Developing person-centred practice in hip fracture care for older people.

AIM: To facilitate a multidisciplinary collaborative approach to developing person-centred practice in hip fracture care for older people. METHOD: Collaborative inquiry, a form of action research, was used to collect data for this study. It involved exploration of dilemmas, questions and problems that are part of human experience. Clinical leaders from different disciplines (n=16), who work with older people with hip fractures at different stages of the care pathway, participated in a series of facilitated action meetings. The practice development techniques used in this study included: identifying the strengths and limitations of the current service, values clarification, creating a shared vision, sharing clinical stories, reviewing case records, and reflecting on the experiences of three older people and two caregivers. FINDINGS: Hip fracture care was based on meeting service targets, national guidelines and audits. Care was fragmented across different service delivery units, with professional groups working independently. This resulted in suboptimal communication between members of the multidisciplinary group of clinical leaders and care that was process-driven rather than person-centred. Spending time away from clinical practice enabled the multidisciplinary group to collaborate to understand care from the patients' and caregivers' perspectives, and to reflect critically on the care experience as a whole. CONCLUSION: To develop a person-centred workplace culture, the multidisciplinary team requires facilitated time for reflection. Ongoing facilitative leadership would enable the multidisciplinary team to collaborate effectively to deliver safe, effective person-centred practice in hip fracture care for older people.

Nasogastric feeding for stroke patients: practice and education.

BACKGROUND AND AIMS: Dysphagia is common after stroke, so feeding through a nasogastric (NG) tube may be necessary. These tubes are frequently dislodged, causing interruption to feeding and hydration, and potential aspiration of feed or fluids into the lungs. Interventions to prevent this may include taping tubes to the face; the application of hand mittens or bandaging patients' hands; inserting the NG tube into the nostril on the stroke-affected side; and nasal bridles. The aims of this survey were to investigate the management of NG feeding for stroke patients, including current tube confirmation and securing techniques, and associated nurse education. This was part of a three-phased sequential mixed-methods study. This paper reports on the second quantitative phase. METHODS: A quantitative postal survey, based on initial qualitative findings, was sent to registered nurses (n=528) from the National Stroke Nurses Forum and Scottish Stroke Nurses Forum, in addition to registered nurses working on stroke units within the local health board. RESULTS: The overall response rate was 59% (n=314/528). Tape was the most commonly used method for securing tube position, followed by inserting the tube on the stroke-affected side. Hand mittens were used more frequently than the nasal bridle; bandaging hands was reported once. Taping was considered to be more acceptable and safer than hand mittens or the nasal bridle, but less effective. Training in inserting NG feeding tubes was received by 56% (n=176/314). Methods used for confirming tube position included aspiration and X-ray. Provision of training in confirmation techniques varied. CONCLUSIONS: This study shows that the management of NG feeding for dysphagic stroke patients requires standardisation, as does the education for nurses to ensure that this intervention is carried out safely, effectively and acceptably.

Improving the experience of hip fracture care: A multidisciplinary collaborative approach to implementing evidence-based, person-centred practice.

BACKGROUND: Hip fracture care is well supported by national guidelines and audit that provide evidence of safe interventions and an improved process. In the drive for organisational efficiency, complications have been reduced and length of stay shortened. Prioritising targets and performance alone can lead to poor multidisciplinary communication that potentially omits the psychosocial needs of older people recovering from hip fracture. AIM: To explore a multidisciplinary collaborative approach to implementing evidence-based, person-centred hip fracture care. DESIGN: Collaborative inquiry. METHODS: Sixteen clinical leaders (n = 16) from different disciplines, working with older people with hip fracture at different stages of the care pathway participated in eight two-hourly facilitated action meetings. Data collection included strengths and limitations of the present service, values clarification, clinical stories, review of case records and reflections on the stories of three older people and two carers. RESULTS: Hip fracture care was driven by service pressures, guidelines and audits. The care journey was divided into service delivery units. Professional groups worked independently resulting in poor communication. Time away from practice enabled collaboration and the sharing of different perspectives. CONCLUSIONS: Working together improved communication and enhanced understanding of the whole care experience. IMPLICATIONS FOR PRACTICE: Enabling teams to find evidence of safe, effective person-centred cultures requires facilitated time for reflective practice.

The formal support experiences of mothers of adolescents with intellectual disabilities in Edinburgh, UK: a longitudinal qualitative design.

BACKGROUND: In the United Kingdom, healthcare provision for children with intellectual disabilities (ID) has shifted away from institutions to the community. Today, family members most often assume the primary caregiver role and look after care recipients in the home. The support needs of caregivers, therefore, represent an important area of research that should help caregivers enhance their quality of life. PURPOSE: The aim of this study was to understand the received formal support perceptions of mothers of ID adolescents over time. METHODS: This study used a longitudinal qualitative method in three phases. Semistructured interviews were conducted with seven mothers at three points in time (initial, at 6 months, and at 18 months). Constant comparative analysis was conducted on transcribed interviews. RESULTS: The three themes that emerged from research included (1) the process of complex emotions, (2) the perception of received support, and (3) the process of fighting reactions. Mothers expressed different levels of satisfaction and dissatisfaction with the range of support received. Respite care was, overall, a beneficial intervention for participants. However, some mothers felt health professionals to be insensitive, showing lack of understanding and empathy, diminished personhood, and perceived lack of respect for the human value of their children with ID. The "fighting process" experienced when applying for financial help from the social welfare system was also pointed out as stressful. Further exploration of the professional support needs of mothers is important to support effectively their effective caregiving role. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Professionals should increase their awareness of caregiver sensitivities and be respectful of individual responses by providing empathy and understanding from the caregivers' point of view.

