Purposeful Sampling for Qualitative Data Collection and Analysis in Mixed Method Implementation Research

Experiences of a health coaching self-management program in patients with COPD: a qualitative content analysis

Purpose

To describe the experiences of patients with COPD participating in a health coaching self-management program.

Patients and methods

Twenty patients who had participated in a 6-month health coaching self-management program intervention were purposefully selected for a qualitative evaluation of the program using semi-structured interviews. The interviews were analyzed using inductive qualitative content analysis.

Results

Four categories and 13 subcategories emerged describing the participants’ experiences of the program. Their experiences were expressed as gaining insight into the importance of knowledge and personal responsibilities in the management of COPD, taking action to maintain a healthy lifestyle, feeling supported by the program, and being hindered by individual and program limitations.

Conclusion

Iterative interactions between patients and health care professionals together with the content of the program are described as important to develop skills to manage COPD. However, in future self-management programs more awareness of individual prerequisites should be considered.

Continue, adjust, or stop antipsychotic medication: developing and user testing an encounter decision aid for people with first-episode and long-term psychosis

BACKGROUND

People with psychosis struggle with decisions about their use of antipsychotics. They often want to reduce the dose or stop, while facing uncertainty regarding the effects these decisions will have on their treatment and recovery. They may also fear raising this issue with clinicians. The purpose of this study was to develop and test a shared decision making (SDM) tool to support patients and clinicians in making decisions about antipsychotics.

METHODS

A diverse editorial research team developed an Encounter Decision Aid (EDA) for patients and clinicians to use as part of the psychiatric consultation. The EDA was tested using 24 semistructured interviews with participants representing six stakeholder groups: patients with first-episode psychosis, patients with long-term psychosis, family members, psychiatrists, mental health counselors, and administrators. We used inductive and deductive coding of interview transcripts to identify points to revise within three domains: general impression and purpose of the EDA; suggested changes to the content, wording, and appearance; and usability and potential contribution to the psychiatric consultation.

RESULTS

An EDA was developed in an iterative process that yielded evidence-based answers to five frequently asked questions about antipsychotic medications. Patients with long-term psychosis and mental health counselors suggested more changes and revisions than patients with first-episode psychosis and psychiatrists. Family members suggested more revisions to the answers about potential risks of stopping or adjusting antipsychotics than other respondents.

CONCLUSIONS

The EDA was perceived as potentially useful and feasible in psychiatric routine care, especially if presented during the consultation.

Prevalence of chronic kidney disease in Nigeria: systematic review of population-based studies

Background

The aim of this study was to identify and discuss published population-based studies carried out in Nigeria that have information on the prevalence of chronic kidney disease (CKD) and have also used the Kidney Disease Outcomes Quality Initiative (KDOQI) practice guidelines in defining CKD, with emphasis on the performance of three estimating equations for glomerular filtration rate (GFR) – Modification of Diet in Renal Disease (MDRD), Cock-croft–Gault, and CKD epidemiology collaboration (CKD-EPI) creatinine equation.

Materials and methods

A systematic literature search was carried out in Google, MEDLINE, PubMed, and AJOL database, with the aim of identifying relevant population-based studies with information on the prevalence of CKD in a location in Nigeria.

Results

Seven cross-sectional population-based studies were identified. Two of the studies used the Cockcroft–Gault and observed a prevalence of 24.4% and 26%. Four of the studies used the MDRD and the prevalences observed were 12.3%, 14.2%, 2.5%, and 13.4%. One of the studies used the CKD-EPI equation and the prevalence was 11.4%. The male to female ratios of CKD prevalence in six studies were 1:1.9, 0.8:1, 1:1.6, 1:2, 1:1.8, 1:1.4, and the observed risk factors in the studies were old age, obesity, diabetes mellitus, hypertension, family history of hypertension, family history of renal disease, low-income occupation, use of traditional medication, low hemoglobin, and abdominal obesity.

Conclusion

The prevalence of CKD was high but variable in Nigeria, influenced by the equation used to estimate the GFR. MDRD and CKD-EPI results are agreeable. There is a need for more population-based studies, with emphasis on repeating the GFR estimation after 3 months in subjects with GFR <60 mL/min/1.7 m².

Views and experiences with regard to antibiotic use of hospitalized patients in five European countries: a qualitative descriptive study

OBJECTIVES

To explore inpatients experiences and views with regard to antibiotics in five European hospitals.

METHODS

Qualitative study where a patient-centred framework was used to explore inpatients' experiences concerning antibiotic treatment. A purposeful sample of inpatients treated with antibiotics in five hospitals participated in interviews (all centres) and focus groups (Switzerland only).

RESULTS

A total of 31 interviews (five in Belgium, ten in Croatia, nine in France, five in the Netherlands and two in Switzerland) and three focus groups (in Switzerland, 11 participants) were performed. The median age of participants was 61 years (range 33-86 years). The following main themes emerged: (a) patients trust doctors to take the best decisions for them even though communication concerning different antibiotic-related aspects is often insufficient, (b) patients feel that doctors do not prioritize communication due to time constraints and do not seem to adapt information based on patients' preferences, (c) patients differ in their wish to be informed but overall want to be informed on the main aspects in an understandable way, (d) patients often find reassurance in sharing information about their antibiotic treatment with close family, (e) professionals should explore patients' preferences to be involved or not in shared decision making for antibiotic treatment.

CONCLUSION

Inpatients often doubt their ability to understand medical information and trust their physicians to take the best decisions for them. Tailored strategies that inform hospitalized patients, acknowledging their concerns and preferences, may be useful to promote patient involvement and to improve communication regarding antibiotic use.

A methodology for generating a tailored implementation blueprint: an exemplar from a youth residential setting

BACKGROUND

Tailored implementation approaches are touted as more likely to support the integration of evidence-based practices. However, to our knowledge, few methodologies for tailoring implementations exist. This manuscript will apply a model-driven, mixed methods approach to a needs assessment to identify the determinants of practice, and pilot a modified conjoint analysis method to generate an implementation blueprint using a case example of a cognitive behavioral therapy (CBT) implementation in a youth residential center.

METHODS

Our proposed methodology contains five steps to address two goals: (1) identify the determinants of practice and (2) select and match implementation strategies to address the identified determinants (focusing on barriers). Participants in the case example included mental health therapists and operations staff in two programs of Wolverine Human Services. For step 1, the needs assessment, they completed surveys (clinician N = 10; operations staff N = 58; other N = 7) and participated in focus groups (clinician N = 15; operations staff N = 38) guided by the domains of the Framework for Diffusion [1]. For step 2, the research team conducted mixed methods analyses following the QUAN + QUAL structure for the purpose of convergence and expansion in a connecting process, revealing 76 unique barriers. Step 3 consisted of a modified conjoint analysis. For step 3a, agency administrators prioritized the identified barriers according to feasibility and importance. For step 3b, strategies were selected from a published compilation and rated for feasibility and likelihood of impacting CBT fidelity. For step 4, sociometric surveys informed implementation team member selection and a meeting was held to identify officers and clarify goals and responsibilities. For step 5, blueprints for each of pre-implementation, implementation, and sustainment phases were generated.

RESULTS

Forty-five unique strategies were prioritized across the 5 years and three phases representing all nine categories.

CONCLUSIONS

Our novel methodology offers a relatively low burden collaborative approach to generating a plan for implementation that leverages advances in implementation science including measurement, models, strategy compilations, and methods from other fields.

Muslim physicians and palliative care: attitudes towards the use of palliative sedation

Background

Muslim norms concerning palliative sedation can differ from secular and non-Muslim perceptions. Muslim physicians working in a Western environment are expected to administer palliative sedation when medically indicated. Therefore, they can experience tension between religious and medical norms.

Objective

To gain insight into the professional experiences of Muslim physicians with palliative sedation in terms of religious and professional norms.

Design

Interpretative phenomenological study using semi-structured interviews to take a closer look at the experiences of Muslim physicians with palliative sedation. Data were recorded, transcribed and analysed by means of interpretative phenomenological analysis (IPA).

Participants

Ten Muslim physicians, working in the Netherlands, with professional experience of palliative sedation.

Results

Two main themes were identified: professional self-concept and attitudes towards death and dying. Participants emphasized their professional responsibility when making treatment decisions, even when these contravened the prevalent views of Islamic scholars. Almost all of them expressed the moral obligation to fight their patients’ pain in the final stage of life. Absence of acceleration of death was considered a prerequisite for using palliative sedation by most participants.

