Professor Jill Maben

Calls by the Royal College of Physicians (RCP) for more research in NHS trusts and the Care Quality Commission’s (CQC) decision to award extra points to trusts doing research, seem to signal a new era for research in the NHS.

The RCP statement Delivering Research for All says every NHS clinician should be supported to take part in research. Highlighting evidence that research active trusts have better patient outcomes, the college calls for protected time for doctors, nurses, and other clinicians to undertake research. In collaboration with the National Institute for Health Research, the CQC will add questions to the leadership inspection framework for providers (the well led framework) that recognise the role of research in high quality patient care and strengthen the assessment of research activity.

An increase in research capacity is welcome, but there are serious challenges to implementation. Substantial change, some might say a revolution, will be required in the way research is conducted in the NHS.

Background The ‘Productive Ward: Releasing Time to Care’ programme is a quality improvement (QI) intervention introduced in English acute hospitals a decade ago to: (1) Increase time nurses spend in direct patient care. (2) Improve safety and reliability of care. (3) Improve experience for staff and patients. (4) Make changes to physical environments to improve efficiency.

Objective To explore how timing of adoption, local implementation strategies and processes of assimilation into day-to-day practice relate to one another and shape any sustained impact and wider legacies of a large-scale QI intervention.

Design Multiple methods within six hospitals including 88 interviews (with Productive Ward leads, ward staff, Patient and Public Involvement representatives and senior managers), 10 ward manager questionnaires and structured observations on 12 randomly selected wards.

Results Resource constraints and a managerial desire for standardisation meant that, over time, there was a shift away from the original vision of empowering ward staff to take ownership of Productive Ward towards a range of implementation ‘short cuts’. Nonetheless, material legacies (eg, displaying metrics data; storage systems) have remained in place for up to a decade after initial implementation as have some specific practices (eg, protected mealtimes). Variations in timing of adoption, local implementation strategies and contextual changes influenced assimilation into routine practice and subsequent legacies. Productive Ward has informed wider organisational QI strategies that remain in place today and developed lasting QI capabilities among those meaningfully involved in its implementation.

Conclusions As an ongoing QI approach Productive Ward has not been sustained but has informed contemporary organisational QI practices and strategies. Judgements about the long-term sustainability of QI interventions should consider the evolutionary and adaptive nature of change processes.

Background:

Ever-growing demands on care systems have increased reliance on healthcare support workers. In the UK, their training has been variable, but organisation-wide failures in care have prompted questions about how this crucial section of the workforce should be developed. Their training, support and assessment has become a policy priority.

Objectives:

This paper examines: healthcare support workers’ access to training, support and assessment; perceived gaps in training provision; and barriers and facilitators to implementation of relevant policies in acute care.

Design and settings:

We undertook a qualitative study of staff caring for older inpatients at ward, divisional or organisational-level in three acute National Health Service hospitals in England in 2014.

Participants:

58 staff working with older people (30 healthcare support workers and 24 staff managing or working alongside them) and 4 healthcare support worker training leads.

Methods:

One-to-one semi-structured interviews included: views and experiences of training and support; translation of training into practice; training, support and assessment policies and difficulties of implementing them. Transcripts were analysed to identify themes.

Results:

Induction training was valued, but did not fully prepare healthcare support workers for the realities of the ward. Implementation of hospital policies concerning supervision and formal assessment of competencies varied between and within hospitals, and was subject to availability of appropriate staff and competing demands on staff time. Gaps identified in training provision included: caring for people with cognitive impairment; managing the emotions of patients, families and themselves; and having difficult conversations. Access to ongoing training was affected by: lack of time; infrequent provision; attitudes of ward managers to additional support workforce training, and their need to balance this against patients’ and other staff members’ needs; and the use of e-learning as a default mode of training delivery.

Conclusions:

With the current and unprecedented policy focus on training, support and assessment of healthcare support workers, our study suggests improved training would be welcomed by them and their managers. Provision of training, support and assessment could be improved by organisational policy that promotes and protects healthcare support worker training; formalising the provision and availability of on-ward support; and training and IT support provided on a drop-in basis. Challenges in implementation are likely to be faced in all international settings where there is increased reliance on a support workforce. While recent policies in the UK offers scope to overcome some of these challenges there is a risk that some will be exacerbated.

