A comparison of four dementia palliative care services using the RE-AIM framework.

BACKGROUND: Living with a life-limiting illness, people with dementia benefit from palliative care which considers the holistic needs of the person and their family. However, little is known about how palliative care may be best provided to people living with dementia at home in the community. We examined four exemplary dementia palliative care services for people with dementia in the community, to see what activities they were providing, what were the commonalities and differences, and what lessons could be learned. METHODS: A long-list of dementia palliative care services in Ireland, Northern Ireland, England, Scotland, and Wales, was identified through a survey, and four exemplar services were chosen based on criteria including: in operation >six months; provides identifiable activities; availability of routinely collected service data; not exclusively for people with dementia in final hours or days of life. Mixed-methods of data collection included interviews, focus-groups and surveys with service staff, surveys of service users, and routinely collected service data. The RE-AIM framework was used to describe and understand the sample of dementia palliative care services. RESULTS: The four services had varied organisational structures and were led by different disciplines. However, they all provided common core activities including holistic and person-centred care, early advance care planning with service user involvement, carer support, integrated healthcare services, continuity of care, 24/7 support, bereavement support. All had needs-based referral criteria, accepting any age or dementia sub-type. All supported people with dementia to remain living at home and to have a comfortable, dignified death in their preferred place. CONCLUSIONS: An effective dementia palliative care service may take different forms. Whether the service is dementia-led or Specialist Palliative Care-led, efficacy is associated with providing a range of key activities and implementing them effectively. The data collected strongly suggests the benefits of the dementia palliative care services to a person with dementia and their families and offers valuable insight into the key factors for the establishment and successful running of such services.

Evaluating midwife-led antenatal care: choice, experience, effectiveness, and preparation for pregnancy.

OBJECTIVE: to evaluate midwife-led care (MLC) antenatal care compared with antenatal care provided in traditional obstetric-led hospital antenatal clinics (usual care). DESIGN: a mixed methods approach involving a chart audit, postal survey, focus group and in-depth interviews. SETTING: data were collected at a large maternity hospital and satellite clinics in Dublin from women attending for antenatal care between June 2011 and May 2012. PARTICIPANTS: 300 women with low-risk pregnancy who attended midwife-led antenatal care or usual clinics during the study period were randomly selected to participate. MEASUREMENTS: data were collected from 292 women׳s charts and from 186 survey participants (63% response rate). Nine women participated in in-depth interviews and a focus group. FINDINGS: MLC was as effective as usual care in relation to number of antenatal visits and ultrasound scans, referral to other clinicians, women׳s health in pregnancy, gestation at childbirth, and birth weight. Women attending MLC booked significantly earlier, fewer women attending MLC were admitted to hospital antenatally and more women breast fed their infant. Women attending MLC reported better choice and that shorter waiting times and having more time for discussion were important reasons for choosing MLC. Women attending MLC reported a better experience overall, and recorded better outcomes in relation to how they were treated, along with easier access to antenatal care and shorter waiting times to see a midwife. Although women attending MLC clinics reported higher satisfaction with the information that they received, they also identified that antenatal education could be improved in relation to labour, breast-feeding, depression and emotional well-being, and caring for the infant. KEY CONCLUSIONS: midwife-led antenatal care was as effective as usual care for women with low-risk pregnancy and better in relation to choice, breast feeding and women׳s experience of care.

Evaluating midwifery-led antenatal care: using a programme logic model to identify relevant outcomes.

BACKGROUND: a range of initiatives has been introduced in Ireland and internationally in recent years to establish midwifery-led models of care, generally aimed at increasing the choices available for women for maternity care. A midwifery-led antenatal clinic was first established at the study site (a large urban maternity hospital in Dublin) and extended over recent years. This paper reports on the design of an evaluation of these midwives clinics, in particular the use of a programme logic model to select outcomes to be included in the evaluation. AIMS AND OBJECTIVES: the programme logic model is used to identify the theory of a programme and is an integrative framework for the design and analysis of evaluations using qualitative and quantitative methods. Through an inclusive approach, the aim was to identify the most relevant outcomes to be included in the evaluation, by identifying and linking programme (midwifery-led antenatal clinic) outcomes to the goals, inputs and processes involved in the production of these outcomes. METHODS: the process involved a literature review, a review of policy documents and previous reviews of the clinics, interviews with midwives, obstetricians and managers to identify possible outcomes, a focus group with midwives, obstetricians, managers and women who had attended the clinics to refine and prioritise outcomes, and a follow-up survey to refine and prioritise the outcomes identified and to identify sources of data on each outcome. FINDINGS: seven categories of outcomes were identified: (1) choice, (2) relationship/interaction with caregiver, (3) experience of care, (4) preparation and education for childbirth and parenthood, (5) effectiveness of care, (6) organisational outcomes, and (7) programme viability. A range of sources of information was identified for each outcome, including existing documentation and data, chart audit, survey of women, and interviews and focus groups with midwives, obstetricians, managers and women. CONCLUSIONS: the programme logic model provided an inclusive, systematic and transparent approach to identifying relevant outcomes to be included in the evaluation. The information obtained has been used since to design the evaluation project, which is currently being concluded.