The attitudes of student and registered nurses to sleep promotion in hospitals.

This study explored the attitudes of student and registered nurses regarding sleep promotion in hospitals. Qualitative data were obtained using semistructured interviews with volunteer samples and subsequently transcribed and analysed. The findings showed that the study participants held generally positive attitudes to sleep as a curative and beneficial medium. However, for many there were clear blocks to their practice, including the attitudes of others, the ward culture and routine orientation of care, resulting in sleep promotion having a low priority. The implications of the findings include the need to foster staff awareness and practice of this element of care, particularly through managers who have to take responsibility for encouraging a positive ethos towards sleep promotion.

The knowledge and educational experiences of student nurses regarding sleep promotion in hospitals.

AIM: This study explored the knowledge and educational experiences of student nurses regarding sleep and its promotion in hospitals. BACKGROUND: Nurses have a key role to play in sleep promotion, with the knowledge of sleep an important component of skilled patient care. From a review of the literature, minimal research was found on what student nurses know, or how they learn about, sleep and its promotion. METHODS: A mixed method approach was used. 1. Questionnaires were completed by student volunteers in the last six months of their nursing programme(n = 120) from four Higher Education Institutions.2. Semi-structured interviews were carried out with a sample of the students (n = 26). RESULTS: The students lacked a complete knowledge about basic sleep physiology. Their knowledge of sleep disruption and sleep promoting factors was more evident, although this was generally not based on empirical evidence. The students viewed knowledge of sleep and its promotion positively, but reported that their educational programmes did not prepare them in this respect. The students felt that they had learnt most about sleep promotion through clinical experience, from staff, patients and their own life experiences, though this learning was unstructured. CONCLUSIONS: These findings highlight the need to address the acquisition of knowledge and skills for the promotion of sleep in a structured learning framework in pre-registration nursing programmes. Academic and clinical staff need to be proactive in this respect.

Devising and evaluating a model for teaching therapeutic handling and moving skills to complementary therapists.

This two phase, mixed methods study, developed and evaluated the effectiveness of a model for teaching the neuromuscular approach (NMA) to human movement. From an original volunteer sample of 74 students, 33 completed the 15-week (Phase 1) moving and handling training which demonstrated that the model resulted in significant change (p<0.05) in movement patterns and detection of potentially hazardous postures. Phase 2, using 24 students, showed that the model worked successfully (95% positive evaluation) in the context of a Complementary Therapies degree programme.

Randomized comparison of dry dressings versus hydrogel in management of radiation-induced moist desquamation.

PURPOSE: We present the results of a randomized controlled clinical trial that evaluated the effect of a hydrogel or dry dressing on the time to healing of moist desquamation after radiotherapy to the head-and-neck, breast, or anorectal areas. METHODS AND MATERIALS: A total of 357 patients were randomized before radiotherapy to receive simple dry dressings (Tricotex) or a hydrogel (Intrasite), with Tricotex as a secondary dressing. Patients were instructed to use their dressings from the onset of moist desquamation, if it occurred. RESULTS: Of the 357 patients, 100 (28%) developed moist desquamation. The time to healing was significantly prolonged (hazard ratio, 0.64; 95% confidence interval, 0.42-0.99), in patients assigned to gel dressings. No evidence was found that gel dressings had a significant impact on subjectively reported skin symptoms. CONCLUSION: The results of this study have not supported the routine use of hydrogels in the care of patients with moist desquamation and suggests that the healing times are prolonged, without any improvement in patient comfort.

Does aqueous or sucralfate cream affect the severity of erythematous radiation skin reactions? A randomised controlled trial.

BACKGROUND AND PURPOSE: Evidence on which to base decisions about the management of radiation skin reactions is lacking. The purpose of this study was to investigate whether sucralfate or aqueous cream reduced acute skin toxicity during radiotherapy to the head and neck, breast or anorectal area (phase A), and to evaluate the effect of hydrogels and dry dressings on moist desquamation (phase B). This paper presents the results of phase A. PATIENTS AND METHODS: Three hundred and fifty seven patients were randomised to apply aqueous cream, sucralfate cream or no cream to the irradiated area from day one of radical radiotherapy treatment. All patients were instructed to wash using unperfumed soap. Acute skin toxicity was measured using a modified radiation therapy oncology group (RTOG) score, reflectance spectrophotometry, patient diary card and dermatology life quality index (DLQI). A cost minimisation approach was used to compare the costs of each skin care approach. RESULTS: No consistent differences were found in the severity of skin reactions or levels of discomfort suffered by patients in each of the randomised groups. Patients with a higher body mass index, who smoked, received concomitant chemotherapy, boost or bolus during treatment were more likely to develop skin reactions. CONCLUSIONS: There is no evidence to support the prophylactic application of either of the creams tested for the prevention of radiation skin reactions. Our results show that it is possible to predict which patients are at greatest risk of skin reactions. We suggest that known risk factors should be incorporated into future study protocols.