Older People Who Are Frequent Users of Acute Care: A Symptom of Fragmented Care? A Case Series Report on Patients' Pathways of Care

Older frequent users of acute care can experience fragmented care. There is a need to understand the issues in a local context before attempting to address fragmented care. 0.5% (n=61) of the population in a defined local government area were identified as having ≥4 unplanned emergency department (ED) presentations/ admissions to an acute-care hospital over 13 months. A retrospective case-series study was conducted to examine detailed pathways of care for 17 patients within the identified population. The two dominant presentation reasons were clinical symptoms associated with a declining/significant loss of capacity in fundamental self-care activities and chronic cardiac/respiratory conditions. Of patients discharged home, 21% of discharge letters were delayed >7 days and only 19% received a written discharge plan. Half of community dwelling patients received home nursing and/or assistance. Frequent users of acute care can experience untimely hospital communication and may require more coordinated care provided in the community to assist self-care and manage chronic conditions.

Transdisciplinary Research In Frailty: Knowledge Translation To Inform New Models of Care

Transforming care for frail older adults requires more than rigorous research. While preventing, identifying and managing frailty are critical to reducing the personal and health systems impact of frailty worldwide, collaborative approaches to research and research application that reflect stakeholder perspectives and priorities are necessary to create meaningful solutions to frailty-related challenges. In South Australia, a new Centre for Research Excellence in Frailty was recently launched with funding from the National Health and Medical Research Council of Australia. Comprised of a national team with international partnerships and expertise spanning geriatric medicine, nursing, general practice, health economics, pharmacy and rehabilitation medicine, the team is working across traditional disciplinary silos to achieve system level improvements. Drawing from this exemplar, we discuss how a co-design approach to knowledge translation underpins this transdisciplinary research, and how successfully restructuring health services to meet the physical, emotional and social needs of older adults hinges upon such collaboration.

OLDER PEOPLE WHO ARE FREQUENT USERS OF ACUTE CARE: A SYMPTOM OF FRAGMENTED CARE? A CASE SERIES REPORT ON PATIENTS’ PATHWAYS OF CARE

Older frequent users of acute care can experience fragmented care. There is a need to understand the issues in a local context before attempting to address fragmented care. 0.5% (n=61) of the population in a defined local government area were identified as having ≥4 unplanned emergency department (ED) presentations/admissions to an acute-care hospital over 13 months. A retrospective case-series study was conducted to examine detailed pathways of care for 17 patients within the identified population. The two dominant presentation reasons were clinical symptoms associated with a declining/significant loss of capacity in fundamental self-care activities and chronic cardiac/respiratory conditions. Of patients discharged home, 21% of discharge letters were delayed >7 days and only 19% received a written discharge plan. Half of community dwelling patients received home nursing and/or assistance. Frequent users of acute care can experience untimely hospital communication and may require more coordinated care provided in the community to assist self-care and manage chronic conditions.

Management of Musculoskeletal Conditions in Rural South Australia: A Randomised Controlled Trial

With age, the prevalence of musculoskeletal conditions increases markedly. This rural-based study determined the benefits of two approaches for managing musculoskeletal conditions: a multiple-component 'Self-management Plus' intervention, and usual care. The intervention combined self-management education with physical activity and health professional support. 6-month outcomes included: Clinical Global Impression-Improvement Scale (CGI-IS) and Quality of Life (QoL). A total of 145 people were recruited; mean (SD) age was 66.1 (11.1) and 63.3 (10.9) years for intervention and control groups respectively. The intervention resulted in greater improvements in global functioning (CGI-IS mean (SD) = 3.2 (1.3)) than usual care (CGI-IS mean (SD) = 4.2 (1.5)). There was no difference in QoL improvement between study groups. A multiple-component 'Self-management Plus' intervention had a positive effect on physical functioning for older adults with musculoskeletal conditions. However, recruitment and retention of participants was problematic, which raises questions about the intervention's feasibility in its current form.

