Enhancing the quality of oral nutrition support for hospitalized patients: a mixed methods knowledge translation study (The EQONS study).

AIM: The aim of this study was to report a multifaceted knowledge translation intervention to facilitate use of the Malnutrition Universal Screening Tool and innovation in nutritional care for patients at risk of malnutrition. BACKGROUND: Malnutrition among hospitalized patients is a widespread problem leading to adverse health outcomes. Despite evidence of the benefits of malnutrition screening and recommendations for achieving good nutrition, shortfalls in practice continue. DESIGN: A mixed method integrated knowledge translation study. METHODS: The knowledge translation intervention comprised nutrition champions supported by knowledge translation facilitators and an action planning process. Data collection was undertaken over 18 months between 2011-2012 in a hospital in England. Data comprised observation of mealtimes, audit of patient records, survey of nurses and semi-structured interviews with nutrition champions, knowledge translation facilitators, senior ward nurses and nurse managers. FINDINGS: Statistically significant relationships (Chi Square) were observed between self-reported confidence of nurses (a) to assess patients using the Malnutrition Universal Screening Tool, (b) to teach colleagues how to use the Malnutrition Universal Screening Tool and (c) to ensure that patients were assessed within 24 hours of admission. Ward-based nutrition champions facilitated successful innovation in nutrition support. Contextual factors operating at micro (ward), meso (organization) and macro (healthcare system) levels acted as barriers and enablers for change. CONCLUSION: Nutrition champions were successful in increasing the timely assessment of patients at risk of malnutrition and promoting innovation in nutritional care. Support from knowledge translation facilitators helped nutrition champions develop their role and work collaboratively with senior ward nurses to implement action plans for improving nutrition.

Development of a conceptual policy framework for advanced practice nursing: an ethnographic study.

AIM: To report on a study examining policy development for advanced practice nursing from intent of policy to realization in practice. BACKGROUND: Inclusion of advanced practice nursing roles in the healthcare workforce is a worldwide trend. Optimal advanced nursing practice requires supportive policies. Little is known about how policy is developed and implemented. DESIGN: Ethnography using an instrumental case study approach was selected to give an in-depth understanding of the experiences of one country (Singapore) to contribute to insight into development elsewhere. METHODS: The four-phase study was conducted from 2008-2012 and included document analysis (n = 47), interviews with key policy decision makers (n = 12), interviews with nursing managers and medical directors (n = 11), interviews and participant observation with advanced practice nurses (n = 15). RESULTS: Key policymakers in positions of authority were able to promote policy development. However, this was characterized by lack of strategic planning for implementation. A vague understanding by nursing managers and medical directors of policies, the role and its position in the healthcare workforce led to indecision and uncertainty in execution. Advanced practice nurses developed their role based on theory acquired in their academic programme but were unsure what role to assume in practice. Lack of clear guidelines led to unanticipated difficulties for institutions and healthcare systems. CONCLUSION: Strategic planning could facilitate integration of advanced practice nurses into the healthcare workforce. A Conceptual Policy Framework is proposed as a guide for a coordinated approach to policy development and implementation for advanced practice nursing.

An evaluation of the implementation of Advanced Nurse Practitioner (ANP) roles in an acute hospital setting.

AIM: To evaluate the impact of implementing Advanced Nurse Practitioner roles on patients, staff members and organizational outcomes in an acute hospital. BACKGROUND: The worldwide development of advanced practice roles in nursing has been influenced by increasing demands and costs of health care. A key issue in the UK has been the reduction in hours junior doctors can work. While there is evidence these roles can have a positive impact in a variety of clinical specialties, little is known about the impact advanced nurses substituting for junior doctors can have on patients, staff members and organizational outcomes in general hospital care settings. DESIGN: Collective case study. METHODS: A collective case study in a district general hospital in England was undertaken in 2011-2012. Interviews with strategic stakeholders (n = 13) were followed by three individual case studies. Each case study represented the clinical area in which the roles had been introduced: medicine, surgery and orthopaedics and included interviews (n = 32) and non-participant observation of practice. FINDINGS: The ANPs had a positive impact on patient experience, outcomes and safety. They improved staff knowledge, skills and competence and enhanced quality of working life, distribution of workload and team-working. ANPs contributed to the achievement of organizational priorities and targets and development of policy. CONCLUSION: ANPs undertaking duties traditionally performed by junior doctors in acute hospital settings can have a positive impact on a range of indicators relating to patients, staff members and organizational outcomes which are highly relevant to nursing.

