How experienced wound care nurses conceptualize what to do in pressure injury management

BACKGROUND

Conceptual understanding of the perceptions that wound care nurses use to determine how to manage pressure injuries may provide information for improving their pressure injury care competency. The aim of this study is to explore and describe the way wound care nurses experience and perceive pressure injury management.

METHODS

A qualitative, phenomenographic approach, a method designed to explore the different ways in which people comprehend a phenomenon and develop a practical knowledge-based framework, was used in this study. Semi-structured interviews were used for data collection with twenty wound care nurses. All participants were female with a mean age of 38.0, mean total clinical experience of 15.2 years and mean clinical experience as wound care nurse of 7.7 years. The eight steps of qualitative data analysis for a phenomenographic study were employed to develop an understanding of participants' experience of pressure injury management.

RESULTS

The analysis resulted in an assessment domain and an intervention domain, each containing three descriptive categories based on five identified conceptions. The categories were as follows: "comparison", "consideration", and "monitoring" in assessment, and "creation", "conversation" and "judgement" in intervention.

CONCLUSIONS

This study has created a framework for understanding pressure injury management based on practical knowledge. This framework of the nurses' pressure injury care reflected the need for an awareness of a harmonious approach to patients and wounds. There is a pattern of transcending a reliance on only theoretical knowledge, and this key factor in the framework should be considered when developing education programs and tools for improving nurse pressure injury care competency and patient safety.

A proposal to embed patient and public involvement within qualitative data collection and analysis phases of a primary care based implementation study

BACKGROUND

Patient and public involvement (PPI) is increasingly seen as essential to health service research. There are strong moral and ethical arguments for good quality PPI. Despite the development of guidance aimed at addressing the inconsistent reporting of PPI activities within research, little progress has been made in documenting the steps taken to undertake PPI and how it influences the direction of a study. Without this information, there are minimal opportunities to share learnings across projects and strengthen future PPI practices. The aim of this paper is to present details on the processes and activities planned to integrate PPI into the qualitative research component of a mixed-methods, multi-site study evaluating the implementation of a smart template to promote personalised primary care for patients with multiple long-term conditions.

METHODS

This proposal describes the processes and activities planned to integrate PPI into the development and piloting of qualitative data collection tools (topic guides for both practice staff and patients) and a tailored data analysis package developed for PPI members incorporating broad concepts and specific methods of qualitative data analysis.

DISCUSSION

Outputs relating to PPI activity may include clear, concise and suitably worded topic guides for qualitative interviews. Piloting of the topic guides via mock interviews will further develop researchers' skills including sensitisation to the experiences of participants being interviewed. Working with PPI members when analysing the qualitative data aims to provide reciprocal learning opportunities and may contribute to improving the overall rigour of the data analysis. The intent of publishing proposed PPI activities within this project is to inform the future delivery of high quality PPI.

Acceptability of the FIGO Nutrition Checklist in Preconception and Early Pregnancy to Assess Nutritional Status and Prevent Excess Gestational Weight Gain: A Study of Women and Healthcare Practitioners in the UK

Optimum nutrition and weight before and during pregnancy are associated with a lower risk of conditions such as pre-eclampsia and gestational diabetes. There is a lack of user-friendly tools in most clinical settings to support healthcare practitioners (HCPs) in implementing them. This study aimed to evaluate the acceptability of (1) using a nutrition checklist designed by the International Federation of Gynecology and Obstetrics (FIGO) for nutritional screening of women in the preconception and early pregnancy period and (2) routine discussion of nutrition and weight in clinical care. An online cross-sectional survey was conducted with women (aged 18-45) and HCPs (e.g., general practitioners, obstetricians, and midwives). Quantitative statistical analysis and qualitative content analysis were performed. The concept and content of the checklist were acceptable to women (n = 251) and HCPs (n = 47) (over 80% in both groups). Several barriers exist to implementation such as lack of time, training for HCPs, and the need for sensitive and non-stigmatizing communication. Routine discussion of nutrition was considered important by both groups; however, results suggest that nutrition is not regularly discussed in perinatal visits in the UK. The FIGO nutrition checklist presents a valuable resource for use in clinical practice, offering long-term and intergenerational benefits for both mother and baby.

