Referral criteria: making the district nursing service visible

Referral criteria: perceptions and experiences of district nursing students in Northern Ireland

An ever-ageing population and widening health inequalities intensify the complexity of care that is now delivered within community settings by district nurses. Appropriate referral criteria are required to facilitate the enhancement of efficient and equitable district nursing service provision. This study aimed to explore district nursing students' perceptions and experiences of district nursing referral criteria in Northern Ireland. A qualitative phenomenological approach was adopted using a purposive convenience sample of 10 district nursing students. Data were collected during online focus group interviews and analysed using a thematic framework. Four themes emerged: referral criteria; insight and inconsistency; task versus patient-centred care; and misunderstanding the service and referral quality. The themes reflect a lack of consensus with respect to referral criteria, contributing to inappropriate and poor-quality referrals. Appropriate and quality referrals to district nursing services are key to assuring sustainable service provision. Suitable access to district nursing services may be enhanced by developing consensus referral criteria.

A feasibility investigation of mindfulness-based cognitive therapy for people with Huntington's disease

BACKGROUND

Huntington's disease (HD) is an inherited neurodegenerative condition which affects movement, coordination and cognitive functioning. Psychological difficulties are commonly experienced; however, psychological interventions have been little researched with this population. We investigated the feasibility of conducting a randomised controlled trial (RCT) of mindfulness-based cognitive therapy (MBCT) with people with the HD genetic mutation, either pre-manifest (before onset of movement symptoms) or at an early disease stage. Specifically, we evaluated the willingness of participants to be recruited into and complete the intervention; the acceptability of the study measures in relation to completion; the feasibility of offering the standard MBCT course to people with HD; the acceptability of the intervention and the estimated effect sizes.

METHODS

Participants were recruited from two UK HD centres and took part in an 8-week course of MBCT, with three reunions throughout the following year. Stress, depression, anxiety, and mindfulness were measured pre-, mid-, and post-course, at 3 months and at 1 year. Sleep, quality of life, positive affect and coping were measured pre- and post-course, at 3 months and at 1 year. Descriptive data and approximate effect sizes were calculated. Interviews were conducted post-course and at 1 year and data pertaining to the acceptability of the course were extracted.

RESULTS

Twelve participants took part in two groups; all were pre-manifest. Levels of depression and anxiety were low pre-course leaving little room for improvement. Changes in stress and in some aspects of mindfulness were medium to large. The qualitative data suggested participants rated the course highly and found it helpful and no changes to the standard course were needed. Recruitment levels were below those anticipated. Most measures were found to be acceptable.

CONCLUSIONS

Although the course was acceptable to those who took part, given the difficulties in recruiting and the rarity of HD, conducting an RCT of MBCT teaching groups in person does not seem feasible. However, alternative modes of course delivery (e.g. online) would allow the recruitment of people from a greater geographical area and may make an RCT feasible; this revised focus would be suitable for future feasibility studies.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT02464293, registered 8 June 2015.

Harms from discharge to primary care: mixed methods analysis of incident reports

Background

Discharge from hospital presents significant risks to patient safety, with up to one in five patients experiencing adverse events within 3 weeks of leaving hospital.

Aim

To describe the frequency and types of patient safety incidents associated with discharge from secondary to primary care, and commonly described contributory factors to identify recommendations for practice.

Design and setting

A mixed methods analysis of 598 patient safety incident reports in England and Wales related to ‘Discharge’ from the National Reporting and Learning System.

Method

Detailed data coding (with 20% double-coding), data summaries generated using descriptive statistical analysis, and thematic analysis of special-case sample of reports. Incident type, contributory factors, type, and level of harm were described, informing recommendations for future practice.

Results

A total of 598 eligible reports were analysed. The four main themes were: errors in discharge communication (n = 151; 54% causing harm); errors in referrals to community care (n = 136; 73% causing harm); errors in medication (n = 97; 87% causing harm); and lack of provision of care adjuncts such as dressings (n = 62; 94% causing harm). Common contributory factors were staff factors (not following referral protocols); and organisational factors (lack of clear guidelines or inefficient processes). Improvement opportunities include developing and testing electronic discharge methods with agreed minimum information requirements and unified referrals systems to community care providers; and promoting a safety culture with ‘safe discharge’ checklists, discharge coordinators, and family involvement.

