Developing family-centred care in a neonatal intensive care unit: An action research study.

AIM: To develop, implement and evaluate family-centred interventions to promote parental involvement in caregiving in a Neonatal Intensive Care Unit. METHODOLOGY: A participatory action research approach was used to implement two changes in practice a) improved skin-to-skin contact b) unlimited parental presence at the cot-side. The changes were underpinned by a family-centred philosophy of care and education. Data were collected from staff using a questionnaire, focus groups and interviews, and from parents using focus groups and interviews. Qualitative data were analysed using Framework and quantitative data analysed using descriptive and t-test statistics. SETTING: A Neonatal Intensive Care Unit in England. FINDINGS: Changes in practice were successfully implemented. Nurses reported positively on improvements in Family Centred Care; most notably information-sharing with parents, providing family support, enabling parental participation in care and improved competence supporting parents in care-giving. These changes were reflected in parental feedback. CONCLUSION: Understanding the context of the neonatal unit can support cultural change when change is actively facilitated and owned by the staff concerned. Acknowledging parents as the main caregiver can be challenging for nurses and they require support and education to enable them to manage the changes necessary to provide Family-Centred Care.

Exploring the acceptability and usability of a novel social innovation to encourage physical activity: The iStep prototype.

This study explored the acceptability and usability of the iStep prototype a novel social innovation to encourage intergenerational physical activity (PA) to help reduce obesity levels in older age. Obesity is a major public health issue and physical inactivity is one of the many factors that influence this, especially in childhood and later life. iStep (a pedometer and interactive website) sought to increase PA levels across the life course through intergenerational partnerships participating in walking challenges together. This was a qualitative mixed methods study involving 130 participants from two different settings. Pupils and teachers from a local secondary school (n = 120) tested the iStep prototype over two separate 2-week periods. Pupil and teacher partnerships engaged in a walking challenge using pedometers and the website platform. In addition, 10 retirement age women were involved in a modified co-operative evaluation of the prototype. Two focus groups with pupils (n = 9 and 20), semistructured interviews with teachers (n = 5), and one dyadic interview (pupil/teacher) were undertaken. Data were analysed using an iterative thematic approach. Five themes were identified: perceptions of the technology, attitudes towards the walking challenge, attitudes to the intergenerational partnership, competition versus collaboration and promoting PA. The pedometer was a useful motivational tool which raised awareness of PA levels. The website was thought to be simple and easy to use. Walking was deemed inclusive and accessible to all age groups and setting a target goal was considered beneficial. Engaging in PA with a partner was regarded as a good way to provide support and encouragement. Overall, this early prototype evaluation showed that iStep has potential to be an innovative and engaging way to encourage increased PA across generations. It may positively contribute towards reducing obesity levels in older age but outcomes that effectively measure this need to be incorporated in any future iStep testing.

Learning from a clinical microsystems quality improvement initiative to promote integrated care across a falls care pathway.

AIM: To identify learning from a clinical microsystems (CMS) quality improvement initiative to develop a more integrated service across a falls care pathway spanning community and hospital services. BACKGROUND: Falls present a major challenge to healthcare providers internationally as populations age. A review of the falls care pathway in Sheffield, United Kingdom, identified that pathway implementation was constrained by inconsistent co-ordination and integration at the hospital-community interface. APPROACH: The initiative utilised the CMS quality improvement approach and comprised three phases. Phase 1 focussed on developing a climate for change through engaging stakeholders across the existing pathway and coaching frontline teams operating as microsystems in quality improvement. Phase 2 involved initiating change by working at the mesosystem level to identify priorities for improvement and undertake tests of change. Phase 3 engaged decision makers at the macrosystem level from across the wider pathway in achieving change identified in earlier phases of the initiative. FINDINGS: The initiative was successful in delivering change in relation to key aspects of the pathway, engaging frontline staff and decision makers from different services within the pathway, and in building quality improvement capability within the workforce. Viewing the pathway as a series of interrelated CMS enabled stakeholders to understand the complex nature of the pathway and to target key areas for change. Particular challenges encountered arose from organisational reconfiguration and cross-boundary working. CONCLUSION: CMS quality improvement methodology may be a useful approach to promoting integration across a care pathway. Using a CMS approach contributed towards clinical and professional integration of some aspects of the service. Recognition of the pathway operating at meso- and macrosystem levels fostered wider stakeholder engagement with the potential of improving integration of care across a range of health and care providers involved in the pathway.