Background

Nurses and midwives make up almost 50% of the global healthcare shift working workforce. Shift work interferes with sleep and causes fatigue with adverse effects for nurses’ and midwives’ health, as well as on patient safety and care. Where other safety-critical sectors have developed Fatigue Risk Management Systems, healthcare is behind the curve; with published literature only focussing on the evaluation of discreet sleep-related/fatigue-management interventions. Little is known, however, about which interventions have been evaluated for nurses and midwives. Our review is a critical first step to building the evidence-base for healthcare organisations seeking to address this important operational issue.

Objectives

We address two questions: (1) what sleep-related/fatigue-management interventions have been assessed in nurses and midwives and what is their evidence-base? and (2) what measures are used by researchers to assess intervention effectiveness?

Design and data sources

The following databases were searched in November, 2018 with no limit on publication dates: MEDLINE, PsychINFO and CINAHL.

Review methods

We included: (1) studies conducted in adult samples of nurses and/or midwives that had evaluated a sleep-related/fatigue-management intervention; and (2) studies that reported intervention effects on fatigue, sleep, or performance at work, and on measures of attention or cognitive performance (as they relate to the impact of shift working on patient safety/care).

Results

The search identified 798 potentially relevant articles, out of which 32 met our inclusion criteria. There were 8619 participants across the included studies and all were nurses (88.6% female). We did not find any studies conducted in midwives nor any studies conducted in the UK, with most studies conducted in the US, Italy and Taiwan. There was heterogeneity both in terms of the interventions evaluated and the measures used to assess effectiveness. Napping could be beneficial but there was wide variation regarding nap duration and timing, and we need to understand more about barriers to implementation. Longer shifts, shift patterns including nights, and inadequate recovery time between shifts (quick returns) were associated with poorer sleep, increased sleepiness and increased levels of fatigue. Light exposure and/or light attenuation interventions showed promise but the literature was dominated by small, potentially unrepresentative samples.

Conclusions

The literature related to sleep-related/fatigue-management interventions for nurses and midwives is fragmented and lacks cohesion. Further empirical work is warranted with a view to developing comprehensive Fatigue Risk Management Systems to protect against fatigue in nurses, midwives, and other shift working healthcare staff.

At the time of writing (11th April 2020) there are 1.72 million Covid‐19 infections and 104,889 deaths worldwide. In the UK the first recorded death was on the 5th of March 2020 and in just 37 days 9,875 deaths in hospital have been recorded. The 10th of April saw the highest number of UK daily deaths (980) to date. These UK figures do not include those who died in care homes or in the community. Similar death rates have been experienced in China earlier this year (3,339) and are rising globally with particularly high death rates in the US (18,761 with over half of deaths in New York State), Italy (18,939), Spain (16,353) and France (13,197).

As the Coronavirus disease 2019 (Covid-19) pandemic takes hold, nurses are on the front line of health and social care in the most extreme of circumstances. We reflect during a moment in time (week three of lockdown in the UK and week 5/6 across Europe) to highlight the issues facing nurses at this unprecedented time.

At the bedside 24 hours a day seven days a week, in similar outbreaks, nurses have had the highest levels of occupational stress and resulting distress compared to other groups (Cheong and Lee, 2004, Maunder et al., 2006, Nickell et al., 2004). Nurses are already a high-risk group, with the suicide rate among nurses 23% higher than the national average (ONS 2017). Despite this, the RCN (Royal College of Nursing in the UK) has reported that nurses feel “repeatedly” ignored by their employers when they raise concerns about their mental health (Mitchell 2019). A focus on personal responsibility for psychological health and well-being and an over-emphasis on nurses being ‘resilient’ in the face of under-staffing and often intense emotional work is consistently challenged by nurses and nurse academics (Traynor 2018). Treating resilience as an individual trait is seen to ‘let organisations off the hook’ (Traynor 2018); yet has often been the focus of organisational strategies to date. This does not work at the best of times and certainly is not appropriate now in these most difficult of circumstances.

