Nursing

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354 To refer or not to refer?: ethical challenges of appropriate patient selection to obtain optimum survival and quality of life post lung transplant
(ScienceDirect, 2017-06) Robertson, Julie; MacDonald, Kath
Objectives: We present a case study which raises several ethical issues as to refer or not to refer and seek discussion and debate within this session. Currently in the UK there are 321 patients on the active lung transplant list. With a shortfall of available suitable organs, not all patients will receive a transplant. Up to 1 in 6 patients on the active lung transplant list die or become too sick to receive a graft. Successful transplant can achieve a 60% survival to 5 years. Contraindications to transplant can be physical and or psychosocial. This limited supply highlights the responsibility of CF teams to have consensus on referring candidates that are most likely to benefit from receiving this limited resource. The CF team need to be honest with patients and give a realistic account of process, outcomes and survival before a referral is made.
398 Exploring experiences of the in-patient ward round with young people with CF
(ScienceDirect, 2017-06) MacDonald, Kath; Mathews, A.
Objectives: The in-patient ward round, which involves a bedside visit by members of the multidisciplinary team to discuss treatment, progress and discharge plans, is central to the patient experience. However, its impact upon patients is often underestimated [1]. Research suggests that patients can feel anxious or dissatisfied with this vital clinical activity, as echoed by some patients in our Cystic Fibrosis (CF) Service. Our aim was to gain a better understanding of patient perspectives of our in-house ward round with a view to service improvement, if needed.
A Bridge Over Turbulent Waters: Illustrating the Interaction Between Managerial Leaders and Facilitators When Implementing Research Evidence
(Blackwell, 2016-01-20) van der Zijpp, Teatske Johanna; Niessen, Theo; Eldh, Ann Catrine; Hawkes, Claire; McMullan, Christel; Mockford, Carole; Wallin, Lars; McCormack, Brendan; Rycroft-Malone, Jo; Seers, Kate
Background: Emerging evidence focuses on the importance of the role of leadership in successfully transferring research evidence into practice. However, little is known about the interaction between managerial leaders and clinical leaders acting as facilitators (internal facilitators [IFs]) in this implementation process. Aims: To describe the interaction between managerial leaders and IFs and how this enabled or hindered the facilitation process of implementing urinary incontinence guideline recommendations in a local context in settings that provide long-term care to older people. Methods: Semistructured interviews with 105 managers and 22 IFs, collected for a realist process evaluation across four European countries informed this study. An interpretive data analysis unpacks interactions between managerial leaders and IFs. Results: This study identified three themes that were important in the interactions between managerial leaders and IFs that could hinder or support the implementation process: realising commitment negotiating conditions and encouragement to keep momentum going. The findings revealed that the continuous reciprocal relationships between IFs and managerial leaders influenced the progress of implementation, and could slow the process down or disrupt it. A metaphor of crossing a turbulent river by the building of a bridge emerged as one way of understanding the findings. Linking Evidence to Action: Our findings illuminate a neglected area, the effects of relationships between key staff on implementing evidence into practice. Relational aspects of managerial and clinical leadership roles need greater consideration when planning guideline implementation and practice change. In order to support implementation, staff assigned as IFs as well as stakeholders like managers at all levels of an organisation should be engaged in realising commitment, negotiating conditions, and keeping momentum going. Thus, communication is crucial between all involved. 2016 Sigma Theta Tau International.
A case study of a whole system approach to improvement in an acute hospital setting
(MDPI, 2022-01-22) Ward, Marie E.; Daly, Ailish; McNamara, Martin; Garvey, Suzanne; Teeling, Sean Paul
Changes in healthcare tend to be project-based with whole system change, which acknowledges the interconnectedness of socio-technical factors, not the norm. This paper attempts to address the question of whole system change posed by the special issue and brings together other research presented in this special issue. A case study approach was adopted to understand the deployment of a whole system change in the acute hospital setting along four dimensions of a socio-technical systems framework: culture, system functioning, action, and sense-making. The case study demonstrates evidence of whole system improvement. The approach to change was co-designed by staff and management, projects involving staff from all specialities and levels of seniority were linked to each other and to the strategic objectives of the organisation, and learnings from first-generation projects have been passed to second and third-generation process improvements. The socio-technical systems framework was used retrospectively to assess the system change but could also be used prospectively to help healthcare organisations develop approaches to whole system improvement.
