A study of prisms and therapy in attention loss after stroke (SPATIAL): A feasibility randomised controlled trial.

OBJECTIVE: Investigate feasibility and acceptability of prism adaptation training for people with inattention (spatial neglect), early after stroke, during usual care. DESIGN: Phase II feasibility randomised controlled trial with 3:1 stratified allocation to standard occupational therapy with or without intervention, and nested process evaluation. SETTING: Ten hospital sites providing in-patient stroke services. PARTICIPANTS: Screened positive for inattention more than one-week post-stroke; informal carers. Occupational therapists participated in qualitative interviews. INTERVENTION: Adjunctive prism adaptation training at the start of standard occupational therapy sessions for three weeks. MAIN MEASURES: Feasibility measures included recruitment and retention rates, intervention fidelity and attrition. Outcomes collected at baseline, 3 weeks and 12 weeks tested measures including Nottingham Extended Activities of Daily Living Scale. Acceptability was explored through qualitative interviews and structured questions. RESULTS: Eighty (31%) patients were eligible, 57 (71%) consented, 54 randomised (40:13, +1 exclusion) and 39 (74%) completed 12-week outcomes. Treatment fidelity was good: participants received median eight intervention sessions (IQR: 5, 12) lasting 4.7 min (IQR: 4.1, 5.0). All six serious adverse events were unrelated. There was no signal that patients allocated to intervention did better than controls. Twenty five of 35 recruited carers provided outcomes with excellent data completeness. Therapists, patients and carers found prism adaptation training acceptable. CONCLUSIONS: It is feasible and acceptable to conduct a high-quality definitive trial of prism adaptation training within occupational therapy early after stroke in usual care setting, but difficult to justify given no sign of benefit over standard occupational therapy. CLINICAL TRIAL REGISTRATION: https://www.isrctn.com/ Ref ISRCTN88395268.

Patient view of the advanced practitioner (AP) role in primary care: A realist-informed synthesis.

BACKGROUND: Approximately 30% of general practitioner consultations are due to musculoskeletal disorders (MSKDs). Physiotherapists are trained to assess, diagnose and treat a range of MSKDs, and could provide the first point of contact for primary care patients. There is limited evidence on whether this role is acceptable to patients; however, previous research has explored advanced practitioner (AP) roles in primary care, which could inform this new initiative. AIMS: This study used realist synthesis to explore factors that influence patient acceptability of AP roles in primary care. MATERIALS & METHODS: A realist synthesis was undertaken to identify initial programme theories regarding acceptability. Databases were searched to identify relevant literature. Identified studies were subject to inclusion and exclusion criteria, resulting in 38 studies included for synthesis. Theory-specific data extraction sheets were created and utilised. Data were analysed through identifying contexts, mechanisms and outcomes to formulate hypotheses. Hypotheses were validated through consultation with expert stakeholders. RESULTS: Eight theory areas were identified that potentially impacted on patient acceptability of the role: patient's prior experience of condition management; patient's expectations of condition management; communication; continuity of the individual practitioner; practitioner's scope of practice; accessibility; professional hierarchy and promoting the role. Nineteen hypotheses on the AP role were developed around these theory areas. DISCUSSION: Role acceptabiliy was influenced significantly by context and may change as the role develops, for instance, as waiting times change. CONCLUSION: Hypotheses will inform a subsequent realist evaluation exploring the physiotherapy AP role in primary care. Future research is needed to understand the acceptability of first contact physiotherapists delivering certain skills.

Patient acceptability of the physiotherapy first contact practitioner role in primary care: A realist informed qualitative study.

BACKGROUND: Approximately 30% of general practitioner (GP) consultations are due to musculoskeletal disorders (MSKDs). Physiotherapists are trained to assess, diagnose and treat MSKDs and provide an alternative to GP consultation for primary care patients as first contact physiotherapists (FCPs). AIM: To explore patient perceived acceptability of the FCP role using realist methods to understand what works for whom, how, why and in what circumstances. METHODS: A realist evaluation was undertaken, which involved three stages: forming the theory area framework; testing the theory framework and refining the programme theory. The theory framework was formed through realist synthesis. Realist interviews tested this framework. Data were collected from two GP practice case study sites and interviews were undertaken at each site. N = 20 participants were interviewed in total. In each practice, this constituted patients (n = 5), GPs (n = 1), FCPs (n = 2), receptionists (n = 1) and practice managers (n = 1). Interview data were analysed against preliminary hypotheses and, where appropriate, new theory areas were created. RESULTS: The evaluation highlighted that acceptability of the FCP role was influenced by 'expectations', 'accessibility' and 'promoting the role'. Whilst some findings were shared by both practices, different contexts resulted in unique practice findings. CONCLUSION: Patients were predominantly accepting of FCPs, nevertheless, there was a scope to increase acceptability through an implementation strategy that considered the contexts of the individual patient, as well as wider practice contexts.

