Feasibility of a placebo-controlled trial of antibiotics for possible urinary tract infection in care homes: a qualitative interview study.

BACKGROUND: Diagnosis of suspected urinary tract infection (UTI) in care and nursing home residents is commonly based on vague non-localising symptoms (for example, confusion), potentially leading to inappropriate antibiotic prescription. The safety of withholding antibiotics in such cases could be addressed by a randomised controlled trial (RCT); however, this would require close monitoring of residents, and support from care home staff, clinicians, residents, and families. AIM: To explore the views of residential care and nursing home staff (herein referred to as care home staff) and primary care clinicians on the feasibility and design of a potential RCT of antibiotics for suspected UTI in care home residents, with no localising urinary symptoms. DESIGN & SETTING: A qualitative interview study with primary care clinicians and care home staff in the UK. METHOD: Semi-structured interviews with 16 care home staff and 11 primary care clinicians were thematically analysed. RESULTS: Participants were broadly supportive of the proposed RCT. The safety of residents was a priority and there was strong support for using the RESTORE2 (Recognise Early Soft Signs, Take Observations, Respond, Escalate) assessment tool to monitor residents; however, there were concerns about associated training requirements, especially for night and temporary staff. Effective communication (with residents, families, and staff) was deemed essential, and carers were confident that residents and families would be supportive of the RCT if the rationale was clearly explained and safety systems were robust. There were mixed views on a placebo-controlled design. The perceived additional burden was seen as a potential barrier, and the use of temporary staff and the out-of-hours period were highlighted as potential risk areas. CONCLUSION: The support for this potential trial was encouraging. Future development will need to prioritise resident safety (especially in the out-of-hours period), effective communication, and minimising additional burden on staff to optimise recruitment.

Researchers' perspective of real-world impact from UK public health research: A qualitative study.

Research funded by the National Institute for Health Research Public Health Research Programme is being undertaken in a complex system which brings opportunities and challenges for researchers to maximise the impact of their research. This study seeks to better understand the facilitators, challenges and barriers to research impact and knowledge mobilisation from the perspective of UK public health researchers. A qualitative study using semi-structured interviews, informed by the Payback Framework, with public health researchers who held a research award with the National Institute for Health Research Public Health Research programme up to March 2017 was conducted. Following a thematic analysis, three strongly interlinked themes were extracted from the data and three key factors were highlighted as important for facilitating knowledge mobilisation and impact in UK public health research: (1) Public health researcher's perception of the purpose of the research (2) Approaches to undertaking Knowledge mobilisation activities (3) The complex nature of public health research in the wider research context. These have been reflected onto the Payback framework. Public health researchers can maximise the likelihood for impact by being aware of the context in which they are undertaking research, using different methods, and employing several strategies to take advantage of opportunities. There is a need to support researchers with knowledge mobilisation activities and for funders to identify their expectations of the impact resulting from research. Our findings have relevance to public health researchers and funders interested in increasing the benefit that research brings to society.

Using digital tools in the recruitment and retention in randomised controlled trials: survey of UK Clinical Trial Units and a qualitative study.

BACKGROUND: Recruitment and retention of participants in randomised controlled trials (RCTs) is a key determinant of success but is challenging. Trialists and UK Clinical Research Collaboration (UKCRC) Clinical Trials Units (CTUs) are increasingly exploring the use of digital tools to identify, recruit and retain participants. The aim of this UK National Institute for Health Research (NIHR) study was to identify what digital tools are currently used by CTUs and understand the performance characteristics required to be judged useful. METHODS: A scoping of searches (and a survey with NIHR funding staff), a survey with all 52 UKCRC CTUs and 16 qualitative interviews were conducted with five stakeholder groups including trialists within CTUs, funders and research participants. A purposive sampling approach was used to conduct the qualitative interviews during March-June 2018. Qualitative data were analysed using a content analysis and inductive approach. RESULTS: Responses from 24 (46%) CTUs identified that database-screening tools were the most widely used digital tool for recruitment, with the majority being considered effective. The reason (and to whom) these tools were considered effective was in identifying potential participants (for both Site staff and CTU staff) and reaching recruitment target (for CTU staff/CI). Fewer retention tools were used, with short message service (SMS) or email reminders to participants being the most reported. The qualitative interviews revealed five themes across all groups: 'security and transparency'; 'inclusivity and engagement'; 'human interaction'; 'obstacles and risks'; and 'potential benefits'. There was a high level of stakeholder acceptance of the use of digital tools to support trials, despite the lack of evidence to support them over more traditional techniques. Certain differences and similarities between stakeholder groups demonstrated the complexity and challenges of using digital tools for recruiting and retaining research participants. CONCLUSIONS: Our studies identified a range of digital tools in use in recruitment and retention of RCTs, despite the lack of high-quality evidence to support their use. Understanding the type of digital tools in use to support recruitment and retention will help to inform funders and the wider research community about their value and relevance for future RCTs. Consideration of further focused digital tool reviews and primary research will help to reduce gaps in the evidence base.