A clinicopathological study of selected cognitive impairment cases in Lothian, Scotland: enhanced CJD surveillance in the 65 + population group
(BioMed Central, 2022-07-20) Kanguru, Lovney; Logan, Gemma; Waddel, Briony; Smith, Colin; Molesworth, Anna; Knight, Richard
Abstract: Background: Variant Creutzfeldt-Jakob Disease (vCJD) is primarily associated with dietary exposure to bovine-spongiform-encephalopathy. Cases may be missed in the elderly population where dementia is common with less frequent referral to specialist neurological services. This study’s twin aims were to determine the feasibility of a method to detect possible missed cases in the elderly population and to identify any such cases. Methods: A multi-site study was set-up in Lothian in 2016, to determine the feasibility of enhanced CJD-surveillance in the 65 + population-group, and undertake a clinicopathological investigation of patients with features of ‘atypical’ dementia. Results: Thirty patients are included; 63% male, 37% female. They were referred because of at least one neurological feature regarded as ‘atypical’ (for the common dementing illnesses): cerebellar ataxia, rapid progression, or somato-sensory features. Mean-age at symptom-onset (66 years, range 53–82 years), the time between onset-of-symptoms and referral to the study (7 years, range 1–13 years), and duration-of-illness from onset-of-symptoms until death or the censor-date (9.5 years, range 1.1–17.4 years) were determined. By the censor-date, 9 cases were alive and 21 had died. Neuropathological investigations were performed on 10 cases, confirming: Alzheimer’s disease only (2 cases), mixed Alzheimer’s disease with Lewy bodies (2 cases), mixed Alzheimer’s disease with amyloid angiopathy (1 case), moderate non-amyloid small vessel angiopathy (1 case), a non-specific neurodegenerative disorder (1 case), Parkinson's disease with Lewy body dementia (1 case), and Lewy body dementia (2 cases). No prion disease cases of any type were detected. Conclusion: The surveillance approach used was well received by the local clinicians and patients, though there were challenges in recruiting sufficient cases; far fewer than expected were identified, referred, and recruited. Further research is required to determine how such difficulties might be overcome. No missed cases of vCJD were found. However, there remains uncertainty whether this is because missed cases are very uncommon or because the study had insufficient power to detect them.
A complex intervention to reduce avoidable hospital admissions in nursing homes: A research programme including the BHiRCH-NH pilot cluster RCT
(National Institute for Health Research, 2021-03) Downs, Murna; Blighe, Alan; Carpenter, Robin; Feast, Alexandra; Froggatt, Katherine; Gordon, Sally; Hunter, Rachael; Jones, Liz; Lago, Natalia; McCormack, Brendan; Marston, Louise; Nurock, Shirley; Panca, Monica; Permain, Helen; Powell, Catherine; Rait, Greta; Robinson, Louise; Woodward-Carlton, Barbara; Wood, John; Young, John; Sampson, Elizabeth
Background An unplanned hospital admission of a nursing home resident distresses the person, their family and nursing home staff, and is costly to the NHS. Improving health care in care homes, including early detection of residents’ health changes, may reduce hospital admissions. Previously, we identified four conditions associated with avoidable hospital admissions. We noted promising ‘within-home’ complex interventions including care pathways, knowledge and skills enhancement, and implementation support. Objectives Develop a complex intervention with implementation support [the Better Health in Residents in Care Homes with Nursing (BHiRCH-NH)] to improve early detection, assessment and treatment for the four conditions. Determine its impact on hospital admissions, test study procedures and acceptability of the intervention and implementation support, and indicate if a definitive trial was warranted. Design A Carer Reference Panel advised on the intervention, implementation support and study documentation, and engaged in data analysis and interpretation. In workstream 1, we developed a complex intervention to reduce rates of hospitalisation from nursing homes using mixed methods, including a rapid research review, semistructured