Introducing on-ward volunteers to work with patients with dementia.

This article reports on an evaluation of the effect of an on-ward volunteer service in an acute orthopaedic ward with a number of dementia patients. A mixed-methods evaluation was undertaken in 2012. This included interviews with individuals who have strategic, management, operational and clinical roles in the voluntary organisation and the NHS trust, focus group discussions with volunteers, non-participant observations of practice and focused conversations with ward staff. The service had a positive effect on patient experience. Patients were engaged through a variety of activities and enjoyed the volunteers' presence. Staff valued the initiative because they could see the difference that it made to patients and their own working lives. The lessons learned from the evaluation can inform the development of similar initiatives elsewhere and are relevant, given the emphasis in healthcare policy to improve patient experience.

The development of a framework for evaluating the impact of nurse consultant roles in the UK.

AIM: To develop a framework to evaluate the impact of nurse consultants on patient, professional and organizational outcomes and identify associated indicators of impact. BACKGROUND: Since nurse consultants were introduced into the UK in 2000, there has been growing interest in demonstrating their impact, although robust evidence of impact is lacking. Existing frameworks for evaluating the impact of advanced practice roles do not cover the four dimensions of the nurse consultant role sufficiently. DESIGN: Multiple case study. METHOD: Individual case studies of six nurse consultants in England were undertaken between December 2009-October 2010. Each case study involved interviews with the nurse consultant, healthcare staff, managers, patients and carers. Interviews explored participants' perceptions of the impact of the nurse consultant and indicators of actual and/or potential impact. Data were analysed using framework approach. FINDINGS: Three domains of impact of nurse consultant roles were identified: clinical significance, professional significance and organizational significance. Each domain included three to four indicators of impact. All nurse consultants showed some evidence of impact in all three domains although the primary focus varied across the different nurse consultants. Due to the wide diversity in nurse consultant roles there was little commonality in the specific indicators of impact across all nurse consultants. CONCLUSION: The framework for capturing the impact of nurse consultants could be used by researchers and by nurse consultants to demonstrate their impact. Further research is required to assess the suitability of the framework for capturing the impact of other advanced practice roles.

A before and after study assessing the impact of a new model for recognizing and responding to early signs of deterioration in an acute hospital.

AIM: To evaluate the impact of a new model for the detection and management of deteriorating patients on knowledge and confidence of nursing staff in an acute hospital. BACKGROUND: International evidence shows that clinical deterioration is not always recognized or acted on by nurses. The use of physiological track and trigger scoring systems accompanied by a graded response strategy has been recommended to monitor all adult patients in acute UK hospitals. However, little is known about the impact of these new systems in practice. DESIGN: A single centre, mixed methods before-and-after study. METHODS: A mixed methods before-and-after study, set in a district general hospital in England, in 2009, including a survey (n = 213) and qualitative interviews (n = 15) with nursing staff. The questionnaire examined knowledge and confidence in recognition and management of deteriorating patients 6 weeks before and after an intervention which included training, new observation charts and a new track and trigger system. Interviews further explored participants' perspectives. Comparisons were made between registered and unregistered nurses. RESULTS: Following the intervention, knowledge, and confidence to recognize and manage deteriorating patients increased; the number of concerns were reduced. Scores were higher for registered than unregistered nurses before and after the intervention. Interviews confirmed these findings and provided detail on how nurses felt the new system had improved practice. CONCLUSION: The new model had a positive impact on the self-assessed knowledge and confidence of registered and unregistered nurses. Similar initiatives should take into account the clinical context and tailor training packages accordingly.

Evaluation of the impact of a smoke-free home initiative in Rotherham, a deprived district in Northern England.