Conclusions

Although the application of palliative sedation caused friction with their personal religious conceptions on a good death, participants followed a comfort-oriented care approach corresponding to professional medical standards. All of them adopted efficient strategies for handling of palliative sedation morally and professionally. The results of this research can contribute to and provide a basis for the emergence of new, applied Islamic ethics regarding palliative sedation.

Exploring Education and Training Needs in Palliative Care among Family Physicians in Mumbai: A Qualitative Study

Context:

Patients with chronic life-limiting conditions on palliative care (PC) prefer to be treated at home. Medical care by family physicians (FPs) reduces demand on costly and busy hospital facilities. Working of PC team in collaboration with FPs is thus helpful in home-based management of patients.

Aims:

This study aimed at exploring the extent of knowledge of FPs about PC and the need for additional training.

Settings and Design:

Semi-structured interviews were conducted with ten FPs from two suburbs of Mumbai, currently served by home care services of a tertiary cancer care center.

Subjects and Methods:

Data were digitally recorded, transcribed, and analyzed using exploratory analysis followed by content analysis to develop thematic codes.

Results and Conclusions:

FPs perceive PC as symptom control and psychological support helpful in managing patients with advanced life-limiting illnesses. Further training would help them in PC provision. Such training programs should preferably focus on symptom management and communication skills. There is a need for further research in designing a training module for FPs to get better understanding of the principles of PC.

"When no-one's looking," the application of lung recruitment and normal saline instillation with paediatric endotracheal suction: An exploratory study of nursing practice

BACKGROUND

The complex nature of the Paediatric Intensive Care Unit (PICU) patient requires the bedside nurse to make rapid, complex decisions regarding endotracheal suction (ETS) interventions. It is not understood what influences nurses' decision making in the context of ETS, however, the actions of the clinician have a direct impact on the efficacy of the ETS event and patient outcomes.

OBJECTIVES

To explore and describe the use of normal saline instillation and lung recruitment with paediatric ETS in a cohort of Australian nurses, and to identify factors that influence normal saline use with ETS.

METHODS

A descriptive, exploratory study. An evidence-based practice model formed the conceptual basis for the study. Semi-structured interviews were conducted with 12 nurses from an Australian tertiary referral paediatric intensive care unit. Audiotaped interviews were transcribed. Inductive thematic analysis was used to code and analyse the interview data and identify themes.

FINDINGS

Data analysis revealed three themes: patient's clinical presentation, clinician judgement and unit practice norms.

CONCLUSIONS

Variability in nurses ETS practice was marked. In the absence of evidence based clinical guidelines, nurses relied on knowledge derived from clinical experience and the local setting to guide NSI and LR intervention decisions. Participants reported uncertainty regarding ETS best practice and perceived the lack of research evidence as a barrier to making informed clinical decisions at the bedside. Rigorous research evaluating the safety and efficacy of NSI and LR with ETS is urgently required for patient care; however PICU nurses rely on multiple sources of evidence to inform ETS practice decision.

Use of verbal autopsy and social autopsy in humanitarian crises

INTRODUCTION

Two billion people live in countries affected by conflict, violence and fragility. These are exceptional situations in which mortality shifts dramatically and in which civil registration and vital statistics systems are often weakened or cease to function. Verbal autopsy and social autopsy (VA and SA) are methods used to assign causes of death and understand the contexts in which these occur, in settings where information is otherwise unavailable. This review sought to explore the use of VA and SA in humanitarian crises, with a focus on how these approaches are used to inform policy and programme responses.

METHODS

A rapid scoping review was conducted on the use of VA and SA in humanitarian crises in low and middle-income countries since 1991. Drawing on a maximum variation approach, two settings of application ('application contexts') were selected and investigated via nine semi-structured expert interviews.

RESULTS

VA can determine causes of death in crisis-affected populations where no other registration system is in place. Combined with SA and active community involvement, these methods can deliver a holistic view of obstacles to seeking and receiving essential healthcare, yielding context-specific information to inform appropriate responses. The contexts in which VA and SA are used require adaptations to standard tools, and new mobile developments in VA raise specific ethical considerations. Furthermore, collecting and sythesising data in a timely, continuous manner, and ensuring coordination and communication between agencies, is important to realise the potential of these approaches.

CONCLUSION

VA and SA are valuable research methods to foster evidence-informed responses for populations affected by humanitarian crises. When coordinated and communicated effectively, data generated through these methods can help to identify levels, causes and circumstances of deaths among vulnerable groups, and can enable planning and allocating resources effectively, potentially improving health system resilience to future crises.

Pharmaceutical Services in Primary Health Care: are pharmacists and users on the same page?

This study investigated structural and organizational characteristics of the Pharmaceutical Services based on Primary Health Care (PHCPS) from the viewpoints of users and pharmacists. A mixed method design was applied, combining one-to-one semi-structured interviews with four pharmacists in charge of five public dispensing facilities and 69 users, with a secondary database analysis. Data were collected from February to August 2014 in Divinópolis, a municipality in Minas Gerais State. PHCPS were similar in terms of general activities performed and staff profile and background. While users were concerned about medicines' availability and improvements related to the PHCPS' conveniences and personnel, pharmacists pointed out problems regarding infrastructure to storage. Despite most users had low information on how to use their medicines, no pharmacists declared to participate in medicines dispensing activities. There was a low match between users and pharmacists viewpoints and advantages for concentrate medicines dispensing in a smaller number of facilities were not clear.

The barriers and facilitators for recognising distress in people with severe dementia on general hospital wards

Introduction

psychological symptoms and delirium are common, but underreported in people with dementia on hospital wards. Unrecognised and untreated symptoms can manifest as distress. Identifying distress accurately therefore could act as a trigger for better investigation and treatment of the underlying causes. The challenges faced by healthcare professionals to recognise and report distress are poorly understood.

Methods

semi-structured interviews with a purposive sample of 25 healthcare professionals working with older people in general hospitals were conducted. Interviews were analysed generating themes that describe the facilitators and barriers of recognising and caring for distress in dementia.

Results

regardless of training or experience all participants had a similar understanding of distress, and identified it as a term that is easily understood and communicated. All participants believed they recognised distress innately. However, the majority also believed it was facilitated by experience, being familiar with their patients and listening to the concerns of the person's usual carers. Barriers to distress recognition included busy ward environments, and that some people may lack the skill to identify distress in hypoactive patients.

Conclusion

distress may be a simple and easily identified marker of unmet need in people with dementia in hospital. However, modifiable and unmodifiable barriers are suggested that reduce the chance of distress being identified or acted on. Improving our understanding of how distress is identified in this environment, and in turn developing systems that overcome these barriers, may improve the accuracy with which distress is identified on hospital wards.

A qualitative evaluation of a physician-delivered pedometer-based step count prescription strategy with insight from participants and treating physicians

AIMS

The integration of pedometers into clinical practice has the potential to enhance physical activity levels in patients with chronic disease. Our SMARTER randomized controlled trial demonstrated that a physician-delivered step count prescription strategy has measurable effects on daily steps, glycemic control, and insulin resistance in patients with type 2 diabetes and/or hypertension. In this study, we aimed to understand perceived barriers and facilitators influencing successful uptake and sustainability of the strategy, from patient and physician perspectives.

METHODS

Qualitative in-depth interviews were conducted in a purposive sample of physicians (n = 10) and participants (n = 20), including successful and less successful cases in terms of pedometer-assessed step count improvements. Themes that achieved saturation in either group through thematic analysis are presented.

RESULTS

All participants appreciated the pedometer-based monitoring combined with step count prescriptions. Accountability to physicians and support offered by the trial coordinator influenced participant motivation. Those who increased step counts adopted strategies to integrate more steps into their routines and were able to overcome weather-related barriers by finding indoor alternative options to outdoor steps. Those who decreased step counts reported difficulty in overcoming weather-related challenges, health limitations and work constraints. Physicians indicated the strategy provided a framework for discussing physical activity and motivating patients, but emphasized the need for support from allied professionals to help deliver the strategy in busy clinical settings.

CONCLUSION

A physician-delivered step count prescription strategy was feasibly integrated into clinical practice and successful in engaging most patients; however, continual support is needed for maximal engagement and sustained use.

What Makes Research Useful for Public School Educators?