Conclusion

Significant harm was evident due to deficits in the discharge process. Interventions in this area need to be evaluated and learning shared widely.

Occupational Disruption: Living with Motor Neurone Disease

Little is known of the day-to-day experience of living with motor neurone disease from the perspective of those who have it, apart from what can be found in personal accounts such as those published on web pages. In this study, which was informed by phenomenology, seven people living in an urban setting in New Zealand were asked to describe their experiences.

This report focuses on the study findings that related specifically to disruption to occupation. It describes how early changes in occupational performance alerted the participants to the fact that something was wrong. The findings also showed the pervasive impact of an awkward and unreliable body on participation in occupations that gave meaning to life, expressed identity and filled time. Issues of how the family's world was changed, the introduction of assistive devices into their homes and the betrayal of trust were also powerfully evident in participants' stories.

Although the findings are broadly consistent with those of previous studies, the disruption to occupation and the consequent role losses are new findings. Further research into the impact of the loss of participation in occupation, the ways in which people are perceived when occupations are disrupted and the experience of having occupations taken away prematurely is recommended.

Characterising the nature of primary care patient safety incident reports in the England and Wales National Reporting and Learning System: a mixed-methods agenda-setting study for general practice

Background

There is an emerging interest in the inadvertent harm caused to patients by the provision of primary health-care services. To date (up to 2015), there has been limited research interest and few policy directives focused on patient safety in primary care. In 2003, a major investment was made in the National Reporting and Learning System to better understand patient safety incidents occurring in England and Wales. This is now the largest repository of patient safety incidents in the world. Over 40,000 safety incident reports have arisen from general practice. These have never been systematically analysed, and a key challenge to exploiting these data has been the largely unstructured, free-text data.

Aims

To characterise the nature and range of incidents reported from general practice in England and Wales (2005–13) in order to identify the most frequent and most harmful patient safety incidents, and relevant contributory issues, to inform recommendations for improving the safety of primary care provision in key strategic areas.

Methods

We undertook a cross-sectional mixed-methods evaluation of general practice patient safety incident reports. We developed our own classification (coding) system using an iterative approach to describe the incident, contributory factors and incident outcomes. Exploratory data analysis methods with subsequent thematic analysis was undertaken to identify the most harmful and most frequent incident types, and the underlying contributory themes. The study team discussed quantitative and qualitative analyses, and vignette examples, to propose recommendations for practice.

Main findings

We have identified considerable variation in reporting culture across England and Wales between organisations. Two-thirds of all reports did not describe explicit reasons about why an incident occurred. Diagnosis- and assessment-related incidents described the highest proportion of harm to patients; over three-quarters of these reports (79%) described a harmful outcome, and half of the total reports described serious harm or death (n = 366, 50%). Nine hundred and ninety-six reports described serious harm or death of a patient. Four main contributory themes underpinned serious harm- and death-related incidents: (1) communication errors in the referral and discharge of patients; (2) physician decision-making; (3) unfamiliar symptom presentation and inadequate administration delaying cancer diagnoses; and (4) delayed management or mismanagement following failures to recognise signs of clinical (medical, surgical and mental health) deterioration.

Conclusions

Although there are recognised limitations of safety-reporting system data, this study has generated hypotheses, through an inductive process, that now require development and testing through future research and improvement efforts in clinical practice. Cross-cutting priority recommendations include maximising opportunities to learn from patient safety incidents; building information technology infrastructure to enable details of all health-care encounters to be recorded in one system; developing and testing methods to identify and manage vulnerable patients at risk of deterioration, unscheduled hospital admission or readmission following discharge from hospital; and identifying ways patients, parents and carers can help prevent safety incidents. Further work must now involve a wider characterisation of reports contributed by the rest of the primary care disciplines (pharmacy, midwifery, health visiting, nursing and dentistry), include scoping reviews to identify interventions and improvement initiatives that address priority recommendations, and continue to advance the methods used to generate learning from safety reports.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Capturing district nursing through a knowledge-based electronic caseload analysis tool (eCAT)

