Client and clinical staff perceptions of barriers to and enablers of the uptake and delivery of behavioural interventions for urinary incontinence: qualitative evidence synthesis.

AIM: To evaluate factors influencing uptake and delivery of behavioural interventions for urinary incontinence from the perspective of clients and clinical staff. BACKGROUND: Behavioural interventions are recommended as first-line therapy for the management of urinary incontinence. Barriers to and enablers of uptake and delivery of behavioural interventions have not been reviewed. DESIGN: Qualitative evidence synthesis. DATA SOURCES: MEDLINE, EMBASE, CINAHL, PsychInfo, AMED (inception to May 2013); Proceedings of the International Continence Society (ICS) (2006-2013). REVIEW METHODS: Studies where data were collected from clients or staff about their experiences or perceptions of behavioural interventions were included. Two reviewers independently screened records on title and abstract. Full-text papers were obtained for records identified as potentially relevant by either reviewer. Two reviewers independently filtered all full-text papers for inclusion, extracted findings and critically appraised studies. We used an approach akin to Framework, using a matrix of pre-specified themes to classify the data and facilitate its presentation and synthesis. RESULTS: Seven studies involving 200 participants identified clients' views. Findings identified from at least one study of moderate quality included increased fear of accidents and convenience of treatment. Factors enabling participation included realistic goals and gaining control. Six studies involving 427 participants identified staff views. Findings identified from at least one study of moderate quality included staff education and perceptions of treatment effectiveness. Enabling factors included teamwork and experience of success. CONCLUSION: There is little detailed exploration of clients' experiences of, and responses to, behavioural interventions. Evidence for staff relates predominantly to prompted voiding in long-term residential care. Studies of the uptake and delivery of other behavioural interventions in other settings are warranted.

Repetitive task training for improving functional ability after stroke.

BACKGROUND: Repetitive task training (RTT) involves the active practice of task-specific motor activities and is a component of current therapy approaches in stroke rehabilitation. OBJECTIVES: Primary objective: To determine if RTT improves upper limb function/reach and lower limb function/balance in adults after stroke. Secondary objectives: 1) To determine the effect of RTT on secondary outcome measures including activities of daily living, global motor function, quality of life/health status and adverse events. 2) To determine the factors that could influence primary and secondary outcome measures, including the effect of 'dose' of task practice; type of task (whole therapy, mixed or single task); timing of the intervention and type of intervention. SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register (4 March 2016); the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2016, Issue 5: 1 October 2006 to 24 June 2016); MEDLINE (1 October 2006 to 8 March 2016); Embase (1 October 2006 to 8 March 2016); CINAHL (2006 to 23 June 2016); AMED (2006 to 21 June 2016) and SPORTSDiscus (2006 to 21 June 2016). SELECTION CRITERIA: Randomised/quasi-randomised trials in adults after stroke, where the intervention was an active motor sequence performed repetitively within a single training session, aimed towards a clear functional goal. DATA COLLECTION AND ANALYSIS: Two review authors independently screened abstracts, extracted data and appraised trials. We determined the quality of evidence within each study and outcome group using the Cochrane 'Risk of bias' tool and GRADE (Grades of Recommendation, Assessment, Development and Evaluation) criteria. We did not assess follow-up outcome data using GRADE. We contacted trial authors for additional information. MAIN RESULTS: We included 33 trials with 36 intervention-control pairs and 1853 participants. The risk of bias present in many studies was unclear due to poor reporting; the evidence has therefore been rated 'moderate' or 'low' when using the GRADE system. There is low-quality evidence that RTT improves arm function (standardised mean difference (SMD) 0.25, 95% confidence interval (CI) 0.01 to 0.49; 11 studies, number of participants analysed = 749), hand function (SMD 0.25, 95% CI 0.00 to 0.51; eight studies, number of participants analysed = 619), and lower limb functional measures (SMD 0.29, 95% CI 0.10 to 0.48; five trials, number of participants analysed = 419). There is moderate-quality evidence that RTT improves walking distance (mean difference (MD) 34.80, 95% CI 18.19 to 51.41; nine studies, number of participants analysed = 610) and functional ambulation (SMD 0.35, 95% CI 0.04 to 0.66; eight studies, number of participants analysed = 525). We found significant differences between groups for both upper-limb (SMD 0.92, 95% CI 0.58 to 1.26; three studies, number of participants analysed = 153) and lower-limb (SMD 0.34, 95% CI 0.16 to 0.52; eight studies, number of participants analysed = 471) outcomes up to six months post treatment but not after six months. Effects were not modified by intervention type, dosage of task practice or time since stroke for upper or lower limb. There was insufficient evidence to be certain about the risk of adverse events. AUTHORS' CONCLUSIONS: There is low- to moderate-quality evidence that RTT improves upper and lower limb function; improvements were sustained up to six months post treatment. Further research should focus on the type and amount of training, including ways of measuring the number of repetitions actually performed by participants. The definition of RTT will need revisiting prior to further updates of this review in order to ensure it remains clinically meaningful and distinguishable from other interventions.