Self-management of a musculoskeletal condition for people from harder to reach groups: a qualitative patient interview study

Background: This study recorded the functional health literacy levels of people with musculoskeletal (MSK) conditions from harder to reach groups and explored their experiences in engaging with health care professionals to self-manage their MSK condition.Methods: We recruited participants, identified by key health and social care contacts as likely to have lower health literacy levels, and used semi-structured interviews to collect data. Thematic analysis was used to identify the main key themes arising from the transcribed interviews.Results: Eighteen participants were identified and recruited from harder to reach community populations, 10 were scored as having inadequate functional health literacy on the Short Form Rapid Estimate of Adult Literacy Measure. Three themes were identified in relation to participants' experiences of MSK self-management approaches: engaging with health care services; interpreting the health care providers' message; and facilitating participation in MSK self-management.Conclusions: Our findings indicate that people with a MSK condition, from harder to reach groups, experience multi-morbidity, find health care systems complicated and hear from health care professionals that their MSK condition cannot be cured. People interpreted that a lack of cure meant that nothing could be done to help their MSK pain. Engaging with self-management strategies was not seen as a priority for our participants. Strategies to simplify health communication, more time to process health information and supportive social networks helped our participants to understand and manage their MSK health on a day-to-day basis. Implications for RehabilitationMSK conditions are long term and prevalent in the UK with substantial impact on people's daily life.Currently self-management strategies for MSK conditions are poorly communicated and many patients believe that nothing can be done to help their MSK pain.Good clinician communication that supports self-management is needed so that key messages can be effectively understood and used by patients with a range of literacy skills.Health services need to be even more accessible to help all individuals from a range of backgrounds better self-manage their MSK conditions.

Duration of intravenous antibiotic therapy for children with acute osteomyelitis or septic arthritis: a feasibility study

BACKGROUND

There is little current consensus regarding the route or duration of antibiotic treatment for acute osteomyelitis (OM) and septic arthritis (SA) in children.

OBJECTIVE

To assess the overall feasibility and inform the design of a future randomised controlled trial (RCT) to reduce the duration of intravenous (i.v.) antibiotic use in paediatric OM and SA.

DESIGN

(1) A prospective service evaluation (cohort study) to determine the current disease spectrum and UK clinical practice in paediatric OM/SA; (2) a prospective cohort substudy to assess the use of targeted polymerase chain reaction (PCR) in diagnosing paediatric OM/SA; (3) a qualitative study to explore families' views and experiences of OM/SA; and (4) the development of a core outcome set via a systematic review of literature, Delphi clinician survey and stakeholder consensus meeting.

SETTING

Forty-four UK secondary and tertiary UK centres (service evaluation).

PARTICIPANTS

Children with OM/SA.

INTERVENTIONS

PCR diagnostics were compared with culture as standard of care. Semistructured interviews were used in the qualitative study.

RESULTS

Data were obtained on 313 cases of OM/SA, of which 218 (61.2%) were defined as simple disease and 95 (26.7%) were defined as complex disease. The epidemiology of paediatric OM/SA in this study was consistent with existing European data. Children who met oral switch criteria less than 7 days from starting i.v. antibiotics were less likely to experience treatment failure (9.6%) than children who met oral switch criteria after 7 days of i.v. therapy (16.1% when switch was between 1 and 2 weeks; 18.2% when switch was > 2 weeks). In 24 out of 32 simple cases (75%) and 8 out of 12 complex cases (67%) in which the targeted PCR was used, a pathogen was detected. The qualitative study demonstrated the importance to parents and children of consideration of short- and long-term outcomes meaningful to families themselves. The consensus meeting agreed on the following outcomes: rehospitalisation or recurrence of symptoms while on oral antibiotics, recurrence of infection, disability at follow-up, symptom free at 1 year, limb shortening or deformity, chronic OM or arthritis, amputation or fasciotomy, death, need for paediatric intensive care, and line infection. Oral switch criteria were identified, including resolution of fever for ≥ 48 hours, tolerating oral food and medicines, and pain improvement.

LIMITATIONS

Data were collected in a 6-month period, which might not have been representative, and follow-up data for long-term complications are limited.

CONCLUSIONS

A future RCT would need to recruit from all tertiary and most secondary UK hospitals. Clinicians have implemented early oral switch for selected patients with simple disease without formal clinical trial evidence of safety. However, the current criteria by which decisions to make the oral switch are made are not clearly established or evidence based.