The Electronic Caseload Analysis Tool (eCAT) is a knowledge-based software tool to assist the caseload analysis process. The tool provides a wide range of graphical reports, along with an integrated clinical advisor, to assist district nurses, team leaders, operational and strategic managers with caseload analysis by describing, comparing and benchmarking district nursing practice in the context of population need, staff resources, and service structure. District nurses and clinical lead nurses in Northern Ireland developed the tool, along with academic colleagues from the University of Ulster, working in partnership with a leading software company. The aim was to use the eCAT tool to identify the nursing need of local populations, along with the variances in district nursing practice, and match the workforce accordingly. This article reviews the literature, describes the eCAT solution and discusses the impact of eCAT on nursing practice, staff allocation, service delivery and workforce planning, using fictitious exemplars and a post-implementation evaluation from the trusts.

A 10-year literature review of family caregiving for motor neurone disease: moving from caregiver burden studies to palliative care interventions

BACKGROUND

There is growing awareness that different terminal diseases translate into different family caregiver experiences, and the palliative and supportive care needs of these families are both similar and unique. Family members caring for people with motor neurone disease may experience exceptional strain due to the usually rapid and progressive nature of this terminal illness.

AIM

The purpose of this review is to synthesize contemporary research and provide a comprehensive summary of findings relevant to motor neurone disease family caregivers, as well as highlight some of the suggested interventions to alleviate burden and improve quality of life for this group.

DESIGN

We conducted a comprehensive review of empirical research on family caregiving for people with motor neurone disease in peer-reviewed journals published in English, January 2000-April 2011. Fifty-nine studies met the inclusion criteria.

RESULTS

This comprehensive literature review was consistent with previous research documenting the substantial burden and distress experienced by motor neurone disease family caregivers and revealed important points in the trajectory of care that have the potential for negative effects. The diagnosis experience, assisted ventilation, cognitive changes and end-of-life decision making create challenges within a short time. This review has also implicated the need for improvements in access to palliative care services and highlighted the absence of interventions to improve care.

CONCLUSIONS

Caregiver burden and quality-of-life studies on motor neurone disease family caregivers have so far dominated the research landscape .The focus needs to be on developing interventions that provide direct practical and psychosocial supports for motor neurone disease family caregivers.

The health promotion work of the district nurse: interpreting its embeddedness

AIM

This article presents an interpretation of health promotion within the work of a district nurse (DN).

BACKGROUND

Literature supports the centrality of health promotion within nursing. It also presents debate about its meaning and suggests uncertainties for educators and practitioners about its relationship to nursing care. Two studies in Scotland on community nurses' health promotion work with older people suggested that health promotion was evident and recognisable in planned initiatives or projects but could be hidden and unrecognised in day-to-day nursing work with individual patients and their families.

METHODS

An experienced DN's interpretation of health promotion embedded in her work with a patient with multiple sclerosis is presented. The case was one of a number derived from a study designed in the constructivist paradigm, which addressed health promotion in relation to community nurse education and practice for a range of community nursing roles, including district nursing. The case study data were derived from observation of practice, interviews with the DN and the patient and from field notes.

FINDINGS

Health promotion emerged as embedded within day-to-day holistic nursing care. The DN illustrated an understanding of the dimensions of health and of the significance of core health promotion concepts such as education, prevention, advocacy, empowerment, self-esteem and self-efficacy. However, health promotion could be invisible, described as weaved into everything and on the back of other things, and therefore not normally acknowledged and clearly articulated. Embeddedness highlighted the challenge for evaluation, when nursing and health promotion activities are intrinsically related and can be argued as sharing certain principles, processes and outcomes.

CONCLUSION

Embeddedness is a significant issue for learning in practice. The ability of experienced community nurses to interpret and articulate the concept of health promotion clearly and to make tacit knowledge evident would be of benefit to students.

Motor Neurone Disease family carers' experiences of caring, palliative care and bereavement: an exploratory qualitative study

BACKGROUND

Motor Neurone Disease (MND) is a neurodegenerative disease with a sudden onset, a rapid progression, a profile of complex disabilities and fatal consequences. Caring for a person with MND is an unremitting commitment, yet little research has examined the experiences and needs of carers for palliative care and bereavement care.