Implementing a Systematic Voiding Program for Patients With Urinary Incontinence After Stroke.

We explored health professionals' views of implementing a systematic voiding program (SVP) in a multi-site qualitative process evaluation in stroke services recruited to the intervention arms of a cluster randomized controlled feasibility trial during 2011-2013. We conducted semi-structured group or individual interviews with 38 purposively selected nursing, managerial, and care staff involved in delivering the SVP. Content analysis of transcripts used normalization process theory (NPT) as a pre-specified organization-level exploratory framework. Barriers to implementing the SVP included perceived lack of suitability for some patient groups, patient fear of extending hospital stay, and difficulties with SVP enactment, scheduling, timing, recording, and monitoring. Enablers included the guidance provided by the SVP, patient and relative involvement, extra staff, improved nursing skill and confidence, and experience of success. Three potential mechanisms of consistency, visibility, and individualization linked the SVP process with improvements in outcome, and should be emphasized in SVP implementation.

Identifying continence options after stroke (ICONS): a cluster randomised controlled feasibility trial.

BACKGROUND: Urinary incontinence (UI) affects half of patients hospitalised after stroke and is often poorly managed. Cochrane systematic reviews have shown some positive impact of conservative interventions (such as bladder training) in reducing UI, but their effectiveness has not been demonstrated with stroke patients. METHODS: We conducted a cluster randomised controlled feasibility trial of a systematic voiding programme (SVP) for the management of UI after stroke. Stroke services were randomised to receive SVP (n = 4), SVP plus supported implementation (SVP+, n = 4), or usual care (UC, n = 4).Feasibility outcomes were participant recruitment and retention. The main effectiveness outcome was presence or absence of UI at six and 12 weeks post-stroke. Additional effectiveness outcomes included were the effect of the intervention on different types of UI, continence status at discharge, UI severity, functional ability, quality of life, and death. RESULTS: It was possible to recruit patients (413; 164 SVP, 125 SVP+, and 124 UC) and participant retention was acceptable (85% and 88% at six and 12 weeks, respectively). There was no suggestion of a beneficial effect on the main outcome at six (SVP versus UC: odds ratio (OR) 0.94, 95% CI: 0.46 to 1.94; SVP+ versus UC: OR: 0.62, 95% CI: 0.28 to 1.37) or 12 weeks (SVP versus UC: OR: 1.02, 95% CI: 0.54 to 1.93; SVP+ versus UC: OR: 1.06, 95% CI: 0.54 to 2.09).No secondary outcomes showed a strong suggestion of clinically meaningful improvement in SVP and/or SVP+ arms relative to UC at six or 12 weeks. However, at 12 weeks both intervention arms had higher estimated odds of continence than UC for patients with urge incontinence. CONCLUSIONS: The trial has met feasibility outcomes of participant recruitment and retention. It was not powered to demonstrate effectiveness, but there is some evidence of a potential reduction in the odds of specific types of incontinence. A full trial should now be considered. TRIAL REGISTRATION: ISRCTN Registry, ISRCTN08609907, date of registration: 7 July 2010.