Here we discuss the stressors and challenges and present evidence-informed guidance to address the physical and psychological needs of nurses during the Covid-19 pandemic. We stress the importance of peer and team support to enable positive recovery after acutely stressful and emotionally draining experiences, and outline what managers, organisations and leaders can do to support nurses at this most critical of times.

Understanding barriers to early diagnosis of symptomatic breast cancer among Black African, Black Caribbean and White British women in the UK.

In-depth qualitative interviews using grounded theory methods to identify themes. Findings validated through focus groups.

94 women aged 33-91 years; 20 Black African, 20 Black Caribbean and 20 White British women diagnosed with symptomatic breast cancer were interviewed. Fourteen Black African and 20 Black Caribbean women with (n=19) and without (n=15) breast cancer participated in six focus groups.

Eight cancer centres/hospital trusts in London (n=5), Somerset (n=1), West Midlands (n=1) and Greater Manchester (n=1) during 2012-2013.

There are important differences and similarities in barriers to early diagnosis of breast cancer between Black African, Black Caribbean and White British women in the UK. Differences were influenced by country of birth, time spent in UK and age. First generation Black African women experienced most barriers and longest delays. Second generation Black Caribbean and White British women were similar and experienced fewest barriers. Absence of pain was a barrier for Black African and Black Caribbean women. Older White British women (≥70 years) and first generation Black African and Black Caribbean women shared conservative attitudes and taboos about breast awareness. All women viewed themselves at low risk of the disease, and voiced uncertainty over breast awareness and appraising non-lump symptoms. Focus group findings validated and expanded themes identified in interviews.

Findings challenged reporting of Black women homogenously in breast cancer research. This can mask distinctions within and between ethnic groups. Current media and health promotion messages need reframing to promote early presentation with breast symptoms. Working with communities and developing culturally appropriate materials may lessen taboos and stigma, raise awareness, increase discussion of breast cancer and promote prompt help-seeking for breast symptoms among women with low cancer awareness.

To first, validate in English hospitals the internal structure of the ‘Patient Evaluation of Emotional Care during Hospitalisation’ (PEECH) survey tool which was developed in Australia and, second, to examine how it may deepen the understanding of patient experience through comparison with results from the Picker Patient Experience Questionnaire (PPE-15).

A 48-item survey questionnaire comprising both PEECH and PPE-15 was fielded. We performed exploratory factor analysis and then confirmatory factor analysis using a number of established fit indices. The external validity of the PEECH factor scores was compared across four participating services and at the patient level, factor scores were correlated with the PPE-15.

Four hospital services (an Emergency Admissions Unit; a maternity service; a Medicine for the Elderly department and a Haemato-oncology service) that contrasted in terms of the reported patient experience performance.

Selection of these acute service settings was based on achieving variation of the following factors: teaching hospital/district general hospital, urban/rural locality and high-performing/low-performing organisations (using results of annual national staff and patient surveys). A total of 423 surveys were completed by patients (26% response rate).

A different internal structure to the PEECH instrument emerged in English hospitals. However, both the existing and new factor models were similar in terms of fit. The correlations between the new PEECH factors and the PPE-15 were all in the expected direction, but two of the new factors (personal interactions and feeling valued) were more strongly associated with the PPE-15 than the remaining two factors (feeling informed and treated as an individual).

PEECH can help to build an understanding of complex interpersonal aspects of quality of care, alongside the more transactional and functional aspects typically captured by PPE-15. Further testing of the combined instrument should be undertaken in a wider range of healthcare settings.

Background

Schwartz Center Rounds® (henceforce Rounds) were developed in the United States (US) in 1995 to provide a regular, structured time and safe place for staff to meet to share the emotional, psychological and social challenges of working in healthcare. Rounds were adopted in the United Kingdom (UK) in 2009 and have been subsequently implemented in over 180 healthcare organisations. Using Rounds as a case study, we aim to inform current debates around maintaining fidelity when an intervention developed in one country is transferred and implemented in another.