Medicines reablement in intermediate health and social care services.

Aim To evaluate a medicines reablement initiative involving health and social care, to include consideration of the training package, proportion of patients reabled successfully, and patient and staff perspectives of the service. BACKGROUND: Intermediate care services provide short-term intervention to support patients with chronic conditions transition from hospital to community-based services and involves maximising patients' independence through reablement. The term 'medicines reablement' describes the process of rehabilitating patients to be independent with their medication. METHODS: Pharmacy technicians led the medicines reablement initiative. They delivered a competency-based training programme for frontline health and social care staff. They assessed and set goals with patients to facilitate independence in self-administration of their medication. The pharmacy technicians provided on-going support to staff helping patients to reable. They reassessed patients after six weeks to determine if medicines reablement had been successful or whether further input was needed. Data were collected by means of a questionnaire and semi-structured interviews with pharmacy technicians, frontline staff, managers, and patients. Findings Twenty per cent of patients discharged from hospital to intermediate care were assessed to be suitable for medicines reablement. Of these patients, 44% were successfully reabled and a further 25% benefited from the input of a pharmacy technician. Patients and staff were positive about medicines reablement, emphasising the importance of patients attaining independence for self-administration of medication. Although following training, health and social care staff felt confident in facilitating medicines reablement they valued on-going access to pharmacy technicians for timely support, help with problem solving, and advice throughout the reablement process. CONCLUSION: Medicines reablement can lead to patients becoming independent with taking medication and contribute to staff satisfaction. Pharmacy technicians can play an important part in delivering medicines reablement training to frontline staff and overseeing the reablement process. Further research examining medicines reablement is needed to develop a stronger evidence base.

Exploring factors that influence the spread and sustainability of a dysphagia innovation: an instrumental case study.

BACKGROUND: Swallowing difficulties challenge patient safety due to the increased risk of malnutrition, dehydration and aspiration pneumonia. A theoretically driven study was undertaken to examine the spread and sustainability of a locally developed innovation that involved using the Inter-Professional Dysphagia Framework to structure education for the workforce. A conceptual framework with 3 spread strategies (hierarchical control, participatory adaptation and facilitated evolution) was blended with a processual approach to sustaining organisational change. The aim was to understand the processes, mechanism and outcomes associated with the spread and sustainability of this safety initiative. METHODS: An instrumental case study, prospectively tracked a dysphagia innovation for 34 months (April 2011 to January 2014) in a large health care organisation in England. A train-the-trainer intervention (as participatory adaptation) was deployed on care pathways for stroke and fractured neck of femur. Data were collected at the organisational and clinical level through interviews (n = 30) and document review. The coding frame combined the processual approach with the spread mechanisms. Pre-determined outcomes included the number of staff trained about dysphagia and impact related to changes in practice. RESULTS: The features and processes associated with hierarchical control and participatory adaptation were identified. Leadership, critical junctures, temporality and making the innovation routine were aspects of hierarchical control. Participatory adaptation was evident on the care pathways through stakeholder responses, workload and resource pressures. Six of the 25 ward based trainers cascaded the dysphagia training. The expected outcomes were achieved when the top-down mandate (hierarchical control) was supplemented by local engagement and support (participatory adaptation). CONCLUSIONS: Frameworks for spread and sustainability were combined to create a 'small theory' that described the interventions, the processes and desired outcomes a priori. This novel methodological approach confirmed what is known about spread and sustainability, highlighted the particularity of change and offered new insights into the factors associated with hierarchical control and participatory adaptation. The findings illustrate the dualities of organisational change as universal and context specific; as particular and amendable to theoretical generalisation. Appreciating these dualities may contribute to understanding why many innovations fail to become routine.