interviews and consensus workshops. The complex intervention comprised care pathways, approaches to enhance staff knowledge and skills, implementation support and clarity regarding the role of family carers. In workstream 2, we tested the complex intervention and implementation support via two work packages. In work package 1, we conducted a feasibility study of the intervention, implementation support and study procedures in two nursing homes and refined the complex intervention to comprise the Stop and Watch Early Warning Tool (S&W), condition-specific care pathways and a structured framework for nurses to communicate with primary care. The final implementation support included identifying two Practice Development Champions (PDCs) in each intervention home, and supporting them with a training workshop, practice development support group, monthly coaching calls, handbooks and web-based resources. In work package 2, we undertook a cluster randomised controlled trial to pilot test the complex intervention for acceptability and a preliminary estimate of effect. Setting Fourteen nursing homes allocated to intervention and implementation support (n = 7) or treatment as usual (n = 7). Participants We recruited sufficient numbers of nursing homes (n = 14), staff (n = 148), family carers (n = 95) and residents (n = 245). Two nursing homes withdrew prior to the intervention starting. Intervention This ran from February to July 2018. Data sources Individual-level data on nursing home residents, their family carers and staff; system-level data using nursing home records; and process-level data comprising how the intervention was implemented. Data were collected on recruitment rates, consent and the numbers of family carers who wished to be involved in the residents’ care. Completeness of outcome measures and data collection and the return rate of questionnaires were assessed. Results The pilot trial showed no effects on hospitalisations or secondary outcomes. No home implemented the intervention tools as expected. Most staff endorsed the importance of early detection, assessment and treatment. Many reported that they ‘were already doing it’, using an early-warning tool; a detailed nursing assessment; or the situation, background, assessment, recommendation communication protocol. Three homes never used the S&W and four never used care pathways. Only 16 S&W forms and eight care pathways were completed. Care records revealed little use of the intervention principles. PDCs from five of six intervention homes attended the training workshop, following which they had variable engagement with implementation support. Progression criteria regarding recruitment and data collection were met: 70% of homes were retained, the proportion of missing data was < 20% and 80% of individual-level data were collected. Necessary rates of data collection, documentation completion and return over the 6-month study period were achieved. However, intervention tools were not fully adopted, suggesting they would not be sustainable outside the trial. Few hospitalisations for the four conditions suggest it an unsuitable primary outcome measure. Key cost components were estimated. Limitations The study homes may already have had effective approaches to early detection, assessment and treatment for acute health changes; consistent with government policy emphasising the need for enhanced health care in homes. Alternatively, the implementation support may not have been sufficiently potent. Conclusion A definitive trial is feasible, but the intervention is unlikely to be effective. Participant recruitment, retention, data collection and engagement with family carers can guide subsequent studies, including service evaluation and quality improvement methodologies. Future work Intervention research should be conducted in homes which need to enhance early detection, assessment and treatment. Interventions to reduce avoidable hospital admissions may be beneficial in residential care homes, as they are not required to employ nurses. Trial registration Current Controlled Trials ISRCTN74109734 and ISRCTN86811077. Funding This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 2. See the NIHR Journals Library website for further project information.
