Providing 'the bigger picture': benefits and feasibility of integrating remote monitoring from smartphones into the electronic health record.

OBJECTIVES: To establish the acceptability and feasibility of collecting daily patient-generated health data (PGHD) using smartphones and integrating PGHD into the electronic health record, using the example of RA. METHODS: The Remote Monitoring of RA smartphone app was co-designed with patients, clinicians and researchers using qualitative semi-structured interviews and focus groups, including selection of question sets for symptoms and disease impact. PGHD were integrated into the electronic health record of one hospital and available in graphical form during consultations. Acceptability and feasibility were assessed with 20 RA patients and two clinicians over 3 months. A qualitative evaluation included semi-structured interviews with patients and clinicians before and after using the app, and audio-recordings of consultations to explore impact on the consultation. PGHD completeness was summarized descriptively, and qualitative data were analysed thematically. RESULTS: Patients submitted data on a median of 91% days over 3 months. Qualitative analysis generated three themes: RA as an invisible disease; providing the bigger picture of RA; and enabling person-centred consultations. The themes demonstrated that the system helped render patients' RA more visible by providing the 'bigger picture', identifying real-time changes in disease activity and capturing symptoms that would otherwise have been missed. Graphical summaries during consultations enabled a more person-centred approach whereby patients felt better able to participate in consultations and treatment plans. CONCLUSION: Remote Monitoring of RA has uniquely integrated daily PGHD from smartphones into the electronic health record. It has delivered proof-of-concept that such integrated remote monitoring systems are feasible and can transform consultations for clinician and patient benefit.

Who cares for the carers at hospital discharge at the end of life? A qualitative study of current practice in discharge planning and the potential value of using The Carer Support Needs Assessment Tool (CSNAT) Approach.

BACKGROUND: Carer factors prevent patients achieving timely and appropriate hospital discharge. There is a lack of research into interventions to support carers at hospital discharge. AIM: To explore whether and how family carers are currently supported during patient discharge at end of life; to assess perceived benefits, acceptability and feasibility of using The Carer Support Needs Assessment Tool (CSNAT) Approach in the hospital setting to support carers. DESIGN: Qualitative. SETTING/PARTICIPANTS: Three National Health Service Trusts in England: focus groups with 40 hospital and community-based practitioners and 22 carer interviews about experiences of carer support during hospital discharge and views of The CSNAT Approach. Two workshops brought together 14 practitioners and five carers to discuss implementation issues. Framework analysis was conducted. RESULTS: Current barriers to supporting carers at hospital discharge were an organisational focus on patients' needs, what practitioners perceived as carers' often 'unrealistic expectations' of end-of-life caregiving at home and lack of awareness of patients' end-of-life situation. The CSNAT Approach was viewed as enabling carer support and addressing difficulties of discussing the realities of supporting someone at home towards end of life. Implementation in hospital required organisational considerations of practitioner workload and training. To enhance carer support, a two-stage process of assessment and support (hospital with community follow-up) was suggested using the CSNAT as a carer-held record to manage the transition. CONCLUSION: This study identifies a novel intervention, which expands the focus of discharge planning to include assessment of carers' support needs at transition, potentially preventing breakdown of care at home and patient readmissions to hospital.

The role of the Carer Support Needs Assessment Tool in palliative home care: A qualitative study of practitioners' perspectives of its impact and mechanisms of action.

BACKGROUND: The importance of supporting family carers is well recognised in healthcare policy. The Carer Support Needs Assessment Tool is an evidence-based, comprehensive measure of carer support needs to facilitate carer support in palliative home care. AIM: To examine practitioner perspectives of the role of the Carer Support Needs Assessment Tool intervention in palliative home care to identify its impact and mechanisms of action. DESIGN: Qualitative - practitioner accounts of implementation (interviews, focus groups, reflective audio diaries) plus researcher field notes. SETTING/PARTICIPANTS: A total of 29 staff members from two hospice home-care services - contrasting geographical locations, different service sizes and staff composition. A thematic analysis was conducted. RESULTS: Existing approaches to identification of carer needs were informal and unstructured. Practitioners expressed some concerns, pre-implementation, about negative impacts of the Carer Support Needs Assessment Tool on carers and expectations raised about support available. In contrast, post-implementation, the Carer Support Needs Assessment Tool provided positive impacts when used as part of a carer-led assessment and support process: it made support needs visible, legitimised support for carers and opened up different conversations with carers. The mechanisms of action that enabled the Carer Support Needs Assessment Tool to make a difference were creating space for the separate needs of carers, providing an opportunity for carers to express support needs and responding to carers' self-defined priorities. CONCLUSION: The Carer Support Needs Assessment Tool delivered benefits through a change in practice to an identifiable, separate assessment process for carers, facilitated by practitioners but carer-led. Used routinely with all carers, the Carer Support Needs Assessment Tool has the potential to normalise carer assessment and support, facilitate delivery of carer-identified support and enable effective targeting of resources.