In this study, we explored the extent to which educators discuss and prioritize Rogers' (Diffusion of innovations, The Free Press: New York, 1995) five attributes of innovations-relative advantage, compatibility, complexity, observability, and trialability-in the context of research use. Using a directed content analysis of 54 semi-structured interviews and exemplar quotes, we describe how educators mentioned compatibility most frequently, but also commonly invoked observability and complexity in their discussions of research use. Our results also revealed key differences between educators in executive and non-executive roles. We discuss the implications of our findings for closing the research-practice gap in school-based mental health services and psychosocial interventions.

Improving Teamwork and Patient Outcomes with Daily Structured Interdisciplinary Bedside Rounds: A Multimethod Evaluation

BACKGROUND

Previous research has shown that interdisciplinary ward rounds have the potential to improve team functioning and patient outcomes.

DESIGN

A convergent parallel multimethod approach to evaluate a hospital interdisciplinary ward round intervention and ward restructure.

SETTING

An acute medical unit in a large tertiary care hospital in regional Australia.

PARTICIPANTS

Thirty-two clinicians and inpatients aged 15 years and above, with acute episode of care, discharged during the year prior and the year of the intervention.

INTERVENTION

A daily structured interdisciplinary bedside round combined with a ward restructure.

MEASUREMENTS

Qualitative measures included contextual factors and measures of change and experiences of clinicians. Quantitative measures included length of stay (LOS), monthly "calls for clinical review," and cost of care delivery.

RESULTS

Clinicians reported improved teamwork, communication, and understanding between and within the clinical professions, and between clinicians and patients, after the intervention implementation. There was no statistically significant difference between the intervention and control wards in the change in LOS over time (Wald ?2 = 1.05; degrees of freedom [df] = 1; P = .31), but a statistically significant interaction for cost of stay, with a drop in cost over time, was observed in the intervention group, and an increase was observed in the control wards (Wald ?2 = 6.34; df = 1; P = .012). The medical wards and control wards differed significantly in how the number of monthly "calls for clinical review" changed from prestructured interdisciplinary bedside round (SIBR) to during SIBR (F (1,44) = 12.18; P = .001).

CONCLUSIONS

Multimethod evaluations are necessary to provide insight into the contextual factors that contribute to a successful intervention and improved clinical outcomes.

Supporting teams to optimize function and independence in Veterans: a multi-study program and mixed methods protocol

Background

Successful implementation of new clinical programs depends on effectively establishing, reorganizing, or enhancing team structures and processes to coordinate the work of individuals who are interdependent in their tasks, manage relationships, and share responsibility for outcomes. However, a one-size-fits-all approach is rarely effective. In partnership with VA national clinical leaders and local clinical champions, the Optimizing Function and Independence VA Quality Enhancement Research Initiative program (Function QUERI) will evaluate efforts to implement team-based clinical programs for Veterans at risk for functional decline and disability.

Methods

Function QUERI will implement and evaluate three innovative, evidence-based clinical programs in VA medical centers: (1) a group physical therapy program for knee osteoarthritis (Group PT); (2) assisted early mobility for hospitalized older veterans (STRIDE), a supervised walking program for hospitalized older veterans; and (3) implementation of helping invested family members improve veteran experiences study (iHI-FIVES), a skills training program for caregivers of disabled Veterans. A common reason for clinical care gaps in these populations is poor communication and coordination among the many interdisciplinary providers involved in their care. To facilitate the implementation of the clinical programs, Function QUERI will evaluate the impact of complexity science-based implementation intervention to promote team readiness (CONNECT), an implementation intervention designed as a bundle of interaction-oriented activities to promote team function and readiness for change, on the implementation of clinical programs across multiple sites. The evaluation will use a mixed methods design. Group PT is a local, single-site quality improvement project where a modified CONNECT intervention will be tested to inform the remaining program implementation projects. For STRIDE and iHI-FIVES projects, we will randomize participating sites to implement the clinical program, with the CONNECT intervention or not, and will use a stepped-wedge cluster randomized trial design.

Discussion

Function QUERI will translate its findings across its projects to identify the contextual factors and components from CONNECT that improve team processes and function to optimize effective implementation for future rollout of VA clinical programs. Synthesizing findings within and across projects, we will specify dimensions of team characteristics and function that enhance capacity for clinical innovation and uptake of evidence-based programs.

Trial registration

NCT03300336 Registered September 28, 2017, NCT03474380 Registered March 15, 2018.

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0748-3) contains supplementary material, which is available to authorized users.

A Web-Based Decision Tool to Improve Contraceptive Counseling for Women With Chronic Medical Conditions: Protocol For a Mixed Methods Implementation Study

BACKGROUND

Women with chronic medical conditions, such as diabetes and hypertension, have a higher risk of pregnancy-related complications compared with women without medical conditions and should be offered contraception if desired. Although evidence based guidelines for contraceptive selection in the presence of medical conditions are available via the United States Medical Eligibility Criteria (US MEC), these guidelines are underutilized. Research also supports the use of decision tools to promote shared decision making between patients and providers during contraceptive counseling.

OBJECTIVE

The overall goal of the MiHealth, MiChoice project is to design and implement a theory-driven, Web-based tool that incorporates the US MEC (provider-level intervention) within the vehicle of a contraceptive decision tool for women with chronic medical conditions (patient-level intervention) in community-based primary care settings (practice-level intervention). This will be a 3-phase study that includes a predesign phase, a design phase, and a testing phase in a randomized controlled trial. This study protocol describes phase 1 and aim 1, which is to determine patient-, provider-, and practice-level factors that are relevant to the design and implementation of the contraceptive decision tool.

METHODS

This is a mixed methods implementation study. To customize the delivery of the US MEC in the decision tool, we selected high-priority constructs from the Consolidated Framework for Implementation Research and the Theoretical Domains Framework to drive data collection and analysis at the practice and provider level, respectively. A conceptual model that incorporates constructs from the transtheoretical model and the health beliefs model undergirds patient-level data collection and analysis and will inform customization of the decision tool for this population. We will recruit 6 community-based primary care practices and conduct quantitative surveys and semistructured qualitative interviews with women who have chronic medical conditions, their primary care providers (PCPs), and clinic staff, as well as field observations of practice activities. Quantitative survey data will be summarized with simple descriptive statistics and relationships between participant characteristics and contraceptive recommendations (for PCPs), and current contraceptive use (for patients) will be examined using Fisher exact test. We will conduct thematic analysis of qualitative data from interviews and field observations. The integration of data will occur by comparing, contrasting, and synthesizing qualitative and quantitative findings to inform the future development and implementation of the intervention.

RESULTS

We are currently enrolling practices and anticipate study completion in 15 months.

CONCLUSIONS

This protocol describes the first phase of a multiphase mixed methods study to develop and implement a Web-based decision tool that is customized to meet the needs of women with chronic medical conditions in primary care settings. Study findings will promote contraceptive counseling via shared decision making and reflect evidence-based guidelines for contraceptive selection.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03153644; https://clinicaltrials.gov/ct2/show/NCT03153644 (Archived by WebCite at http://www.webcitation.org/6yUkA5lK8).

A Novel Information Retrieval Tool to Find Hospital Care Team Members: Development and Usability Study

BACKGROUND

Hospital communication among members of a patient's care team is a central part of clinical workflow and consumes a large amount of a health care provider's time. Oftentimes the complexity of hospital care leads to difficulty in finding the appropriate contact, which can lead to inefficiencies and frustration. Squire is a Web-based information retrieval app created to improve the speed and efficiency in reaching the appropriate team member during the care of a hospitalized patient.

OBJECTIVE

The objective of the study was to design and develop Squire and to evaluate the usage, usability, and perceived effect of the app on finding the correct contact within a hospital.

METHODS

We used a mixed-methods design using a before-after survey methodology combined with one-on-one interviews to understand the perceived effect of Squire. The study took place at an academic medical center with internal medicine resident physicians. We surveyed residents on demographics, as well as time and efficiency of hospital communication before and after the use of Squire. After using Squire, participants were also asked to evaluate Squire's Net Promoter Score (NPS). A subset of voluntary participants participated in one-on-one interviews and completed the System Usability Scale (SUS). We performed descriptive statistics on participant characteristics, app usage data, and responses to surveys. Survey results were compared before and after Squire adoption using the Wilcoxon rank-sum test and a general linear model. Interview data were analyzed using content analysis with a qualitative description approach to review and categorize feedback from participants.