Developing a typology of the roles public contributors undertake to establish legitimacy: a longitudinal case study of patient and public involvement in a health network.

OBJECTIVE: To identify how public contributors established their legitimacy in the functioning of a patient and public involvement programme at a health network. DESIGN: A longitudinal case study with three embedded units (projects) involving public contributors. Interviews (n=24), observations (n=27) and documentary data collection occurred over 16 months. SETTING: The West of England Academic Health Science Network (WEAHSN), 1 of 15 regional AHSNs in England. PARTICIPANTS: Interviews were conducted with public contributors (n=5) and professionals (n=19) who were staff from the WEAHSN, its member organisations and its partners. RESULTS: Public contributors established their legitimacy by using nine distinct roles: (1) lived experience, as a patient or carer; (2) occupational knowledge, offering job-related expertise; (3) occupational skills, offering aptitude developed through employment; (4) patient advocate, promoting the interests of patients; (5) keeper of the public purse, encouraging wise spending; (6) intuitive public, piloting materials suitable for the general public; (7) fresh-eyed reviewer, critiquing materials; (8) critical friend, critiquing progress and proposing new initiatives and (9) boundary spanner, urging professionals to work across organisations. Individual public contributors occupied many, but not all, of the roles. CONCLUSIONS: Lived experience is only one of nine distinct public contributor roles. The WEAHSN provided a benign context for the study because in a health network public contributors are one of many parties seeking to establish legitimacy through finding valuable roles. The nine roles can be organised into a typology according to whether the basis for legitimacy lies in: the public contributor's knowledge, skills and experience; citizenship through the aspiration to achieve a broad public good; or being an outsider. The typology shows how public contributors can be involved in work where lived experience appears to lack relevance: strategic decision making; research unconnected to particular conditions; or acute service delivery.

Preparing non-medical clinicians to deliver GP out-of-hours services: lessons learned from an innovative approach.

Despite the need to develop a non-medical out-of-hours (OOHs) workforce to address increasing healthcare demands and to support a strained GP workforce, there is no consensus on the required training and clinical competencies needed for nurses and paramedics to be developed as safe OOH practitioners. This paper presents the development and evaluation of one programme delivered in 2017 to paramedics seeking to work in OOHs services. Details of the course delivery are outlined and the mixed-methods evaluation presented. Following successful university ethical approval, student and staff experiences were reviewed through interviews, questionnaires and graded feedback of completed electronic patient case records. The findings provided useful learning that can be transferred to other organisations seeking to develop such training. In particular, the findings suggest the course was able to provide the students with the skills, knowledge and confidence to become safe practitioners in the OOHs service. Challenges in course delivery were highlighted. It was suggested that course organisation, duration and scope require careful consideration to enable students to complete and practise successfully.

Evaluating the implementation of a quality improvement process in General Practice using a realist evaluation framework.

RATIONALE, AIMS, AND OBJECTIVES: Underuse of anticoagulants in atrial fibrillation is known to increase the risk of stroke and is an international problem. The National Institute for Health Care and Excellence guidance CG180 seeks to reduce atrial fibrillation related strokes through prescriptions of Non-vitamin K antagonist Oral Anticoagulants. A quality improvement programme was established by the West of England Academic Health Science Network (West of England AHSN) to implement this guidance into General Practice. A realist evaluation identified whether the quality improvement programme worked, determining how and in what circumstances. METHODS: Six General Practices in 1 region, became the case study sites. Quality improvement team, doctor, and pharmacist meetings within each of the General Practices were recorded at 3 stages: initial planning, review, and final. Additionally, 15 interviews conducted with the practice leads explored experiences of the quality improvement process. Observation and interview data were analysed and compared against the initial programme theory. RESULTS: The quality improvement resources available were used variably, with the training being valued by all. The initial programme theories were refined. In particular, local workload pressures and individual General Practitioner experiences and pre-conceived ideas were acknowledged. Where key motivators were in place, such as prior experience, the programme achieved optimal outcomes and secured a lasting quality improvement legacy. CONCLUSION: The employment of a quality improvement programme can deliver practice change and improvement legacy outcomes when particular mechanisms are employed and in contexts where there is a commitment to improve service.

Evaluation and its importance for nursing practice.

Evaluation of service delivery is an important aspect of nursing practice. Service evaluation is being increasingly used and led by nurses, who are well placed to evaluate service and practice delivery. This article defines evaluation of services and wider care delivery and its relevance in NHS practice and policy. It aims to encourage nurses to think about how evaluation of services or practice differs from research and audit activity and to consider why and how they should use evaluation in their practice. A process for planning and conducting an evaluation and disseminating findings is presented. Evaluation in the healthcare context can be a complicated activity and some of the potential challenges of evaluation are described, alongside possible solutions. Further resources and guidance on evaluation activity to support nurses' ongoing development are identified.

