Older persons' experiences of whole systems: the impact of health and social care organizational structures.

AIMS: An in-depth case study of whole systems working. BACKGROUND: This paper reports on the second part of a two-part study exploring whole systems working. Part 1 of the study focused on an in-depth review of the literature pertaining to continuity of care and service integration. The second part, reported here, focused on an in-depth case study of one whole system. Evaluation Informed by the findings of part 1 of the study, data collection methods included in-depth interviews, real-time tracking of 18 older people, focus groups and consensus conferencing. Different data sets were analysed individually and synthesized using matrices derived from the literature review findings. KEY ISSUE: Key themes from data synthesis include: (1) access to the most appropriate services; (2) service fragmentation; (3) continuity of care; and (4) routinized care. CONCLUSIONS: The four themes of the case study reflect the need to address issues of demarcation of professional responsibilities, complicated channels of communication, information flows, assessment and reassessment in whole systems working. IMPLICATIONS FOR NURSING MANAGEMENT: The impact of disempowering relationships on actual continuity of care and perceptions of quality among service users and providers. Lessons need to be learnt from specialist services and applied to service delivery in general.

The impact of research governance in the United Kingdom on research involving a national survey.

PURPOSE: The purpose of this paper is to examine the impact that research governance processes in the National Health Service (NHS) are having on the conduct of research that involves a national survey and to point to ways that existing processes may develop to facilitate such research. DESIGN/METHODOLOGY/APPROACH: The paper describes the experiences of a research team of seeking approval in 357 NHS organisations to carry out a national postal survey to investigate specialist services and specialist staffing for older people in England in the wake of recent policy developments. Through reflection on this experience, the team propose approaches for the development of existing research governance processes. The national survey was the first stage of the study, which was followed by a detailed investigation of the development of specialist service provision for older people in six case study sites across England. The national survey aimed to map specialist service provision for older people by identifying the range of service models, agency and professional involvements, and nature of the case load in statutory services (health and social care), independent and voluntary sector organisations. FINDINGS: Of the 357 NHS organisations approached for approval to carry out the survey within the organisation, this was achieved only in 247 organisations over 12 months. Many organisations were facilitative of the process; however, protracted and extensive approval processes in others led to long delays and redesigning of the research that was commissioned by the Department of Health. ORIGINALITY/VALUE: The paper is of value in that it highlights processes and practices that hinder research and builds on those that work well.

Specialist nurses for older people: implications from UK development sites.

AIM: This paper is a report of a study to explore the development of specialist staffing for older people in six case study sites in the United Kingdom. BACKGROUND: In the United Kingdom there has been some concern about the health care available to older people, leading to the development of a National Service Framework. A key theme of this framework is the development of specialist staff skilled in providing services tailored to the needs of older people. METHOD: A soft systems methodology was used in 2004-2005 to carry out interviews with key people, including specialist nurses for older people, other service providers, patients and informal carers (n = 132) in six case study sites identified from a national questionnaire. Interviewees were asked to describe their perceptions of the development, its history and its impact. FINDINGS: The development of specialist nursing services seemed to be shaped by national policy drivers for service development, which may not have been directly linked to the needs of older people. The ideal qualities of a specialist nurse for older people were described by participants as including not only knowledge and skills, but also personal characteristics. CONCLUSION: While progress has been made in establishing specialist posts, much remains to be explored about the roles of postholders, the qualities needed, and the support and preparation required. While advanced practice is a professional aspiration, a number of questions arise about the development of nursing as a self-directing profession in diverse international settings. Theories of specialist nursing practice also need to address the tensions between universal and local models and to consider theories about nursing older people.

Assessing the Registered Nursing Care Contribution for older people in care homes: issues of reliability and validity.

The present paper reports on a study designed to investigate the validity and reliability of the Registered Nursing Care Contribution (RNCC) tool for assessing the level of nursing care required by care home residents. Care plan data from 186 residents in participating care homes were assessed by multiple assessors using the RNCC tool (i.e. care home registered nurses, a nurse researcher, an external care home expert and a nurses consultant). The Minimum Data Set (MDS) rating was used as a validated comparison. The findings from the study indicated that there were disparities between the RNCC and MDS bandings, and between different raters, with the external care home expert achieving the closest agreement with the MDS. This suggests that the use of the RNCC tool varies considerably according to the assessor, which also suggests that training of users is needed to ensure consistency and reliability. However, the difference between the outcomes of using the RNCC tool and the MDS suggests that assessment of nursing need may need to be re-examined to ensure validity.

The SEIQoL and functional status: how do they relate?