Enhancing the quality of oral nutrition support for hospitalized patients: a mixed methods knowledge translation study (The EQONS study).

AIM: The aim of this study was to report a multifaceted knowledge translation intervention to facilitate use of the Malnutrition Universal Screening Tool and innovation in nutritional care for patients at risk of malnutrition. BACKGROUND: Malnutrition among hospitalized patients is a widespread problem leading to adverse health outcomes. Despite evidence of the benefits of malnutrition screening and recommendations for achieving good nutrition, shortfalls in practice continue. DESIGN: A mixed method integrated knowledge translation study. METHODS: The knowledge translation intervention comprised nutrition champions supported by knowledge translation facilitators and an action planning process. Data collection was undertaken over 18 months between 2011-2012 in a hospital in England. Data comprised observation of mealtimes, audit of patient records, survey of nurses and semi-structured interviews with nutrition champions, knowledge translation facilitators, senior ward nurses and nurse managers. FINDINGS: Statistically significant relationships (Chi Square) were observed between self-reported confidence of nurses (a) to assess patients using the Malnutrition Universal Screening Tool, (b) to teach colleagues how to use the Malnutrition Universal Screening Tool and (c) to ensure that patients were assessed within 24 hours of admission. Ward-based nutrition champions facilitated successful innovation in nutrition support. Contextual factors operating at micro (ward), meso (organization) and macro (healthcare system) levels acted as barriers and enablers for change. CONCLUSION: Nutrition champions were successful in increasing the timely assessment of patients at risk of malnutrition and promoting innovation in nutritional care. Support from knowledge translation facilitators helped nutrition champions develop their role and work collaboratively with senior ward nurses to implement action plans for improving nutrition.

Development of a conceptual policy framework for advanced practice nursing: an ethnographic study.

AIM: To report on a study examining policy development for advanced practice nursing from intent of policy to realization in practice. BACKGROUND: Inclusion of advanced practice nursing roles in the healthcare workforce is a worldwide trend. Optimal advanced nursing practice requires supportive policies. Little is known about how policy is developed and implemented. DESIGN: Ethnography using an instrumental case study approach was selected to give an in-depth understanding of the experiences of one country (Singapore) to contribute to insight into development elsewhere. METHODS: The four-phase study was conducted from 2008-2012 and included document analysis (n = 47), interviews with key policy decision makers (n = 12), interviews with nursing managers and medical directors (n = 11), interviews and participant observation with advanced practice nurses (n = 15). RESULTS: Key policymakers in positions of authority were able to promote policy development. However, this was characterized by lack of strategic planning for implementation. A vague understanding by nursing managers and medical directors of policies, the role and its position in the healthcare workforce led to indecision and uncertainty in execution. Advanced practice nurses developed their role based on theory acquired in their academic programme but were unsure what role to assume in practice. Lack of clear guidelines led to unanticipated difficulties for institutions and healthcare systems. CONCLUSION: Strategic planning could facilitate integration of advanced practice nurses into the healthcare workforce. A Conceptual Policy Framework is proposed as a guide for a coordinated approach to policy development and implementation for advanced practice nursing.

Obstacles to "race equality" in the English National Health Service: Insights from the healthcare commissioning arena.

