care was regarded as problematic because of its complex nature. Categories identified in the data that reflect this difficulty include distinguishing compassionate care from other concepts, relying on informal indicators, making the subjective objective, incorporating external influences and putting a measurement tool to use. Conclusion Findings highlighted the complexities associated with measuring compassionate care, and how attempts to do this by managers could be problematic.

Otitis media with effusion: experiences of children with cleft palate and their parents.

OBJECTIVE: To explore the views of children with cleft palate and their parents about daily life with otitis media with effusion and associated hearing loss. DESIGN: A qualitative study. Semistructured interviews were used to collect data from parents. Participatory techniques, including activities on a tablet computer, were used to collect data from children. Framework analysis was applied to interview transcripts. SETTING: Two English cleft units. PARTICIPANTS: A purposive sample of parents of 37 children aged 0 to 11 years with experience of otitis media with effusion. Their children also took part if aged 6 to 11 years (n = 22). RESULTS: Themes related to the following: (1) emotions (frustration, anger, sadness, happiness, anxiety), (2) educational experiences (struggling at school, having to sit at the front of the class, requiring extra support, missing lessons for appointments or due to ear infections), (3) social interactions (isolation, communication, reliance on siblings, participation in activities). CONCLUSIONS: A number of areas of interviewees' everyday life were affected by the presence of otitis media with effusion. Parents may need to be forewarned about the possible ongoing nature of this condition and its impact on a child's social and emotional experiences. Children may also benefit from age-appropriate information about otitis media with effusion and its treatment, including information on hearing tests, to help reduce any anxiety.

A qualitative study of a primary-care based intervention to improve the management of patients with heart failure: the dynamic relationship between facilitation and context.

BACKGROUND: There is currently a growing emphasis in primary care on upscaling the provision of evidence-based services for specific conditions, such as heart failure (HF), which have traditionally been seen as part of a specialist's domain. While contextual challenges associated with improvement in primary care have been documented previously, we still know relatively little about how the intentional, theory-informed facilitation of evidence-based change is shaped by contextual factors within this healthcare setting. Hence, a qualitative study was conducted to address the question: How is the process of facilitating evidence-based practice affected by the context of primary care? METHODS: Data collection took place across general practices in northwest England as part of a process evaluation of the Greater Manchester HF Investigation Tool (GM-HFIT) - a programme of work aiming to improve the management of HF in primary care. Semi-structured interviews, with purposefully selected GM-HFIT team members (n = 9) and primary care practitioners (n = 7), were supplemented by observational data and a three-month diary reflecting on facilitation activities. Framework analysis was used to manage and interpret data. RESULTS: We describe a complex and dynamic interplay between facilitation and context, focusing on three major themes: (1) Addressing macro and micro agendas; (2) Forming a facilitative unit; (3) Maintaining momentum. We show that HF specialist nurses (HFSNs) have a high level of professional credibility, which allows them to play a key role in making recommendations to practices for improving patient care. At the same time, we argue that contextual factors, such as top-level endorsement, the necessity to comply with a performance measurement system, and the varying involvement of practice nurses produce tensions that can have both an enabling and constraining effect on the process of facilitation. CONCLUSIONS: When facilitating the transfer of evidence, context is an important aspect to consider at a macro and micro level; a complex interplay can exist between these levels, which may constrain or enable efforts to amend practice. Those involved in facilitating change within primary care have to manage tensions arising from the interplay of these different contextual forces to minimise their impact on efforts to alter practice based on best evidence.