Ingredients for change: revisiting a conceptual framework

Finding ways to deliver care based on the best possible evidence remains an ongoing challenge. Further theoretical developments of a conceptual framework are presented which influence the uptake of evidence into practice. A concept analysis has been conducted on the key elements of the framework--evidence, context, and facilitation--leading to refinement of the framework. While these three essential elements remain key to the process of implementation, changes have been made to their constituent sub-elements, enabling the detail of the framework to be revised. The concept analysis has shown that the relationship between the elements and sub-elements and their relative importance need to be better understood when implementing evidence based practice. Increased understanding of these relationships would help staff to plan more effective change strategies. Anecdotal reports suggest that the framework has a good level of validity. It is planned to develop it into a practical tool to aid those involved in planning, implementing, and evaluating the impact of changes in health care.

Nursing leadership: bringing caring back to the future

Leadership, whether it is nursing, medical or healthcare leadership, is about knowing how to make visions become reality. The vision that many nurses hold dear to their hearts is one where patients are treated with dignity and respect at all times; where systems are designed for the benefit of individual needs; and where the work performed by nurses and other carers is valued and respected. Achieving such a vision will require a paradigm shift in the philosophy, priorities, policies, and power relationships of the health service. Fundamentally, it will require the rhetoric of patient centred care to become a reality. The following scenario is set in the UK in the year 2012 and describes a health service that is on the pathway to achieving this vision. It tells the story from a nursing perspective and outlines the three key foundation stones that helped nursing achieve the vision of a patient centred health service: (1) development of patient centred care measures as part of performance management and the clinical governance agenda; (2) leadership based on personal growth and development principles; (3) new clinical career and competency framework for nursing.

Nursing leadership: bringing caring back to the future

Leadership, whether it is nursing, medical or healthcare leadership, is about knowing how to make visions become reality. The vision that many nurses hold dear to their hearts is one where patients are treated with dignity and respect at all times; where systems are designed for the benefit of individual needs; and where the work performed by nurses and other carers is valued and respected. Achieving such a vision will require a paradigm shift in the philosophy, priorities, policies, and power relationships of the health service. Fundamentally, it will require the rhetoric of patient centred care to become a reality. The following scenario is set in the UK in the year 2012 and describes a health service that is on the pathway to achieving this vision. It tells the story from a nursing perspective and outlines the three key foundation stones that helped nursing achieve the vision of a patient centred health service: (1) development of patient centred care measures as part of performance management and the clinical governance agenda; (2) leadership based on personal growth and development principles; (3) new clinical career and competency framework for nursing.

An evaluation of the RCN Clinical Leadership Development Programme: Part 2

AIM

The RCN Clinical Leadership Development Programme was set up in 1995 and sought to identify how clinical nurses in recognised leadership positions could improve the quality of patient care.

METHOD

The programme was tested on four senior nurses and 24 ward sisters in four acute hospital trusts in England over an 18-month period. The primary research question was whether the intervention improved the clinical leadership skills of participants. A pre-test/post-test design incorporating action research was deployed.

RESULTS

On a number of leadership dimensions, ward sisters' and senior nurses' performance had significantly improved. Five key themes emerged from the process data documenting the journey towards more effective clinical leadership: managing self; managing the team; patient-centred care; networking; and becoming more politically aware. There was evidence to show that patient care had also improved as measured by the way nursing care was organised; by patients' accounts of care they received and by documented improvements nurses carried out as a result of direct observation of care.

CONCLUSION

From the results of the study, it appears that there is a need for more effective clinical leadership development programmes for nurses to achieve better patient-centred care.

An evaluation of the RCN Clinical Leadership Development Programme: Part 1

AIM

The RCN Clinical Leadership Development Programme was set up in 1995 and sought to identify how clinical nurses in recognised leadership positions could improve the quality of patient care.

METHOD

The programme was tested on four senior nurses and 24 ward sisters in four acute hospital trusts in England over an 18-month period. The primary research question was whether the intervention improved the clinical leadership skills of participants. A pre-test/post-test design incorporating action research was deployed.

