Enablers and barriers to progressing a clinical academic career in nursing, midwifery and allied health professions: A cross-sectional survey.

AIMS AND OBJECTIVES: This study aimed to understand the routes by which nurses, midwives and allied health professionals (NMAHPs) pursue and sustain a research career and the enablers and barriers to career progression. BACKGROUND: Robust evidence is central to practice and professional decision making of NMAHPs, with generation and translation of research arguably best led by those clinically active. Whilst countries like the UK and USA have fellowship schemes to support research career development, anecdotal reports suggest barriers exist in translating these opportunities into sustainable clinical academic careers. DESIGN: Online survey. METHODS: An online questionnaire addressing career choices, facilitators/barriers and support was emailed to 1074 past applicants (doctoral and post-doctoral) to National Institute of Health Research fellowship schemes (awarded and rejected) in England between March and May 2017; 231 responded (25.6%). Study reporting adheres to STROBE checklist. RESULTS: Overall, 134 doctoral and 96 post-doctoral applicants participated; two-thirds were from allied health professions. Most were early in their research career. Interest in research was most frequently sparked by interaction with people in research positions. Nearly half had their first research experience during their BSc project; though less often for nurses/midwives/health visitors (37.5%) than other NMAHPs (51.6%). The award of a fellowship resulted in higher likelihood of being research-active (doctoral level). Nearly three quarters pursuing a clinical academic career indicated 'clearer career paths' and 'greater integration across clinical and academic departments' were desirable. Most common barriers related to research roles, availability of positions and funding. CONCLUSIONS: Fellowship schemes are important to NMAHPs' research careers, but there are serious challenges to establishing and sustaining a career. RELEVANCE TO CLINICAL PRACTICE: Lack of a clear model of career progression, at national and local level, and barriers to creating joint posts impacts on capacity of clinical academics to strengthen integration of research with practice.

In Nightingale's footsteps: A qualitative analysis of the impact of leadership development within the clinical learning environment.

AIM: To identify and describe the impact areas of a newly developed leadership development programme focussed on positioning leaders to improve the student experience of the clinical learning environment. BACKGROUND: There is a need to consider extending traditional ways of developing leaders within the clinical learning in order to accommodate an increased number of students and ensure their learning experience is fulfilling and developmental. The Florence Nightingale Foundation implemented a bespoke leadership development programme within the clinical learning environment. Identifying the areas of impact will help to inform organisational decision making regarding the benefits of encouraging and supporting emerging leaders to undertake this type of programme. METHOD: For this qualitative descriptive study, eight health care professionals who took part in a bespoke leadership development programme were interviewed individually and then collectively. The Florence Nightingale Foundation fellowship/scholarship programme is examined to determine impact. RESULTS: Two key themes were described in relation to impact of the programme. These were 'Personal Development' and 'Professional Impact'. The two key themes comprised several subthemes. The notion of time and space to think was subsumed within each theme. CONCLUSION: Data highlights that the Florence Nightingale Foundation programme had a distinct impact on participants by transforming thinking and increasing self-confidence to enable changes to make improvements both within their organisations and at national level. IMPLICATIONS FOR NURSING MANAGEMENT: Health care managers must continue to invest in building leadership capacity and capability through programmes that can help position individuals to realize their potential to positively influence health outcomes and wider society.

Patient experiences of alcohol specialist nurse interventions in a general hospital, and onwards care pathways.