Developing a person-centred approach to carer assessment and support.

Community nurses play an important role in providing palliative care and support for patients and carers at home. The Carer Support Needs Assessment Tool (CSNAT) provides practitioners with an evidence-based comprehensive tool to use with carers in palliative home care. As a practice tool, the CSNAT uses a person-centred approach-that is, the process of carer assessment and support is facilitated by practitioners but is carerled. In this paper, the CSNAT research team provides an overview of the development of the tool and the benefits for both carers and practitioners arising from using the CSNAT as a person-centred approach in practice. The authors outline the five stages of the CSNAT approach to assist practitioners wishing to implement the CSNAT in practice.

Supported decision-making and mental capacity assessment in care homes: A qualitative study.

Up to 75% of UK care home residents may lack the mental capacity to make certain decisions (Wade, Clinical Rehabilitation, 2019, 33, 1561-1570). Care home staff need evidence-based tools to help them assess residents' mental capacity and provide decision-making support (NICE, Decision-making and mental capacity NICE guideline NG108, 2018). The Mental Capacity Assessment Support Toolkit (MCAST) was designed to support multidisciplinary healthcare staff to prepare, complete and document legally compliant mental capacity assessments. MCAST has not yet been trialled in care homes. This study used a descriptive qualitative design to: (a) understand the current challenges faced by care home staff when supporting residents to make decisions and participate in mental capacity assessments; (b) explore staff members' support needs in this context and (c) to identify if and how the toolkit could be adapted for use in care homes. A purposive sample of 29 staff working as managers (n = 18), nurses (n = 7) and care assistants (n = 4) across five care homes in North West England participated in five semi-structured focus groups between May and July 2019. Data from the focus group transcripts were analysed thematically (Braun & Clarke, Qualitative Research in Psychology, 2006, 3, 77-101). Five main themes were identified: (a) involvement of residents in decision-making; (b) approaches to mental capacity assessment; (c) working with residents with communication difficulties; (d) feelings about practice and (e) responses to MCAST. Participants appeared competent and confident about supporting decision-making and assessing capacity, but recognised the complexity of this area of practice, and identified a need for further support. They reported a range of challenges, including accessing support from speech and language therapists for residents with communication needs. They responded positively to the toolkit and were keen to use it in practice. This study suggests that care home staff would benefit from, and welcome, support to develop their practice. Furthermore, MCAST appears usable in this context and formal feasibility testing is justified.

Implementing disruptive technological change in UK healthcare: exploring development of a smart phone app for remote patient monitoring as a boundary object using qualitative methods.

PURPOSE: Developing technological innovations in healthcare is made complex and difficult due to effects upon the practices of professional, managerial and other stakeholders. Drawing upon the concept of boundary object, this paper explores the challenges of achieving effective collaboration in the development and use of a novel healthcare innovation in the English healthcare system. DESIGN/METHODOLOGY/APPROACH: A case study is presented of the development and implementation of a smart phone application (app) for use by rheumatoid arthritis patients. Over a two-year period (2015-2017), qualitative data from recorded clinical consultations (n = 17), semi-structured interviews (n = 63) and two focus groups (n = 13) were obtained from participants involved in the app's development and use (clinicians, patients, researchers, practitioners, IT specialists and managers). FINDINGS: The case focuses on the use of the app and its outputs as a system of inter-connected boundary objects. The analysis highlights the challenges overcome in the innovation's development and how knowledge sharing between patients and clinicians was enhanced, altering the nature of the clinical consultation. It also shows how conditions surrounding the innovation both enabled its development and inhibited its wider scale-up. ORIGINALITY/VALUE: By recognizing that technological artefacts can simultaneously enable and inhibit collaboration, this paper highlights the need to overcome tensions between the transformative capability of such healthcare innovations and the inhibiting effects simultaneously created on change at a wider system level.