RESULTS

There was a 67.9% (74/109) response rate to the pre-Squire survey and 89.9% (98/109) response rate to the post-Squire survey. At baseline, there was an average of 22.2 (95% CI 18.4-26.0) minutes/day spent searching for the right contact, and this decreased to 16.3 (95% CI 13.9-18.7) minutes/day after Squire was launched (P=.01). There were favorable usability scores, with an average SUS of 84.7, and a marginal NPS of +6.1. Overall, the use of Squire included 22,283 page views, most commonly to contact the admissions office or portable chest x-ray technician. Interviews highlighted common benefits of Squire, including decreased perceived time spent on hold with operators and improvement in connecting with the appropriate contact in specialized, complex departments. Future opportunities were also identified to improve Squire including adding a two-way communication between physician and nursing staff and providing offline access.

CONCLUSIONS

Squire decreased the perceived time required to find an appropriate contact and had a favorable usability score; however, the NPS was marginal and several opportunities were identified to improve Squire for future use.

Kaizen philosophy

Purpose

The purpose of this paper is to perform a context analysis about a specific Kaizen program, suggestion systems in permanent teams, and identified the barriers and facilitators that companies encounter while implementing them from the workers’ perspective.

Design/methodology/approach

The authors applied an inductive method, the Grounded Theory, to develop a specific context theory using the information that emerged from a convenience sample of 182 workers in several countries.

Findings

The facilitators and barriers identified for the workers in the field study are aligned with those identified in previous studies, generally obtained using information provided by managers. The methodology enabled us to identify the relationships between them and their level of relevance.

Research limitations/implications

The main limitations were linked with the source of the data as the authors worked with a convenience sample and only analyzed the information provided by the workers.

Practical implications

The identified facilitators, their relationships and their relevance, contribute to understand the functioning phenomena of suggestion systems in permanent teams to facilitate organizations using this continuous improvement program more effectively.

Originality/value

The originality of this study, apart from identifying facilitators from the workers’ perspective, is that the used method enabled us to identify the relationships between them and know how the operators perceived their relevance.

Relational continuity with primary and secondary care doctors: a qualitative study of perceptions of users of the Catalan national health system

Background

In the current context of increasingly fragmented healthcare systems where patients are seen by multiple doctors in different settings, patients’ relational continuity with one doctor is regaining relevance; however little is known about relational continuity with specialists. The aim of this study is to explore perceptions of relational continuity with primary care and secondary care doctors, its influencing factors and consequences from the viewpoint of users of the Catalan national health system (Spain).

Methods

We conducted a descriptive-interpretative qualitative study using a two-stage theoretical sample; (i) contexts: three healthcare areas in the Catalan national health system with differing characteristics; (ii) informants: users 18 years or older attended to at both care levels. Sample size (n = 49) was reached by saturation. Data were collected by individual semi-structured interviews, which were audio recorded and transcribed. A thematic content analysis was carried out segmenting data by study area, and leaving room for new categories to emerge from the data.

Results

Patients across the areas studied generally experienced consistency of primary care doctors (PCD), alongside some inconsistency of specialists. Consistency of specialists did not seem to be relevant to some patients when their clinical information was shared and used. Patients who experienced consistency and frequent visits with the same PCD or specialist described and valued having established an ongoing relationship characterised by personal trust and mutual accumulated knowledge. Identified consequences were diverse and included, for example, facilitated diagnosis or improved patient-doctor communication. The ascription to a PCD, a health system-related factor, facilitated relational continuity with the PCD, whereas organizational factors (for instance, the size of the primary care centre) favoured consistency of PCD and specialists. Doctor-related factors (for example, high technical competence or commitment to patient care) particulary fostered the development of an ongoing relationship.

Conclusions

Consistency of doctors differs depending on the care level as does the relevance attributed to it. Most influencing factors can be applied to both care levels and might be addressed by healthcare managers to foster relational continuity. More research is needed to fully understand the relevance patients assign to relational continuity with specialists.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3042-9) contains supplementary material, which is available to authorized users.

Protocol for a mixed methods study of hospital readmissions: sensemaking in Veterans Health Administration healthcare system in the USA

INTRODUCTION

Effective delivery of healthcare in complex systems requires managing interdependencies between professions and organisational units. Reducing 30-day hospital readmissions may be one of the most complex tasks that a healthcare system can undertake. We propose that these less than optimal outcomes are related to difficulties managing the complex interdependencies among organisational units and to a lack of effective sensemaking among individuals and organisational units regarding how best to coordinate patient needs.

METHODS AND ANALYSIS

This is a mixed method, multistepped study. We will conduct in-depth qualitative organisational case studies in 10 Veterans Health Administration facilities (6 with improving and 4 with worsening readmission rates), focusing on relationships, sensemaking and improvisation around care transition processes intended to reduce early readmissions. Data will be gathered through multiple methods (eg, chart reviews, surveys, interviews, observations) and analysed using analytic memos, qualitative coding and statistical analyses. We will construct an agent-based model based on those results to explore the influence of sensemaking and specific care transition processes on early readmissions.

ETHICS AND DISSEMINATION

Ethical approval has been obtained through the Institutional Review Board of the University of Texas Health Science Center at San Antonio (approval number: 14-258 hour). We will disseminate our findings in manuscripts in peer-reviewed journals, professional conferences and through short reports back to participating entities and stakeholders.

Building motivation to participate in a quality improvement collaborative in NHS hospital trusts in Southeast England: a qualitative participatory evaluation

OBJECTIVES

This study explores the barriers and facilitators that impact on the motivation of practitioners to participate in a quality improvement collaborative.

DESIGN

A qualitative and formative evaluation using a participatory approach, the researcher-in-residence model which embraces the concept of 'coproducing' knowledge between researchers and practitioners using a range of research methods such as participant observation, interviews and documentary analysis. The design, creation and application of newly generated evidence are facilitated by the researcher through negotiation and compromise with team members.

PARTICIPANTS

Senior and middle managers, doctors and nurses.

SETTING

Two hospitals in Southeast England participating in a Patient Safety Improvement Collaborative and the facilitator (host) of the collaborative, based in Central London.

RESULTS

The evaluation has revealed facilitators and barriers to motivation categorised under two main themes: (1) inherent motivation and (2) factors that influence motivation, interorganisational and intraorganisational features as well as external factors. Facilitators included collaborative 'champions,' individuals who drove the quality improvement agenda at a local level, raising awareness and inspiring colleagues. The collaborative itself acted as a facilitator, promoting shared learning as well as building motivation for participation. A key barrier was the lack of board engagement in the participating National Health Service organisations which may have affected motivation among front-line staff.

CONCLUSIONS

Collaboratives maybe an important way of engaging practitioners in quality improvement initiatives. This study highlights that despite a challenging healthcare environment in the UK, there remains motivation among individuals to participate in quality improvement programmes as they recognise that improvement approaches may facilitate positive change in local clinical processes and systems. Collaboratives can harness this individual motivation to facilitate spread and adoption of improvement methodology and build engagement across their membership.

Sex, PrEP, and Stigma: Experiences with HIV Pre-exposure Prophylaxis Among New York City MSM Participating in the HPTN 067/ADAPT Study

The HPTN 067/Alternative Dosing to Augment Pre-Exposure Prophylaxis Pill Taking (ADAPT) study evaluated daily and non-daily dosing schedules for oral pre-exposure prophylaxis (PrEP) to prevent HIV. A qualitative sub-study including focus groups and in-depth interviews was conducted among men who have sex with men participating in New York City to understand their experience with PrEP and study dosing schedules. The 37 sub-study participants were 68% black, 11% white, and 8% Asian; 27% were of Hispanic/Latino ethnicity. Mean age was 34 years. Themes resulting from qualitative analysis include: PrEP is a significant advance for HIV prevention; non-daily dosing of PrEP is congruent with HIV risk; and pervasive stigma connected to HIV and risk behavior is a barrier to PrEP adherence, especially for non-daily dosing schedules. The findings underscore how PrEP intersects with other HIV prevention practices and highlight the need to understand and address multidimensional stigma related to PrEP use.

Effects of mastic oleoresin on wound healing and episiotomy pain: A mixed methods study

INTRODUCTION

Mastic (Pistacia lentiscus) oleoresin (MO is used by traditional Baluch healers to precipitate wound healing and relieve episiotomy pain.

OBJECTIVE(S)

To investigate the effects of MO on wound healing and episiotomy pain intensity in nulliparous Baluch women.

MATERIALS AND METHODS

This study had a mixed methods design. In the qualitative phase, we interviewed 9 traditional healers and 13 women to understand how the indigenous people use MO for wound healing. In the quantitative phase, a randomized controlled trial was performed on primiparous women during July 23-November 22 in 2016. One hundred and forty-seven women were randomly assigned to intervention (n=73) and control (n=74) groups. At 48h postpartum, 15g of MO was provided to the women to be administered for three days (through smoking the episiotomy wound). Pain and wound healing were measured at 3, 7, and 10 days postpartum using the visual analogue scale and REEDA scale, respectively.