Methods

Interpretive design using nine qualitative interviews (UK = 3, US = 6) and four focus groups (UK: Focus group 1 (4 participants), Focus group 2 (5 participants; US: focus group 1 (5 participants) focus group 2 (2 participants) with participants involved in Rounds design and implementation, for example, programme architects, senior leaders, mentors and trainers. We also conducted non-participant observations of Rounds (UK = 42: USA = 2) and training days (UK = 2). Data were analysed using thematic analysis.

Results

We identified four core and seven sub-core Rounds components, based upon the US design, and seven peripheral components, based on our US and UK fieldwork. We found high core component fidelity and examples of UK adaptations. We identified six strategies used to maintain high fidelity during Rounds transfer and implementation from the US to UK settings: i) having a legal contract between the two national bodies overseeing implementation, ii) requiring adopting UK healthcare organisations to sign a contract with the national body, iii) piloting the intervention in the UK context, iv) emphasising the credibility of the intervention, v) promoting and evaluating Rounds, and vi) providing implementation support and infrastructure.

Conclusions

This study identifies how fidelity to the core components of a particular intervention was maintained during transfer from one country to another by identifying six strategies which participants argued had enhanced fidelity during transfer of Rounds to a different country, with contractual agreements and legitimacy of intervention sources key. Potential disadvantages include limitations to further innovation and adaptation.

People aged 75 years and over account for 1 in 4 of all hospital admissions. There has been increasing recognition of problems in the care of older people, particularly in hospitals. Evidence suggests that older people judge the care they receive in terms of kindness, empathy, compassion, respectful communication and being seen as a person not just a patient. These are aspects of care to which we refer when we use the term ‘relational care’. Healthcare assistants deliver an increasing proportion of direct care to older people, yet their training needs are often overlooked.

This study will determine the acceptability and feasibility of a cluster randomised controlled trial of ‘Older People’s Shoes’ a 2-day training intervention for healthcare assistants caring for older people in hospital. Within this pilot, 2-arm, parallel, cluster randomised controlled trial, healthcare assistants within acute hospital wards are randomised to either the 2-day training intervention or training as usual. Registered nurses deliver ‘Older People’s Shoes’ over 2 days, approximately 1 week apart. It contains three components: experiential learning about ageing, exploration of older people’s stories, and customer care. Outcomes will be measured at the level of patient (experience of emotional care and quality of life during their hospital stay), healthcare assistant (empathy and attitudes towards older people), and ward (quality of staff/patient interaction). Semi-structured interviews of a purposive sample of healthcare assistants receiving the intervention, and all trainers delivering the intervention, will be undertaken to gain insights into the experiences of both the intervention and the trial, and its perceived impact on practice.

Few training interventions for care staff have been rigorously tested using randomised designs. This study will establish the viability of a definitive cluster randomised controlled trial of a new training intervention to improve the relational care proided by healthcare assistants working with older people in hospital.

The study was registered as an International Standard Randomised Controlled Trial (ISRCTN10385799) on 29 December 2014.

The aim of this paper was to briefly describe how the experience-based co-design (EBCD) approach was used to identify and implement improvements in the experiences of breast and lung cancer patients before (1) comparing the issues identified as shaping patient experiences in the different tumour groups and (2) exploring participants' reflections on the value and key characteristics of this approach to improving patient experiences.

Fieldwork involved 36 filmed narrative patient interviews, 219 h of ethnographic observation, 63 staff interviews and a facilitated co-design change process involving patient and staff interviewees over a 12-month period. Four of the staff and five patients were interviewed about their views on the value of the approach and its key characteristics. The project setting was a large, inner-city cancer centre in England.

Patients from both tumour groups generally identified similar issues (or 'touchpoints') that shaped their experience of care, although breast cancer patients identified a need for better information about side effects of treatment and end of treatment whereas lung cancer patients expressed a need for more information post-surgery. Although the issues were broadly similar, the particular improvement priorities patients and staff chose to work on together were tumour specific. Interviewees highlighted four characteristics of the EBCD approach as being key to its successful implementation: patient involvement, patient responsibility and empowerment, a sense of community, and a close connection between their experiences and the subsequent improvement priorities.

EBCD positions patients as active partners with staff in quality improvement. Breast and lung cancer patients identified similar touchpoints in their experiences, but these were translated into different improvement priorities for each tumour type. This is an important consideration when developing patient-centred cancer services across different tumour types.