The challenges of implementing a telestroke network: a systematic review and case study.

BACKGROUND: The use of telemedicine in acute stroke care can facilitate rapid access to treatment, but the work required to embed any new technology into routine practice is often hidden, and can be challenging. We aimed to collate recommendations and resources to support telestroke implementation. METHODS: Systematic search of healthcare databases and the Internet to identify descriptions of the implementation of telestroke projects; interviews with key stakeholders during the development of one UK telestroke network. Supporting documentation from existing projects was analysed to construct a framework of implementation stages and tasks, and a toolkit of documents. Interviews and literature were analysed with other data sources using Normalisation Process Theory as described in the e-Health Implementation Toolkit. RESULTS: 61 telestroke projects were identified and contacted. Twenty projects provided documents, 13 with published research detailing four stages of telestroke system development, implementation, use, and evaluation. Interviewees identified four main challenges: engaging and maintaining the commitment of a wide range of stakeholders across multiple organisations; addressing clinicians perceptions of evidence, workload, and payback; managing clinical and technical workability across diverse settings; and monitoring how the system is used and reconfigured by users. CONCLUSIONS: Information to guide telestroke implementation is sparse, but available. By using multiple sources of data, sufficient information was collated to construct a web-based toolkit detailing implementation tasks, resources and challenges in the development of a telestroke system for assessment and thrombolysis delivery in acute care. The toolkit is freely available online.

Mental health advocacy and African and Caribbean men: good practice principles and organizational models for delivery.

BACKGROUND: Advocacy has a critical role to play in addressing concerns about access to appropriate mental health care and treatment for African and Caribbean men. AIM: To investigate good practice principles and organizational models for mental health advocacy provision for African and Caribbean men. STUDY DESIGN: The study consisted of: (i) A systematic literature review. Bibliographic and internet searching was undertaken from 1994 to 2006. The inclusion criteria related to mental health, advocacy provision for African and Caribbean men. (ii) Four focus groups with African and Caribbean men to explore needs for and experiences of mental health advocacy. (iii) An investigation into current advocacy provision through a survey of advocacy provision in England, Wales and Northern Ireland. (iv) Twenty-two qualitative stakeholder interviews to investigate the operation of mental health advocacy for this client group. The study was undertaken in partnership with two service user-led organizations and an African Caribbean mental health service. RESULTS: Primary research in this area is scant. Mainstream mental health advocacy services are often poor at providing appropriate services. Services developed by the Black Community and voluntary sector are grounded in different conceptualizations of advocacy and sharper understanding of the needs of African and Caribbean men. The lack of sustainable funding for these organizations is a major barrier to the development of high-quality advocacy for this group, reflecting a lack of understanding about their distinctive role. CONCLUSIONS: The commissioning and provision of mental health advocacy needs to recognize the distinct experiences of African and Caribbean men and develop capacity in the range of organizations to ensure equitable access.

Study protocol: ICONS: identifying continence options after stroke: a randomised trial.