A critical review: a combined conceptual framework of severity of illness and clinical judgement for analysing diagnostic judgements in critical illness
(Wiley-Blackwell, 2013-12-27) Smith, Margaret Coulter; Smith, Pam; Crow, Rosemary
Aims and objectives To analyse theoretical literature on severity of illness and clinical judgement and propose a combined conceptual framework for judgements taken to identify patients' clinical states in critical illness and also to critically review and synthesise general severity of illness prognostic models to identify dimensions and attributes of severity of illness in critical illness. Background The effective treatment of the critically ill requires the early identification of severe illness, and in acute wards, this is predominantly addressed by applying early warning scores focusing on indicators of physiological severity. Clinical judgement complements the application of early warning scores, but is generally not the focus of research and so requires further investigation. Design A critical review of the literature. Methods Severity of illness and clinical judgement literature was reviewed to identify themes for a combined conceptual framework for patient assessment in critical illness. MEDLINE and CINAHL (January 1981-December 2011) were searched for general severity of illness prognostic models in critical illness. Eleven research and five systematic review papers meeting review inclusion criteria were selected. Results Severity of illness is found to be a crucial theoretical construct in critical illness. It can enhance descriptive models of clinical judgement (such as social judgment theory and an inference/correspondence model in diagnostic judgment) when used to analyse and reflect on judgements made to diagnose the clinical state of the patient. Conclusions A combined conceptual framework of severity of illness and a descriptive clinical judgement model further informs patient assessments about the identification of clinical states in critical illness, alongside early warning scores. Relevance to clinical practice This article contributes to an understanding of the complexity of patient assessment and diagnostic judgement in critical illness.
A critique of Paulo Freire’s perspective on human nature to inform the construction of theoretical underpinnings for research
(Wiley, 2020-04-20) Sanders, Kate
This article presents a critique of Paulo Freire's philosophical perspective on human nature in the context of a doctoral research study to explore “muchness” or nurses’ subjective experience of well‐being; and demonstrates how this critique has informed the refinement of the theoretical principles used to inform research methodology and methods. Engaging in philosophical groundwork is essential for research coherence and integrity. Through this groundwork, largely informed by Freire's critical pedagogy and his ideas on humanization, I recognized the need to clarify my understanding of the concepts of persons and personhood and how this related to Freire's use of the term human beings. This clarification process is essential to ensure congruence between the theoretical principles that I draw from his work and my beliefs about persons, personhood and person‐centredness. The article begins with a brief introduction to the research, followed by an overview of Freire's philosophical perspectives, and subsequently, the critique process is presented and discussed. This process involved engaging with the vast literature and debates about what it means to be a person, to make sense of the often complex and contradictory arguments. Eventually, three headings emerged that helped me to frame my evolving understanding: Our species: human beings ; The kind that we are: human nature ; and This person that I am: personhood. Through this process of exploration, I recognized that Freire's perspective on human nature (a) foregrounded cognitive rationality, which presented itself as a limitation when considering my ontological beliefs and the focus of my research, leading me to draw on the work of Mark Johnson and his ideas about embodiment to help me to further develop my theoretical principles; (b) focused on the “collective” rather than individuals, which is a shortcoming in relation to person‐centred research that acknowledges the uniqueness of participants.