To examine the evidence of how poorly performing nurses and midwives are managed in the UK National Health Service (NHS).

Nurses and midwives form the largest clinical group in the NHS. There is little evidence, however, about poor performance and its management in nursing and midwifery literature.

The present study comprised a literature search, analysis of recent Nursing and Midwifery Council (NMC) data and observation at NMC fitness to practice hearings.

Nurses and midwives are the clinical groups most likely to be suspended in the NHS; Trusts do not report data on suspensions therefore no data exist on numbers, reasons for suspensions, managerial processes, gender, area of work, or ethnicity of those suspended; the few major research projects identify variable management practices, the significant financial cost to the NHS and the personal cost to those suspended; there is evidence that inexperienced, poorly trained, or poorly supported managers use suspension inappropriately. Our observation supported this.

There is a need for robust data gathering and research in the field of NHS managerial practice.

Managers should refrain from adopting punitive forms of performance management. Frontline staff and management need better training and support for dealing with poor performance.

The purpose of this paper is to explore the nature and impact of leadership in relation to the local implementation of quality improvement interventions in health care organisations.

Using empirical data from two studies of the implementation of The Productive Ward: Releasing Time to Care in English hospitals, the paper explores leadership in relation to local implementation. Data were attained from in-depth interviews with senior managers, middle managers and frontline staff (n = 79) in 13 NHS hospital case study sites. Framework Approach was used to explore staff views and to identify themes about leadership.

Four overall themes were identified: different leadership roles at multiple levels of the organisation, experiences of "good and bad" leadership styles, frontline staff having a sense of permission to lead change, leader's actions to spread learning and sustain improvements.

This paper offers useful perspectives in understanding informal, emergent, developmental or shared "new" leadership because it emphasises that health care structures, systems and processes influence and shape interactions between the people who work within them. The framework of leadership processes developed could guide implementing organisations to achieve leadership at multiple levels, use appropriate leadership roles, styles and behaviours at different levels and stages of implementation, value and provide support for meaningful staff empowerment, and enable leader's boundary spanning activities to spread learning and sustain improvements.

Understanding and improving ‘patient experience’ is essential to delivering high quality healthcare. However, little is known about the provision of education and training to healthcare staff in this increasingly important area.

This study aims to ascertain the extent and nature of such provision in England and to identify how it might be developed in the future.

An on-line survey was designed to explore training provision relating to patient experiences. To ensure that respondents thought about patient experience in the same way we defined patient experience training as that which aims to teach staff: ‘How to measure or monitor the experience, preferences and priorities of patients and use that knowledge to improve their experience’. Survey questions (n = 15) were devised to cover nine consistently reported key aspects of patient experience; identified from the research literature and recommendations put forward by professional bodies. The survey was administered to (i) all 180 providers of Higher Education (HE) to student/qualified doctors, nurses and allied health professionals, and (ii) all 390 National Health Service (NHS) trusts in England. In addition, we added a single question to the NHS 2010 Staff Survey (n = 306,000) relating to the training staff had received to deliver a good patient experience.

Two hundred and sixty-five individuals responded to the on-line survey representing a total of 159 different organizations from the HE and healthcare sectors. Respondents most commonly identified ‘relationships’ as an ‘essential’ aspect of patient experience education and training. The biggest perceived gaps in current provision related to the ‘physical’ and ‘measurement’ aspects of our conceptualization of patient experience. Of the 148,657 staff who responded to the Staff Survey 41% said they had not received patient experience training and 22% said it was not applicable to them.

While some relevant education courses are in place in England, the results suggest that specific training with regard to the physical needs and comfort of patients, and how patient experiences can be measured and used to improve services, should be introduced. Future developments should also focus, firstly, on involving a wider range of patients in planning and delivering courses and, secondly, evaluating whether courses impact on the attitudes and behaviors of different professional groups and might therefore contribute to improved patient experiences.

A wide range of patient benefits have been attributed to single room hospital accommodation including a reduction in adverse patient safety events. However, studies have been limited to the US with limited evidence from elsewhere. The aim of this study was to assess the impact on safety outcomes of the move to a newly built all single room acute hospital.