BACKGROUND: An evaluation of a smoke-free home initiative launched in Rotherham, northern England, in July 2009. METHODS: Two approaches were used: (i) a postal survey of participants 4 months after signing up as a SFH and (ii) a telephone consultation. The survey was sent to 620 households (of 654 who signed up to the scheme); 289 (46.6%) were returned. The telephone consultation involved 20 households before and 20 after signing up to the scheme. RESULTS: Of the households that permitted some smoking at home before the initiative, ~78% became smoke free after signing up (uncertainty due to missing replies). A high number of participants (169, 60.8%) were already informally smoke free. The most common reasons for participation concerned health, environment, and fire safety. Participants were motivated by, amongst other things, information given in a booklet and by the offer of a fire-safety referral. The most immediate benefits noted by participants were improvements in house hygiene. The most important hindrance to success seemed to be a lack of power to enforce the ban at home, particularly on the part of those living in smokers' homes. CONCLUSION: The Rotherham initiative succeeded in creating smoke-free homes. The results should help those planning similar initiatives. Important points include that: many participants had already instituted some rules regarding smoking at home; whether and how to include households that are already smoke-free; risk of fire and concern with house hygiene are important motivations; those living in smokers' homes may lack power to initiate smoke-free rules.

Evaluation of the impact of nurse consultant roles in the United Kingdom: a mixed method systematic literature review.

AIM: This paper reports a mixed methods systematic review examining the impact of nurse consultant roles in adult healthcare settings, with a view to identifying indicators for demonstrating their impact on patient and professional outcomes. BACKGROUND: Nurse consultants were introduced in England in 2000 with the intention to achieve better outcomes for patients by improving quality and services. Previous studies have investigated the impact of nurse consultants, but attempts to amalgamate this evidence have been methodologically limited. Since these reviews were published, the importance of demonstrating the contribution of nurse consultants has prompted new research. A robust review of the evidence is now required. DATA SOURCES: A broad search strategy was adapted for eight databases. Grey literature was sought from various sources. REVIEW METHODS: Quantitative and qualitative studies were included. Study quality was assessed using appropriate instruments. Cross-study synthesis combined the quantitative and qualitative findings in relation to the dimensions of impact identified. Measures of impact were mapped against a framework for assessing clinical and professional outcomes. RESULTS: Thirty-six studies were included. The findings suggest a largely positive influence of nurse consultants on a range of clinical and professional outcomes, which map onto the proposed framework of impact. However, there was very little robust evidence and the methodological quality of studies was often weak. CONCLUSION: Further robust research is required to explore nurse consultants' impact on patient and professional outcomes. The proposed framework for assessing impact could be used to guide future research and assist nurse consultants assess their impact.

Factors influencing advanced practice nurses' ability to promote evidence-based practice among frontline nurses.

BACKGROUND: Advanced practice nurses (APNs) have an important role in promoting evidence-based practice (EBP) among frontline nurses (FLNs). Factors influencing FLNs' engagement with EBP are well documented but little is known about factors that affect APNs' ability to facilitate evidence in practice. AIMS: To identify factors that influence APNs' ability to promote EBP among FLNs. METHODS: A multiple case study of 23 APNs from hospital and primary care settings across seven English health authorities was undertaken. Data collection comprised interviews and observation of APNs and interviews with FLNs and other healthcare professionals. Data were analysed using the Framework approach. FINDINGS: Four groups of influencing factors were identified: (1) Personal attributes of APNs included knowledge and skills in EBP, clinical credibility with frontline staff and leadership style. (2) Relationships with stakeholders included APNs' interactions with FLNs and the level of support from managers and medical colleagues. (3) Aspects of the APN role included their sphere of responsibility and workload. (4) Organisational context included the organisational culture, FLNs' workload, professional networks and available resources. IMPLICATIONS: Educational preparation for APNs should enable them to develop expertise in EBP plus interpersonal and leadership skills to manage relational dynamics in clinical settings. APN role specifications should provide the opportunity to promote EBP. The organisational culture should be conducive to enabling EBP with managers supportive of this aspect of the APNs' role. CONCLUSIONS: APNs need to be supported to address the individual, interpersonal and organisational factors, which influence their ability to promote EBP. Organisational commitment at the highest level is key to APNs' ability to fulfil this aspect of their role.

