A population health approach to workplace mental health: rationale, implementation and engagement.

Objectives: To describe a population health-based program to support employee and dependent mental health and learn from engagement trends. Methods: Retrospective analysis of a program utilizing an assessment of mental health risk. For scoring "at risk," a Care Concierge is offered to connect users with resources. Results: Participation was offered to 56,442 employees and dependents. Eight thousand seven hundred thirty-one completed the assessment (15%). Of those, 4,644 (53%) scored moderate or higher. A total of 418 (9%) engaged the Care Concierge. Factors that negatively influenced the decision to engage care included bodily pain, financial concerns. Positive influences were younger age, high stress, anxiety, PTSD and low social support. Conclusion: Proactive assessment plus access to a Care Concierge facilitates mental healthcare utilization. Several factors influence likelihood to engage in care. A better understanding of these factors may allow for more targeted outreach and improved engagement.

The Collaboration Compass: A Preliminary Model for Navigating Collaborative Practice.

PURPOSE: To investigate the meaning and manifestation of collaboration in practice including the experience and outcomes for patients and professionals. METHODS: Grounded theory was used to investigate collaboration in an integrated outpatient parenteral antimicrobial therapy (OPAT) service. The sample consisted of staff and patients with experience of OPAT. Interviews and focus groups were used to generate data, and grounded theory methods were used to progress the study through constant comparative analysis and theoretical sampling to data saturation. Coding, categorizing, and techniques of situational analysis were used to analyze data and develop theory. RESULTS: The relationship between the influences in the situation and the interaction which takes place between individuals was found to produce four different types of collaboration: developing, maintaining, limiting, and disrupting collaboration. The collaboration compass model was developed to illustrate and aid interactive navigation of collaborative situations. DISCUSSION: The findings present the complexity of practice, and a model to explain the multiple influences and interaction which shape collaboration. In this model, patients are part of collaboration, and this ensures that patients' views and experiences, as well as those of professionals, are included and represented in knowledge about collaboration. This adds a new dimension to existing interprofessional presentations of collaborative practice and examines collaboration as it is operationalized in practice and co-constructed between patients and professionals during day to day practice.

Does respite care address the needs of palliative care service users and carers? Their perspectives and experiences.

AIM: To establish whether respite care addresses the needs of palliative care service users and carers. BACKGROUND: Respite care is often described in UK policy and guidance as a key need to providing support for this group and yet little is known about it and there is a lack of research to support its efficacy. DESIGN: The approach was qualitative and the methodology was interpretive. The method used was constructivist grounded theory. METHODS: Data collection was carried out by unstructured informal interview with three couples and two bereaved carers who had experienced hospice respite care. RESULTS: Findings showed that respite care is valued by palliative care service users and carers although there are some fundamental tensions in service models which limit its potential. CONCLUSION: A reframing of respite care as an empathic response within a new palliative care approach is proposed. Within this, the centrality of the relationship is reinforced.

Lay health advisers: scoping the role and intervention landscape.

The use of lay health advisers has become an established approach within public health, in particular for impact on health inequalities and engaging socially excluded groups. Evidence on how differences in terms of the multiple role dimensions impact the outcomes of programs is limited. This creates ambiguity for decision makers on which roles should be implemented in different contexts for different needs. This paper applies realist logic to an inquiry to explore the mechanisms that may operate in lay-led intervention models and understand how, why, and in what respect these lead to particular outcomes. It draws on a project focusing on health-related lifestyle advisers and further insights gained from a subsequent related project about outreach with traveler communities. Analysis highlights multiple and potentially interacting aspects of lay health-adviser roles that may influence their success, including characteristics of lay health advisers, characteristics of target populations, purpose or intent of interventions, and how advice is given. A model is proposed from which to examine the contexts and mechanisms of lay health advisers that may impact outcomes, and is subsequently applied to two examples of reported lay health-adviser interventions. The combination of skills and characteristics of lay health advisers must be considered when planning which interventions might be appropriate when targeting specific needs or target populations. Focus only on the peer/layperson distinction may overlook other potentially important skills and mechanisms of action integral to lay health-adviser roles.