Hospital nurse staffing models and patient and staff-related outcomes.

BACKGROUND: Nurse staffing interventions have been introduced across countries in recent years in response to changing patient requirements, developments in patient care, and shortages of qualified nursing staff. These include changes in skill mix, grade mix or qualification mix, staffing levels, nursing shifts or nurses' work patterns. Nurse staffing has been closely linked to patient outcomes, organisational outcomes such as costs, and staff-related outcomes. OBJECTIVES: Our aim was to explore the effect of hospital nurse staffing models on patient and staff-related outcomes. SEARCH STRATEGY: We searched the following databases from inception through to May 2009: Cochrane/EPOC resources (DARE, CENTRAL, the EPOC Specialised Register), PubMed, EMBASE, CINAHL Plus, CAB Health, Virginia Henderson International Nursing Library, the Joanna Briggs Institute database, the British Library, international theses databases, as well as generic search engines. SELECTION CRITERIA: Randomised control trials, controlled clinical trials, controlled before and after studies and interrupted time series analyses of interventions relating to hospital nurse staffing models. Participants were patients and nursing staff working in hospital settings. We included any objective measure of patient or staff-related outcome. DATA COLLECTION AND ANALYSIS: Seven reviewers working in pairs independently extracted data from each potentially relevant study and assessed risk of bias. MAIN RESULTS: We identified 6,202 studies that were potentially relevant to our review. Following detailed examination of each study, we included 15 studies in the review. Despite the number of studies conducted on this topic, the quality of evidence overall was very limited. We found no evidence that the addition of specialist nurses to nursing staff reduces patient death rates, attendance at the emergency department, or readmission rates, but it is likely to result in shorter patient hospital stays, and reductions in pressure ulcers. The evidence in relation to the impact of replacing Registered Nurses with unqualified nursing assistants on patient outcomes is very limited. However, it is suggested that specialist support staff, such as dietary assistants, may have an important impact on patient outcomes. Self-scheduling and primary nursing may reduce staff turnover. The introduction of team midwifery (versus standard care) may reduce medical procedures in labour and result in a shorter length of stay without compromising maternal or perinatal safety. We found no eligible studies of educational interventions, grade mix interventions, or staffing levels and therefore we are unable to draw conclusions in relation to these interventions. AUTHORS' CONCLUSIONS: The findings suggest interventions relating to hospital nurse staffing models may improve some patient outcomes, particularly the addition of specialist nursing and specialist support roles to the nursing workforce. Interventions relating to hospital nurse staffing models may also improve staff-related outcomes, particularly the introduction of primary nursing and self-scheduling. However, these findings should be treated with extreme caution due to the limited evidence available from the research conducted to date.

Identifying research priorities for midwifery in Ireland.

OBJECTIVE: to identify research priorities for midwifery in Ireland in the short, medium and long term. METHOD: a three-round Delphi survey design was used to identify midwifery research topics. Issues identified through content analysis formed Questionnaires 2 and 3. Participants rated the importance of each topic (1=low importance to 7=high importance), and a mean score of 6.0 or more was considered a priority issue. A final discussion group set short-, medium- or long-term timeframes for the research topics. PARTICIPANTS: 334 midwives were recruited from a national invitation to all midwives. Response rates were 43% (Round 1; 142/334), 85% (Round 2; 121/142) and 81% (Round 3; 98/121). Nine consumers of maternity services were included in the discussion group workshop. FINDINGS: participants identified 11 clinical, eight management, and seven education midwifery research topics with six high-priority issues: promoting woman-centred care (management), promoting the distinctiveness of midwifery (education), satisfaction with care (clinical), care in labour (clinical), preparation for practice (clinical), and promoting research/evidence-based practice (education). KEY CONCLUSIONS: this research sought to achieve consensus amongst a representative sample of midwives on the priorities for midwifery research in Ireland. Midwives can now select topics for graduate or other research studies of importance to practice, management and education. Funding agencies can confidently direct the allocation of national and local funding for priority areas of midwifery research within Ireland.