The role of advanced practice nurses in knowledge brokering as a means of promoting evidence-based practice among clinical nurses.

AIM: To identify approaches used by advanced practice nurses to promote evidence-based practice among clinical nurses. BACKGROUND: Barriers encountered at individual and organizational levels hinder clinical nurses in their ability to deliver evidence-based practice. Advanced practice nurses are well placed to promote evidence-based practice through interactions with clinical nurses. However, little is understood about how advanced practice nurses might realize this potential. METHOD: A multiple instrumental case study of 23 advanced practice nurses from hospital and primary care settings across seven Strategic Health Authorities in England was undertaken in 2006. Data collection comprised interviews and observation of advanced practice nurses and interviews with clinical nurses and other healthcare professionals. Data were analysed using the Framework approach. FINDINGS: Advanced practice nurses acted as knowledge brokers in promoting evidence-based practice among clinical nurses. Knowledge management and promoting the uptake of knowledge were key components of knowledge brokering. Knowledge management involved generating different types of evidence, accumulating evidence to act as a repository for clinical nurses, synthesizing different forms of evidence, translating evidence by evaluating, interpreting and distilling it for different audiences and disseminating evidence by formal and informal means. Advanced practice nurses promoted the uptake of evidence by developing the knowledge and skills of clinical nurses through role modelling, teaching, clinical problem-solving and facilitating change. CONCLUSION: The role of advanced practice nurses in knowledge brokering is complex and multi-faceted. It extends beyond the knowledge management, linkage and capacity building identified in the literature to include active processes of problem-solving and facilitating change.

Factors influencing the contribution of advanced practice nurses to promoting evidence-based practice among front-line nurses: findings from a cross-sectional survey.

AIM: This paper is a report of a study to identify factors influencing advanced practice nurses' contribution to promoting evidence-based practice among front-line nurses. BACKGROUND: Despite widespread recognition that care should be evidence-based, nurses experience challenges implementing evidence-based practice. As opinion leaders, advanced practice nurses can influence the practice of front-line nurses by promoting research use. Little is known about how advanced practice nurses use evidence and their influence on care given by front-line nurses. METHOD: A cross-sectional survey of 855 advanced practice nurses working in 87 hospital/primary care settings in England. The questionnaire examined understandings of evidence-based practice, sources of evidence used, ways of working with front-line nurses, perceived impact on front-line nurses, skills in evidence-based practice and barriers to promoting evidence-based practice. Data were collected in 2005 and analysed using descriptive statistics. Comparisons were made between advanced practice nurses with Masters qualifications and those with lower qualifications. FINDINGS: Advanced practice nurses used different sources of evidence. They engaged in various activities to promote evidence-based practice and had a positive influence on front-line nurses' practice. Advanced practice nurses' skills in evidence-based practice varied with few considering themselves expert. Advanced practice nurses with Masters qualifications perceived themselves to be more skilled in all aspects of evidence-based practice than those with lower qualifications. CONCLUSION: Advanced practice nurses are well placed as clinical leaders to promote evidence-based practice by frontline nurses but require further development of their skills in evidence-based practice. In order to maximize their potential, advanced practice nurses require Master's preparation.

Systematic review and evaluation of physiological track and trigger warning systems for identifying at-risk patients on the ward.

OBJECTIVE: Physiological track and trigger warning systems (TTs) are used to identify patients outside critical care areas at risk of deterioration and to alert a senior clinician, Critical Care Outreach Service, or equivalent. The aims of this work were: to describe published TTs and the extent to which each has been developed according to established procedures; to review the published evidence and available data on the reliability, validity and utility of existing systems; and to identify the best TT for timely recognition of critically ill patients. DESIGN AND SETTING: Systematic review of studies identified from electronic, citation and hand searching, and expert informants. Cohort study of data from 31 acute hospitals in England and Wales. MEASUREMENTS AND RESULTS: Thirty-six papers were identified describing 25 distinct TTs. Thirty-one papers described the use of a TT, and five were studies examining the development or testing of TTs. None of the studies met all methodological quality standards. For the cohort study, outcome was measured by a composite of death, admission to critical care, 'do not attempt resuscitation' or cardiopulmonary resuscitation. Fifteen datasets met pre-defined quality criteria. Sensitivities and positive predictive values were low, with median (quartiles) of 43.3 (25.4-69.2) and 36.7 (29.3-43.8), respectively. CONCLUSION: A wide variety of TTs were in use, with little evidence of reliability, validity and utility. Sensitivity was poor, which might be due in part to the nature of the physiology monitored or to the choice of trigger threshold. Available data were insufficient to identify the best TT.

