Cognitive testing of the Children's Palliative Outcome Scale (C-POS) with children, young people and their parents/carers

BACKGROUND

The Children's Palliative Outcome Scale (C-POS) is being developed using best methodological guidance on outcome measure development, This recommends cognitive testing, an established method of item improvement, prior to psychometric testing.

AIM

To cognitively test C-POS within the target population to establish comprehensibility, comprehensiveness, relevance and acceptability.

DESIGN

Cross-sectional cognitive interview study following COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology and Rothrock guidance on outcome measure development. Cognitive interviews were conducted using 'think aloud' and verbal probing techniques.

SETTING/PARTICIPANTS

Children 5-⩽17 years old with life-limiting conditions and parents/carers of children with life-limiting conditions were recruited from 14 UK sites.

RESULTS

Forty-eight individuals participated (36 parents; 12 children) in cognitively testing the five versions of C-POS over two to seven rounds. Content and length were acceptable, and all questions were considered important. Refinements were made to parent/carer versions to be inclusive of non-verbal children such as changing 'share' to 'express' feelings; and 'being able to ask questions' to 'having the appropriate information'. Changes to improve comprehensibility of items such as 'living life to the fullest' were also made. Parents reported that completing an outcome measure can be distressing but this is anticipated and that being asked is important.

CONCLUSION

Cognitive interviewing has facilitated refinement of the C-POS, especially for non-verbal children who represent a large proportion of those with a life-limiting condition. This study has enhanced the face and content validity of the measure and provided preliminary evidence for acceptability for use in routine practice.

What are the anticipated benefits, risks, barriers and facilitators to implementing person-centred outcome measures into routine care for children and young people with life-limiting and life-threatening conditions? A qualitative interview study with key stakeholders

BACKGROUND

There is a growing evidence-base underpinning implementation of person-centred outcome measures into adult palliative care. However evidence on how best to achieve this with children facing life-threatening and life-limiting conditions is limited.

AIM

To identify the anticipated benefits, risks, barriers and facilitators to implementing person-centred outcome measures for children with life-limiting and life-threatening conditions.

DESIGN

Cross-sectional qualitative semi-structured interview study with key stakeholders analysed using Framework analysis informed by the adapted-Consolidated Framework for Implementation Research.

SETTING/PARTICIPANTS

A total of n = 26 children with life-limiting or life-threatening conditions, n = 40 parents/carers, n = 13 siblings and n = 15 health and social care professionals recruited from six hospitals and three children's hospices and n = 12 Commissioners of health services.

RESULTS

All participants were supportive of future implementation of person-centred outcome measures into care. Anticipated benefits included: better understanding of patient and family priorities, improved communication and collaborative working between professionals and families and standardisation in data collection and reporting. Anticipated risks included increased workload for staff and measures not being used as intended. Implementation barriers included: acceptability and usability of outcome measures by children; burden and capacity of parents/carers regarding completion; privacy concerns; and language barriers. Implementation facilitators included designing measures using language that is meaningful to children and families, ensuring potential benefits of person-centred outcome measures are communicated to encourage 'buy-in' and administering measures with known and trusted professional.

CONCLUSIONS

Implementation of person-centred outcome measures offer potential benefits for children with life-limiting and life-threatening conditions. Eight recommendations are made to maximise benefits and minimise risks in implementation.

'My life is a mess but I cope': An analysis of the language children and young people use to describe their own life-limiting or life-threatening condition

BACKGROUND

Children and young people with life-limiting and life-threatening conditions have multidimensional needs and heterogenous cognitive and communicative abilities. There is limited evidence to support clinicians to tailor their communication to each individual child.

AIM

To explore the language children and young people use to describe their own condition, to inform strategies for discussing needs and priorities.

DESIGN

Positioned within a social constructivist paradigm, a secondary discourse analysis of semi-structured interview data was conducted incorporating the discourse dynamics approach for figurative language.