A description of a tailored knowledge translation intervention delivered by knowledge brokers within public health departments in Canada
(2019-06-20) Dobbins, Maureen; Greco, Lori; Yost, Jennifer; Traynor, Robyn; Decorby-Watson, Kara; Yousefi-Nooraie, Reza
BACKGROUND:While there is an expectation to demonstrate evidence-informed public health there is an ongoing need for capacity development. The purpose of this paper is to provide a description of a tailored knowledge translation intervention implemented by knowledge brokers (KBs), and reflections on the factors that facilitated or hindered its implementation. METHODS:The 22-month knowledge translation intervention, implemented by two KBs, sought to facilitate evidence-informed public health decision-making. Data on outcomes were collected using a knowledge, skills and behavioural assessment survey. In addition, the KBs maintained reflective journals noting which activities appeared successful or not, as well as factors related to the individual or the organisation that facilitated or hindered evidence-informed decision-making. RESULTS:Tailoring of the knowledge translation intervention to address the needs, preferences and structure of each organisation resulted in three unique interventions being implemented. A consistent finding across organisations was that each site needed to determine where evidence-informed decision-making 'fit' within pre-existing organisational processes. Components of the intervention consistent across the three organisations included one-to-one mentoring of teams through rapid evidence reviews, large group workshops and regular meetings with senior management. Components that varied included the frequency of the KB being physically onsite, the amount of time staff spent with the KB and proportion of time spent one-to-one with a KB versus in workshops. Key facilitating factors for implementation included strong leadership, influential power of champions, supportive infrastructure, committed resources and staff enthusiasm. CONCLUSIONS:The results of this study illustrate the importance of working collaboratively with organisations to tailor knowledge translation interventions to best meet unique needs, preferences, organisational structures and contexts. Organisational factors such as leadership, champions and supportive infrastructure play a key role in determining the impact of the knowledge translation interventions. Future studies should explore how these factors can be fostered and/or developed within organisations. While KBs implemented the knowledge translation intervention in this study, more research is needed to understand the impact of all change agent roles including KBs, as well as how these roles can be maintained in the long-term if proven effective.
A Kaleidoscope of Hope: Exploring Experiences of Hope Among Service Users and Informal Carers in Health Care Contexts
(SAGE, 2017-07-06) McCormack, Brendan; Borg, Marit; Cardiff, Shaun; Dewing, Jan; Jacobs, Gaby; Titchen, Angie; van Lieshout, Famke; Wilson, Valerie
Background: There is a large and diverse literature on the concept of hope in health care. This literature covers a broad spectrum of perspectives, from philosophical, conceptual, and theoretical analysis through to attempts at measuring the concept of hope with differing health care users. Aims: To explore the concept of hope through the secondary analysis of existing data sets, with the intention of understanding hope in the context of person-centeredness. Research Question: What is the experience of hope among service users and informal carers in different health care contexts? Method: Secondary analysis of data derived from three research studies. Findings: We identified four key themes that together illustrate what we describe as a kaleidoscope of hope, reinforcing the view that there is no one presentation of hope and that practitioners must engage authentically with service users to determine the most effective and appropriate intervention strategies. Conclusions: Hope is not a singular phenomenon, and in the context of person-centered practice there is a need for practitioners to engage authentically with service users and listen carefully to what may bring hope for them. 2016, The Author(s) 2016.
A literature review of the health of Gypsy/Traveller families in Scotland: the challenges for health promotion
(2003) Smart, H.; Titterton, M.; Clark, Colin
In this paper, findings from a detailed literature review (which was commissioned in March 2002 by Queen Margaret University College, UK) on Gypsy/Travellers' health are presented as well as suggestions on where gaps- exist in related empirical research. The review found that much of the existing research is out of date and found few thorough empirical studies of the health of Gypsy/Traveller communities in Scotland. The authors found that a predominant focus within the literature concerns health beliefs and cultural practices, with far less discussion about the material problems of poverty and social exclusion which affect Traveller communities. Emphasis is given in this paper to problems of access, health inequalities and wider concerns with social inclusion/exclusion. The authors identify the main challenges for health promotion among Gypsy/Traveller families in Scotland and argue that a key route to tackling social exclusion may lie in adopting a community development approach.