Inequitable healthcare access, experiences and outcomes across ethnic groups are of concern across many countries. Progress on this agenda appears limited in England given the apparently strong legal and policy framework. This disjuncture raises questions about how central government policy is translated into local services. Healthcare commissioning organisations are a potentially powerful influence on services, but have rarely been examined from an equity perspective. We undertook a mixed method exploration of English Primary Care Trust (PCT) commissioning in 2010-12, to identify barriers and enablers to commissioning that addresses ethnic healthcare inequities, employing:- in-depth interviews with 19 national Key Informants; documentation of 10 good practice examples; detailed case studies of three PCTs (70+ interviews; extensive observational work and documentary analysis); three national stakeholder workshops. We found limited and patchy attention to ethnic diversity and inequity within English healthcare commissioning. Marginalization of this agenda, along with ambivalence, a lack of clarity and limited confidence, perpetuated a reinforcing inter-play between individual managers, their organisational setting and the wider policy context. Despite the apparent contrary indications, ethnic equity was a peripheral concern within national healthcare policy; poorly aligned with other more dominant agendas. Locally, consideration of ethnicity was often treated as a matter of legal compliance rather than integral to understanding and meeting healthcare needs. Many managers and teams did not consider tackling ethnic healthcare inequities to be part-and-parcel of their job, lacked confidence and skills to do so, and questioned the legitimacy of such work. Our findings indicate the need to enhance the skills, confidence and competence of individual managers and commissioning teams and to improve organizational structures and processes that support attention to ethnic inequity. Greater political will and clearer national direction is also required to produce the system change needed to embed action on ethnic inequity within healthcare commissioning.

Developing family-centred care in a neonatal intensive care unit: an action research study protocol.

AIM: The aim of this study was to develop, implement and evaluate evidence-based family-centred interventions and to promote parental involvement in the care of infants in neonatal intensive care. BACKGROUND: Parental involvement in the care of their infants in Neonatal Intensive Care Units leads to improved neonatal outcomes. Although research identifies the benefits of individual interventions to promote family-centred care, little is known about how they might be implemented in everyday practice. DESIGN: Participatory action research. METHODS: Funding commenced in January 2015. The study comprises three phases: (i) Exploration: Baseline measures of staff and parental satisfaction with care and parental stress will be obtained using validated survey instruments. Baseline infant data includes breast feeding and skin-to-skin contact. Staff focus groups and interviews will provide insight into the context of parental involvement and perceived barriers to change. Parent focus groups and diaries will provide insight into factors influencing parental involvement in care. The data will inform the development of the evidence-based intervention; (ii) INTERVENTION: Three action research cycles and ongoing data collection from parents and staff will inform the further development of the intervention and change process; (iii) EVALUATION: Baseline measures will be repeated to identify changes. Focus groups and interviews with staff and parents will provide insight into their perceptions of the success of the initiative in promoting family-centred care. DISCUSSION: This study will contribute new knowledge about approaches to actively involve parents in the care of their infant on neonatal intensive care units. Greater understanding of the impact of family-centre care on staff and parents will be gained with the potential to inform future policy and practice.

An evaluation of the implementation of Advanced Nurse Practitioner (ANP) roles in an acute hospital setting.

AIM: To evaluate the impact of implementing Advanced Nurse Practitioner roles on patients, staff members and organizational outcomes in an acute hospital. BACKGROUND: The worldwide development of advanced practice roles in nursing has been influenced by increasing demands and costs of health care. A key issue in the UK has been the reduction in hours junior doctors can work. While there is evidence these roles can have a positive impact in a variety of clinical specialties, little is known about the impact advanced nurses substituting for junior doctors can have on patients, staff members and organizational outcomes in general hospital care settings. DESIGN: Collective case study. METHODS: A collective case study in a district general hospital in England was undertaken in 2011-2012. Interviews with strategic stakeholders (n = 13) were followed by three individual case studies. Each case study represented the clinical area in which the roles had been introduced: medicine, surgery and orthopaedics and included interviews (n = 32) and non-participant observation of practice. FINDINGS: The ANPs had a positive impact on patient experience, outcomes and safety. They improved staff knowledge, skills and competence and enhanced quality of working life, distribution of workload and team-working. ANPs contributed to the achievement of organizational priorities and targets and development of policy. CONCLUSION: ANPs undertaking duties traditionally performed by junior doctors in acute hospital settings can have a positive impact on a range of indicators relating to patients, staff members and organizational outcomes which are highly relevant to nursing.

Using the Knowledge to Action Framework in practice: a citation analysis and systematic review.