BACKGROUND: Urinary incontinence following acute stroke is common, affecting between 40%-60% of people in hospital after a stroke. Despite the availability of clinical guidelines for urinary incontinence and urinary incontinence after stroke, national audit data suggest incontinence is often poorly managed. Conservative interventions (e.g. bladder training, pelvic floor muscle training and prompted voiding) have been shown to have some effect with participants in Cochrane systematic reviews, but have not had their effectiveness demonstrated with stroke patients. METHODS/DESIGN: A cluster randomised controlled pilot trial designed to assess the feasibility of a full-scale cluster randomised trial and to provide preliminary evidence of the effectiveness and cost-effectiveness of a systematic voiding programme for the management of continence after stroke. Stroke services will be randomised to receive the systematic voiding programme, the systematic voiding programme plus supported implementation, or usual care. The trial aims to recruit at least 780 participants in 12 stroke services (4 per arm). The primary outcome is presence/absence of incontinence at six weeks post-stroke. Secondary outcomes include frequency and severity of incontinence, quality of life and cost-utility. Outcomes will be measured at six weeks, three months and (for participants recruited in the first three months) twelve months after stroke. Process data will include rates of recruitment and retention and fidelity of intervention delivery. An integrated qualitative evaluation will be conducted in order to describe implementation and assist in explaining the potential mediators and modifiers of the process. TRIAL REGISTRATION: ISRCTN: ISRCTN08609907

The experience of community engagement for individuals: a rapid review of evidence.

Community engagement is central to strategies to promote health and well-being and reduce health inequalities in many countries, particularly interventions which focus on improving health in disadvantaged populations. Despite the widespread use of community engagement approaches, however, there have been relatively few attempts to review the evidence on the impact that participation has on the lives of individuals involved. Drawing on a wider review of evidence carried out on behalf of the National Institute for Health and Clinical Excellence (NICE), this article reports on a rapid review of evidence of the effectiveness of initiatives which seek to engage communities in action to address the wider social determinants of health, to explore individuals' subjective experiences of engagement. The rapid review process was guided by NICE's public health methods manual, adapted to suit the diversity of the evidence. A total of 22 studies were identified containing empirical data on subjective experiences of community engagement for individuals. The findings of the rapid review suggest that the majority of 'engaged' individuals perceived benefits for their physical and psychological health, self-confidence, self-esteem, sense of personal empowerment and social relationships. Set against these positive outcomes, however, the evidence suggests that there are unintended negative consequences of community engagement for some individuals, which may pose a risk to well-being. These consequences included exhaustion and stress, as involvement drained participants' energy levels as well as time and financial resources. The physical demands of engagement were reported as particularly onerous by individuals with disabilities. Consultation fatigue and disappointment were negative consequences for some participants who had experienced successive waves of engagement initiatives. For some individuals, engagement may involve a process of negotiation between gains and losses. This complexity needs to be more widely recognised among those who seek to engage communities.

Does repetitive task training improve functional activity after stroke? A Cochrane systematic review and meta-analysis.

OBJECTIVE: To determine if repetitive task training after stroke improves functional activity. DESIGN: Systematic review and meta-analysis of trials comparing repetitive task training with attention control or usual care. DATA SOURCES: The Cochrane Stroke Trials Register, electronic databases of published, unpublished and non-English language papers; conference proceedings, reference lists, and trial authors. REVIEW METHODS: Included studies were randomized/quasi-randomized trials in adults after stroke where an active motor sequence aiming to improve functional activity was performed repetitively within a single training session. We used Cochrane Collaboration methods, resources, and software. RESULTS: We included 14 trials with 17 intervention-control pairs and 659 participants. Results were statistically significant for walking distance (mean difference 54.6, 95% confidence interval (95% CI) 17.5, 91.7); walking speed (standardized mean difference (SMD) 0.29, 95% CI 0.04, 0.53); sit-to-stand (standard effect estimate 0.35, 95% CI 0.13, 0.56), and activities of daily living: SMD 0.29, 95% CI 0.07, 0.51; and of borderline statistical significance for measures of walking ability (SMD 0.25, 95% CI 0.00, 0.51), and global motor function (SMD 0.32, 95% CI -0.01, 0.66). There were no statistically significant differences for hand/arm functional activity, lower limb functional activity scales, or sitting/standing balance/reach. CONCLUSION: Repetitive task training resulted in modest improvement across a range of lower limb outcome measures, but not upper limb outcome measures. Training may be sufficient to have a small impact on activities of daily living. Interventions involving elements of repetition and task training are diverse and difficult to classify: the results presented are specific to trials where both elements are clearly present in the intervention, without major confounding by other potential mechanisms of action.