A natural experiment investigating the move to 100% single room accommodation in acute assessment, surgical and older people’s wards. Move to 100% single room accommodation compared to ‘steady state’ and ‘new build’ control hospitals. Falls, pressure ulcer, medication error, meticillin-resistant Staphylococcus aureus and Clostridium difficile rates from routine data sources were measured over 36 months.

Five of 15 time series in the wards that moved to single room accommodation revealed changes that coincided with the move to the new all single room hospital: specifically, increased fall, pressure ulcer and Clostridium difficile rates in the older people’s ward, and temporary increases in falls and medication errors in the acute assessment unit. However, because the case mix of the older people’s ward changed, and because the increase in falls and medication errors on the acute assessment ward did not last longer than six months, no clear effect of single rooms on the safety outcomes was demonstrated. There were no changes to safety events coinciding with the move at the new build control site.

For all changes in patient safety events that coincided with the move to single rooms, we found plausible alternative explanations such as case-mix change or disruption as a result of the re-organization of services after the move. The results provide no evidence of either benefit or harm from all single room accommodation in terms of safety-related outcomes, although there may be short-term risks associated with a move to single rooms.

To explore why innovations in service and delivery are adopted and how they are then successfully implemented and eventually assimilated into routine nursing practice.

The ‘Productive Ward’ is a national quality improvement programme that aims to engage nursing staff in the implementation of change at ward level.

Mixed methods (analysis of routine data, online survey, interviews) to apply an evidence-based diffusion of innovations framework.

(1) Broad and narrow indicators of the timing of ‘decisions to adopt’ the Productive Ward were applied. (2) An online survey explored the perceptions of 150 respondents involved with local implementation. (3) Fifty-eight interviews in five organisational case studies to explore the process of assimilation in each context.

Since the launch of the programme in May 2008 staff in approximately 85% of NHS acute hospitals had either downloaded Productive Ward materials or formally purchased a support package (as of March 2009). On a narrower measure, 40% (140) of all NHS hospitals had adopted the programme (i.e. purchased a support package) with large variation between geographical regions. Four key interactions in the diffusion of innovations framework appeared central to the rapid adoption of the programme. Despite widespread perception of significant benefits, frontline nursing staff report that more needs to be carried out to ensure that impact can be demonstrated in quantifiable terms and include patient perspectives.

The programme has been rapidly adopted by NHS hospitals in England. A variety of implementation approaches are being employed, which are likely to have implications for the successful assimilation of the programme into routine nursing practice.

This paper summarises the perceived benefits of the Productive Ward programme and highlights important lessons for nurse leaders who are designing (or adapting) and then implementing quality improvement programmes locally, particularly in terms of how to frame such initiatives – and provide support to – ward-level staff.

Older people account for an increasing proportion of those receiving NHS acute care. The quality of health care delivered to older people has come under increased scrutiny. Health-care assistants (HCAs) provide much of the direct care of older people in hospital. Patients’ experience of care tends to be based on the relational aspects of that care including dignity, empathy and emotional support.

We aimed to understand the relational care training needs of HCAs caring for older people, design a relational care training intervention for HCAs and assess the feasibility of a cluster randomised controlled trial to test the new intervention against HCA training as usual (TAU).

(1) A telephone survey of all NHS hospital trusts in England to assess current HCA training provision, (2) focus groups of older people and carers, (3) semistructured interviews with HCAs and other care staff to establish training needs and inform intervention development and (4) a feasibility cluster randomised controlled trial.

(1) All acute NHS hospital trusts in England, and (2–4) three acute NHS hospital trusts in England and the populations they serve.

(1) Representatives of 113 out of the total of 161 (70.2%) NHS trusts in England took part in the telephone survey, (2) 29 older people or carer participants in three focus groups, (3) 30 HCA and 24 ‘other staff’ interviewees and (4) 12 wards (four per trust), 112 HCAs, 92 patients during the prerandomisation period and 67 patients during the postrandomisation period.

For the feasibility trial, a training intervention (Older People’s Shoes™) for HCAs developed as part of the study was compared with HCA TAU.