SETTING/PARTICIPANTS

A total of 26 children and young people aged 5-17 years with life-limiting or life-threatening conditions (6 cancer; 20 non-cancer) were recruited from nine clinical services (six hospitals and three hospices) across two UK nations.

RESULTS

The language children and young people use positions them as 'experts in their condition'. They combine medical terminology with their preferred terms for their body to describe symptoms and treatments, and use comparatives and superlatives to communicate their health status. Their language depicts their condition as a 'series of (functional and social) losses', which single them out from their peers as 'the sick one'. Older children and young people also incorporate figurative language to expand their descriptions.

CONCLUSION/DISCUSSION

Children and young people can provide rich descriptions of their condition. Paying attention to their lexical choices, and converging one's language towards theirs, may enable more child-centred discussions. Expanding discussions about 'what matters most' with consideration of the losses and differences they have experienced may facilitate a fuller assessment of their concerns, preferences and priorities.

Achieving consensus on priority items for paediatric palliative care outcome measurement: Results from a modified Delphi survey, engagement with a children's research involvement group and expert item generation

BACKGROUND

There is no validated outcome measure for use in children's palliative care outside sub-Saharan Africa. Stakeholders must be involved in the development of such measures to ensure face and content validity.

AIM

To gain expert stakeholder consensus on items for inclusion in a paediatric palliative care outcome measure to establish face and content validity.

DESIGN

This study was conducted in two phases following Rothrock and COSMIN guidance on patient-reported outcome measure development. Phase 1: Three-round modified Delphi survey to establish consensus on priority items. Phase 2: Item generation meeting with key stakeholders to develop initial measure versions. A young person's advisory group was also consulted on priority outcomes.

SETTING AND PARTICIPANTS

Delphi survey: Parents and professionals with experience of caring for a child with a life-limiting condition. Young person's advisory group: young people age 10-20 years. Item generation meeting: bereaved parents, academics and clinicians.

RESULTS

Phase 1: Delphi survey (n = 82). Agreement increased from Kendall's W = 0.17 to W = 0.61, indicating movement towards consensus. Agreement between professional and parent ranking was poor (Cohen's kappa 0.13). Professionals prioritised physical symptoms, whereas parents prioritised psychosocial and practical concerns. Advisory group: Children (n = 22) prioritised items related to living a 'normal life' in addition to items prioritised by adult participants. Phase 2: Five age/developmental stage appropriate child and proxy-reported versions of C-POS, containing 13 items, were drafted.

CONCLUSIONS

This study highlights the importance and feasibility of involving key stakeholders in PROM item generation, as important differences were found in the priority outcomes identified by children, parents and professionals.

Design and Administration of Patient-Centred Outcome Measures: The Perspectives of Children and Young People with Life-Limiting or Life-Threatening Conditions and Their Family Members

BACKGROUND

Self-reported health data from children with life-limiting conditions is rarely collected. To improve acceptability and feasibility of child and family-centred outcome measures for children, they need to be designed in a way that reflects preferences, priorities and abilities.

OBJECTIVES

The aim was to identify preferences for patient-reported outcome measure design (recall period, response format, length, administration mode) to improve the feasibility, acceptability, comprehensibility and relevance of a child and family-centred outcome measure, among children with life-limiting conditions and their family members.

METHOD

A semi-structured qualitative interview study seeking the perspectives of children with life-limiting conditions, their siblings and parents on measure design was conducted. Participants were purposively sampled and recruited from nine UK sites. Verbatim transcripts were analysed using framework analysis.

RESULTS

A total of 79 participants were recruited: 39 children aged 5-17 years (26 living with a life-limiting condition; 13 healthy siblings) and 40 parents (of children aged 0-17 years). Children found a short recall period and a visually appealing measure with ten questions or fewer most acceptable. Children with life-limiting conditions were more familiar with using rating scales such as numeric and Likert than their healthy siblings. Children emphasised the importance of completing the measure alongside interactions with a healthcare professional to enable them to talk about their responses. While parents assumed that electronic completion methods would be most feasible and acceptable, a small number of children preferred paper.