AIMS: To provide insight into patient experiences of a general hospital-based alcohol specialist nurse intervention during alcohol detoxification, experiences of alcohol specialist nurse hospital-based follow-up appointments (Pathway A) as well as the experiences of patients who did not have access to this additional help post detoxification (Pathway B). DESIGN: A longitudinal qualitative study. METHODS: A thematic analysis of semi-structured interviews (2016-2017) with 24 patient participants (N = 12 in each pathway; purposive selection) 1-4 weeks post-detoxification and at 3 and 6 months, to identify patient experiences of these interventions. RESULTS: Participants gave accounts of how 'empathic' and 'straight talking' interactions with alcohol specialist nurses during detoxification helped them to 'open up' and orient towards change. After detoxification follow-up, outpatient appointments in the hospital setting were seen as supporting change in early recovery and engagement with a wider range of services. Those with no access to nurse follow-up described experiencing a 'void' in available help. Participants in both groups described barriers to engagement with community alcohol services, peer groups and access to help for mild-moderate mental health problems. CONCLUSION: Patient accounts indicate alcohol specialist nurse interventions during and after unplanned detoxification in a hospital setting can help orient patients towards change and support early recovery. IMPACT: Providing alcohol specialist nurse interventions in general hospitals offers one route to initiating recovery in alcohol-dependent patients. This has potential to improve the lives of those affected and to reduce related demands on hospital services, but further research is needed.

A fundamental conflict of care: Nurses' accounts of balancing patients' sleep with taking vital sign observations at night.

AIMS AND OBJECTIVES: To explore why adherence to vital sign observations scheduled by an early warning score protocol reduces at night. BACKGROUND: Regular vital sign observations can reduce avoidable deterioration in hospital. early warning score protocols set the frequency of these observations by the severity of a patient's condition. Vital sign observations are taken less frequently at night, even with an early warning score in place, but no literature has explored why. DESIGN: A qualitative interpretative design informed this study. METHODS: Seventeen semi-structured interviews with nursing staff working on wards with varying levels of adherence to scheduled vital sign observations. A thematic analysis approach was used. RESULTS: At night, nursing teams found it difficult to balance the competing care goals of supporting sleep with taking vital sign observations. The night-time frequency of these observations was determined by clinical judgement, ward-level expectations of observation timing and the risk of disturbing other patients. Patients with COPD or dementia could be under-monitored, while patients nearing the end of life could be over-monitored. CONCLUSION: In this study, we found an early warning score algorithm focused on deterioration prevention did not account for long-term management or palliative care trajectories. Nurses were therefore less inclined to wake such patients to take vital sign observations at night. However, the perception of widespread exceptions and lack of evidence regarding optimum frequency risks delegitimising the early warning score approach. This may pose a risk to patient safety, particularly patients with dementia or chronic conditions. RELEVANCE TO CLINICAL PRACTICE: Nurses should document exceptions and discuss these with the wider team. Hospitals should monitor why vital sign observations are missed at night, identify which groups are under-monitored and provide guidance on prioritising competing expectations. early warning score protocols should take account of different care trajectories.

Universal screening for alcohol misuse in acute medical admissions is feasible and identifies patients at high risk of liver disease.

BACKGROUND & AIMS: Many people who die from alcohol related liver disease (ARLD) have a history of recurrent admissions to hospital, representing potential missed opportunities for intervention. Universal screening for alcohol misuse has been advocated but it is not known if this is achievable or effective at detecting individuals at high risk of ARLD. METHODS: We systematically screened all admissions to the Acute Medical Unit (AMU) of a large acute hospital using an electronic data capture system in real time. Patients at an increasing risk of alcohol harm were referred for either brief intervention (BI) or further assessment by an Alcohol Specialist Nursing Service (ASNS). Additional data were recorded on admission diagnoses, alcohol unit consumption, previous attendances, previous admissions, length of stay and mortality. RESULTS: Between July 2011 and March 2014, there were 53,165 admissions and 48,211 (90.68%) completed screening. Of these, 1,122 (2.3%) were classified as "increasing", and 1,921 (4.0%) as "high" risk of alcohol harm. High risk patients had more hospital admissions in the three previous years (average 4.74) than the low (3.00) and increasing (2.92) risk groups (p<0.001). The high risk patients also had more frequent emergency department (ED) attendances (7.68) than the lower (2.64) and increasing (3.81) groups (p<0.001 for both). A total of 1,396 (72.6%) of the high risk group were seen by the ASNS and 1,135 (81.2%) had an Alcohol Use Disorders Identification Test (AUDIT) score over 20 with 527 (37.8%) recording the maximum value of 40. Compared to the other groups, high risk patients had a distinct profile of admissions with the most common diagnoses being mental health disorders, gastro-intestinal bleeding, poisoning and liver disease. CONCLUSIONS: Universal screening of admissions for alcohol misuse is feasible and identifies a cohort with frequent ED attendances, recurrent admissions and an elevated risk of ARLD. An additional group of patients at an increasing risk of alcohol harm can be identified in a range of common presentations. These patients can be targeted with interventions to reduce the burden of alcohol related harm. Lay summary: Many people who die from alcohol related liver disease (ARLD) have a recent history of recurrent admissions to hospital. These admissions may represent missed opportunities to intervene earlier and offer effective therapies for alcohol misuse. Unfortunately, we know that patients are often missed because medical staff may not routinely ask about alcohol consumption. In our study of over 50,000 admissions, we have demonstrated the feasibility of offering screening for alcohol misuse to all medical admissions to hospital and delivered this 24hours a day, 7days a week, with automatic referral to treatment services. We have shown that it is possible to identify those people who are at the highest risk of dependency, those who have attended the emergency department the most and those who are at an increased risk of ARLD. We hope this study will lead to improved detection and management of alcohol problems in acute hospitals.