A narrative review of staff views about dementia care in hospital through the lens of a systems framework
(SAGE Publications, 2022-12-29) Duah-Owusu White, Mary; Kelly, Fiona
Background: Significant numbers of people with dementia are admitted into acute settings. They are likely to face poor health outcomes during hospitalisation. There is the need to fully understand the care provided to people with dementia through novel methods such a systems approach (i.e. human interactions, policy, environment and equipment). Aim: The aim of this literature review is to explore hospital practitioners’ views on dementia care and to analyse findings using a systems approach. Methods: We conducted a narrative review of primary studies that examined dementia care in acute settings. We analysed a total of 33 papers using Thomas and Harden’s thematic synthesis guidelines. Results: Thirty-three papers met the inclusion criteria for the review. The findings were as follows: (1) staff-patient relationships (e.g. coping with difficult behaviour), (2) staff–family relationships (e.g. the benefits of involving families in patient care), (3) staff–staff relationships (e.g. building a robust multidisciplinary team), (4) staff–patient care decisions (e.g. decisions directly related to the patient), (5) the environment (e.g. difficulty in adjusting to the hospital environment), (6) policies (e.g. hospital bureaucratic processes) and (7) equipment (e.g. pain assessment tools). Conclusion: The paper revealed multidimensional challenges in the provision of dementia care within hospitals. We conclude that training programmes, hospital policies and processes aimed at improving outcomes for patients with dementia should adopt a systems approach which focuses on the relational, environmental, procedural and instrumental aspects of the hospital system.
A qualitative exploration of living with dementia in supported living environments using a peer researcher approach
(Elsevier, 2022-02-02) Daly-Lynn, Jean; Ryan, Assumpta; McCormack, Brendan; Martin, Suzanne
Background The aim of the paper is to examine the experiences and perspectives of people living with dementia who live in supported living environments. Methods Peer researchers conducted semi-structured interviews with twenty-two people living with dementia in nine different supported living environments. Results Three themes developed from the thematic analysis: “You can come and go when you like” (Independence and Autonomy); “Everybody the staff and all, all works together” (Collaborative Relationships); and “When I came first, I saw this –I said is this all mine?” (Correct Fit of the Environment). Participants reported living environments that fostered their independence, choice, and control. Collaborative relationships with staff members and family caregivers were important to live the life of their choice. Finally, the correct environment created a sense of ownership and belonging within this space. Conclusions These findings illustrate that supported living can be an environment that empowers individuals on their dementia journey.
A qualitative meta-synthesis of studies of patients' experience of exercise interventions in advanced cancer
(Frontiers Media S.A., 2024-01-04) Young, Julie; Lloyd, Anna; Haraldsdottir, Erna
Background: People with advanced cancer often experience reduced functional capacity and quality of life. Research evaluating the potential benefit of exercise programmes for limiting such decline is accumulating. However, an appraisal of the evidence that considers the patient experience of exercise programmes, what mattered to them and what motivated and encouraged them to engage in exercise, has not been published. The aim of this meta-synthesis was to identify, appraise and bring together evidence from qualitative research in this area. Methods: Four databases were searched from 2nd January to 8th January 2023 for relevant studies. Qualitative studies investigating the experience of exercise as an intervention for adults with advanced cancer were included. Major findings and study characteristics were extracted. Findings were summarised, compared, and synthesised using meta-synthesis. Results: Eight studies were eligible and generated seven sub themes which informed the construction of three key themes: (1) Impact of Delivery Method; (2) Emerging Motivation; and (3) Physical Impact. Conclusion: The analysis revealed that exercise has the potential to positively influence all four dimensions of well-being: physical, psychological, social, and spiritual, for people with advanced cancer. Future research is required to consider the differential impact that the type, volume, and duration of exercise may have on the exercise experience for this patient group.
A qualitative study of family members' experiences of their loved one developing dementia and their subsequent placement in a nursing home
(Wiley, 2021-02-07) Fekonja, Zvonka; Kmetec, Sergej; Novak, Barbara; McCormack, Brendan; Mlinar Reljić, Nataša
Aim: To investigate the family members' experiences with receiving help and support while their loved one develops dementia and their subsequent placement in nursing homes.