Care planning for long-term conditions ­ a concept mapping.

OBJECTIVE: This article focuses on approaches within clinical practice that seek to actively involve patients with long-term conditions (LTCs) and how professionals may understand and implement them. Personalized care planning is one such approach, but its current lack of conceptual clarity might have impeded its widespread implementation to date. A variety of overlapping concepts coexist in the literature, which have the potential to impair both clinical and research agendas. The aim of this article is therefore to explore the meaning of the concept of care planning in relation to other overlapping concepts and how this translates into clinical practice implementation. METHODS: Searches were conducted in the Cochrane database for systematic reviews, CINHAL and MEDLINE. A staged approach to conducting the concept mapping was undertaken, by (i) an examination of the literature on care planning in LTCs; (ii) identification of related terms; (iii) locating reviews of those terms. Retrieved articles were subjected to a content analysis, which formed the basis of our concept maps. (iv) We then appraised these against knowledge and experience of the implementation of care planning in clinical practice. RESULTS AND CONCLUSIONS: Thirteen articles were retrieved, in which the core importance of patient-centredness, shared decision making and self-management was highlighted. Literature searches on these terms retrieved a further 24 articles. Our concept mapping exercise shows that whilst there are common themes across the concepts, the differences between them reflect the context and intended outcomes within clinical practice. We argue that this clarification exercise will allow for further development of both research and clinical implementation agendas.

Cost-effectiveness of health-related lifestyle advice delivered by peer or lay advisors: synthesis of evidence from a systematic review.

BACKGROUND: Development of new peer or lay health-related lifestyle advisor (HRLA) roles is one response to the need to enhance public engagement in, and improve cost-effectiveness of, health improvement interventions. This article synthesises evidence on the cost-effectiveness of HRLA interventions aimed at adults in developed countries, derived from the first systematic review of the effectiveness, cost-effectiveness, equity and acceptability of different types of HRLA role. METHODS: The best available evidence on the cost-effectiveness of HRLA interventions was obtained using systematic searches of 20 electronic databases and key journals, as well as searches of the grey literature and the internet. Interventions were classified according to the primary health behaviour targeted and intervention costs were estimated where necessary. Lifetime health gains were estimated (in quality-adjusted life years, where possible), based on evidence of effectiveness of HRLAs in combination with published estimates of the lifetime health gains resulting from lifestyle changes, and assumptions over relapse. Incremental cost-effectiveness ratios are reported. RESULTS: Evidence of the cost-effectiveness of HRLAs was identified from 24 trials included in the systematic review. The interventions were grouped into eight areas. We found little evidence of effectiveness of HRLAs for promotion of exercise/improved diets. Where HRLAs were effective cost-effectiveness varied considerably: Incremental Cost effectiveness Ratios were estimated at £6,000 for smoking cessation; £14,000 for a telephone based type 2 diabetes management; and £250,000 or greater for promotion of mammography attendance and for HIV prevention amongst drug users. We lacked sufficient evidence to estimate ICERs for breastfeeding promotion and mental health promotion, or to assess the impact of HRLAs on health inequalities. CONCLUSIONS: Overall, there is limited evidence suggesting that HRLAs are cost-effective in terms of changing health-related knowledge, behaviours or health outcomes. The evidence that does exist indicates that HRLAs are only cost-effective when they target behaviours likely to have a large impact on overall health-related quality of life. Further development of HRLA interventions needs to target specific population health needs where potential exists for significant improvement, and include rigorous evaluation to ensure that HRLAs provide sufficient value for money.

'Viewing in slow motion': patients', families', nurses' and doctors' perspectives on end-of-life care in critical care.