What can management theories offer evidence-based practice? A comparative analysis of measurement tools for organisational context.

BACKGROUND: Given the current emphasis on networks as vehicles for innovation and change in health service delivery, the ability to conceptualize and measure organisational enablers for the social construction of knowledge merits attention. This study aimed to develop a composite tool to measure the organisational context for evidence-based practice (EBP) in healthcare. METHODS: A structured search of the major healthcare and management databases for measurement tools from four domains: research utilisation (RU), research activity (RA), knowledge management (KM), and organisational learning (OL). Included studies were reports of the development or use of measurement tools that included organisational factors. Tools were appraised for face and content validity, plus development and testing methods. Measurement tool items were extracted, merged across the four domains, and categorised within a constructed framework describing the absorptive and receptive capacities of organisations. RESULTS: Thirty measurement tools were identified and appraised. Eighteen tools from the four domains were selected for item extraction and analysis. The constructed framework consists of seven categories relating to three core organisational attributes of vision, leadership, and a learning culture, and four stages of knowledge need, acquisition of new knowledge, knowledge sharing, and knowledge use. Measurement tools from RA or RU domains had more items relating to the categories of leadership, and acquisition of new knowledge; while tools from KM or learning organisation domains had more items relating to vision, learning culture, knowledge need, and knowledge sharing. There was equal emphasis on knowledge use in the different domains. CONCLUSION: If the translation of evidence into knowledge is viewed as socially mediated, tools to measure the organisational context of EBP in healthcare could be enhanced by consideration of related concepts from the organisational and management sciences. Comparison of measurement tools across domains suggests that there is scope within EBP for supplementing the current emphasis on human and technical resources to support information uptake and use by individuals. Consideration of measurement tools from the fields of KM and OL shows more content related to social mechanisms to facilitate knowledge recognition, translation, and transfer between individuals and groups.

Re-visioning the doctoral research degree in nursing in the United Kingdom.

In the light of concerns about the wider social and economic value of the PhD training programme, this article discusses the challenges being directed primarily at the traditional doctoral programme of study. While the PhD is primarily concerned with the student making an original contribution to knowledge, the value-added component of the doctoral research degree needs to respond to the needs of a wider market of purchasers, and to meet practice and policy requirements for research leadership. The United Kingdom Research Councils (UK GRAD, 2001. Joint Skills Statement of Skills Training Requirements. Available at http://www.grad.ac.uk/downloads/documents/general/Joint%20Skills%20Statementpdf. (last accessed 1st April 2008.) suggest a range of seven skill domains over and above research design and management that should be offered to students. The seven domains are research skills and techniques, participation in the research environment, research management, personal effectiveness, communication, networking and team working, and career management. This article develops and extends these skill domains for the current healthcare context and considers how these should guide the development and evaluation of the value-added components of doctoral research degree programmes in nursing. The challenges that these issues present to academic departments are also discussed. Our conclusion is that PhD research training needs re-visioning and broadening so that the students' experience includes these value-added components.

Uncertainty and information need in nursing.

The assumption of practitioner uncertainty as a cause of practice variation has focussed attention on the information behaviour of health care professionals, but there is very little research into clinical groups other than doctors. This study considered the information needs of nurses and their attributions for uncertainty. The method was participant observation of three groups of nurse specialists from multiple health care providers who met over time to construct evidence-based consensus recommendations for practice. Practitioners were uncertain about the best course of action in half of the issues discussed. There were clearly expressed areas of information need, but the workgroup process uncovered more implicit uncertainty than was expressed. The recognition of problems in practice was central to the articulation of information need, rather than the existence of new solutions. Of the known areas of uncertainty, only those that were problematic and had a visible, practical solution were followed up. Factors contributing to uncertainty included a perception of lack of evidence, and differences in how problems were presented in practice and research. The occurrence of unrecognised uncertainty suggests that there are areas of clinical practice where helping to recognise and articulate information need may stimulate further interest in evidence-based practice.