Factors influencing practitioner adoption of carer-led assessment in palliative homecare: A qualitative study of the use of the Carer Support Needs Assessment Tool (CSNAT).

INTRODUCTION: Informal caregivers play a pivotal role in supporting patients approaching the end of life. The Carer Support Needs Assessment Tool (CSNAT) is designed to facilitate person-centred assessment and support through a process that is practitioner-facilitated, but carer-led. This study explored practitioners' experiences of implementing the CSNAT in palliative homecare. METHODS: We conducted qualitative interviews/focus groups with 20 practitioners in one UK hospice homecare service (18 nurses, two healthcare assistants) before and after the implementation of the CSNAT. Thematic analysis of the data was underpinned by framework analysis. RESULTS: Not all practitioners appreciated that using the CSNAT required a shift towards a more person-centred approach to assessment; consequently they tagged the tool onto their existing practitioner-led practice. Practitioners who did use the CSNAT as intended were able to act as role models and support their colleagues in making this transition. Practitioners' comments revealed a number of contradictions: 1) Most felt that they 'already do' identify carer support needs, but feared using the CSNAT could increase their workload; 2) some worried about introducing the CSNAT 'too soon', but recognised that it was 'too late' once patients were close to the end of life; 3) whilst practitioners stated 'they were there for the family as well as the patient', care provision was overtly centred around patients. CONCLUSION: This study provides vital insights into barriers and facilitators to implementing the CSNAT as part of a person-centred approach to assessment. The findings identified the training and support required to help practitioners make this transition to this new way of working.

Assessing the impact of a Carer Support Needs Assessment Tool (CSNAT) intervention in palliative home care: a stepped wedge cluster trial.

OBJECTIVES: To test the impact on family carers of a Carer Support Needs Assessment Tool (CSNAT) intervention to facilitate carer-led assessment and support during end of life care. METHOD: Mixed method, part-randomised, stepped wedge cluster trial with 6 palliative home care services comparing carers receiving the intervention with those receiving standard care. Postal survey with carers 4-5 months postbereavement measured adequacy of end of life support, current mental and physical health (Short Form 12 Health Survey SF-12), level of grief (Texas Revised Inventory of Grief, TRIG) and distress (Distress Thermometer, DT), place of death and carer satisfaction with place of death. RESULTS: Surveys were sent to 3260 (76%) carers of 4311 deceased patients; 681 (21%) were returned (N=333 control, N=348 intervention). Compared with controls, intervention carers had significantly lower levels of early grief, better psychological and physical health, were more likely to feel the place of death was right, and patients were more likely to die at home. However, differences were small and process measures showed low level of implementation, indicating differences may partially relate to increased awareness of carer issues rather than a direct impact of the intervention. CONCLUSIONS: Carers had better outcomes in the intervention condition, albeit modest. If this can be achieved through low level implementation and awareness raising of carers' needs from implementation activities, substantial impact should be possible if the CSNAT intervention can be fully implemented with a majority of carers. The study illustrates challenges of implementing and testing a complex intervention in real-life practice and of achieving comprehensive carer assessment and support in line with government recommendations.

HIV/AIDS in correctional settings: a salient priority for the CDC and HRSA.

Correctional facilities constitute an excellent opportunity to provide treatment, care, and prevention services for a population that may not otherwise access these services. The Centers for Disease Control and Prevention (CDC) and the Health Resources and Services Administration (HRSA) recognize the public health importance of correctional settings and have begun to develop formal strategies to address the HIV/AIDS-relevant needs of incarcerated individuals. The Centers for Disease Control and Prevention and HRSA have implemented policies, activities, and strategic plans to reduce the HIV/AIDS disease burden among the high-risk populations that pass through the nation's prisons and jails. They have also collaborated to address the HIV/AIDS needs of incarcerated populations and have initiated processes for expanding collaboration on these issues to include other federal agencies and prevention partners.

Predicting National Dental Hygiene Board Examination success based on specific admission factors.