CONCLUSIONS

This study demonstrates that children with life-limiting conditions can engage in communicating preferences regarding the design of a patient-centred outcome measure. Where possible, children should be given the opportunity to participate in the measure development process to enhance acceptability and uptake in clinical practice. Results of this study should be considered in future research on outcome measure development in children.

Spiritual, religious, and existential concerns of children and young people with life-limiting and life-threatening conditions: A qualitative interview study

BACKGROUND

Despite being a core domain of palliative care, primary data on spiritual and existential concerns has rarely been collected among children with life-limiting and life-threatening conditions and their families. Existing evidence has tended to focus on the religious aspects among children with cancer.

AIM

To identify the spiritual needs of children with life-limiting and life-threatening conditions.

DESIGN

Cross-sectional semi-structured, qualitative interview study with children, families and health and social care professionals. Verbatim transcripts were analysed using Framework analysis.

SETTING/PARTICIPANTS

Purposively sampled children with life-limiting and life-threatening conditions, their parents and siblings, health and social care professionals recruited from six hospitals and three children's hospices in the UK, and commissioners of paediatric palliative care services recruited through networks and a national charity.

RESULTS

One hundred six participants were interviewed: 26 children (5-17 years), 53 family members (parents/carers of children 0-17 years and siblings (5-17 years)), 27 professionals (health and social care professionals and commissioners of paediatric palliative care). Themes included: living life to the fullest, meaning of life and leaving a legacy, uncertainty about the future, determination to survive, accepting or fighting the future and role of religion. Children as young as 5 years old identified needs or concerns in the spiritual domain of care.

CONCLUSIONS

Addressing spiritual concerns is essential to providing child- and family-centred palliative care. Eliciting spiritual concerns may enable health and social care professionals to identify the things that can support and enhance a meaningful life and legacy for children and their families.

COVID-19: Impact on Pediatric Palliative Care

CONTEXT

Children and young people with life-limiting or life-threatening conditions and their families are potentially vulnerable during COVID-19 lockdowns due to pre-existing high clinical support needs and social participation limitations.

OBJECTIVES

To explore the impact of the COVID-19 pandemic and lockdowns on this population.

METHODS

Sub-analysis of an emergent COVID-19 related theme from a larger semi-structured interview study investigating priority pediatric palliative care outcomes. One hundred and six United Kingdom-wide purposively-sampled Children and young people with life-limiting or life-threatening conditions, parent/carers, siblings, health professionals, and commissioners.

RESULTS

COVID-19 was raised by participants in 12/44 interviews conducted after the United Kingdom's first confirmed COVID-19 case. Key themes included loss of vital social support, disruption to services important to families, and additional psychological distress.

CONCLUSION

Continued delivery of child- and family-centered palliative care requires innovative assessment and delivery of psycho-social support. Disruptions within treatment and care providers may compound support needs, requiring cordination for families facing multiagency delays.

How do person‐centered outcome measures enable shared decision‐making for people with dementia and family carers?—A systematic review

Objectives

To identify published evidence on person‐centered outcome measures (PCOMs) used in dementia care and to explore how PCOMs facilitate shared decision‐making and improve outcomes of care. To build a logic model based on the findings, depicting linkages with PCOM impact mechanisms and care outcomes.

Design

Mixed‐methods systematic review. We searched PsycINFO, MEDLINE, CINAHL, and ASSIA from databases and included studies reporting experiences and/or impact of PCOM use among people with dementia, family carers, and/or practitioners. Groen Van de Ven's model of collaborative deliberation informed the elements of shared decision‐making in dementia care in the abstraction, analysis, and interpretation of data. Data were narratively synthesized to develop the logic model.

Setting

Studies were conducted in long‐term care, mixed settings, emergency department, general primary care, and geriatric clinics.