BACKGROUND: Conceptual frameworks are recommended as a way of applying theory to enhance implementation efforts. The Knowledge to Action (KTA) Framework was developed in Canada by Graham and colleagues in the 2000s, following a review of 31 planned action theories. The framework has two components: Knowledge Creation and an Action Cycle, each of which comprises multiple phases. This review sought to answer two questions: 'Is the KTA Framework used in practice? And if so, how?' METHODS: This study is a citation analysis and systematic review. The index citation for the original paper was identified on three databases-Web of Science, Scopus and Google Scholar-with the facility for citation searching. Limitations of English language and year of publication 2006-June 2013 were set. A taxonomy categorising the continuum of usage was developed. Only studies applying the framework to implementation projects were included. Data were extracted and mapped against each phase of the framework for studies where it was integral to the implementation project. RESULTS: The citation search yielded 1,787 records. A total of 1,057 titles and abstracts were screened. One hundred and forty-six studies described usage to varying degrees, ranging from referenced to integrated. In ten studies, the KTA Framework was integral to the design, delivery and evaluation of the implementation activities. All ten described using the Action Cycle and seven referred to Knowledge Creation. The KTA Framework was enacted in different health care and academic settings with projects targeted at patients, the public, and nursing and allied health professionals. CONCLUSIONS: The KTA Framework is being used in practice with varying degrees of completeness. It is frequently cited, with usage ranging from simple attribution via a reference, through informing planning, to making an intellectual contribution. When the framework was integral to knowledge translation, it guided action in idiosyncratic ways and there was theory fidelity. Prevailing wisdom encourages the use of theories, models and conceptual frameworks, yet their application is less evident in practice. This may be an artefact of reporting, indicating that prospective, primary research is needed to explore the real value of the KTA Framework and similar tools.

Engaging minorities in researching sensitive health topics by using a participatory approach.

AIM: To report the use of a community participatory approach (PA) in a project investigating tuberculosis (TB) in UK Somali migrants. BACKGROUND: It is crucial to address health inequalities and persistent health problems, particularly in groups who are often excluded or seem hard to reach. TB is an illness stigmatised in the Somali population, making it a difficult topic for research. In this study, a community PA was used to investigate TB and members of the Somali community were recruited as co-researchers. DATA SOURCES: Four community researchers (CRs), eight focus groups (n=48), interviews with members of the community (n=24), people with TB and ex-TB patients (n=14), and healthcare practitioners (n=18). REVIEW METHODS: This is an informative paper. Discussion The paper describes the approach used in the recruitment of community researchers and how engaging early with community leaders using oral communication made it possible to research TB in the Somali community. CONCLUSION: The PA led to capacity building, trust and a longer sustainable partnership with members of the Somali community. The success of the approach in the study suggests that there are valuable lessons for those researching similar topics with minority groups. IMPLICATIONS FOR PRACTICE/RESEARCH: Involving people in health research topics with a stigma is possible. This paper highlights how this could be achieved using a community PA and the recruitment of community members as co-researchers. However, the PA is time-consuming and will depend on the skills of academic researchers in knowing and engaging with the community.

Capacity development for knowledge translation: evaluation of an experiential approach through secondment opportunities.

BACKGROUND: Experiential approaches to skills development using secondment models are shown to benefit healthcare organizations more generally, but little is known about the potential of this approach to develop capacity for knowledge translation (KT). AIM: To evaluate the success of KT capacity development secondments from the perspective of multiple stakeholders. METHODS: A pluralistic evaluation design was used. Data were collected during 2011-2012 using focus group and individual interviews with 14 clinical and academic secondees, and five managers from host and seconding organizations to gain insight into participants' perceptions of the success of secondments and the criteria by which they judged success. Six After Action Reviews were undertaken with KT project teams to explore participants' perceptions of the contribution secondees made to KT projects. Semistructured interviews were undertaken with three healthcare managers on completion of projects to explore the impact of secondments on the organization, staff, and patients. Qualitative content analysis was used to identify criteria for success. The criteria provided a framework through which the overall success of secondments could be judged. RESULTS: Six criteria for judging the success of the secondments at individual, team, and organization level were identified: KT skills development, effective workload management, team working, achieving KT objectives, enhanced care delivery, and enhanced education delivery. Benefits to the individual, KT team, seconding, and host organizations were identified. IMPLICATIONS FOR PRACTICE: Hosting teams should provide mentorship support to secondees, and be flexible to accommodate secondees' needs as team members. Ongoing support of managers from seconding organizations is needed to maximize the benefits to individual secondees and the organization. LINKING EVIDENCE TO ACTION: Experiential approaches to KT capacity development using secondments can benefit individual secondees, project teams, seconding, and host organizations.