RESULTS

On a number of leadership dimensions, ward sisters' and senior nurses' performance had significantly improved. Five key themes emerged from the process data documenting the journey towards more effective clinical leadership: managing self; managing the team; patient-centred care; networking; and becoming more politically aware. There was evidence to show that patient care had also improved as measured by the way nursing care was organised; by patients' accounts of care they received and by documented improvements nurses carried out as a result of direct observation of care.

CONCLUSION

From the results of the study, it appears that there is a need for more effective clinical leadership development programmes for nurses to achieve better patient-centred care.

Towards evidence-based quality improvement: perspectives from nursing practice

This paper explores how the evidence-based practice and quality improvement movements are informing our understanding of what counts as quality patient care. Implicit in the debate is that we have understood and can manage the concept of patient safety. Using a true case study, the paper will illustrate how a clearer, more integrated understanding of safety, evidence-based practice and quality improvement principles can lead to more effective care. Central to this shift is the ability to move out of traditional, professionally bound ways of thinking to new systems and new ways of providing patient-centred care. Equally, how we generate the evidence to find out how safe or otherwise health care delivery systems are, must be as important an area of investigation as the search for a new therapy or treatment for a particular disease.

Towards practice development--a vision in reality or a reality without vision?

This paper describes the development of a conceptual framework for practice development. Drawing on the authors' combined experiences of facilitating developments in practice, a conceptual framework is proposed. It is argued that much practice development in health care today lacks a systematic approach and is often undertaken by individual practitioners who are poorly prepared for their roles. A short history of practice development is outlined to contextualize current development activities. The proposed framework is located in a critical social science philosophy and it is suggested that such a philosophy enables individual growth and development, empowerment of practitioners and the generation of cultural change that sustains continuous growth and innovation in practice. An example of the framework in use is described and recommendations proposed to enable organizations to embrace a systematic approach to practice development.

Nursing leadership: influencing and shaping health policy and nursing practice

The leadership discourse in the United Kingdom has to date been concerned with professional issues and as a result has focused upon developing nurses and nursing. This paper reports on the findings of a research study which examined the broader socio-political factors impacting upon nursing leadership. The study forms an integral part of the Royal College of Nursing's leadership programme. The principal aim of the research was to examine critically contemporary nursing leadership within the context of health policy. An ethnographic approach was used. Informal semi-structured interviews were undertaken with a purposive sample of 24 leaders who were recognized for their effectiveness in leading nursing. Data were analysed for themes. The main themes are presented and discussed here. The findings of the study question the political success which the internally focused nature of leadership has had for the profession. Nursing and therefore nursing leadership is shaped dramatically by the impact of politics and policy. The research discovered that in recognition of this, contemporary nursing leadership has both an internal and an external focus. That is, effective nursing leadership currently is a vehicle through which both nursing practice and health policy can be influenced and shaped. The research also identified the profile of the effective nurse leader, together with the processes through which leaders interpret and translate between the macro issues of policy and the micro issues of practice. In addition, an understanding of what nursing leadership is, has been proposed. Appropriate recommendations for the future of nursing and nursing leadership are outlined.

The essence of nursing

In the first of two articles, Alison Kitson outlines the fundamental elements of nursing, and how they should be protected and communicated. She argues that having the ability to care for the patient as a whole person is the essence of good nursing practice, in which a range of environmental and organisational conditions prevail, and over which the nurse must be in control. Similarly, basic observation and practical skills in traditional nursing must be evident before nurses can be assured they have met basic needs. She considers the effect of health care and other changes on nursing, along with strategies for ensuring that the essence of nursing is protected. The second article will appear next week.

Enabling the implementation of evidence based practice: a conceptual framework

The argument put forward in this paper is that successful implementation of research into practice is a function of the interplay of three core elements--the level and nature of the evidence, the context or environment into which the research is to be placed, and the method or way in which the process is facilitated. It also proposes that because current research is inconclusive as to which of these elements is most important in successful implementation they all should have equal standing. This is contrary to the often implicit assumptions currently being generated within the clinical effectiveness agenda where the level and rigour of the evidence seems to be the most important factor for consideration. The paper offers a conceptual framework that considers this imbalance, showing how it might work in clarifying some of the theoretical positions and as a checklist for staff to assess what they need to do to successfully implement research into practice.