RESULTS

MO had no significant effect on episiotomy pain intensity at 3, 7, and 10 days postpartum (p=0.61, p=0.76, and p=0.45, respectively). In addition, healing rates of the episiotomy wounds treated by MO (mean: 0.11±0.45, 0.15±0.51, and 0.15±0.57, respectively) were higher than those in the control group (mean: 0.21±0.70, 0.16±0.63, and 0.49±0.28, respectively) at 3, 7, and 10 days postpartum; however, the difference between the two groups was not significant (p=0.27, p=0.76, and p=0.23, respectively).

CONCLUSION

In the current study, healing rates in the MO group were higher than those in the control group; however, further studies should be undertaken to identify the effects of MO.

Becoming an Advocate: Processes and Outcomes of a Relationship-Centered Advocacy Training Model

Counseling programs across the country are increasingly incorporating social justice advocacy training into their curricula. However, much remains to be learned about the developmental processes by which students develop advocacy skills and apply those skills after they graduate. To address these questions and drive further innovation in the field of advocacy training, we conducted an evaluation of the Community Advocacy Project, a yearlong microlevel advocacy training model that teaches mental health counseling master’s students to use relationship-centered advocacy with individuals in marginalized communities. We interviewed 19 counselors within 2.5 years of their graduation from the project about their experiences of the program and their current advocacy work. Using qualitative description, we developed a model describing processes of Internal Grappling, Building the Advocacy Relationship, and Integrating the Advocate Identity that highlights the importance of a yearlong one-on-one advocacy relationship, intensive reflection and supervision, and community collaboration.

Patients and hospital managers want laparoscopic simulation training to become mandatory before live operating: a multicentre qualitative study of stakeholder perceptions

Background

Surgical procedures are complex and susceptible to human error. Individual surgical skill correlates with improved patient outcomes demonstrating that surgical proficiency is vitally important for patient safety. Evidence demonstrates that simulation training improves laparoscopic surgical skills; however, projects to implement and integrate laparoscopic simulation into core surgical curricula have had varied success. One barrier to successful implementation has been the lack of awareness and prioritisation of simulation initiatives by key stakeholders.

Objective

To determine the knowledge and perceptions of patients and hospital managers on laparoscopic surgery and simulation training in patient safety and healthcare.

Method

A qualitative study was conducted in the Southwest of England. 40 semistructured interviews were undertaken with patients attending general gynaecology clinics and general surgical and gynaecology hospital managers.

Results

Six key themes identified included: positive expectations of laparoscopic surgery; perceptions of problems and financial implications of laparoscopic surgery; lack of awareness of difficulties with surgical training; desire for laparoscopic simulation training and competency testing for patient benefit; conflicting priorities of laparoscopic simulation in healthcare; and drawbacks of surgical simulation training. Patients and managers were largely unaware of the risks of laparoscopic surgery and challenges for training. Managers highlighted conflicting financial priorities when purchasing educational equipment. Patients stated that they would have greater confidence in a surgeon who had undertaken mandatory surgical simulation training and perceived purchasing simulation equipment to be a high priority in the National Health Services. Most patients and hospital managers believed trainees should pass an examination on a simulator prior to live operating.

Conclusions

Competency-based mandatory laparoscopic simulation was strongly supported by the majority of stakeholders to augment the initial learning curve of surgeons.

Understanding barriers to the introduction of precision medicines in non-small cell lung cancer: A qualitative interview protocol

Background: While precision medicines targeting genetic mutations and alterations in non-small cell lung cancer (NSCLC) have been available since 2010, their adoption into clinical practice has been slow. Evidence suggests that a number of barriers, such as insufficient clinician knowledge, a need for training of test providers, or a lack of specific clinical guidelines, may slow the implementation of precision in general. However, little attention has been given to the barriers to providing precision medicines in NSCLC. The purpose of this protocol is to outline the design for a qualitative interview study to identify the barriers and facilitators to the provision of precision medicines for NSCLC. Methods: This study will use semi-structured interviews with clinicians (n=10), test providers (n=10), and service commissioners (n=10) to identify the perceived barriers and facilitators to providing historical, current, and future precision medicines in NSCLC. Participants will be identified through mailing list advertisements and snowball sampling. Recruitment will continue until data saturation, indicated by no new themes arising from the data. Interviews will be conducted by telephone to facilitate geographical diversity. The qualitative data will be analysed using a framework analysis with themes anticipated to relate to; relevant barriers to providing precision medicines, the impact of different barriers on medicine provision, changes in the ability to provide precision medicines over time, and strategies to facilitate the provision of precision medicines. Ethics: This study has been approved by the University of Manchester Proportionate Review Research Ethics Committee (Reference number: 2017-1885-3619). Written consent will be obtained from all participants. Conclusion: This study is the first to explore the barriers and facilitators to providing precision medicines for NSCLC in the English NHS. The findings will inform strategies to improve the implementation of future precision medicines. These findings will be disseminated in peer-reviewed publications and national and international conferences.

'I felt pain. Deep pain…': Experiences of primary caregivers of stroke survivors with aphasia in a South African township

Background

Aphasia is an acquired impairment in language and in the cognitive processes that underlie language. Aphasia affects the quality of life of the person with aphasia (PWA) and his or her families in various ways in diverse contexts and cultures. It is therefore important that speech language therapists understand how different contextual and cultural factors may mediate experiences.

Purpose

The aim of the study was to describe the caregiving experience of female caregivers of PWA residing in Tembisa, a township situated in the east of Johannesburg.

Method

Qualitative, semi-structured interviews were conducted with primary caregivers of PWA. Purposive sampling was used to recruit 14 primary caregivers of PWA who were daughters, daughters-in-law or wives of the PWA. The interviews were conducted in participants’ first language and analysed by the researcher, who is proficient in isiZulu. Data were analysed according to the principles of thematic analysis.

Results

Findings indicated that caregivers are unfamiliar with aphasia and the support available to them. Participants experienced frustration and found communication to be challenging owing to their lack of communication strategies. The participants’ experiences reflected their context-specific experiences, such as feminisation of caregiving, barriers to healthcare, the influence of low health literacy and contextual perspectives on stroke and aphasia.

Conclusions

Contextual factors of caregivers in Tembisa have an influence on the experiences between caregivers and PWA, the feelings of individuals and families and health-seeking behaviours of individuals and families.

Improving interpretation of publically reported statistics on health and healthcare: the Figure Interpretation Assessment Tool (FIAT-Health)

BACKGROUND

Policy-makers, managers, scientists, patients and the general public are confronted daily with figures on health and healthcare through public reporting in newspapers, webpages and press releases. However, information on the key characteristics of these figures necessary for their correct interpretation is often not adequately communicated, which can lead to misinterpretation and misinformed decision-making. The objective of this research was to map the key characteristics relevant to the interpretation of figures on health and healthcare, and to develop a Figure Interpretation Assessment Tool-Health (FIAT-Health) through which figures on health and healthcare can be systematically assessed, allowing for a better interpretation of these figures.

METHODS

The abovementioned key characteristics of figures on health and healthcare were identified through systematic expert consultations in the Netherlands on four topic categories of figures, namely morbidity, healthcare expenditure, healthcare outcomes and lifestyle. The identified characteristics were used as a frame for the development of the FIAT-Health. Development of the tool and its content was supported and validated through regular review by a sounding board of potential users.

RESULTS

Identified characteristics relevant for the interpretation of figures in the four categories relate to the figures' origin, credibility, expression, subject matter, population and geographical focus, time period, and underlying data collection methods. The characteristics were translated into a set of 13 dichotomous and 4-point Likert scale questions constituting the FIAT-Health, and two final assessment statements. Users of the FIAT-Health were provided with a summary overview of their answers to support a final assessment of the correctness of a figure and the appropriateness of its reporting.

CONCLUSIONS

FIAT-Health can support policy-makers, managers, scientists, patients and the general public to systematically assess the quality of publicly reported figures on health and healthcare. It also has the potential to support the producers of health and healthcare data in clearly communicating their data to different audiences. Future research should focus on the further validation of the tool in practice.