Patient-level outcomes were the experience of emotional care and quality of life during patients’ hospital stay, as measured by the Patient Evaluation of Emotional Care during Hospitalisation and the EuroQol-5 Dimensions questionnaires. HCA outcomes were empathy, as measured by the Toronto Empathy Questionnaire, and attitudes towards older people, as measured by the Age Group Evaluation and Description Inventory. Ward-level outcomes were the quality of HCA–patient interaction, as measured by the Quality of Interaction Scale.

(1) One-third of trust telephone survey participants reported HCA training content that we considered to be ‘relational care’. Training for HCAs is variable across trusts and is focused on new recruits. The biggest challenge for HCA training is getting HCAs released from ward duties. (2) Older people and carers are aware of the pressures that ward staff are under but good relationships with care staff determine whether or not their experience of hospital is positive. (3) HCAs have training needs related to ‘difficult conversations’ with patients and relatives; they have particular preferences for learning styles that are not always reflected in available training. (4) In the feasibility trial, 187 of the 192 planned ward observation sessions were completed; the response to HCA questionnaires at baseline and at 8 and 12 weeks post randomisation was 64.2%, 46.4% and 35.7%, respectively, and 57.2% of eligible patients returned completed questionnaires.

This was an intervention development and feasibility study so no conclusions can be drawn about the clinical effectiveness or cost-effectiveness of the intervention.

The intervention had high acceptability among nurse trainers and HCA learners. Viability of a definitive trial is conditional on overcoming specific methodological (patient recruitment processes) and contextual (involvement of wider ward team) challenges.

Schwartz Center Rounds (‘Rounds’) are a multidisciplinary forum in which healthcare staff within an organisation discuss the psychological, emotional and social challenges associated with their work in a confidential and safe environment. Implemented in over 375 North American organisations, since 2009, they have been increasingly adopted in England. This study aimed to establish how many and what types of organisations have adopted Rounds in England, and to explore why they did so.

Public healthcare organisations in England. Participants: Secondary data analysis was used to map and profile all 116 public healthcare organisations that had adopted Rounds in England by July 2015. Semistructured telephone interviews were conducted with 45 Round coordinators within adopting organisations.

The rate of adoption increased after a major national report in 2013. Rounds were typically adopted in order to improve staff well-being. Adopting organisations scored better on staff engagement than non-adopters; among adopting organisations, those performing better on patient experience were more likely to adopt earlier. Most adoption decision-making processes were straightforward. A confluence of factors—a generally favourable set of innovation attributes (including low cost), advocacy from opinion leaders in different professional networks, active dissemination by change agents and a felt need to be seen to be addressing staff well-being—initially led to Rounds being seen as ‘an idea whose time had come’. More recent adoption patterns have been shaped by the timing of charitable and other agency funding in specific geographical areas and sectors, as well as several forms of ‘mimetic pressure’.

The innate attributes of Rounds, favourable circumstances and the cumulative impact of a sequence of distinct informal and formal social processes have shaped the pattern of their adoption in England.

Objectives

There is an international policy trend for building government hospitals with greater proportions of single‐occupancy rooms. The study aim was to identify advantages and disadvantages for patients and nursing staff of a pending move to 100% single room hospital, in anticipation of the challenges for nurse managers of a different ward environment. This paper presents these findings, summarising potential advantages and disadvantages as well as comparison with findings from similar studies in England.

Methods

Mixed method case study design was undertaken in four wards of a large hospital with multi‐bed rooms. Three components of a larger study are reported here: nurse surveys and interviews, patient interviews of their experiences of the current multi‐bedroom environment and expectations of new single room environment. Integration was achieved via data transformation where results of the nursing staff survey and interviews and patient interviews were coded as narrative allowing for quantitative and qualitative data to be merged.

Results

Four constructs were derived: physical environment; patient safety and comfort; staff safety; and importance of interaction.

Conclusion

There are important factors that inform nurse managers when considering a move to an all single room design. These factors are important for nurses’ and patients’ well‐being.

Implications for nursing management

This study identified for nurse managers key factors that should consider when contributing to the design of a 100% single room hospital. Nurses’ voices are critically important to inform the design for a safe and efficient ward environment.