AIMS AND OBJECTIVES: To explore the meaning of end-of-life care for critically ill cancer patients, families, oncologists, palliative care specialists, critical care consultants and nurses. BACKGROUND: End-of-life care for critically ill patients, of whom nearly 20% will die in critical care, remains somewhat problematic (Truog et al. 2008). End-of-life care is an established domain in cancer; however, research has not been conducted previously into dying, critically ill cancer patients' experiences. DESIGN: Qualitative, phenomenological in-depth interviews were undertaken. METHODS: Phenomenology was used to explore experiences of 27 participants: surviving patients at high risk of dying, bereaved families, oncologists, palliative and critical care consultants, and nurses. Purposive sampling from a UK critical care unit was carried out. In-depth interviews were taped analysed using Van Manen's phenomenological analysis framework. RESULTS: A phenomenological interpretation of dying in cancer critical illness, and the impact on opportunities for end-of-life care, is presented. Three main themes included: dual prognostication; the meaning of decision-making; and care practices at end of life: choreographing a good death. End-of-life care was an emotive experience for all participants; core tenets for good end-of-life care included comfort, less visible technology, privacy and dignity. These findings are discussed in relation to end-of-life care, cancer and critical illness. CONCLUSION: The speed of progressing towards dying in critical illness is often unknown and subsequently affects potential for end-of-life care. Caring was not unique to nurses and end-of-life care in critical care came with considerable emotional cost. RELEVANCE TO CLINICAL PRACTICE: There is an opportunity for nurses to use the care of patients dying in critical care to develop specialist knowledge and lead in care, but it requires mastery and reconciliation of both technology and end-of-life care. Healthcare professionals can help facilitate acceptance for families and patients, particularly regarding involvement in decisions and ensuring patient advocacy.

The manager's role in mobilizing and nurturing development: entrenched and engaged approaches to change.

AIMS: Drawing on findings from the evaluation of a Health Action Zone (HAZ), this paper explores the manager's role in promoting and nurturing learning. BACKGROUND: Initiating practice development is a core function of the manager's role. Learning must be nurtured to reach beyond individual to organizational learning and address knowledge exchange as well as creation. In the United Kingdom, HAZs were established to reduce health inequalities. They embraced a variety of service delivery approaches, all with an emphasis on developing new ways of working and innovation. METHODS: Qualitative interviews of the HAZ coordinators, performance manager and staff delivering services. RESULTS: Two alternative ways of engagement and entrenchment to practice were identified to developing new ways of working and learning from experience. CONCLUSIONS: Development of sustainable and enduring structures which facilitate learning at both individual and organizational levels are key to utilization of knowledge and accumulation of learning. IMPLICATIONS FOR NURSING MANAGEMENT: When entrenched and engaged experiential learning in practice are pursued, the role of the manager as a catalyst needs to be highlighted. A tool is proposed to facilitate reflection and promote action plan development. This tool has potential general application, but our experience is that it makes a specific contribution to public health and primary care.

The supervision of professional doctorates: experiences of the processes and ways forward.

The doctoral research terrain is changing, as new-styles, for example professional doctorates, are being developed (Park, C., 2005. New variant PhDL the changing nature of the doctorate in the UK. Journal of Higher Education Policy and Management 27(2), 189-207). There is a scarcity of literature aimed at supervisors (Gatfield, T., 2005, An investigation into PhD supervisory management styles: development of a dynamic conceptual model and its managerial implications. Journal of Higher Education Policy and Management 27(3), 311-325) and this is particularly so in relation to professional doctorates. In this position paper we argue that the supervisory approach required for a professional doctorate student is different than that required for a PhD. Professional doctorate students, like PhD students, are required to make an explicit contribution to knowledge. Their emphasis, however, needs to be in producing knowledge that is theoretically sound, original, and of relevance to their practice area. This is of increasing importance within healthcare with the growing emphasis on patient driven translational research. As such, the students and their supervisors face unique challenges of balancing academic requirements with praxis. We suggest this requires specific tools to make explicit the dialogical relationship between a particular project and the cultural, social, educational and political aspects of its environment. We expose the potential of soft systems methodology as a means to highlight the emergent aspects of a doctoral practice development project, their respective and evolving supervisory interactions. This focus of this paper is therefore not about guiding supervision in a managerial sense, but rather at offering methodological suggestions that could underpin applied research at doctoral level.

Leadership for health improvement--implementation and evaluation.