Women Veterans' Experiences of Intimate Partner Violence and Non-Partner Sexual Assault in the Context of Military Service: Implications for Supporting Women's Health and Well-Being

Women who have served in the military in the United States experience high rates of intimate partner violence (IPV) and non-partner sexual assault (SA). The military setting presents challenges and opportunities not experienced in other employment contexts that may compound the negative impacts of IPV/SA on women's lives. The purpose of this study was to explore the intersection of women's experiences of IPV/SA and military service through analysis of women veterans' narrative accounts. We conducted in-depth face-to-face qualitative interviews with 25 women veterans receiving primary care at a U.S. Veterans Affairs Medical Center. We draw upon Adler and Castro's (2013) Military Occupational Mental Health Model to frame our understanding of the impact of IPV/SA as a stressor in the military cultural context and to inform efforts to prevent, and support women service members who have experienced, these forms of violence. Our findings highlight the impact of IPV/SA on women's military careers, including options for entering and leaving military service, job performance, and opportunities for advancement. Women's narratives also reveal ways in which the military context constrains their options for responding to and coping with experiences of IPV/SA. These findings have implications for prevention of, and response to, intimate partner or sexual violence experienced by women serving in the military and underscore the need for both military and civilian communities to recognize and address the negative impact of such violence on women service members before, during, and after military service.

Implementation between text and work-a qualitative study of a readmission prevention program targeting elderly patients

Background

Numerous studies emphasize the importance of context in implementation. Successful implementation across the health care system depends on conditions and requirements that are often presented to health professionals through text-based materials and might present contradictory expectations to the work of health professionals. In this study, we operationalize institutional context as the text-based material, which from the perspective of health professionals, influence health care work. Via the case of a readmission prevention program for elderly patients, we examine the experiences of health professionals that work with implementation, concerning the contradictions that arise between the demands imposed by program implementation and their everyday work routines, and the role of text-based materials in these contradictions.

Method

We conducted five focus group interviews among health professionals working at different locations in a single administrative region of Denmark. The 24 health professionals in our study included hospital physicians, hospital nurses, medical secretaries, municipal care managers, registered municipal nurses, and general practitioners. All focus group interviews were transcribed verbatim. Inspired by institutional ethnography, we look into text-based materials, such as written guidelines, if health professionals indicate they are important.

Results

The health professionals experience that specific demands of the readmission prevention program come into conflict with the existing demands and daily work routines. Professional resistance to control and the existing digital communication tools create tensions with a program requirement for standardized enrollment of patients to the program. In addition, the striving for autonomy among health professionals and the high level of mono-professional working routines create tension with the program requirements for an additional amount of interdisciplinary work. The different demands are widely mediated by text-based materials such as the existing digital communication tools and the instructions on how to use them, and the official agreement of the role and assignment for Danish GPs.

Conclusion

Successful implementation of the prevention program is affected by various tensions between the program demands and the existing health care work. Text-based materials mediate the different demands of the institutional context in to health care work and influence the process of implementation.

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0730-0) contains supplementary material, which is available to authorized users.

A Qualitative Study Identifying Key Components to Standardize Across Inpatient General Medicine Advanced Pharmacy Practice Experiences

Objective. To identify common components of inpatient general medicine advanced pharmacy practice experiences (APPEs) across sites, determine which components were important to standardize, and distinguish a benchmark of each component that would indicate standardization. Methods. In-depth interviews about the student experience were conducted with two students and one or more preceptors at each of 12 inpatient general medicine sites in the greater Seattle metropolitan area. Data from transcribed interviews were analyzed, then collapsed into a single spreadsheet for comparison. Overall themes for component groups were identified and components within each theme tested for importance in overall quality of the student experience. Components important for quality of the student experience were deemed "key components" and component metrics were developed for benchmarking. Results. Three themes were essential in the quality of the learning experience at inpatient general medicine sites: welcoming of the student by the preceptors, integration of the student into the site, and student interaction with patients and other health care providers. Key components to be standardized across sites were a structured orientation, written site-specific student guidelines and performance expectations, regular and meaningful student-preceptor interactions, identified performance competency standards, clear delineation of student patient care load and responsibilities, and daily interactions with patients and other health care providers. Conclusion. Qualitative evidence from sites can be used to identify key components to standardize across practice sites offering the same experiential course. These key components aid in the welcoming of the student to the site, integration of the student into the workflow, and daily opportunities for the student to interact with patients and with health care providers.

Quantifying the effectiveness of shoreline armoring removal on coastal biota of Puget Sound

Shoreline armoring is prevalent around the world with unprecedented human population growth and urbanization along coastal habitats. Armoring structures, such as riprap and bulkheads, that are built to prevent beach erosion and protect coastal infrastructure from storms and flooding can cause deterioration of habitats for migratory fish species, disrupt aquatic–terrestrial connectivity, and reduce overall coastal ecosystem health. Relative to armored shorelines, natural shorelines retain valuable habitats for macroinvertebrates and other coastal biota. One question is whether the impacts of armoring are reversible, allowing restoration via armoring removal and related actions of sediment nourishment and replanting of native riparian vegetation. Armoring removal is targeted as a viable option for restoring some habitat functions, but few assessments of coastal biota response exist. Here, we use opportunistic sampling of pre- and post-restoration data for five biotic measures (wrack % cover, saltmarsh % cover, number of logs, and macroinvertebrate abundance and richness) from a set of six restored sites in Puget Sound, WA, USA. This broad suite of ecosystem metrics responded strongly and positively to armor removal, and these results were evident after less than one year. Restoration responses remained positive and statistically significant across different shoreline elevations and temporal trajectories. This analysis shows that removing shoreline armoring is effective for restoration projects aimed at improving the health and productivity of coastal ecosystems, and these results may be widely applicable.

Private healthcare provider experiences with social health insurance schemes: Findings from a qualitative study in Ghana and Kenya

Background

Incorporating private healthcare providers into social health insurance schemes is an important means towards achieving universal health coverage in low and middle income countries. However, little research has been conducted about why private providers choose to participate in social health insurance systems in such contexts, or their experiences with these systems. We explored private providers’ perceptions of and experiences with participation in two different social health insurance schemes in Sub-Saharan Africa—the National Health Insurance Scheme (NHIS) in Ghana and the National Hospital Insurance Fund (NHIF) in Kenya.

Methods

In-depth interviews were held with providers working at 79 facilities of varying sizes in three regions of Kenya (N = 52) and three regions of Ghana (N = 27). Most providers were members of a social franchise network. Interviews covered providers’ reasons for (non) enrollment in the health insurance system, their experiences with the accreditation process, and benefits and challenges with the system. Interviews were coded in Atlas.ti using an open coding approach and analyzed thematically.

Results

Most providers in Ghana were NHIS-accredited and perceived accreditation to be essential to their businesses, despite challenges they encountered due to long delays in claims reimbursement. In Kenya, fewer than half of providers were NHIF-accredited and several said that their clientele were not NHIF enrolled. Understanding of how the NHIF functioned was generally low. The lengthy and cumbersome accreditation process also emerged as a major barrier to providers’ participation in the NHIF in Kenya, but the NHIS accreditation process was not a major concern for providers in Ghana.

Conclusions

In expanding social health insurance, coordinated efforts are needed to increase coverage rates among underserved populations while also accrediting the private providers who serve those populations. Market pressure was a key force driving providers to gain and maintain accreditation in both countries. Developing mechanisms to engage private providers as stakeholders in social health insurance schemes is important to incentivizing their participation and addressing their concerns.

Patient perspectives on improving osteoarthritis management in urban and rural communities

Introduction

Although there is no cure for osteoarthritis (OA), there are lifestyle modifications that can mitigate symptoms such as pain, and improve management of the disease. This information is not always translated to community-dwelling seniors. Individuals in rural areas often face additional challenges due to geographic isolation and decreased access to community services.

Methods

We used qualitative research methodology (hermeneutic phenomenology) to better understand the lived experiences of urban and rural community-dwelling seniors diagnosed with OA. We explored their sources of information about OA, how they manage their OA pain, and how OA management could be improved in the community. Purposeful sampling was used to recruit 20 information-rich participants (11 urban, 9 rural) in Ontario, Canada. All participants were aged >65 and diagnosed with OA. Semi-structured interviews were conducted, audio recorded, and transcribed verbatim. NVivo 11 Pro qualitative software was used to code transcripts.

Results

Thematic analysis revealed 9 key themes where 8 were common to urban and rural participants, and 1 was unique to rural participants. Most significant among the common themes was the description of the social network as a source of OA information, the trial-and-error approach used for OA management, and the individual contextualization of OA management. Our results suggest that there are several common experiences among urban- and rural-dwelling seniors living with OA, including the desire for support over time, but also a unique experience to rural-dwelling seniors, namely lack of access to local care.