Participants

A total of 1064 participants were included in the review.

Results

Ten studies were included. PCOMs can facilitate shared decision‐making through “knowing the person,” “identifying problems, priorities for care and treatment and goal setting,” “evaluating decisions”, and “implementation considerations for PCOM use.” Weak evidence on the impact of PCOMs to improve communication between individuals and practitioners, physical function, and activities of daily living.

Conclusions

PCOMs can enable shared decision‐making and impact outcomes through facilitating collaborative working between the person's network of family and practitioners to identify and manage symptoms and concerns. The constructed logic model demonstrates the key mechanisms to discuss priorities for care and treatment, and to evaluate decisions and outcomes. A future area of research is training for family carers to use PCOMs with practitioners.

A feasibility study on a novel well-being intervention for university students

OBJECTIVES

Challenging transitions, increased stress and mental ill health can affect students' academic performance and their capacity to remain in higher education. Prevention and early treatment of mental health problems in college students is therefore a key public health priority, nationally and internationally. Developing a range of evidence-based interventions targeting the mental health of students is critical. We examined the feasibility and acceptability of a new universal time use and well-being intervention, the 'Everyday Matters: Healthy Habits for University Life' digital badge (EMDB), a co-curricular micro-credential for first-year college students.

METHODS

This study used a single-arm, pre-post design for first-year undergraduate students. The EMDB comprised eight 1-hour lunchtime sessions on brain development and time-use habits across the 24 hours of the day including sleep, self-care, leisure, study and work. Validated measures of occupational competence and value, mental well-being, sleep health, mindset, self-compassion and gratitude were completed, along with an evaluation questionnaire.

RESULTS

Eight first-year undergraduate students completed the demographic questionnaire and pre- and post- measures, with one additional student completing only the evaluation questionnaire. There was significantly improved levels of well-being, self-compassion and growth mindset following the intervention. Many of the challenges reported by participants related to occupational issues such as managing finances and having a satisfying routine. Participants appreciated the practical relevance and scientific underpinnings of the programme content. The sense of belonging within the group and having insightful conversations with other group members were particularly valued by participants.

CONCLUSIONS

This study offers preliminary evidence that an occupational therapy based universal time-use and well-being intervention was feasible to deliver and acceptable to first-year undergraduate students. The results of this study and the participant acceptability support further development and evaluation of the EMDB intervention.

Parental alcohol intoxication and adverse health outcomes among offspring. A 4-year follow up HUNT study among 2399 Norwegian adolescents

This study aimed to investigate whether experience of parental alcohol intoxication was associated with adverse health outcomes among adolescents four years later. A population-based Norwegian cohort study of 2399 adolescents who participated in the Young-HUNT1 Survey 1995-97 (T1, 13-15 years old) was followed up four years later (T2) in 2000 (Young-HUNT2, 17-19 years old). Measures were based on adolescent self-report of exposure to parental alcohol intoxication, self-rated general health, mental distress (SCL-5) and lifetime hospital admission. Multivariable logistic regression analyses, adjusted for gender, age and parental education were applied. Results show that half of the adolescents (51%) had seen parents intoxicated at age 13-15 years. Four years later, those who had reported parental alcohol intoxication at T1 had increased odds of admission to hospital with odds ratios ranging from OR1.3; CI 1.0-1.7 to OR 2.2; CI 1.3-3.9, poorer self-rated health (odds ratio ranging from 1.8;1.2-2.6 to 2.0;1.1-3.7) and more mental distress (odds ratio ranging from 1.7;1.1-2.5 to 1.9;1.0-3.6). Furthermore, the increased frequency of experience of parental alcohol intoxication are associated with higher prevalence of admission to hospital and mental distress and lower levels of self-rated health. Findings from this large, representative population of Norwegian adolescents indicate that adverse health outcomes among adolescents in a general population are related to relatively common heavy drinking behaviours among parents.