Using a supervisory framework to support and evaluate a multiproject practice development programme

The paper describes a multiproject practice development programme undertaken over a period of 1 year. The background and development of the programme are outlined, whilst attention is paid to the innovatory nature of the work, particularly the use of inductive, deductive and integrated approaches to both change implementation and project supervision. The programme was monitored throughout using different data sources and the paper uses evaluative material retrospectively to provide answers to organizational and professional difficulties which arose during the course of the programme. The authors conclude that the use of combinations of different models for practice development has potential, but requires careful supervision. They also recommend that those involved in practice development are made fully aware of its local or micropolitics, and develop strategies to deal with change before it occurs, not after it has taken place.

Supporting R&D: the role of a professional organisation, Pt 2

This second of two articles describes how a professional organisation responded to external developments and tried to co-ordinate its nursing professions' response to research and development activity. For the first time an attempt was made to develop a strategy by eliciting the views of stakeholders. The R&D agenda was examined from the perspective of research, management, education and practice and led to the development of an agreed strategy for the RCN. The suitability of this approach as a mechanism for strategy development and as a lever for change is examined and its potential pertinence to other organisations is discussed.

Supporting R&D: the role of a professional organisation, Part 1

The first of two articles describes how a professional organisation responded to external developments and tried to co-ordinate its research and development (R&D) activity. For the first time an attempt was made to develop a strategy by eliciting the views of stakeholders. The R&D agenda was examined from the perspective of research, management, education and practice and led to the development of an agreed strategy for the Royal College of Nursing. The suitability of this approach as a mechanism for strategy development and as a lever for change is examined and its potential pertinence to other organisations is discussed.

From research to practice: one organisational model for promoting research based practice

This paper describes a framework used by the National Institute for Nursing in Oxford to integrate research, development and practice. With the increasing attention given to the topic of how research findings are implemented into clinical practice, it was felt important to share the challenges that have arisen in attempting to combine traditional research activities with more practice based development work. The emerging conceptual framework, structures and functions are described highlighting the variety of partnerships to be established in order to achieve the goal of integrating research into practice. While the underpinning principles of the framework--generating knowledge, implementing research into practice and evaluating the effectiveness of programmes--are not new, it is the way they have been combined within an organisational structure that could be helpful to others considering such a strategy. Both the strengths and weaknesses of the model are discussed, a number of conclusions drawn as to its robustness and consideration given to its replication.

Developing excellence in nursing practice and care

In this article, change, innovation and excellence in nursing practice are discussed. The author argues that nurses must take control of the systems they use to deliver patient care before they can successfully implement change and improve practice.

Lessons from the 1996 Research Assessment Exercise

This is a personal interpretation of the results of, and lessons to be learnt from, the most recent Research Assessment Exercise (RAE). Like many others who entered for the first time, and indeed like those who have gone through it all before, the RAE can be a bittersweet experience.

Using evidence to demonstrate the value of nursing

This article explores the position of nursing in relation to the evidence-based medicine (EBM) and clinical effectiveness (CE) initiatives. It argues that both activities are based on at least three implicit assumptions. By exploring these assumptions nurses can become more involved in evidence-based practice and clinical effectiveness activities.

Practitioner based quality improvement: a review of the Royal College of Nursing's dynamic standard setting system

OBJECTIVE

To explore and describe the implementation of the Royal College of Nursing's approach to audit--the dynamic standard setting system--within the current context of health care, in particular to focus on how the system has developed since its inception in the 1980s as a method for uniprofessional and multiprofessional audit.

DESIGN

Qualitative design with semistructure interviews and field visits.

SETTING

28 sites throughout the United Kingdom that use the dynamic standard setting system.

SUBJECTS

Quality and audit coordinators with a responsibility for implementing the system; clinical staff who practice the system.

MAIN MEASURES

Experiences of the dynamic standard setting system, including reasons for selection, methods of implementation, and observed outcomes.