Conclusion

These findings can be used to improve translation of OA information in both urban and rural communities in Canada, highlighting that common strategies may be effective in different contexts for this disease.

The DEsire to DIe in Palliative care: Optimization of Management (DEDIPOM) - a study protocol

BACKGROUND

A desire to die (DD) is frequent in palliative care (PC). However, uncertainty remains as to the appropriate therapeutic response. (Proactive) discussion of DD is not usually part of standard care. To support health practitioners' (HPs) reactions to a patient's DD, a training program has been developed, piloted and evaluated. Within this framework, a first draft of a semi-structured clinical interview schedule with prompts (CISP) has been developed, including recommendations for action to support HPs' self-confidence. The aim of this study is the further development of the CISP to support routine exploration of death and dying distress and proactive addressing of a DD.

METHODS

This observatory, prospective health services study comprises a three step study design: 1. Revision of the CISP and consensus finding based on semi-structured interviews with patients and a Delphi process with (inter-)national experts, patient representatives and relatives; 2. Increasing confidence in HPs through a 2 day-training program using the consented CISP; 3. A formative quantitative evaluation of conversations between HPs and patients (300 palliative patients at three time points) and a qualitative evaluation based on interview triads of patients, relatives and HPs. The evaluation of conversations will include patient-oriented outcomes, including perceived relationships with HPs and death and dying distress. We will also consider aspects of social inequality and gender.

DISCUSSION

The intervention can provide a framework for open discussion of DD and a basis for enhancing a trustful HP-patient relationship in which such difficult topics can be addressed. The benefits of this study will include (a) the creation of the first consented semi-structured approach to identify and address DD and to respond therapeutically, (b) the multi-professional enhancement of confidence in dealing with patients' DD and an intervention that can flexibly be integrated into other training and education programs and (c) an evaluation of effects of this intervention on patients, relatives and HPs, with attention to social inequality and gender.

TRIAL REGISTRATION

The study is registered in the German Clinical Trials Register ( DRKS00012988 ; registration date: 27.9.2017) and in the Health Services Research Database ( VfD_DEDIPOM_17_003889 ; registration date: 14.9.2017).

Application of four-dimension criteria to assess rigour of qualitative research in emergency medicine

Background

The main objective of this methodological manuscript was to illustrate the role of using qualitative research in emergency settings. We outline rigorous criteria applied to a qualitative study assessing perceptions and experiences of staff working in Australian emergency departments.

Methods

We used an integrated mixed-methodology framework to identify different perspectives and experiences of emergency department staff during the implementation of a time target government policy. The qualitative study comprised interviews from 119 participants across 16 hospitals. The interviews were conducted in 2015–2016 and the data were managed using NVivo version 11. We conducted the analysis in three stages, namely: conceptual framework, comparison and contrast and hypothesis development. We concluded with the implementation of the four-dimension criteria (credibility, dependability, confirmability and transferability) to assess the robustness of the study,

Results

We adapted four-dimension criteria to assess the rigour of a large-scale qualitative research in the emergency department context. The criteria comprised strategies such as building the research team; preparing data collection guidelines; defining and obtaining adequate participation; reaching data saturation and ensuring high levels of consistency and inter-coder agreement.

Conclusion

Based on the findings, the proposed framework satisfied the four-dimension criteria and generated potential qualitative research applications to emergency medicine research. We have added a methodological contribution to the ongoing debate about rigour in qualitative research which we hope will guide future studies in this topic in emergency care research. It also provided recommendations for conducting future mixed-methods studies. Future papers on this series will use the results from qualitative data and the empirical findings from longitudinal data linkage to further identify factors associated with ED performance; they will be reported separately.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-2915-2) contains supplementary material, which is available to authorized users.

Lay Patient Navigators’ Perspectives of Barriers, Facilitators and Training Needs in Initiating Advance Care Planning Conversations With Older Patients With Cancer

Context:

Respecting Choices is an evidence-based model of facilitating advance care planning (ACP) conversations between health-care professionals and patients. However, the effectiveness of whether lay patient navigators can successfully initiate Respecting Choices ACP conversations is unknown. As part of a large demonstration project (Patient Care Connect [PCC]), a cohort of lay patient navigators underwent Respecting Choices training and were tasked to initiate ACP conversations with Medicare beneficiaries diagnosed with cancer.

Objectives:

This article explores PCC lay navigators’ perceived barriers and facilitators in initiating Respecting Choices ACP conversations with older patients with cancer in order to inform implementation enhancements to lay navigator-facilitated ACP.

Methods:

Twenty-six lay navigators from 11 PCC cancer centers in 4 states (Alabama, George, Tennessee, and Florida) completed in-depth, one-on-one semistructured interviews between June 2015 and August 2015. Data were analyzed using a thematic analysis approach.

Results:

This evaluation identifies 3 levels—patient, lay navigator, and organizational factors in addition to training needs that influence ACP implementation. Key facilitators included physician buy-in, patient readiness, and navigators’ prior experience with end-of-life decision-making. Lay navigators’ perceived challenges to initiating ACP conversations included timing of the conversation and social and personal taboos about discussing dying.

Conclusion:

Our results suggest that further training and health system support are needed for lay navigators playing a vital role in improving the implementation of ACP among older patients with cancer. The lived expertise of lay navigators along with flexible longitudinal relationships with patients and caregivers may uniquely position this workforce to promote ACP.

"Mobile technology to improve heart failure outcomes: A proof of concept paper"

BACKGROUND

Heart failure (HF) causes significant symptom burden and human suffering with considerable economic burden due to hospital readmissions. Targeted interventions to encourage and support self-management behavior is warranted.

AIM

To test the proof of concept of a mobile application (HeartMapp) in improving self-care management of patients with heart failure.

METHOD

An exploratory inquiry used a field study strategy with purposeful sampling and constant comparative analysis to test the proof of concept of HeartMapp using The Business Model Canvas framework.

RESULTS

A total of 125 individuals, who were identified as potential candidates to use the HeartMapp completed the interview over a seven-week period in 2016. Constant comparative analysis indicated themes that Skilled Nursing Facilities had increased readmissions. Participants from Skilled Nursing Facilities reported concern on lack of staffing, star rating, and malpractice claims. Two types of patients were identified as early adapters of technology and those in denial. Health care facilities reported challenges on transitional care, nurses struggle with engagement of patients on self-care management. To avoid readmission penalty, hospitals task home care agencies to keep the patients home for 30-days. While home care agencies rely on remote telemonitoring reported that current telemonitoring devices are costly to maintain, thus exploring novel technology.

CONCLUSION

The Business Model Canvas provided directions for future testing of HeartMapp for its usability as an adjunct device in home health setting to improve self-management and enhance communication with providers, and ultimately reduce readmissions.

Donor understandings of blood and the body in relation to more frequent donation

BACKGROUND AND OBJECTIVES

The INTERVAL trial aimed to find the optimum frequency of blood donation to enhance blood supplies and maintain donor health. This not only requires biological knowledge, but also an appreciation of donor perspectives, and how their experiences and beliefs might be central if any changes are ever to be made. To address this, trial participants were interviewed about their ideas of blood and the body in relation to their experiences of increased donation frequency.

MATERIALS AND METHODS

Thirty in depth face-to-face interviews conducted with blood donors participating in the trial.

RESULTS

Three key themes emerged: ideas about how blood and iron reserves are replenished, and what people did to facilitate this; beliefs about physiological differences relating to age and gender; and practical issues that affected the experience of donation. Overall, participants interviewed welcomed more frequent donation, despite a range of pragmatic concerns.

CONCLUSION

Despite some practical obstacles, increased donation frequency aligned with participant's ideas about bodily replenishment, the value of donation, and their identity as enduring blood donors. They therefore supported the idea of increasing frequency of donation, independently of the biomedical evidence from the trial itself.

Home-based pre-surgical psychological intervention for knee osteoarthritis (HAPPiKNEES): a feasibility randomized controlled trial

OBJECTIVE

To determine the feasibility of conducting a trial of a pre-surgical psychological intervention on pain, function, and mood in people with knee osteoarthritis listed for total knee arthroplasty.

DESIGN

Multi-centre, mixed-methods feasibility randomized controlled trial of intervention plus usual care versus usual care.

SETTING

Participants' homes or hospital.