Progress testing in undergraduate dental education: the Peninsula experience and future opportunities

BACKGROUND

Progress testing is well established as a longitudinal form of assessment in undergraduate medical programmes to measure growth in knowledge. Peninsula Dental School is the first school to use progress testing and remains the only one to do so.

AIMS

To share the experience of developing progress testing in an undergraduate dental programme as a major summative assessment tool at a newly established dental school in the United Kingdom.

METHODS

Data were collected for progress tests conducted from 2007 to 14. The tests were formative in the first 2 years of the programme and summative in subsequent years. Each test was based on 100 single best answer multiple-choice items with an appropriate vignette. The students chose their answer from 5 options. A score 1 mark is awarded for each correct answer, minus 0.25 for an incorrect answer and 0 for 'don't know' (DK). The standard setting for each sitting was carried out using Angoff and Hofstee methods.

RESULTS

There were two tests per year with each cohort undertaking eight tests in their 4 years of study providing a total 14 test occasions. The reliability of each test for each student cohort tests was measured using Cronbach's alpha. The average reliability over 42 test/cohort combinations was 0.753 (±SD 0.08). Data analyses show growth in knowledge of dental students across successive years with the largest increase in knowledge observed between tests 1 and 5 and concomitant reduction in DK responses.

CONCLUSION

This is the first study to report the establishment and use of progress testing as the principle form of written summative testing in an undergraduate dental curriculum. Progress testing is a valid and reliable tool to assess growth in knowledge longitudinally over the duration of a dental programme. Although a labour-intensive process, progress testing merits more widespread use in dental programmes.

Key Points to Facilitate the Adoption of Computer-Based Assessments

There are strong pedagogical arguments in favor of adopting computer-based assessment. The risks of technical failure can be managed and are offset by improvements in cost-effectiveness and quality assurance capability. Academic, administrative, and technical leads at an appropriately senior level within an institution need to be identified, so that they can act as effective advocates. All stakeholder groups need to be represented in undertaking a detailed appraisal of requirements and shortlisting software based on core functionality, summative assessment life cycle needs, external compatibility, security, and usability. Any software that is a candidate for adoption should be trialed under simulated summative conditions, with all stakeholders having a voice in agreeing the optimum solution. Transfer to a new system should be carefully planned and communicated, with a programme of training established to maximize the success of adoption.

Palliative and end-of-life care for children with diffuse intrinsic pontine glioma: results from a London cohort study and international survey

BACKGROUND

More than 90% of patients with diffuse intrinsic pontine glioma (DIPG) will die within 2 years of diagnosis. Patients deteriorate rapidly during the disease course, which severely impairs their quality of life. To date, no specific research on this clinically important subject has been conducted. This study aimed to compile an inventory of symptoms experienced, interventions applied, and current service provision in end-of-life care for DIPG.

METHODS

We performed a retrospective cohort study of children with DIPG, aged 0-18 years, who received treatment under the care of 2 London hospitals. Symptoms, interventions, and services applied during the 12 weeks before death were analyzed. In addition, we conducted a global questionnaire-study among health care professionals.

RESULTS

In more than 78% of DIPG patients, problems concerning mobility, swallowing, communication, consciousness, and breathing arose during end-stage disease. Supportive drugs were widely prescribed. The use of medical aids was only documented in <15% of patients. Palliative and end-of-life care was mostly based on the health care professional's experience; only 21% of the questionnaire respondents reported to have a disease-specific palliative care guideline available.

CONCLUSIONS

This research assessed the current state of palliative and end-of-life care for children with DIPG. Our results show the variability and complexity of symptoms at end-stage disease and the current lack of disease-specific guidelines for this vulnerable group of patients. This first descriptive paper is intended to act as a solid basis for developing an international clinical trial and subsequent guideline to support high-quality palliative and end-of-life care.