AIM

This study explored the experiences of MND family carers, both during their time as carers and following bereavement. Particular attention was paid to the carers' prolonged grief status and to the implications for service delivery, including palliative care.

DESIGN

A qualitative approach consisted of interviews with 16 bereaved family carers. The Prolonged Grief tool (PG-13) measured the carers' prolonged grief.

SETTING/PARTICIPANTS

sixteen family carers participated in the study, between one and four years after the death of their spouse from MND in Western Australia.

RESULTS

The thematic analysis of the interview transcripts revealed five themes - the work of family carers, the change in relationship from spouse to family carer, family caring as a series of losses, coping mechanisms of family carers and supportive and palliative care experiences of family carers. The six participants who met the criteria for prolonged grief disorder accessed palliative care at a later stage in the disease trajectory.

CONCLUSIONS

The study provided a basis for more research into the role palliative care services has in supporting MND carers before and after the death of their spouse and in particular the provision of more tailored respite and bereavement support.

A process for developing a principle-centred district nursing service philosophy

While it is well known that team vision and values statements in nursing can promote person-centred care, practitioner role clarity and empowerment, and service effectiveness, especially during times of change, their use in district nursing is limited. Accepted practice is to formulate vision and values statements 'from the top', and then seek buy-in from other staff groups, however, this inhibits practitioner engagement. This paper describes the use of group facilitation, based on principle-centred leadership practices, to engage practitioners in all the creative aspects of developing a values statement. Increasing practitioner engagement would be expected to provide the above benefits by improving communication with service-users and other key stakeholders and by motivating performance evaluation and improvement.

Palliative stage Parkinson's disease: patient and family experiences of health-care services

Little is known about the lived health-care experiences of persons living with palliative stage Parkinson's disease and the family members who care for them. An exploratory phenomenological investigation was adopted to understand participant's lived health-care experiences and the needs flowing from them. Three family groupings participated in semi-structured in-depth interviews. Interpretative phenomenological analysis revealed three main themes: missing information, being on your own, wanting and not wanting to know. Findings support previous research that indicate palliative care needs are not being met in our current health-care model and that palliative care services should be multi-disciplinary team-based in order to provide comprehensive support to patients and families. Based on this current work, we are currently undertaking a comprehensive quantitative-based multi-disciplinary health-care service needs assessment of palliative stage PD patients with the goal to implement expanded services.

How caseload analysis led to the modernization of the DN service

As we move into a new century and care moves out of hospital and into the community, there is a drive to seek new models for providing nursing care to patients in their homes. Following a Caseload Analysis report, the District Nursing Modernization Project was launched in April 2004, aimed to redesign the structure and delivery of the district nursing services in South and East Belfast. The service was totally re-engineered within the existing budget and workforce. Nursing careers changed as new supporting services were developed and new job opportunities became available within the service. The structure of the services was designed on the basis of caseload analysis gathered over a number of years. Evaluation of the project indicated that the project aim and objectives had been achieved. Caseload Analysis was instrumental in establishing the need to modernize district nursing services and how this should be carried out.

District nursing workforce planning: a review of the methods

District nursing services in Northern Ireland face increasing demands and challenges which may be responded to by effective and efficient workforce planning and development. The aim of this paper is to critically analyse district nursing workforce planning and development methods, in an attempt to find a suitable method for Northern Ireland. A systematic analysis of the literature reveals four methods: professional judgement; population-based health needs; caseload analysis and dependency-acuity. Each method has strengths and weaknesses. Professional judgement offers a 'belt and braces' approach but lacks sensitivity to fluctuating patient numbers. Population-based health needs methods develop staffing algorithms that reflect deprivation and geographical spread, but are poorly understood by district nurses. Caseload analysis promotes equitable workloads but poorly performing district nursing localities may continue if benchmarking processes only consider local data. Dependency-acuity methods provide a means of equalizing and prioritizing workload but are prone to district nurses overstating factors in patient dependency or understating carers' capability. In summary a mixed method approach is advocated to evaluate and adjust the size and mix of district nursing teams using empirically determined patient dependency and activity-based variables based on the population's health needs.