Undertaking risk and relational work to manage vulnerability: Acute medical patients' involvement in patient safety in the NHS

Over the last decade a wealth of studies have explored the way that patients are involved in patient safety internationally. Most begin from the premise that patients can and should take on the role of identifying and reporting safety concerns. Most give little attention, however, to the impact of the patient's health status and vulnerability on their ability to participate in their safety. Drawing on qualitative interviews with 28 acute medical patients, this article aims to show how patients' contributions to their safety in the acute medical context are less about involvement as a deliberate intervention, and more about how patients manage their own vulnerability in their interactions with staff. Our analysis is underpinned by theories of vulnerability and risk. This enables us to provide a deeper understanding of how vulnerability shapes patients' involvement in their safety. Acute medical patients engage in reassurance-seeking, relational and vigilance work to manage their vulnerability. Patients undertake reassurance seeking to obtain evidence that they can trust the organisation and the professionals who work in it and relational and vigilance work to manage the vulnerability associated with dependence on others and the unpredictability of their status as acute medical patients. Patients are made responsible for speaking up about their care but simultaneously, by virtue of the expectations of the sick role and their relational vulnerability, encouraged to remain passive, compliant or silent. We show how risk frames the extent to which patients can activate their role in creating patient safety at the point of care. Foregrounding the theory of vulnerability, the concept of the sick role and the relationship of both to risk offers new insights into the potentials and limits of patient involvement in patient safety in the acute care context.

The Specialized Early Care for Alzheimer's method of caring for people with dementia: an investigation of what works and how

BACKGROUND AND RATIONALE

SPECAL is a model of care for people with dementia based on a novel conceptualisation of memory and how this changes in dementia. Carers adapt their communication style to prevent distress and promote well-being for the person with dementia. However, there is limited scientific evidence on the effectiveness of SPECAL.

AIM

This study explored mechanisms of SPECAL through a qualitative enquiry with family carers.

METHOD

Semi-structured interviews were conducted with family carers who had been coached in SPECAL and applied its principles and practices. Thematic analysis was applied.

FINDINGS

All participants had found SPECAL helpful in caring for a person with dementia. The core themes of this positive experience were empathy, harmony and resilience. Synthesis of these themes contributes to a proposed model of the mechanisms of SPECAL.

CONCLUSION

In applying SPECAL, carers gained an empathetic insight to the feelings of the person with dementia. This empathy leads to a more harmonious environment, which enhances the carer's resilience.

Active Care In Practice: Long-Term Experiences From An Education Programme

Purpose

To explore whether the Active Care education programme has influenced the participants in practice over time and if so how.

Method and material

A hermeneutic explorative approach. Semi-structured focus group interviews and individual interviews with participants from the education programme from 2014 to 2015. Participants came from different areas in care and had different professional backgrounds. Systematic text condensation analysis based on Malterud.

Results

The Active Care programme has given the participants new knowledge that motivated, inspired and gave them power to change their practice. The new knowledge seems to give resonance in their basic values and strengthens their understanding of the importance of the users’ basic needs and right to be empowered.

Conclusion

Active teaching methods that appeal to participants help to understand and expand carers’ repertoire and increases professionalism across professions and positions. Structural factors need to be addressed to meet the goal of integrated person-centered services.

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A qualitative investigation of hospital visitors' experiences using the analytic lens of liminality: Informing nursing practice and policy

This research aimed to inform nursing practice and policy by identifying satisfying and problematic experiences of hospital visitors during the hospitalisation episode of a significant other. An extensive contextual review revealed that healthcare systems in advanced economies face multiple pressures and that in England, the government leaves the determination of hospital visiting rules to individual trusts. The analytic lens of liminality provides rich interpretations of visitors' accounts and demonstrates the importance to visitors of structure (hospital rules and systems) and communitas (social bonding among liminal personae). Supportive hospital structures reduce the challenges of liminality and increase satisfaction. The data further suggest an extension to current understandings of liminality. Strong structure and successful communitas permit a safe exit from liminality after the hospitalisation episode for visitors with a close emotional bond with the patient.

A randomised controlled trial to evaluate the impact of a human rights based approach to dementia care in inpatient ward and care home settings

Background

Although it is widely recognised that adopting a person-centred approach is beneficial in the care of people living with dementia, a gap remains between the rhetoric and the reality of quality care. Some widely adopted care practices can result in the personhood of this group being threatened and their human rights being undermined.

Objectives

To evaluate the impact of applying a human rights based approach in dementia inpatient wards and care homes on the quality of care delivered and the well-being of the person living with dementia.

Design

A cluster randomised design was employed to compare the impact of implementing a human rights based approach intervention (i.e. training, applying the ‘Getting It Right’ assessment tool and receiving booster sessions) at 10 intervention sites with 10 control sites.

Setting

Eight NHS dementia inpatient wards and 12 care homes in the north-west of England.

Participants

People living with dementia who were residing on dementia inpatient wards or in care homes, and staff working at these sites. The aim was to recruit 280 people living with dementia.

Interventions

A sample of staff (an average of 8.9 per site) at each of the sites was trained in a human rights based approach to care, including the application of the ‘Getting It Right’ assessment tool. The tool was then introduced at the site and monthly booster sessions were delivered.