Influences of Leadership, Organizational Culture, and Hierarchy on Raising Concerns About Patient Deterioration: A Qualitative Study.

BACKGROUND: Raising concerns is essential for the early detection and appropriate response to patient deterioration. However, factors such as hierarchy, leadership, and organizational culture can impact negatively on the willingness to raise concerns. OBJECTIVES: This study aims to delve into how leadership, organizational cultures, and professional hierarchies in healthcare settings influence healthcare workers, patients, and caregivers in raising concerns about patient deterioration and their willingness to do so. METHODS: The study used a qualitative approach, conducting focus group discussions (N = 27), utilizing authentic audio-visual vignettes to prompt discussions about raising concerns. Deductive thematic analysis was employed to explore themes related to hierarchy, leadership, and organizational culture. RESULTS: Positive leadership that challenged traditional professional hierarchies by embracing multidisciplinary teamwork, valuing the input of all stakeholders, and championing person-centered practice fostered a positive working culture. This culture has the potential to empower clinical staff, patients, caregivers, and family members to confidently raise concerns. Staff development, clinical supervision, and access to feedback, all underpinned by psychological safety, were viewed as facilitating the escalation of concerns and, subsequently, have the potential to improve patient safety. CONCLUSIONS: This study offers crucial insights into the intricate dynamics of leadership, hierarchy, and organizational culture, and their profound impact on the willingness of staff and patients to voice concerns in healthcare settings. Prioritizing the recommendations of this study can contribute to reducing avoidable deaths and elevating the quality of care in healthcare settings.

Evaluation of the impact of leadership development on nurses and midwives underpinned by transformational learning theory: a corpus-informed analysis.

PURPOSE: The purpose of this paper is to evaluate the impact of leadership development programmes, underpinned by Transformational Learning Theory (TLT). DESIGN/METHODOLOGY/APPROACH: A corpus-informed analysis was conducted using survey data from 690 participants. Data were collected from participants' responses to the question "please tell us about the impact of your overall experience", which culminated in a combined corpus of 75,053 words. FINDINGS: Findings identified patterns of language clustered around the following frequently used word types, namely, confidence; influence; self-awareness; insight; and impact. RESEARCH LIMITATIONS/IMPLICATIONS: This in-depth qualitative evaluation of participants' feedback has provided insight into how TLT can be applied to develop future health-care leaders. The extent to which learning has had a transformational impact at the individual level, in relation to their perceived ability to influence, holds promise for the wider impact of this group in relation to policy, practice and the promotion of clinical excellence in the future. However, the latter can only be ascertained by undertaking further realist evaluation and longitudinal study to understand the mechanisms by which transformational learning occurs and is successfully translated to influence in practice. ORIGINALITY/VALUE: Previous research has expounded traditional leadership theories to guide the practice of health-care leadership development. The paper goes some way to demonstrate the impact of using the principles of TLT within health-care leadership development programmes. The approach taken by The Florence Nightingale Foundation has the potential to generate confident leaders who may be instrumental in creating positive changes across various clinical environments.