FUTURE WORK

A RCT in simple OM and SA comparing shorter- or longer-course i.v. therapy is feasible in children randomised after oral switch criteria are met after 7 days of i.v. therapy, excluding children meeting oral switch criteria in the first week of i.v. therapy. This study design meets clinician preferences and addresses parental concerns not to randomise prior to oral switch criteria being met.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Without Leisure … ‘It Wouldn't Be Much of a Life’: The Meaning of Leisure for People with Mental Health Problems

Previous research has explored the occupational engagement of people with mental health problems. This study set out to establish the meaning and value of leisure for people with enduring mental health problems living in the community. Using a mainly qualitative design, semi-structured interviews were conducted with 10 participants randomly selected from clients referred to a local assertive outreach service in South-East England. Initially, the data were analysed for content, phrases, language and words used; subsequently, emerging themes were identified which were confirmed by a second occupational therapist. Three themes are reported here: why certain occupations were considered to be leisure, the feelings expressed during leisure and the value of leisure.

Although the participants had some difficulty in articulating their views, leisure was differentiated from other occupations, with the time available to complete a task in the absence of pressure being the distinguishing feature. Overall, the participants had positive views about leisure, which was valued in terms of meeting their individual and unique needs. The implications for occupational therapy are explored. In determining the meaning and value of leisure for people with mental health problems, more emphasis should be given to their actions and less to their skill in verbalising emotion.

‘Rigour’, ‘Ethical Integrity’ or ‘Artistry’? Reflexively Reviewing Criteria for Evaluating Qualitative Research

Qualitative researchers contest and reject the criteria used by quantitative researchers when evaluating their work: those of reliability, validity and generalisability. Instead, qualitative researchers have developed alternative criteria responsive to their specific research ideals. These criteria encompass various dimensions of ‘rigour’, ‘ethical integrity’ and ‘artistry’.

This article attempts to show something of the range of evaluative criteria available to qualitative researchers, arguing that their choice of criteria needs to be compatible with the special nature of the research in question (its methodology, aims and assumptions). Occupational therapists are encouraged to be clear, thoughtful and reflexive about their position and values when evaluating their research. To this end, recent occupational therapy research is reviewed to identify the criteria that authors favour. I also proffer my own reflexive voice towards critically evaluating my approach in this article.

Rehabilitation professionals' perceptions of the use of new visualisation software tools with people with stroke

PURPOSE

The envisage programme of research was funded to explore and evaluate the use of visualisation software tools using biomechanical data within rehabilitation. Three work packages were developed to evaluate the impact of the tools within stroke rehabilitation. The research presented here aimed at exploring the perceptions of rehabilitation therapists about the use of the visualisation software tools in the context of future randomised controlled trials and stroke rehabilitation practice.

METHODS

Sixteen therapists working in a range of stroke rehabilitation contexts participated in semi-structured interviews. Interview questions explored their current practice, and the perceived impact of the new visualisation technologies on their workplace environment and practice. Framework analysis was used to analyse the textual data.

RESULTS

In general, the stroke therapists were enthusiastic about the potential application of the visualisation software tools. Three themes were identified through qualitative framework analysis: potential uses of the visualisation tools; integration within current service provision; and trial involvement.

CONCLUSIONS

The study highlights important contextual considerations which may impact significantly on the success of novel technologies in stroke rehabilitation. Normalisation process theory was proposed as a useful process evaluation methodology to optimise both trial evaluation and future service implementation. Implications for Rehabilitation There is limited research exploring the use of visual software technologies featuring biomechanical data within stroke rehabilitation. The perspectives of stroke rehabilitation therapists about the potential of such tools are useful both in terms of planning trial evaluations, and implementation. Therapists were generally positive about the contribution of visual software tools in stroke rehabilitation, but highlighted a number of practical constraints which required addressing. Normalisation process theory provides a useful process evaluation methodology which can support both trial evaluation and implementation of such novel technologies within stroke rehabilitation.

A Study of Metaphorical Stories Used by Occupational Therapists to Describe Their Working Lives

Introduction:

This paper describes five metaphorical stories that occupational therapists use in talking about and making sense of health service reforms, and discusses the value of reflecting on metaphorical stories to increase understanding of healthcare practice and concepts of professionalism.

