Developing modern primary care nursing in North Macedonia.

BACKGROUND: Nurses have the potential to make a real impact on the health and well-being of people and populations and contribute to the realisation of delivery of Universal Health Coverage. However, in many parts of the world, the education and practice of nursing and nurses' position in health care and society are restricted by a range of social, cultural, economic and political factors. In North Macedonia, the Ministry of Health in partnership with the WHO Country Office launched a primary healthcare strategy supporting the development of nurses in primary care to fulfil their full scope of service. AIMS: To present information on the education, practice and position of nursing, in particular primary care nursing, in North Macedonia and to describe the ongoing initiatives to support the further development of nursing. APPROACH: Background documents reviewed, and visits to healthcare settings, organisations, interviews with individuals and groups and workshops undertaken in 2019-2020. FINDINGS: Three key areas of development were identified: education of nurses, their service delivery and practice in primary care, and their position in health care and society, all underpinned by the need for workforce planning. The findings formed the basis of a 10-year plan: Making Change Happen: The Nursing and Midwifery Development Roadmap. DEVELOPMENTS: To support the proposed primary care pilots, during the 2020/2021 COVID-19 pandemic, an on-line modular programme for primary care nurses was developed and delivered with the support of members drawn from The National Working Group for Moving Primary Care Nursing Forward in North Macedonia. Further work is planned to develop initial nurse education and to pilot changes in primary care. CONCLUSIONS: The launch of the primary healthcare strategy stimulated initiatives to improve the education, position and practice of primary care nursing. The COVID-19 pandemic required flexibility and changes to the original plans.

Nurse-led projects for people experiencing homelessness and other inclusion health groups: a realist evaluation.

Nursing service development or innovation projects, even small-scale ones, can be difficult to deliver and evaluate, due to a lack of resources and support. Results can also be difficult to disseminate, limiting transfer of learning. This paper presents findings from a realist evaluation of 10 small projects supported by the Queen's Nursing Institute Homeless and Inclusion Health Programme to deliver innovation in health care for people experiencing homelessness and other marginalised groups. These nurse-led projects were funded by the Queen's Nursing Institute and the Oak Foundation, and were largely successful in achieving outcomes to support the improved health of people experiencing homelessness and other marginalised groups. This realist evaluation explores the factors that contributed to the delivery of positive outcomes. All were impacted by the context and the response (mechanisms) of people experiencing homelessness and staff within these settings. It is hoped that the lessons learned will enable better support for nurse innovation projects in the future.

Women's views of continuity of information provided during and after pregnancy: A qualitative interview study.

Straightforward transfer of care from pregnancy to the postpartum period is associated with health benefits and is desired by women worldwide. Underpinning this transfer of care is the sharing of information between healthcare professionals and the provision of consistent information to women. In this qualitative study, two aspects of continuity of information were examined; first the information passed on from midwife to health visitor regarding a woman and her baby before the health visitor meets the woman postnatally and second, the consistency of information received by women from these two healthcare professionals (the main healthcare providers during and after pregnancy in England). To be eligible for the study, women had to have had a baby in England within 12 months prior to the interview. Participants also needed to be able to read and speak English and be over 18 years old. Recruitment of participants was via word of mouth and social media. Twenty-nine mothers were interviewed of whom 19 were first time mothers. The interviews took place in the summer and autumn of 2016 and were transcribed verbatim and analysed using Framework Analysis. Two overarching themes were identified: not feeling listened to and information inconsistencies. Women reported little experience of midwives and health visitors sharing information about their care, forcing women to repeat information. This made women feel not listened to and participants recommended that healthcare professionals share information; prioritising information about labour, mental health, and chronic conditions. Women had mixed experiences regarding receiving information from midwives and health visitors, with examples of both consistent and inconsistent information received. To avoid inconsistent information, joint appointments were recommended. Findings from this study clearly suggest that better communication pathways need to be developed and effectively implemented for midwives and health visitors to improve the care that they provide to women.

A focus group study of women's views and experiences of maternity care as delivered collaboratively by midwives and health visitors in England.

BACKGROUND: Research suggests that collaboratively delivered maternity care can positively impact health outcomes. However, women's perspectives on models of care involving interprofessional collaboration between midwives and health visitors are not well understood. Accounts of women's maternity care experiences are key to improving maternity services. This study considered women's views and experiences of maternity care as collaboratively provided by midwives and health visitors in England. METHODS: A qualitative focus group study with an exercise exploring women's ideal maternity care pathway was conducted. Three focus groups were conducted in London, England between June and August 2017 with women who had had a child within 18 months prior to the study. The participants (n = 12) were recruited from two Children's Centres in London, England. Data were analysed using thematic analysis. RESULTS: Four themes were identified: 'Women's experiences of maternity care from midwives and health visitors', 'Midwife-health visitor communication', 'Midwife-health visitor collaboration for tailored care', and 'Women's ideal maternity care pathway'. Regarding women's experiences of interprofessional collaboration between midwives and health visitors, this was rarely encountered, but welcomed by women. Women's observations of limited tailored care and co-ordination led to several suggestions to improve maternity care, including secure, shared medical recordkeeping systems, clarity on midwives' and health visitors' roles, as well as increased communication. CONCLUSIONS: Maternity care that is collaboratively delivered by midwives and health visitors, from the perspectives of the women in this study, is not routinely provided. However, women recognise the potential benefits of midwife-health visitor collaboration. Future research should explore service configurations that support integrated maternity care pathways, and evaluate the impact of midwife-health visitor collaboration on health and service outcomes.