Development of Nightingale Frontline: a leadership support service for nurses and midwives during the COVID-19 crisis.

BACKGROUND: As COVID-19 hit the UK, it was apparent that frontline healthcare workers would be faced with challenges they had never encountered before. The longer-term leadership support needs of nurses and midwives were considered central to how they would psychologically emerge from the COVID-19 response. In response, a national leadership support service for nurse and midwife leadersat all levels, was rapidly established. METHODS: A collaborative approach was used, drawing from an established community of healthcare leadership development consultants and senior healthcare leaders. Practical plans for how the service would run were formulated via online meetings, held between February and March 2020. An internal questionnaire was distributed to attendees, requesting demographic data and feedback to capture the perceived impact of the service on leadership. RESULTS: Overall, confidence in leadership ability/skills increased after attending the service; 68.8% of those who completed post-attendance questionnaires reported having learnt new leadership skills and a motivation to facilitate co-consulting sessions for their teams. The service was positively appraised and there were reports of a degree of influence on leadership, and improved confidence after attending. CONCLUSION: Leadership and well-being support provided by an independent and external organisation can offer a unique and safe forum for reflection and for healthcare leaders to decompress. This requires a sustainable investment to mitigate the predicted impact of the pandemic.

Midwives' views towards women using mHealth and eHealth to self-monitor their pregnancy: A systematic review of the literature.

INTRODUCTION: There are many mobile telephone apps to help women self-monitor aspects of pregnancy and maternal health. This literature review aims to understand midwives' perspectives on women self-monitoring their pregnancy using eHealth and mHealth, and establish gaps in research. METHODS: MEDLINE, PubMed, Scopus, CINAHL and PsycINFO were systematically searched on midwifery, eHealth/mHealth and perspectives. Qualitative, quantitative and mixed-methods studies published in English were considered for inclusion in the review, without geographical limitations. Relevant articles were critically appraised and narrative synthesis was conducted. RESULTS: Twelve relevant papers covering midwives' perspectives of the use of eHealth and mHealth by pregnant women were obtained for inclusion in this review. Seven of these publications focused on midwives' views of eHealth, and five on their perspectives of mHealth interventions. The studies included demonstrate that midwives generally hold ambivalent views towards the use of eHealth and mHealth technologies in antenatal care. Often, midwives acknowledged the potential benefits of such technologies, such as their ability to modernise antenatal care and to help women make more informed decisions about their pregnancy. However, midwives were quick to point out the risks and limitations of these, such as the accuracy of conveyed information, and negative impacts on the patient-professional relationship. CONCLUSIONS: Post-COVID-19, where technology is continuously developing, there is a compelling need for studies that investigate the role of eHealth and mHealth in self-monitoring pregnancy, and the consequences this has for pregnant women, health professionals and organisations, as well as midwifery curricula.

The response to patient deterioration in the UK National Health Service - A survey of acute hospital policies.

BACKGROUND: The assessment of acute-illness severity in adult non-pregnant patients in the United Kingdom is based on early warning score (EWS) values that determine the urgency and nature of the response to patient deterioration. This study aimed to describe, and identify variations in, the expected clinical response outlined in 'deteriorating patient' policies/guidelines in acute NHS hospitals. METHODS: A copy of the local 'deteriorating patient' policy/guideline was requested from 152 hospitals. Each was analysed against pre-determined areas of interest, e.g., minimum expected vital sign observations frequency, expected response and expected staff response times. RESULTS: In the 55 responding hospitals (36.2%), the documented structure and process of the response to deterioration varied considerably. All hospitals used a 12-hourly minimum vital signs measurement frequency. Thereafter, for a low-risk patient, the minimum frequency varied from '6-12 hourly' to 'hourly'. Frequencies were higher for higher risk categories. Expected escalation responses were highly individualised between hospitals. Other than repeat observations, only nine (16.4%) documents described specific clinical actions for ward staff to consider/perform whilst awaiting responding personnel. Maximum permitted response times for medium-risk and high-risk patients varied widely, even when based on the same EWS. Only 33/55 documents (60%) gave clear instructions regarding who to contact 'out of hours'. CONCLUSIONS: The 'deteriorating patient' policies of the hospitals studied varied in their contents and often omitted precise instructions for staff. We recommend that individual hospitals review these documents, and that research and/or consensus are used to develop a national algorithm regarding the response to patient deterioration.