Methods:

A narrative approach was used to examine how occupational therapists define, experience and practice their work, and describe their professional ‘selves’. The empirical research was conducted over a 12-month period across five National Health Service organizations. Fourteen participants were interviewed three times during this period and were asked to keep monthly diaries of critical incidents.

Findings:

Five dominant types of ‘stories’ were identified and given appropriate metaphorical titles: the battle, the love story, the magazine, the journey, and the pantomime. The research article notes the salient features and implicit relationships selected as important in each story. The stories illustrate how occupational therapists relate to and mediate change, by constructing experiences in ways that facilitate making sense of a situation and seeing a possible direction to take.

Conclusions:

The article suggests that exploring metaphorical stories encourages reflexivity and analytical decision making by illuminating the choices available when mediating change.

Occupational Therapy and Interpretative Phenomenological Analysis: Comparable Research Companions?

Interpretative phenomenological analysis (IPA) is a research method gaining in popularity, particularly in health psychology and related fields. Derived from phenomenology, as the name suggests, it has potential for occupational therapy as an underpinning framework for research. This method was developed to enable researchers to provide participants with the opportunity to describe their perceptions of their lived experiences, which are subsequently interpreted by the researcher. A two-stage data process allows participants to make sense of their own world while the researcher attempts to make sense of participants' lived experiences.

IPA acknowledges that researchers cannot gain complete access to the participant's world and that each participant is an expert in his or her field. However, it does recognise that the researcher's analysis of this world is a dynamic and interpretative process. During the research analysis process, themes are identified and connected and followed by higher-order interpretation. Data can be collected using a variety of methods, including interviews, case studies and focus groups.

This paper describes the potential of IPA as an appropriate and worthy methodology for occupational therapists and, therefore, an important adjunct to the occupational therapy evidence base.

Upfront and enabling: Delivering specialist multidisciplinary neurological rehabilitation

Aims

In the acute hospital setting, rehabilitation issues arising from neurological complications in patients on the medical and surgical wards are common. This article describes the work of one multidisciplinary, highly expert neurological rehabilitation team, which is available to advise and treat patients in a large teaching hospital in the UK, during one calendar year.

Methods

The development of the service, its staff and the interventions that the team employs are described. A review of the data from medical records of all patients referred to the team in the period 1st January to 31st December 2006 is then presented. These data were anonymised and extracted from patient notes using a standardized proforma, and include information on referral, initial diagnosis, rehabilitation interventions and subsequent discharge/transfer.

Findings

Sixty-one patients were seen. Their age ranged from 15 to 87 years with equal gender distribution. The dominant users of the team were surgery, respiratory medicine, intensive care and infectious diseases. Fifteen patients presented with new neurological conditions and 17 patients developed neurological conditions during their inpatient stay (stroke, critical care illness and other rare diagnoses). Twenty-nine patients had established neurological disabilities, and the enforced inactivity of admission threatened their precarious independence.

Conclusions

The team was instrumental in addressing key quality requirements of the UK National Service Framework for people with Long Term Neurological Conditions. Their contribution to better discharges, earlier discharges and the patients' ‘quality of life’ was viewed by staff involved with the patients as significant. Further rigorous research is required to quantify these improvements further.

An Autoethnographic Exploration of an Occupation: Doing a PhD

The systematic and detailed study of occupations is challenging to occupational therapists, who would wish to understand better their meanings and therapeutic value. Such a study must attempt to capture the complexities of occupational form and performance, recognising occupations as spatially, socially and temporally situated phenomena that are culturally recognised and individually experienced.

Autoethnography is a methodological approach in which the researcher is the focus of the research. It offers a way of accessing personal experience by focusing on physical artefacts, documentary evidence and reflections, and so is particularly useful for studying the complexity of occupational engagement. With ‘doing-a-PhD’ as its focus, this study used autoethnography to explore the subjective experience of engagement with an occupation in order to understand better its complexity, meaning and possible therapeutic value.

The findings are presented under six headings, which explore the personal and social aspects of the occupation, the ways in which it interfaces with the contexts of time and space, its relationship with other occupations and roles, and the process of transformation that it brings about. The limitations of the approach are discussed and the implications of the study for occupational therapists are proposed.