The provision of critical care outreach services in England: findings from a national survey.

PURPOSE: The aim of this study was to describe the development, introduction, implementation, and current models of critical care outreach services. MATERIALS AND METHODS: We conducted a national postal survey of National Health Service acute care hospitals in England that routinely provide care for level 1 patients (n = 239). RESULTS: Completed questionnaires were received from 191 (79.9%) hospitals; 139 (72.8%) had a formal critical care outreach service. A third (32.8%, 45/137) of services covered more than one hospital; 33.8% (45/133) of hospitals provided telephone advice 24 hours a day for 7 days per week, but less than 15% of hospitals offered follow-up or direct bedside clinical support on the same basis. There was wide variation in the proportion of hospital wards covered, the size and composition of the team, the aims of the service, and the balance between provision of direct care and advice. CONCLUSIONS: There are still a significant number of National Health Service acute care hospitals in England with no formal critical care outreach service. In addition, critical care outreach is being delivered in many different ways across the country, and thus means different things in different hospitals. The variation may reflect the lack of evidence as to which approaches are likely to be most effective.

Investigating the effectiveness of critical care outreach services: a systematic review.

OBJECTIVE: We explored the impact of critical care outreach activity on patient and service outcomes and aimed to contribute to developing a typology of critical care outreach services. DESIGN: Following a sample search of Medline 15 relevant electronic databases were systematically searched from 1996 to 2004. Searches for publications from nine key authors and citations of eight key articles were performed. Hand searches of journals, bibliographies of reports and review articles, and conference abstracts were conducted. Relevant experts were contacted. A further two studies published after the review date were also included. Two reviewers assessed studies for inclusion, conducted quality assessment and extracted data. Data were synthesised using narrative techniques. MEASUREMENTS AND RESULTS: Seventeen papers and six brief reports were selected for inclusion from a list of 1,760 titles. As anticipated with a relatively new service such as critical care outreach, there were few controlled trials. There were two randomised controlled trials, 16 uncontrolled before and after studies, three quasi-experimental studies, one controlled before and after study and one post-only controlled study. The most frequent outcomes measured were mortality, cardiac arrest, unplanned critical care admissions from wards, length of stay, and critical care readmission rates. CONCLUSIONS: Although improvements in patient outcomes were found, the evidence in this review is insufficient to demonstrate this conclusively. The many differences in service delivery do not permit identification of service typology. Our findings point to a need for more comprehensive research of this expanding service in the United Kingdom.

Good-quality social care for people with Parkinson's disease: a qualitative study.

OBJECTIVES: The study examines the meaning of good-quality social care for people with Parkinson's disease and their carers. It identifies, from their perspective, the impact of good-quality social care on health and well-being. DESIGN: Qualitative case study methodology, interview and framework analysis techniques were used. SETTING: community locations in the north and midlands of England. PARTICIPANTS: Data were collected from 43 participants including individual interviews with people with Parkinson's disease (n=4), formal and informal social care providers (n=13), 2 focus groups, 1 with people with Parkinson's disease and their carers (n=17), and 1 with professionals (n=8), plus a telephone interview with a former commissioner. FINDINGS: Good-quality social care, delivered in a timely fashion, was reported to have a positive impact on health. Furthermore, there is an indication that good-quality social care can prevent untoward events, such as infections, symptom deterioration and deterioration in mental health. The concept of the 'Impact Gap' developed from the findings, illustrates how the costs of care may be reduced by delivering good-quality social care. Control, choice and maintaining independence emerged as indicators of good-quality social care, irrespective of clinical condition. Participants identified characteristics indicative of good-quality social care specific to Parkinson's disease, including understanding Parkinson's disease, appropriate administration of medication, timing of care and reassessment. 'Parkinson's aware' social care was seen to generate psychological, physical and social benefits that were inter-related. CONCLUSIONS: The findings indicate how maximising quality in social care delivery for people with Parkinson's disease can impact on health and well-being. Long-term or short-term benefits may result in prevented events and reductions in health and social care resource. Health professionals can be instrumental in early detection of and signposting to social care.