Evaluating a novel approach to enhancing dysphagia management: workplace-based, blended e-learning.

AIMS AND OBJECTIVES: To evaluate the learning effect and resource use cost of workplace-based, blended e-learning about dysphagia for stroke rehabilitation nurses. BACKGROUND: Dysphagia is a potentially life-threatening problem that compromises quality of life. In many countries, nurses play a crucial role in supporting the management of patients with swallowing problems, yet the literature reports a need for training. DESIGN: A single-group, pre- and post-study with mixed methods. METHODS: Each blended e-learning session comprised a needs analysis, e-learning programmes, practical skills about modifying fluids and action planning to transfer learning into practice. Participants were the population of registered nurses (n = 22) and healthcare assistants (n = 10) on a stroke rehabilitation ward in a large, teaching hospital in England between August 2010-March 2011. Data collection comprised observation (34 hours), questionnaires administered at four time points to examine change in attitude, knowledge and practice, and estimating the resource use cost for the service. Nonparametric tests and content analysis were used to analyse the data. RESULTS: All participants achieved a nationally recognised level of competence. The learning effect was evident on the post- and follow-up measures, with some items of dysphagia knowledge and attitude achieving significance at the p ≤ 0·05 level. The most common self-reported changes in practice related to medicines management, thickening fluids and oral hygiene. The resource use cost was estimated at £2688 for 108 hours training. CONCLUSIONS: Workplace-based, blended e-learning was an acceptable, cost effective way of delivering essential clinical knowledge and skills about dysphagia. RELEVANCE TO CLINICAL PRACTICE: Dysphagia should be viewed as a patient safety issue because of the risks of malnutrition, dehydration and aspiration pneumonia. As such, it is pertinent to many members of the interdisciplinary team. Consideration should be given to including dysphagia management in initial education and continuing professional development programmes.

Exploring scale-up, spread, and sustainability: an instrumental case study tracing an innovation to enhance dysphagia care.

BACKGROUND: Adoption, adaptation, scale-up, spread, and sustainability are ill-defined, undertheorised, and little-researched implementation science concepts. An instrumental case study will track the adoption and adaptation, or not, of a locally developed innovation about dysphagia as a patient safety issue. The case study will examine a conceptual framework with a continuum of spread comprising hierarchical control or 'making it happen', participatory adaptation or 'help it happen', and facilitated evolution or 'let it happen'. METHODS: This case study is a prospective, longitudinal design using mixed methods. The fifteen-month (October 2012 to December 2013) instrumental case study is set in large, healthcare organisation in England. The innovation refers to introducing a nationally recognised, inter-disciplinary dysphagia competency framework to guide workforce development about fundamental aspects of care. Adoption and adaptation will be examined at an organisational level and along two, contrasting care pathways: stroke and fractured neck of femur. A number of educational interventions will be deployed, including training a cadre of trainers to cascade the essentials of dysphagia management and developing a Dysphagia Toolkit as a learning resource. Mixed methods will be used to investigate scale-up, spread, and sustainability in acute and community settings. A purposive sample of senior managers and clinical leaders will be interviewed to identify path dependency or the context specific particularities of implementation. A pre- and post-evaluation, using mealtime observations and a survey, will investigate the learning effect on staff adherence to patient specific dysphagia recommendations and attitudes towards dysphagia, respectively. Official documents and an ethnographic field journal allow critical junctures, temporal aspects and confounding factors to be explored. DISCUSSION: Researching spread and sustainability presents methodological and practical challenges. These include fidelity, adaptation latitude, time, and organisational changes. An instrumental case study will allow these confounding factors to be tracked over time and in place. The case study is underpinned by, and will test a conceptual framework about spread, to explore theoretical generalizability.