Is Co-production Just a Pipe Dream for Applied Health Research Commissioning? An Exploratory Literature Review.

Background and Rationale: Internationally, the idea of "co-production' has become more popular in health research because of the promise of partnership between researchers and patients to create research that focuses on patients' needs. Patient and public involvement (PPI) at an early stage in deciding what research should be funded, can improve the quality and impact of research. However, professional power over the process places limits on the public practising their participatory rights for involvement in commissioning research that affects them and can leave members of the public feeling unheard or excluded, particularly within the context of early phase applied health research. Aim: This article explores whether and how the public can be involved in the co-production of research commissioning early on in the process, with a focus on the power relations that pervade basic and early phase translational applied health research. Methods: An exploratory literature review of international peer-reviewed and gray health research literature using structured searches of electronic databases and key search terms. Results: There is very little literature that critically evaluates how PPI is embedded into the early phases of the commissioning process. The field of basic or early translational applied research appear to be particularly challenging. Four themes which emerged from the review are: reasons for PPI in research commissioning; benefits of PPI at strategic levels of research commissioning; contributions of patients and members of the public; improving PPI in research commissioning. Conclusion: Although the public are being consulted at some stages of the research commissioning process, it is evident that the process of determining research priorities and agendas is far from being widely co-produced. Moving PPI from a consultative paternalistic model to a collaborative partnership model should be a priority for commissioners. Significant changes to communication, practices, systems, structures, or cultures that exclude patients and the public from contributing in meaningful ways, are needed to fulfill the potential of co-produced models of research commissioning.

Evaluation of stakeholder views on peer review of NIHR applications for funding: a qualitative study.

OBJECTIVES: Innovations resulting from research have both national and global impact, so selecting the most promising research studies to fund is crucial. Peer review of research funding applications is part of the selection process, and requires considerable resources. This study aimed to elicit stakeholder opinions about which factors contribute to and influence effective peer review of funding applications to the UK National Institute for Health Research (NIHR), and to identify possible minor improvements to current processes and any major changes or potential innovations to achieve a more efficient peer review process. DESIGN: Qualitative interviews with 30 stakeholders involved in the peer review process. PARTICIPANTS: Participants were drawn from three NIHR coordinating centres and represented four types of stakeholders: board members with responsibility for making funding decisions, applicants, external peer reviewers and NIHR staff. METHODS: All interviews were conducted by telephone apart from three that were face to face with NIHR staff. Data were analysed using a thematic template method. RESULTS: The responses from NIHR staff, board members and reviewers differed from those received from applicants. The first three groups focused on how well the process of peer review did or did not function. The applicants mentioned these points but in addition often reflected on how their personal application was assessed. Process improvements suggested included: developing a more proportionate review process; providing greater guidance, feedback, training, acknowledgement or incentives for peer reviewers; reducing the time commitment and amount of paperwork; and asking reviewers to comment on the importance, strengths and weaknesses of applications and flaws which are potentially 'fixable'. CONCLUSIONS: Overall, participants were supportive of the need for peer review in evaluating applications for research funding. This study revealed which parts of the process are working well and are valued, and barriers, difficulties and potential areas for improvement and development.

Self Management and Telehealth: Lessons Learnt from the Evaluation of a Dorset Telehealth Program.

BACKGROUND: Telehealth is one of the ways in which the UK health service is seeking to improve the care of people living with a long-term condition. One of the aims of its "3 million lives" program is to achieve more effective self care. A lot of the research into telehealth has focused on cost effectiveness, effective working practices, and barriers to adoption. Patient experience is frequently discussed in terms of the reassurance experienced from the support offered through telehealth systems. OBJECTIVE: This study reports the qualitative findings of an evaluation of a local telehealth program introduced by the Dorset Clinical Commissioning Group for patients with chronic obstructive pulmonary disease or chronic heart failure. METHODS: Twenty-nine patients participated in telephone interviews, held at the start of their telehealth experience and after they had been using the system for 3 months. Interviewees included people who had graduated from the telehealth system or had asked to come off it. Healthcare professionals, mainly nurses, involved in the management of patients using the system were also interviewed. RESULTS: The evaluation found that patients were using the telehealth equipment, often beyond the parameters of the formal telehealth scheme, to develop effective self-management techniques. CONCLUSION: These results have implications for policy makers, as removing the equipment when patients graduate as being self managing may mean removing the very tools that make that self management possible.