Maximising influenza vaccination awareness and uptake among older adults in Singapore.

Adults ≥65 are more susceptible to influenza infection and its associated complications. This paper critically reviews the literature, identifying the need for and priorities of a public health strategy to improve vaccination awareness and uptake among older adults. Four electronic databases were searched for peer-reviewed articles in English published between 2001 and 2016. Twelve studies were included. Three themes were identified on analysis: impact on healthcare services; barriers and motivators influencing influenza vaccination uptake; and health promotion interventions. Studies suggest vaccination may reduce the health-care costs of influenza-associated infection. Socioeconomic factors, information about vaccination and cultural beliefs may influence an individual's decision. Multicomponent interventions, such as home visits combined with reminders, support increased uptake. Interventions are identified that could be adopted at the community level in Singapore and other countries to improve influenza vaccination uptake among older adults.

Maximising influenza vaccination awareness and uptake among older adults in Singapore.

Adults ≥65 are more susceptible to influenza infection and its associated complications. This paper critically reviews the literature, identifying the need for and priorities of a public health strategy to improve vaccination awareness and uptake among older adults. Four electronic databases were searched for peer-reviewed articles in English published between 2001 and 2016. Twelve studies were included. Three themes were identified on analysis: impact on healthcare services; barriers and motivators influencing influenza vaccination uptake; and health promotion interventions. Studies suggest vaccination may reduce the health-care costs of influenza-associated infection. Socioeconomic factors, information about vaccination and cultural beliefs may influence an individual's decision. Multicomponent interventions, such as home visits combined with reminders, support increased uptake. Interventions are identified that could be adopted at the community level in Singapore and other countries to improve influenza vaccination uptake among older adults.

Midwives' and health visitors' collaborative relationships: A systematic review of qualitative and quantitative studies.

OBJECTIVES: Interprofessional collaboration between midwives and health visitors working in maternal and child health services is widely encouraged. This systematic review aimed to identify existing and potential areas for collaboration between midwives and health visitors; explore the methods through which collaboration is and can be achieved; assess the effectiveness of this relationship between these groups, and ascertain whether the identified examples of collaboration are in line with clinical guidelines and policy. DESIGN: A narrative synthesis of qualitative and quantitative studies. DATA SOURCES: Fourteen electronic databases, research mailing lists, recommendations from key authors and reference lists and citations of included papers. REVIEW METHODS: Papers were included if they explored one or a combination of: the areas of practice in which midwives and health visitors worked collaboratively; the methods that midwives and health visitors employed when communicating and collaborating with each other; the effectiveness of collaboration between midwives and health visitors; and whether collaborative practice between midwives and health visitors meet clinical guidelines. Papers were assessed for study quality. RESULTS: Eighteen papers (sixteen studies) met the inclusion criteria. The studies found that midwives and health visitors reported valuing interprofessional collaboration, however this was rare in practice. Findings show that collaboration could be useful across the service continuum, from antenatal care, transition of care/handover, to postnatal care. Evidence for the effectiveness of collaboration between these two groups was equivocal and based on self-reported data. In relation, multiple enablers and barriers to collaboration were identified. Communication was reportedly key to interprofessional collaboration. CONCLUSIONS: Interprofessional collaboration was valuable according to both midwives and health visitors, however, this was made challenging by several barriers such as poor communication, limited resources, and poor understanding of each other's role. Structural barriers such as physical distance also featured as a challenge to interprofessional collaboration. Although the findings are limited by variable methodological quality, these were consistent across time, geographical locations, and health settings, indicating transferability and reliability.

Empowering health visitors: a multi-faceted approach.

Health visitors working in Tower Hamlets, a deprived inner London borough, face a large and growing under-5 population, and caseloads with disproportionate numbers of vulnerable families and child protection concerns. This paper reports and evaluation of a project to empower health visitors. Baseline data about their activity (primarily derived from observation and interviews) showed that health visitors would benefit from improved resources (e.g. leaflets, books, training packs); enhanced knowledge of local borough and third sector services; and support for their own wellbeing and morale. After the programme that was implemented to provide these, seven health visitors were interviewed for evaluation purposes. They reported feeling empowered by the project: the training had been invaluable in providing affirmation, reassurance, and the opportunity to reflect; the new sleep information packs were very helpful for families, as was the new leaflet explaining their role; and restorative supervision had been useful in helping individuals think through how to deal with particular challenges in life or work. The project was thus successful in helping the health visitors interviewed to feel more supported and thus empowered in their work with families.

Using the delphi approach to identify priority areas for health visiting practice in an area of deprivation.