Migration and maternity: insights of context, health policy, and research evidence on experiences and outcomes from a three country preliminary study across Germany, Canada, and the United kingdom.

A group from Germany, Canada, and the United Kingdom undertook country-specific scoping reviews and stakeholder consultations before joining to holistically compare migration and maternity in all three countries. We examined four interlinking dimensions to understand how international migrant/minority maternal health might be improved upon using transnational research: (a) wider sociopolitical context, (b) health policy arena, (c) constellation, outcomes, and experiences of maternity services, and (d) existing research contexts. There was clear evidence that the constellation and delivery of services may undermine good experiences and outcomes. Interventions to improve access and quality of care remain small scale, short term, and lacking in rigorous evaluation.

The development of a framework for evaluating the impact of nurse consultant roles in the UK.

AIM: To develop a framework to evaluate the impact of nurse consultants on patient, professional and organizational outcomes and identify associated indicators of impact. BACKGROUND: Since nurse consultants were introduced into the UK in 2000, there has been growing interest in demonstrating their impact, although robust evidence of impact is lacking. Existing frameworks for evaluating the impact of advanced practice roles do not cover the four dimensions of the nurse consultant role sufficiently. DESIGN: Multiple case study. METHOD: Individual case studies of six nurse consultants in England were undertaken between December 2009-October 2010. Each case study involved interviews with the nurse consultant, healthcare staff, managers, patients and carers. Interviews explored participants' perceptions of the impact of the nurse consultant and indicators of actual and/or potential impact. Data were analysed using framework approach. FINDINGS: Three domains of impact of nurse consultant roles were identified: clinical significance, professional significance and organizational significance. Each domain included three to four indicators of impact. All nurse consultants showed some evidence of impact in all three domains although the primary focus varied across the different nurse consultants. Due to the wide diversity in nurse consultant roles there was little commonality in the specific indicators of impact across all nurse consultants. CONCLUSION: The framework for capturing the impact of nurse consultants could be used by researchers and by nurse consultants to demonstrate their impact. Further research is required to assess the suitability of the framework for capturing the impact of other advanced practice roles.

Experiences of the diagnosis and management of tuberculosis: a focused ethnography of Somali patients and healthcare professionals in the UK.

AIM: To explore experiences of the diagnosis and management of tuberculosis from the perspective of Somali patients and healthcare professionals involved in their care. BACKGROUND: The Somali population has the third highest incidence of tuberculosis occurring in persons born outside the UK. Tuberculosis is a disease with sociocultural as well as physical consequences. Nurses should understand how the disease is experienced by people from different ethnic backgrounds to implement strategies for prevention and management of tuberculosis. DESIGN: A focused ethnography. METHOD: Individual interviews with 14 Somali patients and 18 healthcare professionals with experience of providing care to Somalis were undertaken in 2008-2009. Interviews explored the patient experience from onset of symptoms to completion of treatment. Data were analysed using Framework approach. FINDINGS: Despite presenting in primary care early, patients experienced diagnostic delays due to low clinical suspicion of tuberculosis among general practitioners. Although patients reported felt and enacted stigma, it did not adversely affect concordance with treatment. Patients were reticent about sharing their diagnosis among wider networks due to perceived stigma. Psychological support from families and specialist nurses was valued highly. Healthcare professionals perceived that stigmatization of tuberculosis was diminishing among Somalis leading to improved management of tuberculosis. Patients and healthcare professionals raised concerns about the longer term physical and psychosocial implications of tuberculosis once treatment was completed. CONCLUSION: Nurses have a role in promoting early presentation, timely diagnosis, and treatment adherence through supporting Somali patients and raising awareness of the disease among primary care practitioners.