PARTICIPANTS

Patients with knee osteoarthritis listed for total knee arthroplasty and score >7 on either subscales of Hospital Anxiety and Depression Scale.

INTERVENTION

Up-to 10 sessions of psychological intervention (based on cognitive behavioural therapy).

MAIN MEASURES

Feasibility outcomes (recruitment and retention rates, acceptability of trial procedures and intervention, completion of outcome measures), and standardized questionnaires assessing pain, function, and mood at baseline, and four and six months post-randomisation.

RESULTS

Of 222 people screened, 81 did not meet inclusion criteria, 64 did not wish to participate, 26 were excluded for other reasons, and 51 were randomized. A total of 30 completed 4-month outcomes and 25 completed 6-month outcomes. Modal number of intervention sessions completed was three (range 2-8). At 6-month follow-up, mood, pain, and physical function scores were consistent with clinically important benefits from intervention, with effect sizes ranging from small ( d = 0.005) to moderate ( d = 0.74), and significant differences in physical function between intervention and usual care groups ( d = 1.16). Feedback interviews suggested that participants understood the rationale for the study, found the information provided adequate, the measures comprehensive, and the intervention acceptable.

CONCLUSION

A definitive trial is feasible, with a total sample size of 444 people. Pain is a suitable primary outcome, but best assessed 6 and 12 months post-surgery.

The first clinical practice experiences of psychiatric nursing students: A phenomenological study

OBJECTIVE

The purpose of this study was to evaluate student nurses clinical experiences during their first clinical contacts with psychiatric patients by using a qualitative phenomenological approach.

DESIGN

A phenomenological approach was used. Face-to-face interviews were conducted to collect data focusing on the reality of student nurses' experience.

SETTINGS

This study was conducted at a university in the capital city of Turkey.

PARTICIPANTS

The participants were undergraduate nursing students. A purposive sampling of 15 students who had completed their first psychiatric clinical practicum was used in this study.

METHODS

The data were collected by using unstructured interviews. The data were analysed by using Colaizzi's seven-step phenomenological method.

RESULTS

Four themes were identified: theoretical information insufficient to break the stigma; breaking down the mental illness stigma; communication: the medication of mental illness; and personal development.

CONCLUSION

At the end of clinical practice, stigma towards mental illness was reduced with empathy through the development of therapeutic relationships. The students stated that communication had a very important place in the treatment of mental illnesses and that psychiatric clinical practice helped them develop interpersonal relations. The results of this study can provide guidance for educators on the planning and development of clinical education.

Caregivers’ interactions with health care services – Mediator of stress or added strain? Experiences and perceptions of informal caregivers of people with dementia – A qualitative study

Background

There are an estimated 46.8 million people worldwide living with dementia in 2015, being cared for usually by family members or friends (informal caregivers). The challenges faced by informal caregivers often lead to increased levels of stress, burden and risk of care-recipient institutionalisation.

Aim

The overarching aim of this study was to explore the experiences and perceptions of informal caregivers of people with dementia when interacting with the health care system, and whether the support received acted as a mediator of caregiver stress. The secondary aim was to investigate healthcare professionals’ views and current practice regarding people with dementia and their interactions with informal caregivers.

Method

We employed a qualitative research design, using focus groups and one face-to-face interview with a purposive sample of informal caregivers and healthcare professionals in Lincolnshire, UK. Data were collected between March and July 2015. We used the stress-process model of stress in caregivers as a theoretical framework.

Results

We interviewed 18 caregivers and 17 healthcare professionals. Five themes, mapped to the stress-process in caregivers’ model, captured the main challenges faced by caregivers and the type of support they wanted from health care services. Primary stressors included the challenge of diagnosing dementia; caregivers’ needs and expectations of an in-depth knowledge and understanding of dementia from healthcare professionals; and need for carer education. Secondary role strain included lack of support and mismatch of communication and expectations. Caregiver involvement in monitoring care and disease was a potential mediator tool.

Conclusions

Fragmentation of dementia care services, lack of training for healthcare professionals and the dearth of information for caregivers means health care services are only partially fulfilling a support role. In turn, lack of support may be intensifying caregiver stress leading to worsening in their health and well-being; thus, potentially increasing the risk of institutionalisation of their care-recipient.

The effectiveness of a routine versus an extensive laboratory analysis in the diagnosis of anaemia in general practice

Background

We investigated the percentage of patients diagnosed with the correct underlying cause of anaemia by general practitioners when using an extensive versus a routine laboratory work-up.

Methods

An online survey was distributed among 836 general practitioners. The survey consisted of six cases, selected from an existing cohort of anaemia patients ( n = 3325). In three cases, general practitioners were asked to select the laboratory tests for further diagnostic examination from a list of 14 parameters (i.e. routine work-up). In the other three cases, general practitioners were presented with all 14 laboratory test results available (i.e. extensive work-up). General practitioners were asked to determine the underlying cause of anaemia in all six cases based on the test results, and these answers were compared with the answers of an expert panel.

Results

A total of 139 general practitioners (partly) responded to the survey (17%). The general practitioners were able to determine the underlying cause of anaemia in 53% of cases based on the routine work-up, whereas 62% of cases could be diagnosed using an extensive work-up ( P = 0.007). In addition, the probability of a correct diagnosis decreased with the patient’s age and was also affected by the underlying cause itself, with anaemia of chronic disease being hardest to diagnose ( P = 0.003).

Conclusion

The use of an extensive laboratory work-up in patients with newly diagnosed anaemia is expected to increase the percentage of correct underlying causes established by general practitioners. Since the underlying cause can still not be established in 31.3% of anaemia patients, further research is necessary.

Primary palliative Care in General Practice - study protocol of a three-stage mixed-methods organizational health services research study

Background

The focus of this project is on improving the provision of primary palliative care (PC) by general practitioners (GPs). While approximately 10–15% of the incurable, seriously ill or dying people will be in need of specialist PC, the vast majority can be adequately treated within generalist care. The strengthening of the GP’s role in PC, as well as ensuring close collaboration between specialist PC services and GPs have been identified as top priorities for the improvement of PC in Germany. Despite healthcare policy actions, diverse obstacles still exist to successful implementation of primary PC on a structural, process, and economic level. Therefore, this project aims at addressing barriers and facilitators to primary PC delivery in general practice in Germany.

Methods

The study follows a three-step approach; first, it aims at systematically analyzing barriers and facilitators to primary PC provision by GPs. Second, based on these outcomes, a tailored intervention package will be developed to enhance the provision of primary PC by GPs. Third, the intervention package will be implemented and evaluated in practice. The expected outcome will be an evidence-based model for successful implementation of primary PC delivery tailored to the German healthcare system, followed by a strategic action plan on how to improve current practice both on a local level and nationally.

Discussion

The first step of the project has been partly completed at the time of writing. The chosen methodologies of four sub-projects within this first step have opened up different advantages and disadvantages for the data collection. In sum of all sub-projects, the different methodologies and target groups contributed valuable information to the systematic analysis of barriers and facilitators to primary PC provision by GPs.

Trial registration

The study (BMBF-FK 01 GY 1610) was retrospectively registered at the German Clinical Trials Register (Deutsches Register Klinischer Studien) (Registration N° DRKS00011821; date of registration: December 04th 2017) and at the German Register of health care research (Versorgungsforschung Deutschland - Datenbank) (Registration N° VfD_ALLPRAX_16_003817; date of registration: March 30th 2017).

Implementing measurement based care in community mental health: a description of tailored and standardized methods

Objective

Although tailored implementation methods are touted as superior to standardized, few researchers have directly compared the two and little guidance regarding the specific details of each method exist. Our study compares these methods in a dynamic cluster randomized trial seeking to optimize implementation of measurement based care (MBC) for depression in community behavioral health. This specific manuscript provides a detailed, replicable account of the components of each multi-faceted implementation method.

Results

The standardized best practice method includes training, consultation, a clinical guideline, and electronic health record enhancements with the goal to optimize the delivery of MBC with fidelity. Conversely, the tailored, customized and collaborative method is informed by recent implementation science advancements and begins with a needs assessment, followed by tailored training that feeds back barriers data to clinicians, the formation of an implementation team, a clinician-driven clinic-specific guideline, and the use of fidelity data to inform implementation team activities; the goal of the tailored condition is to ensure the intervention and implementation strategies address unique factors of the context. The description of these methods will inform others seeking to implement MBC, as well as those planning to use standardized or tailored implementation methods for interventions beyond behavioral health.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3193-0) contains supplementary material, which is available to authorized users.