The process of research use in nursing.

AIM: This paper describes the process of research use undertaken by groups of specialist nurses involved in the construction of policy recommendations for nursing practice. BACKGROUND: A number of prescriptive models of research use have been described in the nursing literature. Previous studies have attempted to measure the instrumental use of research findings in nursing practice. However, there is no evidence on how research use occurs, or why results differ across individuals, settings, tasks or time. There has been little investigation into the congruence of prescriptive models with the realities of research use in practice. METHOD: The study used an ethnomethodological approach to describe the practical reasoning undertaken by specialist nurses during research use. The method was participant observation with three clinical workgroups, comprising a series of meetings of practitioners from between 11 and 25 health care provider organizations. Data collected from recording discussions at the meetings were analysed using grounded data reduction, and were subject to external verification of description and inference. FINDINGS: The process of research use consistently contained four stages of practical reasoning comprising research identification, confirmation, evaluation and application. Each stage involved practitioners in cognitive work to translate the research evidence into practice policy. CONCLUSIONS: While the process of research use described in the findings is not markedly different in outline from prescriptive models of the process available in the literature, inconsistencies are highlighted in the way the process is conceptualized. Prescriptive models of research use do not adequately reflect the task of problem-setting, use of multiple frames of reference for evaluation, and how information from research is to be integrated with information from other sources.

Contextual factors influencing research use in nursing.

BACKGROUND: Contextual factors are perceived to be significant barriers to research-utilisation-related activity, but little is known about how context impacts on specific research-based decisions, or how the individual interacts with the organisation in the requirement for research-based change. AIM: This study describes the impact of contextual factors on the practical reasoning of nurse specialists in the construction of policy for practice. METHODS: Three groups of clinical nurse specialists were observed during a series of meetings convened to construct evidence-based guidelines for nursing practice. Transcripts of the meetings were analysed to identify and categorise the physical, social, political, and economic influences on 31 nursing issues. FINDINGS: Multiple contextual factors influenced each decision made, with decisions about nursing practice bounded by setting and system considerations, relationships with others in the care team, and resource constraints. Practitioners were involved in weighing up alternative scenarios, contexts, and contingencies for each decision, requiring strategies to adapt and reconstruct the nature of care, to influence others, and to affect organisational decision-making processes. DISCUSSION: The practical accomplishment of evidence-based practice required diverse skills: translating between evidence and practice; mediating the values, preferences, and working practices of multiple stakeholders; negotiating organisational complexity and the management of boundaries; and coordinating inter-organisational and inter-agency working. Nurse specialists in this study had a significant role in instigating, fuelling, and coordinating policy review, predominantly by communication across professional and organisational boundaries. IMPLICATIONS/CONCLUSIONS: Clinical specialists acting as organisational boundary spanners require skills in the informal cultural work of organising, facilitating, and maintaining links across professional, team, and organisational boundaries. If their role in the negotiation of evidence-based practice patterns across professional and organisational boundaries is to be successful, wider skills than information management need to be recognised and their development and enactment supported.

Sharing what works: adaptation programmes for overseas recruits.

Many Trusts are considering overseas recruitment to cope with the current shortage of qualified nurses in the UK. The need to plan for and manage the socio-cultural process can divert attention from issues of professional adaptation. This article considers some of the legal, practical and theoretical guidance used by one Trust in developing its own adaptation programme for nurses recruited from overseas. Given the lack of detailed guidance or research available to identify factors which influence the success of adaptation programmes, learning theories were used to work out a set of guiding principles which were thought suitable for the particular challenges that overseas nurses face in learning to adapt their professional skills to a new environment.