Building clinical academic leadership capacity: sustainability through partnership.

BACKGROUND: A national clinical academic training programme has been developed in England for nurses, midwives and allied health professionals but is insufficient to build a critical mass to have a significant impact on improved patient care. AIM: We describe a partnership model led by the University of Southampton and its neighbouring National Health Service partners that has the potential to address this capacity gap. In combination with the Health Education England/National Institute of Health Research Integrated Clinical Academic programme, we are currently supporting nurses, midwives and allied health professionals at Master's (n = 28), Doctoral (n = 36), Clinical Lecturer (n = 5) and Senior Clinical Lecturer (n = 2) levels working across seven National Health Service organisations, and three nurses hold jointly funded Clinical Professor posts. RESULTS: Key to the success of our partnership model is the strength of the strategic relationship developed at all levels across and within the clinical organisations involved, from board to ward. We are supporting nurses, midwives and allied health professionals to climb, in parallel, both clinical and academic career ladders. We are creating clinical academic leaders who are driving their disciplines forward, impacting on improved health outcomes and patient benefit. CONCLUSIONS: We have demonstrated that our partnership model is sustainable and could enable doctoral capacity to be built at scale.

Relationships between healthcare staff characteristics and the conduct of vital signs observations at night: Results of a survey and factor analysis.

AIM: To explore the association of healthcare staff with factors relevant to completing observations at night. DESIGN: Online survey conducted with registered nurses, midwives, healthcare support staff and student nurses who had worked at least one night shift in a National Health Service hospital in England. METHODS: Exploratory factor analysis and mixed effects regression model adjusting for role, number of night shifts worked, experience and shift patterns. RESULTS: Survey items were summarized into four factors: (a) workload and resources; (b) prioritization; (c) safety culture; (d) responsibility and control. Staff experience and role were associated with conducting surveillance tasks. Nurses with greater experience associated workload and resources with capacity to complete work at night. Responses of student nurses and midwives showed higher propensity to follow the protocol for conducting observations. Respondents working night shifts either exclusively or occasionally perceived that professional knowledge rather than protocol guided care tasks during night shifts.

Do Alcohol Misuse, Service Utilisation, and Demographic Characteristics Differ between UK Veterans and Members of the General Public Attending an NHS General Hospital?

The aim of this paper was to provide insights into alcohol misuse within UK veterans to inform as to whether their presentations differ from the general public. This was done by exploring differences in the severity of alcohol misuse between UK veterans and the general public admitted to a general NHS hospital over an 18 month period using retrospective data. All patients admitted to the hospital were screened for alcohol misuse. Those deemed as experiencing problems were referred for specialist nurse-led support. A total of 2331 individuals were referred for this supported and administered with a standardised assessment that included measures of the severity of alcohol difficulties (AUDIT), dependency levels (LDQ), and assessed for the presence of withdrawal symptoms (CIWA-Ar). In addition, information was collected on service utilisation, referral category (medical or mental health), other substance misuse, and demographic characteristics. No differences were found between the severity of reported alcohol difficulties between veterans and non-veterans. Evidence was found to suggest that veterans were more likely to be referred for support with alcohol difficulties at an older age and to be admitted to hospital for longer periods of time. This could have considerable cost implications for the NHS. It was more common for veterans to present at hospital with physical health difficulties prior to being referred for support for alcohol.

Education for public health capacity in the nursing workforce: findings from a review of education and practice issues.