RESULTS

Issues relating to four themes emerged from the data: practical experiences of the system as a method for improving patient care; issues of facilitation and training; strategic issues of implementation; and the use of the system as a method for multiprofessional audit. The development of clinical practice was described as a major benefit of the system and evidence of improved patient care was apparent. However, difficulties were experienced in motivating staff and finding time for audit, which in part related to the current format of the system and the level of training and support available for clinical staff. Diverse experiences were reported in the extent to which the system had been integrated at a strategic level of quality improvement and its successful application to multiprofessional clinical audit.

CONCLUSIONS

The Royal College of Nursing's dynamic standard setting system can successfully be used as a method for clinical audit at both a uniprofessional and multiprofessional level. However, to capitalise on the strengths of the system, several issues need to be considered further. These include modifications to the system itself, as well as a more strategic focus on resources and support for audit, better integration of quality initiatives in health care, and a continuing focus on ways to achieve true multiprofessional collaboration and involvement of patients in clinical audit.

Doing the right thing right

Is clinical effectiveness just a fancy way of getting nurses to do more with less? No, argues Professor Alison Kitson in a discussion on the issues and challenges clinical effectiveness presents for nurses and nursing.

Future imperatives: developing health visiting in response to changing demands

This paper is based on work undertaken by the National Institute for Nursing to establish mechanisms to enable purchasers to be more explicit about purchasing health visiting services by the commissioning health authority. The paper describes work undertaken to identify current issues, through selected reviews of the literature, the use of questionnaires, interviews with key stakeholders and, as a result, the development of an 'ideal model for practice' for health visitors. The development of possible outcome measures for health visiting practice is also considered in the context of changing health-care demand and delivery which is both a feature and the future of community care.

Achieving improvement through quality: an evaluation of key factors in the implementation process

Quality, audit and standard setting are major issues on the present day nursing and health care agenda. Considerable time, energy and resources have been invested in developing and implementing a range of different quality and audit systems, yet there is limited evidence to date to suggest that they are having any significant impact in terms of changing practice and improving patient care. This paper will present the results of a study undertaken to evaluate the implementation of three of the most common nursing quality systems used in the United Kingdom: Monitor, Qualpacs and the dynamic standard setting system (DySSSy). In each case, the focus was on identifying key factors in the process of implementation that could predict positive programme outcomes--defined in terms of acceptance by clinical nursing staff and perceived impact on the quality of patient care. The study adopted a three-stage evaluation design, with three distinct levels of investigation and analysis, and utilized a range of descriptive and exploratory methods. In total, 14 sites implementing one of the three nursing quality systems were studied. Additional data, derived from individuals' experiences of implementing quality in nursing, were used to enhance and validate the findings. The results indicated a number of important system-related, contextual and practical issues of implementation. These were underpinned by two key factors, defined as ownership for quality and action to improve. However, most present day nursing quality programmes appear to be failing to embrace these two concepts simultaneously. The paper will conclude by discussing the implications of these findings for future developments in nursing and health care quality improvement.

From research to practice: one organizational model for promoting research-based practice

This paper describes a framework used by the National Institute for Nursing in Oxford to integrate research, development and practice. With the increasing attention given to the topic of how research findings are implemented into clinical practice, it was felt important to share the challenges that have arisen in attempting to combine traditional research activities with more practice-based development work. The emerging conceptual framework, structures and functions are described, highlighting the variety of partnerships to be established in order to achieve the goal of integrating research into practice. While the underpinning principles of the framework-generating knowledge, implementing research into practice and evaluating the effectiveness of programmes-are not new, it is the way they have been combined within an organizational structure that could be helpful to others considering such a strategy. Both the strengths and weaknesses of the framework are discussed, a number of conclusions drawn as to its robustness and consideration given to its replication.