PURPOSE: The purpose of this study was to determine if there are specific admissions criteria that are significantly correlated with a student's National Board Dental Hygiene Examination (NBDHE) total score and case-based score. Specifically, the study examined the relation between an individual's reading acuity and their scores on the NBDHE. Because of the competitive nature of most dental hygiene admissions, selecting those applicants who are more likely to be successful in the academic program and pass the NBDHE is critical. METHODS: Total NBDHE scores and case-based scores of 214 students attending Western Kentucky University's Program of Dental Hygiene between 2002 and 2010 were examined to determine if significant correlations existed. Specific factors examined were each student's total NBDHE score, as well as the score on the case-based section of the examination, age, microbiology lecture grade, microbiology lab grade, anatomy and physiology grade, college GPA, English grade, psychology grade, composite ACT score and subcomponent scores of the ACT (math, reading, English and science). RESULTS: Results revealed that the strongest predictors of total NBDHE scores were the score on the reading portion of the ACT (r=0.715, r2=0.511, p=0.01) and the grades in Microbiology lecture (r=0.644, r2=0.414, p=0.01). Results revealed that the strongest predictors of scores on the case-based portion of the NBDHE were students' scores on the reading portion of the ACT (r=0.673, r2=0.452, p=0.01) and the microbiology lecture grade (r = .637, r2 = .405, p = 0.01). CONCLUSION: Traditionally, schools have looked at specific science-based pre-requisite courses as a means of determining admission to schools of dental hygiene. Findings from this study suggest that a broader approach may need to be taken, specifically as it concerns a student's reading aptitude.

Clinical nurse specialists and the practice of community nurses.

AIM: This paper presents the findings of a study of the roles of Clinical Nurse Specialists and community nurses working in primary care. BACKGROUND: Clinical Nurse Specialists are recognized internationally as expert practitioners who could facilitate the implementation of evidence-based practice. However, others may misunderstand their role and greater support may be required if organizations are to capitalize on the skills of Clinical Nurse Specialists. METHODS: Elements of 'Glaserian' grounded theory in a broadly ethnographic approach were used to gain an understanding of the perspectives of 22 Clinical Nurse Specialists working as tissue viability nurses or continence advisors and 19 district nurses in one health region in the United Kingdom. The data were collected in 2001-02. FINDINGS: Clinical Nurse Specialists were keen to use their expertise to inform the practice of community nurses. However, they encountered difficulties when seeking to introduce changes in practice. Although Clinical Nurse Specialists were acknowledged as enabling rather than deskilling community nurses, receptivity to Clinical Nurse Specialists' ideas was dependent on what community nurses viewed as their own roles. As advisors, Clinical Nurse Specialists were dependent on the use of persuasion and vicarious power to bring about desired changes. These approaches are consistent with traditional approaches to change management as opposed to contemporary approaches to practice development. CONCLUSION: If Clinical Nurse Specialists are to reach their full potential and use their expertise to inform the practice of others, organizations need to recognize these posts as central to practice development. In particular, a framework is required which enables practice developers to use more inclusive approaches when seeking to bring about changes in practice.

Clinical nurse specialists as entrepreneurs: constrained or liberated.

AIMS: This qualitative study explored the experiences of two groups of clinical nurse specialists--continence advisors and tissue viability nurses--working in primary care in the UK. In particular, the study focused on how clinical nurse specialists' relationships with other health-care professionals had an impact on their role. BACKGROUND: Clinical nurse specialists are recognized worldwide as having expertise in a given field, which they use to develop the practice of others. Additionally, clinical nurse specialists share many of the characteristics of entrepreneurs, which they use to develop services related to their speciality. However, little research has been conducted in relation to clinical nurse specialists' experiences as they attempt to diversify nursing practice. DESIGN/METHODS: An ethnographic approach was adopted comprising many elements of Glaserian grounded theory. Data were collected via participant observation and face-to-face interviews with 22 clinical nurse specialists. FINDINGS: Services provided by clinical nurse specialists were not static, clinical nurse specialists being the main drivers for service developments. However, clinical nurse specialists encountered difficulties when introducing new ideas. Given their role as advisors, clinical nurse specialists lacked authority to bring about change and were dependent on a number of mechanisms to bring about change, including 'cultivating relationships' with more powerful others, most notably the speciality consultant. CONCLUSIONS: The UK government has pledged to 'liberate the talents of nurses' so that their skills can be used to progress patient services. This study highlights the fact that a lack of collaborative working practices between health-care professionals led to clinical nurse specialists being constrained. RELEVANCE TO CLINICAL PRACTICE: Health-care organizations need to provide an environment in which the entrepreneurial skills of clinical nurse specialists may be capitalized on. In the absence of an outlet for their ideas regarding service developments, clinical nurse specialists may remain dependent on the mechanisms witnessed in this study for some time.