Interprofessional learning in primary care: an exploration of the service user experience leads to a new model for co-learning.

BACKGROUND: Research about service user involvement in research and education focuses on the purpose, the methods, the barriers and the impact of their involvement. Few studies report on the experience of the service users who get involved. This paper reports an exploration of the experience of service users who participated in an interprofessional educational initiative in primary care - the Learning to Improve the Management of Back Pain in the Community (LIMBIC) project. Service users attended workshops with practice teams and assisted them in developing small scale quality improvement projects to improve their provision of care for people with back pain. OBJECTIVES: To explore the experience of service users involved in the LIMBIC project. DESIGN: Using the philosophical and methodological approaches of pragmatism this study analysed data from the wider LIMBIC project and collected primary data through semi structured interviews with service users. Secondary data were reanalysed and integrated with primary data to address the research question. SETTING: The study was undertaken in the primary health care setting. PARTICIPANTS: Patients participated as service users in workshops and quality improvement projects with members from their practice teams. METHODS: Interviews with service users were transcribed and analysed thematically. Document and thematic analyses of secondary data from the LIMBIC project included focus group transcripts, patient stories, film, emails, meeting notes, a wiki and educational material such as presentations. RESULTS: Themes identified through the analyses illustrated the importance, to the service users, of the sense of community, of clear communication, and of influencing change through involvement. A model for co-learning with service users resulted from the analyses. CONCLUSIONS: The experience of service users can be optimised by planning, preparation and support so that their wealth of expertise can be recognised and utilised. A model for co-learning was developed and is presented in this paper.

Translating research into practice: evaluation of an e-learning resource for health care professionals to provide nutrition advice and support for cancer survivors.

BACKGROUND: Nurses and other allied health professionals are in a key position to provide appropriate and consistent advice on nutritional issues to support cancer survivors. However gaps in their nutrition knowledge and education warrant the need for enhanced learning as part of their Continued Professional Development (CPD). In the UK there are currently no formally recognised nutrition education programmes. Therefore e-learning offers a solution to provide flexible learning to target this need. AIMS: This study aimed to develop and evaluate the efficacy of a freely available, internet-based learning resource, for nurses and allied health professionals who provide nutrition, diet and lifestyle advice for cancer survivors. It sought to explore the attitudes and conceptions of the resource and current knowledge base of those involved in the care pathway for cancer survivors. METHOD: The design and development of the e-learning resource were informed by the best available research and policy evidence and in a format to facilitate on-line learning. A robust evaluation strategy incorporated focus groups and telephone interviews to gain in depth insights into the experiences of using the resource. RESULTS: Themes included 'Plugging a Gap' which shows an improved knowledge base for nutrition. Information was 'All in One Place' showing that the resource was valued as being within a 'trusted' organisation. 'Everyone Benefits' illustrates how learners felt that the resource provided them with an evidence base, whilst the 'Current and Live' theme captured how professionals felt about the information being up-to-date. CONCLUSIONS: The project has shown the benefits of interprofessional working to develop an e-learning resource for Health Care Professionals to support cancer survivors in following healthier lifestyles. Positive attitudes and potential improvements in the knowledge base and changes for professional practice were demonstrated. Further research is required to gauge sustained impact in the work environment by embedding the resource as part of CPD.

Improving services for back pain: putting the patient at the centre of interprofessional education.