Over recent years, an emphasis has emerged in the UK and international policy documents, over the involvement of people in the delivery of health care. However, evaluations of health services still largely rest on outcome measures that reflect professional concerns. As new health services are being developed, new patient-centred outcome measures are needed to evaluate them. This paper aims at exploring the possibility of individual quality of life as an outcome measure for health services. As a first step, it aims to elucidate the relationship of functional outcome measures to the Schedule for the Evaluation of Individual Quality of Life (SEIQoL) in groups of people whose age or medical diagnosis serve as the basis for health service design. Its objectives are to study the relation of SEIQoL scores and life areas to functional status in an older population and in a group of people with chronic obstructive pulmonary disease (COPD). Older people selected their health most frequently as one of the most important areas in their life (9.9%, vs. 8.6% for people with COPD) and were more satisfied with it (U = 2,512, p = 0.007). People's health status did not impact on the way they defined their quality of life, but on their level of satisfaction with discrete life areas. The weights attributed to health were significantly negatively correlated to people's overall quality of life score in the overall sample (rho = -0.34, p < 0.001). In the light of recent national and international policy documents advocating for the development of new, more person-centred health services, our results support the proposition of the authors of SEIQoL, that individual quality of life measures have the potential to bring a significant contribution to the evaluation of health services.

Appreciating change in cancer services--an evaluation of service development strategies.

PURPOSE: The purpose of this paper is to report on an evaluative study which used appreciative inquiry (AI) to explore the processes of change during the Cancer Services Collaborative Improvement programme instituted by the Department of Health in the UK. This was a three-stage programme which expanded from nine pilot projects to a national service change, focussing on improving the patient's experience throughout the journey from diagnosis to treatment. DESIGN/METHODOLOGY/APPROACH: The paper uses AI questions in interviews with a range of CSC staff who had had different roles and length of involvement. FINDINGS: The study identified a range of strategies and skills that participants had developed in order to support and facilitate service change. PRACTICAL IMPLICATIONS: The paper offers a discussion of skills and strategies that can facilitate change in health care across clinical areas, and a discussion of the use of AI as a method of evaluation. ORIGINALITY/VALUE: This study is one of the first to use AI in health care evaluation in the UK, and thus makes a contribution to understanding change from an AI perspective.

Using action research in nursing practice with older people: democratizing knowledge.

AIM: This paper reports on an action research study which raised some questions about the processes of developing a sense of shared ownership in action research in a research environment which does not always have the appropriate mechanisms to support and sustain action research. BACKGROUND: Action research has gained popularity in nursing and healthcare research, offering a way of developing practice-based knowledge, which can assist in changing practice and democratizing inquiry. METHODS: There are other organizational constraints on action research which arise at different levels, and which also require discussion. These can be issues about communication and ownership at a practice level and issues of funding and project management procedures. This paper reports on a study in which these issues came to the fore, and offers some thoughts on how they can affect the processes of action research. CONCLUSION: While the principles of action research appear to offer much towards the development of a practice-rooted body of knowledge for nursing, unless some of the issues of ownership are resolved, it is unlikely to move beyond academic rhetoric. RELEVANCE TO CLINICAL PRACTICE: If nursing is to engage in action research, this must be done critically and reflectively and careful attention paid to developing an inclusive and collaborative approach to knowledge and practice development. Furthermore, to develop in nursing and health care research, it must find ways to meet the requirements of funding bodies.

The discipline of improvement: something old, something new?

In response to calls to improve the efficacy of health care services, there is an increasing focus on the processes of achieving a continuous improvement of services and practices. One specific response is that of the NHS Modernization Agency and National Health Service University in relation to the Discipline of Improvement in Health and Social Care. This paper draws on a study that explored the underpinning knowledge base of the Discipline of Improvement and focuses on describing the framework that was developed. The two-dimensional framework is composed of five primary categories, which cross-link to 11 competencies. The study concludes that the Discipline of Improvement draws together a group of ideas that together cohere to form a distinctive model to aid the improvement of health care. While some of these ideas are well-established, the way in which the Discipline of Improvement makes connections between them offers something new to our understanding of change in the complex world of health care provision, and to nursing management.

Partnership research with older people - moving towards making the rhetoric a reality.

As nursing develops closer partnerships with older people in delivering care, it also needs to develop partnerships in order to create the knowledge base for practice in a way that challenges professional hegemony and empowers older people. However, the process of developing partnerships in research takes place against a background of academic research traditions and norms, which can present obstacles to collaboration. This paper is a reflection on the issues that have arisen in three projects where older people were involved in research at different levels, from sources of data to independent researchers. It points to some of the areas that need further exploration and development.