A qualitative study of hospital patients' understanding of health promotion
(John Wiley & Sons, 2013-10) Shoqirat, N.; Cameron, Shona
Aims and objectives: To examine hospital patients' understanding of health promotion in Jordan. Background: Increasingly, hospital nurses are urged to promote patients' health and meet their needs. Yet, internationally, little is known about how patients themselves understand health promotion, and no Jordanian study has been undertaken in this area. Design: A qualitative design was used. Methods: Focus group discussions (n = 4) were undertaken with hospital patients. All discussions were digitally recorded, transcribed verbatim and analysed using qualitative thematic analysis. Results: Three images of health promotion emerged. These include health promotion as having adequate health knowledge, economic independency and good environment. It was also found that gender and spirituality affected patients' conceptualisations. Conclusions: Hospital patients' understanding and expectations of health promotion are complex and go beyond the disease management approach. Therefore, if health promotion is to meet patients' needs and operate at empowerment and socio-economic levels, the images identified in this article should be considered. The study limitations and recommendations for practice and future research are also outlined. Relevance to clinical practice: There is a need for a framework of health promotion that integrates patients' beliefs in general and particularly those related to religion and gender roles within the daily philosophy of care. Having achieved this, hospital nurses will be able to deliver culturally competent and wide-reaching health promotion. 2013 John Wiley & Sons Ltd.
A randomized, feasibility trial of an exercise and nutrition‐based rehabilitation programme (ENeRgy) in people with cancer
(Wiley, 2021-10-05) Hall, Charlie C.; Skipworth, Richard J.E.; Blackwood, Honor; Brown, Duncan; Cook, Jane; Diernberger, Katharina; Dixon, Elizabeth; Gibson, Valerie; Graham, Catriona; Hall, Peter; Haraldsdottir, Erna; Hopkinson, Jane; Lloyd, Anna; Maddocks, Matthew; Norris, Lucy; Tuck, Sharon; Fallon, Marie T.; Laird, Barry J.A.
Background: Despite rehabilitation being increasingly advocated for people living with incurable cancer, there is limited evidence supporting efficacy or component parts. The progressive decline in function and nutritional in this population would support an approach that targets these factors. This trial aimed to assess the feasibility of an exercise and nutrition based rehabilitation programme in people with incurable cancer. Methods: We randomized community dwelling adults with incurable cancer to either a personalized exercise and nutrition based programme (experimental arm) or standard care (control arm) for 8 weeks. Endpoints included feasibility, quality of life, physical activity (step count), and body weight. Qualitative and health economic analyses were also included. Results: Forty‐five patients were recruited (23 experimental arm, 22 control arm). There were 26 men (58%), and the median age was 78 years (IQR 69–84). At baseline, the median BMI was 26 kg/m2 (IQR: 22–29), and median weight loss in the previous 6 months was 5% (IQR: −12% to 0%). Adherence to the experimental arm was >80% in 16/21 (76%) patients. There was no statistically significant difference in the following between trial arms: step count − median % change from baseline to endpoint, per trial arm (experimental −18.5% [IQR: −61 to 65], control 5% [IQR: −32 to 50], P = 0.548); weight − median % change from baseline to endpoint, per trial arm (experimental 1%[IQR: −3 to 3], control −0.5% [IQR: −3 to 1], P = 0.184); overall quality of life − median % change from baseline to endpoint, per trial arm (experimental 0% [IQR: −20 to 19], control 0% [IQR: −23 to 33], P = 0.846). Qualitative findings observed themes of capability, opportunity, and motivation amongst patients in the experimental arm. The mean incremental cost of the experimental arm versus control was £‐319.51 [CI −7593.53 to 6581.91], suggesting the experimental arm was less costly. Conclusions: An exercise and nutritional rehabilitation intervention is feasible and has potential benefits for people with incurable cancer. A larger trial is now warranted to test the efficacy of this approach.