INTRODUCTION: Studies exploring the role of patients in interprofessional education (IPE) are found primarily in undergraduate programmes with few reporting on the postgraduate (continuing professional development) setting. This paper describes an interprofessional quality improvement project around the management of back pain in a primary care setting where patients were part of the practice team. METHODS: Patients participated in eight half-day IPE workshops delivered to nine general practice teams in the UK. Educational content included knowledge about quality improvement and evidence-based back pain knowledge, with teamwork, experiential and didactic learning approaches. On-site practice support from a quality improvement facilitator occurred between the workshops to strengthen practice-based learning. Forty-four practice staff and 11 patients attended the workshops and the facilitated project meetings. Evaluation occurred through focus groups with practice teams (including patients) both before and after the workshops. These were recorded, transcribed and analysed by coding and the inductive development of themes. RESULTS: The context of managing back pain was particularly challenging. Focus group participants indicated that patient involvement was highly valued as it gave practitioners a greater understanding of the effects of back pain on their lives whilst permitting patients to hear the experiences of others and to understand their own world better. Listening was important to patients' experiences of healthcare and practitioners' experiences of the workshops. Learning together emerged as particularly important and finally the challenge of finding time to learn together infiltrated the entire endeavour and was a prominent concern. DISCUSSION: Patients sharing their experience of back pain appeared to be a particularly pivotal point in the learning for practice teams. Meaningful engagement with users in IPE was highly valued and provided a catalyst for behavioural change, where professionals relinquished an unhelpful medical model in favour of an integrative biopsychosocial one.

The impact of the economic recession on well-being and quality of life of older people.

The importance of economic well-being is recognised in the recent UK Government policy. Older people may be particularly vulnerable to economic fluctuations as they are reliant on fixed incomes and assets, which are reducing in value. Within the literature, little is understood about the impact of the current economic downturn on people's general quality of life and well-being and, in particular, there is little research on the financial experiences and capability of the older age group, a concern in light of the ageing UK population. This article reports a qualitative research study into the nature of older peoples' vulnerability by exploring their perceptions of the impact of the economic recession on their well-being and quality of life. It explores specifically a group of older people who are not the poorest within the ageing population, but who may be described as the 'asset rich-income poor' group. Key themes relate to the impact of the recession on the costs of essential and non-essential items and dimensions of mental, physical and social well-being. Implications for health and social care practice in meeting the needs of older people during times of economic recession are then explored. The paper adds to the debate by demonstrating that the recession is having adverse consequences for older people's quality of life in terms of economic, mental and social well-being, although there is also evidence that some of them are equipped with certain resilience factors due to their money management and budgeting skills.

Intersectoral interagency partnerships to promote financial capability in older people.

From the second quarter of 2008, the UK economy entered a period of economic decline. Older people are particularly vulnerable during these times. To promote ways in which older people can be better supported to maintain their financial well-being, this study explored the sources older people utilize to keep themselves financially informed. Interviews with older people (n = 28) showed that older people access trusted sources of information (e.g. healthcare professionals) rather than specialist financial information providers (e.g. financial advisors) which highlighted the need for interagency working between financial services in the private, public and voluntary sectors. An example of how such interagency partnerships might be achieved in practice is presented with some recommendations on directions for future research into interagency working that spans public, private and voluntary sectors.

Back pain outcomes in primary care following a practice improvement intervention:- a prospective cohort study.

BACKGROUND: Back pain is one of the UK's costliest and least understood health problems, whose prevalence still seems to be increasing. Educational interventions for general practitioners on back pain appear to have had little impact on practice, but these did not include quality improvement learning, involve patients in the learning, record costs or document practice activities as well as patient outcomes. METHODS: We assessed the outcome of providing information about quality improvement techniques and evidence-based practice for back pain using the Clinical Value Compass. This included clinical outcomes (Roland and Morris Disability Questionnaire), functional outcomes, costs of care and patient satisfaction. We provided workshops which used an action learning approach and collected before and after data on routine practice activity from practice electronic databases. In parallel, we studied outcomes in a separate cohort of patients with acute and sub-acute non-specific back pain recruited from the same practices over the same time period. Patient data were analysed as a prospective, split-cohort study with assessments at baseline and eight weeks following the first consultation. RESULTS: Data for 1014 patients were recorded in the practice database study, and 101 patients in the prospective cohort study. We found that practice activities, costs and patient outcomes changed little after the intervention. However, the intervention was associated with a small, but statistically significant reduction in disability in female patients. Additionally, baseline disability, downheartedness, self-rated health and leg pain had small but statistically significant effects (p < 0.05) on follow-up disability scores in some subgroups. CONCLUSIONS: GP education for back pain that both includes health improvement methodologies and involves patients may yield additional benefits for some patients without large changes in patterns of practice activity. The effects in this study were small and limited and the reasons for them remain obscure. However, such is the impact of back pain and its frequency of consultation in general practice that this kind of improvement methodology deserves further consideration. TRIAL REGISTRATION NUMBER: ISRCTN: ISRCTN30420389.