Lung cancer treatment rates and the role of the lung cancer nurse specialist: a qualitative study.

OBJECTIVES: This qualitative study examines how the Lung Cancer Nurse Specialist (LCNS) role operates and why they may be able to increase access to treatment. SETTING: 4 Hospital NHS Foundation Trusts in England. DESIGN: A multiple case study design using semistructured interviews, observation and Framework Analysis techniques. PARTICIPANTS: Four LCNSs, comprised the 'cases'. Twenty four clinicians who worked with the LCNS participated in individual interviews. Six LCNSs took part in a group interview and 60 lung cancer multidisciplinary team (MDT) members and coordinators were observed in the MDT meeting. RESULTS: The LCNS is crucial within the MDT and can act as a catalyst to patient access to treatment. The study identified the clinical activity (assessment, managing symptoms, psychological support and information provision) and role characteristics that can facilitate treatment access. These characteristics are the LCNS's presence across the patient pathway, acting as the 'hub' of the MDT, maintaining a holistic patient focus and working to an advanced level of practice. The findings indicate how factors may have a cumulative impact on treatment access. CONCLUSIONS: If UK patient with lung cancer survival rates are to improve in line with comparable countries, we need to employ every advantage. This study demonstrates how the LCNS role may open doors to positive patient outcomes, including treatment. Further research is required to explore patients' experiences, decision-making and attitudes to treatment.

Do different types of nurses give different triage decisions in NHS Direct? A mixed methods study.

OBJECTIVES: To determine whether nurses with different clinical backgrounds make different triage decisions in NHS Direct, the 24-hour telephone helpline staffed by nurses. METHODS: Mixed methods including semistructured interviews with 24 nurses and a multilevel analysis of 60 794 calls triaged by 296 nurses. RESULTS: Nurse accounts helped to identify nurse characteristics that might affect decision-making. The proportion of calls triaged to self-care was 40% (24 049/60 794), varying by individual nurse from a 10th centile of 22% to a 90th centile of 60%, after adjustment for the age and sex of the patient and the time of the call. Variability was partly explained by the length of clinical experience of nurses and the type of software used: nurses with more than 20 years clinical experience were more likely to triage callers to self-care than those with less than ten years experience (42% versus 36%, respectively; odds ratio = 1.41, 95% confidence interval 1.13, 1.78). Proportions triaged to selfcare differed by the type of clinical decision support software used: 31%, 37% and 44%. There was no evidence that the clinical background of nurses (hospital or community), their length of experience in NHS Direct, the range of their experience, or their gender affected triage decisions. Interviews identified that nursing characteristics affected individual nurses in different ways and helped to generate a hypothesis for future research - that individual nurses' approaches to risk may influence triage decisions. CONCLUSION: There is no likely benefit in narrowing nurse recruitment to particular clinical backgrounds. The appropriateness of triage decisions still needs to be evaluated.

Acute Pain Teams in England: current provision and their role in postoperative pain management.

This survey describes the current provision of multidisciplinary Acute Pain Teams (APTs) in acute English hospitals performing adult in-patient surgery (excluding maternity). Associations between the presence of an APT and a number of organizational and clinical initiatives for the management of postoperative pain are also explored. Postal questionnaires were sent to the Clinical Director of Anaesthetics or head of the APT at every acute English hospital providing separate anaesthetic services. After written and telephone reminders, the response rate was 86% (n = 226). Eighty-four per cent (n = 190) of respondents had an APT in their hospital. The presence of an APT was associated (P