Blended foods for tube-fed children: a safe and realistic option? A rapid review of the evidence.

With the growing number of children and young people with complex care needs or life-limiting conditions, alternative routes for nutrition have been established (such as gastrostomy feeding). The conditions of children and young people who require such feeding are diverse but could relate to problems with swallowing (dysphagia), digestive disorders or neurological/muscular disorders. However, the use of a blended diet as an alternative to prescribed formula feeds for children fed via a gastrostomy is a contentious issue for clinicians and researchers. From a rapid review of the literature, we identify that current evidence falls into three categories: (1) those who feel that the use of a blended diet is unsafe and substandard; (2) those who see benefits of such a diet as an alternative in particular circumstances (eg, to reduce constipation) and (3) those who see merit in the blended diet but are cautious to proclaim potential benefits due to the lack of clinical research. There may be some benefits to using blended diets, although concerns around safety, nutrition and practical issues remain.

Realistic nurse-led policy implementation, optimization and evaluation: novel methodological exemplar.

AIM: To report the first large-scale realistic nurse-led implementation, optimization and evaluation of a complex children's continuing-care policy. BACKGROUND: Health policies are increasingly complex, involve multiple Government departments and frequently fail to translate into better patient outcomes. Realist methods have not yet been adapted for policy implementation. DESIGN: Research methodology - Evaluation using theory-based realist methods for policy implementation. METHODS: An expert group developed the policy and supporting tools. Implementation and evaluation design integrated diffusion of innovation theory with multiple case study and adapted realist principles. Practitioners in 12 English sites worked with Consultant Nurse implementers to manipulate the programme theory and logic of new decision-support tools and care pathway to optimize local implementation. Methods included key-stakeholder interviews, developing practical diffusion of innovation processes using key-opinion leaders and active facilitation strategies and a mini-community of practice. New and existing processes and outcomes were compared for 137 children during 2007-2008. RESULTS: Realist principles were successfully adapted to a shorter policy implementation and evaluation time frame. Important new implementation success factors included facilitated implementation that enabled 'real-time' manipulation of programme logic and local context to best-fit evolving theories of what worked; using local experiential opinion to change supporting tools to more realistically align with local context and what worked; and having sufficient existing local infrastructure to support implementation. Ten mechanisms explained implementation success and differences in outcomes between new and existing processes. CONCLUSIONS: Realistic policy implementation methods have advantages over top-down approaches, especially where clinical expertise is low and unlikely to diffuse innovations 'naturally' without facilitated implementation and local optimization.

Home-based care for special healthcare needs: community children's nursing services.

BACKGROUND: Community children's nursing services (CCNS) provides nursing and supportive care, ranging from relatively simple to highly technological interventions, to children and young people (0-18 years) within the family home. OBJECTIVES: The aim of this study was to elicit the perspectives on and experiences about CCNS in England in relation to things that are working well or that could be improved and the vision for services. METHODS: Using a qualitative approach, underpinned by an Appreciative Inquiry philosophy, researchers worked closely with advisory groups (six children and young people, four parents, and five professionals) to design and implement the study. Arts-based participatory appreciative workshops were held in nine regional locations in England; shared activities were undertaken to elicit participants' experiences. Participants unable to attend the workshops were able to contribute via semistructured interview (face to face or by telephone) or by a dedicated blog or e-mail. RESULTS: Thematic analysis was used, and 214 people participated: families (n = 82), children (n = 27), and professionals or stakeholders (n = 105). Things that were working well were effective communication, robust leadership, actively enabling the child's care to be sustained at home, and partnerships based on mutual trust. Problems relating to feelings of marginalization, ineffective commissioning, under provision of services and hours of service availability, lack of equipment or resources, and poor communication between services and settings were areas of concern. The vision for CCNS was for a flexible, equitable, and accessible service that supported children's and families' needs and choices and which enabled parents to be parents first rather than caregivers. DISCUSSION: Care at home reduces the disruption to children's and families' lives and can empower them to make decisions and control routines and practices. Having CCNS situated within larger teams with strong interdisciplinary and transdisciplinary practices seems to offer the best benefits for children and families. Findings from this study have directly influenced government policy and practice. Further research is needed to determine efficacy of particular models and practices.