Current NHS policy highlights the importance of public health as a strategy to reduce health inequalities and to promote the health of communities, and nurses are recognised as key contributors to the public health function. Changes are also taking place in pre- and post-registration nurse education curricula, in the wake of recent education policy recommendations. However, progress towards effective educational preparation for nurses' public health function and the educational issues involved, has not been systematically charted. The study reported below investigated the adequacy of public health education and the issues involved in effective education practice through a literature review and interviews with key informants. Findings highlight issues concerned with programme outcomes, practice placement experiences, and continuing professional development. Findings are discussed, and implications and recommendations for educational and other key stakeholders are outlined.

A primary care specialist genetics service: a cluster-randomised factorial trial.

BACKGROUND: GPs do not have the confidence to identify patients at increased genetic risk. A specialist primary care clinical genetics service could support GPs with referral and provide local clinics for their patients. AIM: To test whether primary care genetic-led genetics education improves both non-cancer and cancer referral rates, and primary care-led genetics clinics improve the patient pathway. DESIGN AND SETTING: Cluster-randomised factorial trial in 73 general practices in the south of England. METHOD: Practices randomised to receive case scenario based seminar (intervention) or not (control), and referred patients a primary (intervention) or secondary (control) care genetic counsellor (GC)-led appointment. OUTCOME MEASURES: GP referral and clinic attendance rates (primary), appropriate cancer and case scenario referral rates, patient satisfaction, clinic costs, and case management (secondary). RESULTS: Eighty-nine and 68 referrals made by 36 intervention and 37 control practices respectively. There was a trend towards an overall higher referral rate among educated GPs (referral rate ratio [RRR] 1.34, 95% confidence interval [CI] = 0.89 to 2.02; P = 0.161), and they made more appropriate cancer referrals (RRR 2.36, 95% CI = 1.07 to 5.24; P = 0.035). No indication of difference in clinic attendance rates (odds ratio 0.91, 95% CI = 0.43 to 1.95; P = 0.802) or patient satisfaction (P = 0.189). Patients spent 49% less travelling (£3.60 versus £6.62; P<0.001) and took 33% less time (39.7 versus 57.7 minutes; P<0.001) to attend a primary than secondary care appointment; 83% of GC-managed appointments met the 18-week referral to treatment, NHS target. CONCLUSION: An integrated primary care genetics service both supports GPs in appropriate cancer referral and provides care in the right place by the right person.

Feasibility and acceptability of providing nurse counsellor genetics clinics in primary care.

AIM: This paper reports a pilot study to test the feasibility of providing genetic nurse counsellor clinics in primary care in the United Kingdom, to develop a questionnaire to evaluate patients' satisfaction with their genetics appointments, and to establish patient and provider costs. BACKGROUND: Genetic counsellors are healthcare professionals with experience in medical genetics and counselling and often have a professional background in nursing, science, genetics, psychology, or public health and work as members of multidisciplinary teams. Professional genetic counsellor accreditation is possible in the United Kingdom, United States of America, Australia and Canada. Increasing referrals to specialist genetics services have precipitated a review of models of service delivery in the United Kingdom. METHODS: A random half of 74 general practices in three primary care trusts were selected for the study, and the patients registered with these practices and referred to the clinical genetics service, were offered an appointment in primary care with a genetic nurse counsellor. A clinic follow-up postal questionnaire was developed. RESULTS: Between July 2002 and May 2003, 64 appointments were offered to patients referred and registered with the selected general practices, 45 (79%) patients attended their appointment and 34 (77%) returned their follow-up questionnaire. Total mean satisfaction score was high and patients were most satisfied with the information and affective domains of the appointment. Those referred with a family history of cancer were more satisfied than those referred with a non-cancer diagnosis. Forty-eight per cent of patients seen by the genetic nurse counsellor did not need to attend a further appointment with a doctor in secondary care. Patients were satisfied with the travel time and distance to clinic and patient clinic costs were low. CONCLUSION: Patients do attend genetic nurse counsellor clinics in primary care, and are satisfied with the new location. A large cluster randomized controlled trial is now being conducted to obtain a controlled comparison of clinic attendance rates and patients' satisfaction with clinics in primary vs. secondary care settings.