Practical guidance on undertaking a service evaluation.

This article describes the basic principles of evaluation, focusing on the evaluation of healthcare services. It emphasises the importance of evaluation in the current healthcare environment and the requirement for nurses to understand the essential principles of evaluation. Evaluation is defined in contrast to audit and research, and the main theoretical approaches to evaluation are outlined, providing insights into the different types of evaluation that may be undertaken. The essential features of preparing for an evaluation are considered, and guidance provided on working ethically in the NHS. It is important to involve patients and the public in evaluation activity, offering essential guidance and principles of best practice. The authors discuss the main challenges of undertaking evaluations and offer recommendations to address these, drawing on their experience as evaluators.

A devolved model for public involvement in the field of mental health research: case study learning.

BACKGROUND: Patient and public involvement in all aspects of research is espoused and there is a continued interest in understanding its wider impact. Existing investigations have identified both beneficial outcomes and remaining issues. This paper presents the impact of public involvement in one case study led by a mental health charity conducted as part of a larger research project. The case study used a devolved model of working, contracting with service user-led organizations to maximize the benefits of local knowledge on the implementation of personalized budgets, support recruitment and local user-led organizations. OBJECTIVE: To understand the processes and impact of public involvement in a devolved model of working with user-led organizations. DESIGN: Multiple data collection methods were employed throughout 2012. These included interviews with the researchers (n = 10) and research partners (n = 5), observation of two case study meetings and the review of key case study documentation. Analysis was conducted in NVivo10 using a coding framework developed following a literature review. FINDINGS: Five key themes emerged from the data; Devolved model, Nature of involvement, Enabling factors, Implementation challenges and Impact. While there were some challenges of implementing the devolved model it is clear that our findings add to the growing understanding of the positive benefits research partners can bring to complex research. CONCLUSIONS: A devolved model can support the involvement of user-led organizations in research if there is a clear understanding of the underpinning philosophy and support mechanisms are in place.

Virtual patients: development in cancer nursing education.

BACKGROUND: The number of men diagnosed with prostate cancer is increasing and internationally there are high incidence rates. It is important that nurses and healthcare professionals are enabled to provide appropriate care to those men affected by prostate cancer and their families. Despite this need, there is recognition that many professionals feel ill prepared and lack knowledge in a number of areas. This paper presents the development of a Virtual Patient (VP) online resource to support practitioner learning. AIM: To develop five online VP simulation scenarios to meet the learning needs of nurses and health-care professionals caring for men with prostate cancer. METHOD: Topic areas for the VPs were taken from previous work exploring the needs of health care professionals working with men with prostate cancer. An initial scoping exercise involving nursing practitioners, students and a prostate cancer charity confirmed the focus of the case study scenarios. Service users and specialist practitioners reviewed an outline of each case study to ensure fidelity of the simulations scenarios. Cases were entered into UChoose, a web based interactive VP player and authoring tool. The final case studies were reviewed by a sample of both registered and non-registered nurses and nursing students. RESULTS: The majority of respondents reported an increase in knowledge and suggested that they would recommend the resource to others. A number of positive aspects of the resource were highlighted. Respondents also commented about areas of weakness, a number of which have been addressed subsequently. CONCLUSIONS: The VP case studies provided an opportunity to develop knowledge and confidence in caring for men with prostate cancer. The mode of delivery and the content was acceptable for less experienced and knowledgeable staff.

Rescheduling nursing shifts: scoping the challenge and examining the potential of mathematical model based tools.

AIM: To review research in the literature on nursing shift scheduling / rescheduling, and to report key issues identified in a consultation exercise with managers in four English National Health Service trusts to inform the development of mathematical tools for rescheduling decision-making. BACKGROUND: Shift rescheduling is unrecognised as an everyday time-consuming management task with different imperatives from scheduling. Poor rescheduling decisions can have quality, cost and morale implications. EVALUATION: A systematic critical literature review identified rescheduling issues and existing mathematic modelling tools. A consultation exercise with nursing managers examined the complex challenges associated with rescheduling. KEY ISSUES: Minimal research exists on rescheduling compared with scheduling. Poor rescheduling can result in greater disruption to planned nursing shifts and may impact negatively on the quality and cost of patient care, and nurse morale and retention. Very little research examines management challenges or mathematical modelling for rescheduling. CONCLUSION: Shift rescheduling is a complex and frequent management activity that is more challenging than scheduling. Mathematical modelling may have potential as a tool to support managers to minimise rescheduling disruption. IMPLICATIONS FOR NURSING MANAGEMENT: The lack of specific methodological support for rescheduling that takes into account its complexity, increases the likelihood of harm for patients and stress for nursing staff and managers.