A rapid review of the rate of attrition from the health workforce
(BioMed Central, 2017-03-01) Castro Lopes, Sofia; Guerra-Arias, Maria; Buchan, James; Pozo-Martin, Francisco; Nove, Andrea
Background Attrition or losses from the health workforce exacerbate critical shortages of health workers and can be a barrier to countries reaching their universal health coverage and equity goals. Despite the importance of accurate estimates of the attrition rate (and in particular the voluntary attrition rate) to conduct effective workforce planning, there is a dearth of an agreed definition, information and studies on this topic. Methods We conducted a rapid review of studies published since 2005 on attrition rates of health workers from the workforce in different regions and settings; 1782 studies were identified, of which 51 were included in the study. In addition, we analysed data from the State of the World's Midwifery (SoWMy) 2014 survey and associated regional survey for the Arab states on the annual voluntary attrition rate for sexual, reproductive, maternal and newborn health workers (mainly midwives, doctors and nurses) in the 79 participating countries. Results There is a diversity of definitions of attrition and barely any studies distinguish between total and voluntary attrition (i.e. choosing to leave the workforce). Attrition rate estimates were provided for different periods of time, ranging from 3 months to 12 years, using different calculations and data collection systems. Overall, the total annual attrition rate varied between 3 and 44% while the voluntary annual attrition rate varied between 0.3 to 28%. In the SoWMy analysis, 49 countries provided some data on voluntary attrition rates of their SRMNH cadres. The average annual voluntary attrition rate was 6.8% across all cadres. Conclusion Attrition, and particularly voluntary attrition, is under-recorded and understudied. The lack of internationally comparable definitions and guidelines for measuring attrition from the health workforce makes it very difficult for countries to identify the main causes of attrition and to develop and test strategies for reducing it. Standardized definitions and methods of measuring attrition are required.
A realist inquiry to identify the contribution of Lean Six Sigma to person-centred care and cultures
(MDPI, 2021-10-03) Teeling, Sean Paul; Dewing, Jan; Baldie, Deborah
A lack of fidelity to Lean Six Sigma’s (LSS) philosophical roots can create division between person-centred approaches to transforming care experiences and services, and system wide quality improvement methods focused solely on efficiency and clinical outcomes. There is little research into, and a poor understanding of, the mechanisms and processes through which LSS education influences healthcare staffs’ person-centred practice. This realist inquiry asks ‘whether, to what extent and in what ways, LSS in healthcare contributes to person-centred care and cultures’. Realist review identified three potential Context, Mechanism, Outcome configurations (CMOcs) explaining how LSS influenced practice, relating to staff, patients, and organisational influences. Realist evaluation was used to explore the CMOc relating to staff, showing how they interacted with a LSS education Programme (the intervention) with CMOc adjudication by the research team and study participants to determine whether, to what extent, and in what ways it influenced person-centred cultures. Three more focused CMOcs emerged from the adjudication of the CMOc relating to staff, and these were aligned to previously identified synergies and divergences between participants’ LSS practice and person-centred cultures. This enabled us to understand the contribution of LSS to person-centred care and cultures that contribute to the evidence base on the study of quality improvement beyond intervention effectiveness alone.
A Realist Review Protocol into the Contexts and Mechanisms That Enable the Inclusion of Environmental Sustainability Outcomes in the Design of Lean Healthcare Improvement Interventions
(MDPI AG, 2024-07-02) Mead, Elaine Shelford; Teeling, Sean Paul; McNamara, Martin
Healthcare makes a significant contribution to the social, economic and environmental benefits of communities. It is correspondingly a significant employer and consumer of both energy and consumables, often at high costs. Lean, a quality improvement methodology focuses on the elimination of non-value add (NVA) activities (steps that do not add value from the perspective of the customer) to improve the flow of people, information or goods. Increasingly, Lean thinking is evolving from its initial focus on eliminating NVA to a more holistic approach that encompasses sustainability. However, little work has been undertaken intentionally, including environmental sustainability outcomes in Lean healthcare interventions. Realist review methodology facilitates an understanding of the extent to which an intervention works, for whom, in what context, why and how, and has proven useful in research relating to Lean interventions in healthcare settings. This protocol provides details for a realist review that will enable an understanding of the specific contexts in which certain mechanisms are activated that enable the inclusion of environmental sustainability outcomes in the design of Lean healthcare improvement interventions.