Management of impacted wisdom teeth: teaching of undergraduate students in UK dental schools

INTRODUCTION

Wisdom tooth removal is one of the most common oral surgical procedures performed across the world. The aim of this study was to gauge the teaching and training of impacted wisdom teeth in undergraduate dental programmes across the UK. The objectives were to identify consistencies and variations in theoretical instructions and clinical training as well as approaches to management of impacted wisdom teeth.

METHODS

This was a cross-sectional survey utilising an online questionnaire. A purposefully designed pro forma with open- as well as closed-ended questions was used. The questionnaire was hosted online on the school's blackboard academic suite (Emily). Prior to conducting the study, approval was gained from the Research and Ethics Committee, and all the ethical principles pertaining to data protection were strictly followed. E-mail invitations were sent to oral surgery leads in all dental schools in the UK. The participants were provided with an information sheet, and an informed consent was obtained. The participants were invited by e-mail to complete the questionnaire online voluntarily.

RESULTS

A total of 16 dental schools offering an undergraduate course in dentistry in the UK, 13 responded positively. (response rate = 81.25%). In majority of dental schools, this subject is taught in the 4th and 5th years. A pre-clinical competency on phantom heads is a requirement in six schools, whilst only one school requires the students to pass a clinical competency. The clinical exposure of students to wisdom tooth surgery is quite variable. Although the dental schools are fairly consistent in their teaching with regard to the indications for surgical intervention, diagnostic/treatment modalities as well as the post-operative care, interesting variations were also observed.

CONCLUSIONS

This study, perhaps the first of its kind, provides useful insights into management of impacted wisdom teeth, as taught in the undergraduate dental programmes across the UK.

Use of peer assessment in tooth extraction competency

INTRODUCTION

Peer assessment is a widely recognised practice in higher education and is being increasingly utilised in healthcare education. It offers multiple advantages and may play a useful role in enhancing students' learning experience. This study was carried out to evaluate the utility of peer assessment in tooth extraction competency in simulated dental learning environment (SDLE).

METHODS

Year 2 dental students were invited to participate in a formative, peer assessment exercise on forceps tooth extraction in SDLE. The ratings made by peers in the formative assessment were compared with the ratings made by academic supervisors in an equivalent summative assessment.

RESULTS

One hundred and twenty-two students participated in both the formative and summative assessments. Descriptive statistics demonstrated that the majority of students were given the same rating in both assessments. However, there were a number of students who were rated as 'Competent' in one assessment and 'Not Competent' in the other assessment. Spearman's Rho correlations showed that there were weak relationships between the formative and summative assessments. There was also weak inter-rater reliability for the ratings of the peers and academic supervisors, as measured by the intraclass correlation coefficient. Feedback from the students and academic supervisors showed unanimously positive perceptions about the peer assessment experience, and they expressed the desire for incorporating peer assessment in other competencies.

CONCLUSIONS

This study shows mixed results with regard to the value of the peer assessment. Given the potential utility of peer assessment as a tool to augment and enrich students' learning experience, further work needs to be done to evaluate the use of peer assessment in operative competencies in dentistry.

Academic environment in a newly established dental school with an enquiry-based curriculum: perceptions of students from the inaugural cohorts

INTRODUCTION

Established in 2007, Peninsula Dental School offers a highly innovative, enquiry-based, student-led, patient-centred curriculum. It is one of the first dental schools in UK to be based exclusively in a primary care setting. This study was carried out to evaluate the academic environment at Peninsula Dental School and to identify differences between expectations of new entrants and perceptions of senior cohorts.

METHODS

This was a cross-sectional survey utilising an online questionnaire based on Dundee Ready Educational Environment Measure (DREEM). The subjects were 234 dental students from all years in this enquiry-based Bachelor of Dental Surgery programme.