Men affected by prostate cancer: a survey of general practitioners' learning needs.

BACKGROUND: With incidence rates for prostate cancer increasing each year in the UK, information and support for men with prostate cancer is crucial. Yet GPs have identified this as an area where they lack knowledge and confidence. Prostate Cancer UK commissioned a training needs analysis for healthcare professionals to inform the development of their education and training strategy. This paper presents the findings for GPs, taken from a wider study of healthcare professionals. AIM: To complete a review of current education provision and need to inform the development of an educational strategy for UK healthcare professionals. METHOD: A mixed methods study including a web-based review of education provision in prostate cancer in the UK, an online questionnaire and telephone interviews. RESULTS: The web-site search identified five educational opportunities specifically targeted at GPs. A total of 72 GPs responded to the online questionnaire. Of those responding, 39 (54.2%) GPs identified the need for further education and training in order to care effectively for men with prostate cancer. CONCLUSION: GPs identified a number of training needs to enable them to support men with prostate cancer. There was no clear preferred mode of educational delivery, with online learning seen as acceptable.

Learning together, working together: an evaluation of experiences of a pilot programme for partnership between unions and management in the health service.

This article describes an innovative initiative to support partnership working between trade unions and management in three National Health Service Trusts, by means of shared participation in a series of learning and development days. Although there is existing evidence, within the literature on partnership, of the benefits of partnership working for employees and employers, there is little discussion of processes by which effective partnership is developed. More specifically, there is no current academic literature on the role of education in enabling improved partnership working between trade unions and managers. The findings of the evaluation suggest that the pilot provided a successful learning experience as well as a number of pointers for improving future developments of this nature. The recommendations include embedding of partnership work within existing staff development processes.

Chlorhexidine and tooth-brushing as prevention strategies in reducing ventilator-associated pneumonia rates.

BACKGROUND: Ventilator-associated pneumonia (VAP) is a common complication of mechanical ventilation after endotracheal intubation. The role of chlorhexidine and tooth-brushing has been considered as a clinical intervention to reduce infection rates, however, evidence to inform this needs appraising. AIM: This paper presents a critical review on the effect of chlorhexidine gluconate (CHX) and tooth-brushing in decreasing rates of VAP in mechanically ventilated adult patients cared for in intensive care settings. METHODS: A literature search was conducted using a number of bibliographic databases (n = 6). A number of parameters were used to exclude irrelevant papers. A total n = 17 papers were located and accessed, which were directly related to the field. Eight studies that met the criteria and addressed the study aims were reviewed. FINDINGS: CHX was successful in reducing the rate of VAP and using a combination of CHX and colistine resulted in better oropharyngeal decontamination which reduced and delayed VAP. Chlorhexidine was also effective in reducing dental plaque in patients cared for in intensive care and had the potential to reduce nosocomial infections. Results of studies investigating the use of tooth-brushing in reducing VAP incidence proved inconsistent, although all recommend tooth-brushing as important in maintaining good oral hygiene. CONCLUSIONS: The use of chlorhexidine has been proven to be of some value in reducing VAP, although may be more effective when used with a solution which targets gram-negative bacteria. Tooth-brushing is recommended in providing a higher standard of oral care to mechanically ventilated patients and reducing VAP when used with chlorhexidine. However, limitations in study design and inconsistency in results suggest that further research is required into the effects of tooth-brushing.

How 'blended' is blended learning?: students' perceptions of issues around the integration of online and face-to-face learning in a Continuing Professional Development (CPD) health care context.

PURPOSE: This paper explores students' perceptions of blended learning modules delivered in a Continuing Professional Development (CPD) health care context in the UK. 'Blended learning' is the term used to describe a hybrid model of learning where traditional face-to-face teaching approaches and newer electronic learning activities and resources are utilised together. METHOD: A new model of CPD for health care practitioners based on a blended learning approach was developed at a university in the south west of England. As part of the evaluation of the new modules, a qualitative study was conducted, in which 17 students who had experienced the modules were interviewed by telephone. RESULTS: Three main themes emerged from the interviews relating to the 'blended' nature of the blended learning modules. These were i) issues around the opportunities for discussion of online materials face-to-face; ii) issues of what material should be online versus face-to-face and iii) balancing online and face-to-face components. CONCLUSION: Teaching staff engaged in the development of blended learning courses need to pay particular attention to the ways in which they develop and integrate online and face-to-face materials. More attention needs to be paid to allowing opportunity for students to come together to create a 'community of inquiry'.