Clinical practice development and research activities in four district health authorities

This review is based on findings from a postal survey undertaken between March and September 1993 to elicit information from nurses in four district health authorities regarding development and research activity in which they were involved. The objectives of the review were to obtain baseline information on the extent, variety and scope of work being carried out, to provide staff with a mechanism for networking good practice and to identify any areas of replication. A snowball sampling technique was used to obtain information from nursing personnel. A total of 141 responses were received out of which 4% (n = 5) reported no activity. Response rates varied between organizations and specialist groups but were similar in terms of the number of small-scale clinical practice developments undertaken without identified support or supervision. Fifty-five per cent (n = 75) of the reported developments related to the organization and management of services while 11% (n = 15) focused on consumer-related issues. Few studies identified dissemination strategies and there was generally a lack of clarity over expected benefits of the study in terms of measurable outcomes to the organization, nursing staff or patients. Funding for clinical practice development and research in nursing was found to be very sparse; the reasons for this were not identified. Overall the review confirmed statements from other sources (DoH, 1993 a,b) that nursing development and research tends to be small scale and unsupported with nursing staff trying hard to implement research findings or be innovative in their practice without the necessary expertise and support. Such findings have implications for the current drive to implement research into practice.

Quality improvement of nursing care in hospitals in India: the dynamic approach

A workshop was held in Calcutta in August 1992 by the Nurses' Research Society of India (NRSI), in partnership with the Royal College of Nursing of the UK, Dynamic Quality Improvement Programme (DQIP), to introduce an approach to quality improvement to nurses in India interested in evaluating and improving the care they provide. Since then, three sites have implemented the system for standard setting and audit (Dynamic Standard Setting System) which is the method for evaluating care used within that approach. An appraisal of the progress of the sites to date indicates that, in the clinical setting, nurses are progressing well with the writing of standards and have experienced little difficulty in understanding the theory and processes involved. They are currently revising the standards written with a view to implementing them and auditing them in the near future. This article outlines the introduction of dynamic quality improvement and the Dynamic Standard Setting System to the nurses in India and describes the progress of one of the test-sites currently working on its implementation.

Criteria formulation and application: an evaluative framework

This paper critically examines how criteria are formulated and applied in quality assurance or quality improvement systems. It begins by drawing attention to the division that exists between criteria derived by so-called expert groups and those developed more locally by practitioners. In seeking to analyse the strengths and weaknesses of these two contrasting approaches, it explores the more fundamental questions of how criteria are formulated in general and how they can best be applied. An evaluative framework is offered as a working checklist for practitioners involved in criteria formulation. The framework identifies three main areas: actual construction of criteria; procedures for formulation and issues related to application. An example of each area is offered from results of the ODySSSy Project. The paper concludes by recommending more systematic studies in this highly complex area.

Post-operative pain management: a literature review

The appropriateness of any set of criteria generated to measure the quality of a particular intervention is dependent upon a thorough, up-to-date assessment of the current state-of-the-art. Few areas in nursing have received as much research attention as that of pain control, particularly post-operative pain control. The following review of the literature* on this subject complements earlier reviews undertaken by Seers (1988) by organizing the information according to four distinct categories, namely environmental issues, nursing actions, patient outcomes and a review of a number of pain measures. This particular format was selected in order to help in the development of structure, process and outcome criteria on the topic of post-operative pain management. The section on measurement is to inform practitioners about pain-assessment charts and provide ideas about auditing this area.

A comparison of expert- and practitioner-derived criteria for post-operative pain management

A comparison of two methods of criteria formulation was carried out as part of a 3-year research study looking at the effectiveness of a nursing quality assurance system (the Royal College of Nursing's Dynamic Standard Setting System). In particular, the study wished to explore whether and to what extent criteria sets derived from an expert group differed from criteria generated by local practitioner groups. One expert group and five local groups were helped to develop criteria on the topic of post-operative pain management. Results showed that the expert group underwent a much more controlled and systematic approach to the task than any of the local groups who were supported by newly trained facilitators. Despite this difference, two of the five local groups had criteria convergence scores of more than 55%, demonstrating that the local knowledge on the topic was acceptable. Whether the lower convergence of the groups was due to lack of knowledge or a combination of difficult group processes and novice facilitation is difficult to say. However, what the study did show was that local groups can generate criteria sets comparable to expert groups, given proper facilitation and support.