Main outcome measures

The primary outcome measure used in the research was the Quality of Life in Alzheimer’s Disease scale to assess the subjective well-being of the person with dementia. Secondary outcome measures included measures of the quality of care provided (dementia care mapping) and direct measures of the effectiveness of the training in increasing knowledge of and attitudes towards human rights. The study also included an economic evaluation utilising the EuroQol-5 Dimensions, three-level version, and the Adult Social Care Outcomes Toolkit measure.

Results

The study recruited 439 people living with dementia: 213 to the intervention arm and 226 to the control arm. Primary outcome data were analysed using a linear mixed model. There were no significant differences found in the reported quality of life of residents between the control and intervention groups after the intervention [F(1,16.51) = 3.63;p = 0.074]. The mean difference between the groups was 1.48 (95% confidence interval –7.86 to 10.82).

Conclusions

Despite the fact that the training increased staff knowledge of and positive attitudes towards human rights, and although there were some changes in staff decision-making strategies in clinical situations, there was no change in the quality of care provided or in the reported well-being of people living with dementia in these settings. This led to questions about the efficacy of training in bringing about cultural change and improving care practices.

Limitations

There was limited uptake of the training and booster sessions that were integral to the intervention.

Future work

Future work could usefully focus on understanding the difficulty in translating change in attitude and knowledge into behaviour.

Trial registration

Current Controlled Trials ISRCTN94553028.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 6, No. 13. See the NIHR Journals Library website for further project information.

The therapeutic role of mental health nurses in psychiatric intensive care: A mixed-methods investigation in an inner-city mental health service

WHAT IS KNOWN ON THE SUBJECT?: Mental health services have been radically transformed since the 1990s, with an emphasis on care in the community. However, acute psychiatric wards remain an important component of service provision. Research shows that patients receive limited therapeutic interaction with nurses in such settings. A recent review showed that just 4%-12% of nurses' time was spent on activities that could be considered therapeutic. WHAT THIS STUDY ADDS TO EXISTING KNOWLEDGE?: Whereas nurses wanted more time for individual therapeutic activity, patients were content with brief interactions. However, such contact was not always available, partly due to workload pressures. Both nurses and patients believed that a collaborative approach, involving the whole multidisciplinary team, was key to the success of therapeutic engagement. The meaning of therapeutic engagement remains nebulous. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurse education, ward management and clinical supervision should have greater emphasis on therapeutic engagement. Further research is needed to develop therapeutic engagement in acute psychiatric settings; such work should involve patients as active and equal partners.

ABSTRACT

Introduction Despite indications that therapeutic interaction is beneficial for patients and for nurses' job satisfaction in acute psychiatric care, research shows a small amount of nurses' time is spent on such activity. Aims This study investigated the actual and potential therapeutic role of the mental health nurse in psychiatric intensive care, where admission is due to violence or aggression. Methods In a mixed-methods concurrent triangulation design, clinician and patient activity was observed using a structured measurement tool, and qualitative interviews were conducted with four practitioners and six patients. Findings were generated using thematic analysis and descriptive statistics. Results Of the directly observed 234 clinician and 309 patient activities, 20.9% and 15.9%, respectively, were classified as therapeutic engagement. Interviews revealed that both clinicians and patients wanted more therapeutic contact, but whereas nurses wanted longer time to spend in individual sessions, patients preferred brief but more frequent interaction with nurses. Discussion This study shows disparity between actual and desirable levels of therapeutic interaction. Apart from organizational constraints, a fundamental problem is the lack of definition or established practices of therapeutic engagement. Implications for Practice There should be more emphasis on therapeutic engagement in nurse education, ward management and clinical supervision.

The origins of a two-tier profession: a nursing school at a Poor Law infirmary

Niall McCrae, Lecturer, and Katerina Kuzminska, Postgraduate Nursing Student, Florence Nightingale Faculty of Nursing and Midwifery, King's College, London, chart the influences of Nightingale's Poor Law infirmary reforms.

Merely a stepping stone? Professional identity and career prospects following postgraduate mental health nurse training

Accelerated mental health nurse training attracts talented graduates, many with a psychology degree. Our study shows that such trainees feel incompatible with the nursing culture. Consequently, professional identification is inhibited, and on qualifying these nurses may choose to develop their careers elsewhere. Nurse educators and mentors should pay greater attention to nurturing a positive professional identity in trainees. Alongside their attainment of knowledge and skills, nursing trainees are moulded by a professional culture and inculcated to norms of beliefs and behaviour. The process of professional identification may be inhibited by accelerated nurse training and an influx of psychology graduates potentially using mental health nursing qualification as a springboard to other career opportunities. This study explored facilitators and barriers to professional identification in newly qualified nurses of accelerated postgraduate training. Qualitative interviews were conducted with 10 nurses who had recently completed a postgraduate diploma in mental health nursing at King's College London. Participants identified more with the mental health field than with the broader profession of nursing. They defined their practice in terms of values rather than skills and found difficulty in articulating a distinct role for mental health nursing. Although participants had found experience in training and as a registered practitioner rewarding, they were concerned that nursing may not fulfil their aspirations. Professional identity is likely to be a major factor in satisfaction and retention of nurses. Training and continuing professional development should promote career advancement within clinical nursing practice.