RESULTS

The response rate to the questionnaire was 56.42% with an equal gender distribution of the participants. The overall mean DREEM score of the four cohorts was 143.58 (SD ± 20.84), and the mean score for individual items was 2.87 (SD ± 0.41). The reliability of the DREEM data as a whole was strong (α = 0.93). The difference in questionnaire means for the new entrants and the senior cohorts was not significant (P > 0.05). The ANOVA results showed that there were no significant effects of age, gender or ethnicity on the mean DREEM scores. The MANOVA results showed a significant effect of ethnicity with regard to perceptions of teachers and atmosphere.

CONCLUSIONS

An enquiry-based, student-centred curriculum at the Peninsula Dental School provides a positive academic environment for the students.

Supportive care for children and young people during cancer treatment

Children, young people and their families come into contact with a large number of health and social care professionals within hospital, education and community settings following a cancer diagnosis. The multiprofessional team best supports these families through an open and communicative approach to care. The side effects of cancer treatment include fever, infection, gastrointestinal upset, altered body image and psychological impact on children, young people and their families. Debate continues as to how children, young people, their siblings and parents cope with childhood cancer and its treatment due to its impact on family quality of life. It is considered that the short- and long-term wellbeing of children, young people and their families during treatment is best supported by continuing routine daily activities, such as attending nursery, school or college.

The lived experience of community mental health nurses working with people who have dual diagnosis: a phenomenological study

Dual diagnosis (the combination of mental health and substance misuse problems) is a significant facing mental health nurses in the UK. The purpose of the study was to describe the lived experience of community mental health nurses working with people who have a dual diagnosis. A phenomenological approach was us and a purposive sample of seven community mental health nurses with experience of working with people with a dual diagnosis was selected. Data were collected through audiotaped, semi-structured interviews lasting approximately 1 h in duration and analysed using Colaizzi's (1978) method. Thirteen theme clusters relating to three major themes were identified: (1) difficulties in understanding the concept of dual diagnosis; (2) feeling deskilled when working with people who have a dual diagnosis; (3) struggling to work in a system which seeks to avoid people with dual diagnosis. Recommendations regarding the need for increased joint working between professionals, improved education and further research are made.

The impact of a practice development project on the quality of in-patient small group therapy

In 1993 a mental health service in South-east England initiated a practice development project that aimed at continuously improving the quality of in-patient small group therapy provided within its four acute wards. From the outset it was intended that the project and the practice it focused on should be robust and research based. In support of this an evaluative study was carried out in 1998. The evaluation covered a 6-month period and coincided with concerns being reported elsewhere about the adequacy of therapeutic activity within acute psychiatric settings across the country. Data collected for the evaluation focused on the quality dimensions of effectiveness, relevance to need, social acceptability, accessibility, efficiency and economy, and equity. Quantitative and qualitative methods were deployed and data were collected at three points in time over the evaluation period to provide a picture of change within each ward. The quantitative data gathered were mainly obtained through two self-report questionnaires that were developed specifically for the study. Both instruments were tested and found to have a high degree of internal consistency. The qualitative data gathered were collected using semistructured interviews. Analysis of the qualitative and quantitative data sets indicated that practice quality diminished rather than improved during the 6-month study period. Factors that emerged from the data as having influenced this outcome were: increases in ward team's overall workload, inadequate staffing levels and changes in expectations placed on those providing small group therapy. The findings are consistent with a national trend of deteriorating quality in in-patient care and point to some of the limitations of action learning as a practice development method. They also point to service factors that work against effective practice development.

Student nurse appraisal of placement (SNAP): an attempt to provide objective measures of the learning environment based on qualitative and quantitative evaluations

Many nurse researchers have emphasised the importance of good clinical learning environments for student nurses. However, there is less emphasis on how measures of the learning environment can be communicated clearly and objectively to educationalists and clinical staff. This paper attempts to show how the findings of a self-administered student nurse appraisal of placement (SNAP) form can be presented in both qualitative and quantitative terms. A questionnaire was specially designed to provide objective and valid feedback from students, and the learning environments of three wards were compared.