Families with children living in areas of high deprivation face multiple health and social challenges, and this high level of need has impacts on the work of health practitioners working in such areas. All families in the UK with children under five years have access to health visiting services, and health visitors have a key role in mitigating the effects of deprivation by addressing health needs through evidence based practice. This paper reports the first stage of a project in Tower Hamlets, London, an area of significant deprivation, which aims to develop an evidence-based toolkit to support health visitors in their practice with families. The first stage used a modified Delphi process to identify the priority health needs of families in the area between June and July 2012. The three-stage Delphi process involved 25 people: four health visitors, four other members of the health visiting service, and 17 representatives of other services working with families. A focus group event was followed by a second event where individuals completed a questionnaire ranking the 27 priorities identified in the first event. The consultation process concluded with participants completing a second questionnaire, by email, confirming or changing their prioritisation of the topics.

An evaluation of a self-management package for people with diabetes at risk of chronic kidney disease.

AIMS AND OBJECTIVES: The overall purpose was to develop, test and evaluate an educational package to help people with diabetes self-manage their risk of developing chronic kidney disease (CKD), one of the main complications of diabetes. BACKGROUND: Management of people in primary care who have both CKD and diabetes can be controlled by strict blood pressure (BP) and blood sugar control and advice on lifestyle changes, such as smoking cessation. However, there is little evidence to support the assertion that self-management can slow the rate of kidney disease progression. DESIGN: A mixed-method longitudinal study. Development of the self-management package was informed by the findings of a case study in six GP Practices and also through interviews with 15 patients. METHODS: Testing of the self-management package was undertaken in the same six Practices, with one additional control Practice. Patients with Type 1 or Type 2 diabetes at risk of kidney disease were included. Outcomes in patients in the participating surgeries who did receive a pack (n = 116) were compared with patients in the control group (n = 60) over 6 time points. RESULTS: At the end of the study (time point 6), the intervention group had a mean systolic BP of 4.1 mmHg lower and mean diastolic BP of 2.7 mmHg lower than in the control group. CONCLUSION: Self-management techniques such as understanding of, and subsequent concordance with, prescribed BP medication may contribute to a reduction in BP, which in turn will reduce cardiovascular risk. RELEVANCE TO CLINICAL PRACTICE: This study contributes to the evidence base for self-management of early kidney disease. Although the exact reason for reduced BP in the intervention group is unclear, the importance of practitioner understanding of kidney disease management and patient understanding of BP medication are likely to be the contributing factors.

Returning to health visiting practice: completing the circle.

One strategic health authority, NHS London, initiated a pilot return to health visiting/nursing practice scheme in London in 2010. This paper reports on the experiences of the first three cohorts of returnees on the City University London programme, one of the London programmes, and the adaptations that have been made to the programme to help provide returnees with the theory base and practice experience to equip them to work in today's health visiting. Written evaluation forms were completed by the returnees and information gathered from their application forms. This information was supplemented for Cohort 1 with some interviews with practice teachers and lecturers and a mid-stage questionnaire to the returnees. Of the 54 students in the three cohorts over half were still on one or both Nursing and Midwifery Council registers, which had not been anticipated at the start of the programme and led to modifications to the programme after Cohort 1 with an increase in the health visiting specific content. The returnees had a wide range of experience to bring back to health visiting reflecting the fact that a large number had been out of health visiting for more than 11 years. The evaluation shows that providing support by the university to the practice placement areas; ensuring that the taught element is current and useful to health visiting practice and having a relevant but not too onerous assessment process are critical.

Service implications from a comparison of the evidence on the effectiveness and a survey of provision in England and Wales of COPD specialist nurse services in the community.

STUDY BACKGROUND: Chronic obstructive pulmonary disease (COPD) is the fifth leading cause of mortality worldwide and is a burden on healthcare resources. Therefore, implementing the right care model(s) for patients with COPD is a priority. Nurses, particularly those with specialist roles, are often the principal health professionals involved in new service models. NEW SERVICES: for patients in the community with COPD are increasing in many countries. Two main types of initiatives have been evaluated; those designed to transfer acute care out of hospital and into the community, and those offering chronic disease management. The extent and nature of such specialist services in the UK and internationally are unknown. OBJECTIVES: To present the results of the first survey of specialist nurse service provision for patients in the community with COPD in England and Wales. To combine the survey findings with systematic review evidence to explore to what extent provision is supported by evidence of effectiveness. METHODS: A postal survey of respiratory healthcare professionals undertaken concurrently with a review of the evidence of the effectiveness of nurse COPD services (review findings are reported fully elsewhere). RESULTS: Two hundred and thirty four specialist nurse services were identified; 71% involved chronic disease management, of which 47% also provided acute care. Seventeen per cent of services involved acute care only. The review identified evidence to support the provision of acute services but data on chronic disease management services are sparse and there is currently little evidence to support these services. Those interventions that have been evaluated to date differed from many of the services provided. CONCLUSIONS: This study identifies a considerable mismatch between existing evidence around effectiveness and services provision for patients with COPD. It clearly highlights the need for greater interaction between what happens in practice and research. This is an issue that has relevance across all healthcare practice, both nationally and internationally.