PURPOSE: The purpose of this paper is to present a co-authored reflection on the health improvement leadership development programme and the key evaluation messages derived from piloting in an English National Health Service region. It highlights the specific attributes of this approach to health improvement leadership development and clarifies health improvement development issues. DESIGN/METHODOLOGY/APPROACH: Appreciative inquiry and soft systems methodology are combined in an evaluation approach designed to capture individual as well as organisation learning and how it impacts on leadership in specific contexts. FINDINGS: The evaluation exposes the health improvement leadership needs of a multi-organisation cohort, offers some explanations for successful achievement of learning needs while also exposing of the challenges and paradoxes faced in this endeavour. ORIGINALITY/VALUE: There are limited reported templates of how to develop leadership for health improvement. This paper details a whole systems approach, acknowledging the impact of context on leadership and an approach to evaluating such complex initiatives.

The potential contribution of realistic evaluation to small-scale community interventions.

This paper aims to inform the development and evaluation of small-scale community-based initiatives by describing an evaluation of one such health promotion programme. Realistic evaluation is an under-explored resource for practice development, particularly within the context of informing evidence-based practice. A combination of the context-mechanism-outcome framework and principles of health impact assessment were used in the evaluation of the programme. Telephone interviews and half-day sessions were utilised in order to conduct reviews of the programme's work with both providers and users. This approach engaged the practitioners in the process of evaluation in a way that was novel to them, and introduced the possibility of a stepped approach to outcomes achievement and measurement. The evaluation gave the practitioners the means to understand and effectively formulate which outcomes were most appropriate to their particular intervention, and to design the means to assess these in future.

Transferring palliative care knowledge: evaluating the use of a telephone advice line.

Accessing specialist palliative expertise, particularly out of hours, is an important, but often problematic aspect of meeting directives to provide comprehensive around-the-clock care. A telephone advice line can be a successful route to transferring palliative care knowledge between specialists and generalists. In contrast to telephone expert systems, which demand standardization, this type of expert system emphasises the use of professional judgement. Based on a three-year evaluation, this article highlights that assessing and advising professionals about the use of a telephone as a communication mechanism demands specific communication skills and processes which need to be developed and nurtured. Another important feature to acknowledge is that the predominate aim of a telephone advice line may most appropriately be to transfer knowledge on a case-by-case basis to contribute to the resolution of a clinical need.

Roles, relationships, perils and values: development of a pathway between practice development and evaluation research.

BACKGROUND: Recent changes in primary care are encapsulated in a drive for enhanced quality, efficiency and effectiveness of care. A key element of the quality agenda is innovation and evaluation. This paper presents a case study of the processes involved in evaluating practice development in primary care, where commissioned research is concomitant to a service development that also integrated its own evaluation. There was an assumption that an 'outside' evaluation would be complementary to the concurrent 'inside' evaluation. However, there is a paucity of literature that overtly discusses or analyses the specific challenges. AIMS: To surface the tensions involved in combining internal and external evaluation, to allow development of a better understanding of the roles, relationships, perils and value of this approach to maintaining and enhancing quality in primary care. DESIGN: A case study presentation of reflexive analysis of inside and outside evaluator experiences of the evaluation of a practice development. RESULTS: We argue that despite recent methodological developments in practice, methodological, methodical, interpretive and political tensions persist between practice development and evaluation. The key problems fuelling the dissonance experienced by both practitioners and researchers appears to be around the co-existence of differing understandings of the evaluation scope and process among stakeholders. This has the potential to jeopardise the coherence of the concurrent external evaluation of a practice development initiative. A pathway enabling the explicit integration of the views of researchers, service developers, commissioners and ethics and research governance boards is presented. CONCLUSION: This article exposes often underlying and unrecognised areas of consonance and dissonance between the views of researchers and practice developers in a context of concurrent practical and academic evaluations. In some cases there is potential to progress from dissonance to consonance. In others, the differing worlds and agendas mean that dissonance will remain, but its existence needs to be acknowledged and worked with, rather than ignored.

The evaluation of an end-of-life integrated care pathway.

AIM: this evaluation set out to examine the needs of staff as they adopted an end-of-life integrated Care Pathway (ICP), and its impact on both service users and providers. METHOD: semi-structured interviews were conducted with palliative care specialists, other health care professionals and bereaved carers. RESULTS: the challenges encountered revolved around the multitude of settings, and professionals involved; around the diagnosing of dying; communication with patients and the provision of emotional or spiritual support. Ongoing challenges at the end of the evaluation were those of addressing spirituality and some of the established practices. However, there was general consensus that the ICP facilitated greater consistency of care, improved continuity, and ensured a proactive rather than a reactive approach to care. All these were recognised and appreciated by bereaved carers. CONCLUSION: end of life is now every health care professional's business and this may have the potential to raise the place of palliative care in general on the professional agenda.

Refocusing health visiting -- sharpening the vision and facilitating the process.

AIM: The purpose of this study was to explore the development of public health nursing in a primary care trust that focused around the evaluation of a newly introduced public health nursing role. The intention was to inform role development during the three year evaluation period. BACKGROUND: Despite health visitors having been identified in the recent past as being in prime position to assume the public health role envisioned by the British Government in the New NHS, the vision for the 'new look' health visitor has been rather blurred. METHODS: An action research approach utilised 22 individual and four group (number of participants 33) interviews with a range of stakeholders. Thematic analysis was used on all transcripts. FINDINGS: Four main headings were identified to organise and present the findings -- definitions of public health; continuum of practice; contextual factors in public health development; and inhibitors to public health practice development. The findings suggest that there are a number of factors challenging the health visiting response to the public health agenda. Facilitating clarity of role and purpose must be a management priority. A tool, developed from this study, offers a means to explore practice within a primary care -- public health continuum and provides a schema against which to set and action practice development.

Knowing nursing - The challenge of articulating knowing in practice.

Learning and teaching in the clinical environment is complex and challenging. Development of the ability to articulate knowing in practice is essential to allow exploration of the richness and complexity of this type of nursing knowledge. This paper describes an innovative approach developed in collaboration with practitioners to assist in revealing hitherto hidden aspects of knowing nursing. The interpretive paradigm provides one means of voicing nursing knowledge, specifically by accessing the lived-experience of nursing. The approach is qualitatively different to reflection and critical incident as it focuses on the taken-for-granted rather than being problem based or problem solving. Hermeneutic phenomenology and constructivism are combined in an innovative model that allows experience to be captured and meaning to be explored, thereby providing a means to articulate knowing in practice. Practitioners involved in operationalising this model considered that it allowed them to articulate a level of practice knowledge which they had previously experienced difficulty in accessing. This approach to knowledge articulation may therefore be useful in assisting to widen the horizon of nursing knowledge.

A framework for understanding clinical reasoning in community nursing.

BACKGROUND: Clinical reasoning is employed to develop solutions to health needs. The impact of the clinical environment on the organization of knowledge-guiding practice has received limited attention. This gap in the clinical landscape restricts the sharing of decision-making processes. AIMS: Focusing on the community, and specifically the patient's home as a context for nursing, this paper describes the creation of a collective conceptual map for a group of community nurses. There is a twofold aim of exploring the process of exposing and articulating the clinical framework and enhancing and sharing understanding of the clinical paradigm in this context. DESIGN: An interpretive research approach was utilized. Hermeneutic phenomenology guided the level of meaning accessed and constructivism was used to build an educational picture. METHODS: Multiple methods including focus groups, observation and narrative recordings were utilized to collect and analyse research data. RESULTS: All nurses may engage with the same concepts--health, need, care and partnerships--but organized into particular frames by the guiding practice philosophy and service organization. A four-stage framework for understanding clinical reasoning in the community setting is presented. This acknowledges the multi-faceted nature of health, the lived experience of health deficits, and is located in a participation and negotiated model of care. Practice examples are presented to expose the construction of need and response which often occurs in a triadic decision-making process. CONCLUSIONS: Environment of care has significant implications on need identification and response. RELEVANCE TO CLINICAL PRACTICE: Mechanisms to enhance the sharing of clinical reasoning and decision-making transparency are essential to aid inter- and intra-professional communication. Presentation of a clinical reasoning framework exposes the breath of 'signals' encountered in practice and the range of knowledge employed in understanding and responding to patient need.