Diabetes affects around 3.6 million people in the UK. Previous research found that general practices employing more nurses delivered better diabetes care, but did not include data on individual patient characteristics or consultations received.

To examine whether the proportion of consultations with patients with diabetes provided by nurses in GP practices is associated with control of diabetes measured by levels of glycated haemoglobin (HbA1c).

A retrospective observational study using consultation records from 319 649 patients with diabetes from 471 UK general practices from 2002 to 2011.

Hierarchical multilevel models to examine associations between proportion of consultations undertaken by nurses and attaining HbA1c targets over time, controlling for case-mix and practice level factors.

The proportion of consultations with nurses has increased by 20% since 2002 but patients with diabetes made fewer consultations per year in 2011 compared with 2002 (11.6 versus 16.0). Glycaemic control has improved and was more uniformly achieved in 2011 than 2002. Practices in which nurses provide a higher proportion of consultations perform no differently to those where nurse input is lower (lowest versus highest nurse contact tertile odds ratio [OR] [confidence interval {95% CI}]: HbA1c ≤53 mmol/mol (7%) 2002, 1.04 [95% CI = 0.87 to 1.25] and 2011, 0.95 [95% CI = 0.87 to 1.03]; HbA1c ≤86 mmol/mol (10%) 2002, 0.97 [95% CI = 0.73 to 1.29] and 2011, 0.95 [95% CI = 0.86 to 1.04]).

Practices that primarily use GPs to deliver diabetes care could release significant resources with no adverse effect by switching their services towards nurse-led care.

Several systematic reviews have suggested that greater nurse staffing as well as a greater proportion of registered nurses in the health workforce is associated with better patient outcomes. Others have found that nurses can substitute for doctors safely and effectively in a variety of settings. However, these reviews do not generally consider the effect of nurse staff on both patient outcomes and costs of care, and therefore say little about the cost-effectiveness of nurse-provided care. Therefore, we conducted a scoping literature review of economic evaluation studies which consider the link between nurse staffing, skill mix within the nursing team and between nurses and other medical staff to determine the nature of the available economic evidence.

Scoping literature review.

English-language manuscripts, published between 1989 and 2009, focussing on the relationship between costs and effects of care and the level of registered nurse staffing or nurse–physician substitution/nursing skill mix in the clinical team, using cost-effectiveness, cost-utility, or cost–benefit analysis. Articles selected for the review were identified through Medline, CINAHL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and Google Scholar database searches.

After selecting 17 articles representing 16 unique studies for review, we summarized their main findings, and assessed their methodological quality using criteria derived from recommendations from the guidelines proposed by the Panel on Cost-Effectiveness in Health Care.

In general, it was found that nurses can provide cost effective care, compared to other health professionals. On the other hand, more intensive nurse staffing was associated with both better outcomes and more expensive care, and therefore cost effectiveness was not easy to assess.

Although considerable progress in economic evaluation studies has been reached in recent years, a number of methodological issues remain. In the future, nurse researchers should be more actively engaged in the design and implementation of economic evaluation studies of the services they provide.

Few empirical studies have directly examined the relationship between staff experiences of providing healthcare and patient experience. Present concerns over the care of older people in UK acute hospitals – and the reported attitudes of staff in such settings – highlight an important area of study.

To examine the links between staff experience of work and patient experience of care in a ‘Medicine for Older People’ (MfOP) service in England.

A mixed methods case study undertaken over 8 months incorporating a 149-item staff survey (66/192 – 34% response rate), a 48-item patient survey (26/111 – 23%), 18 staff interviews, 18 patient and carer interviews and 41 hours of non-participant observation.

Variation in patient experience is significantly influenced by staff work experiences. A high-demand/low-control work environment, poor staffing, ward leadership and co-worker relationships can each add to the inherent difficulties staff face when caring for acutely ill older people. Staff seek to alleviate the impact of such difficulties by finding personal satisfaction from caring for ‘the poppets’; those patients they enjoy caring for and for whom they feel able to ‘make a difference’. Other patients – noting dehumanising aspects of their care – felt like ‘parcels’. Patients are aware of being seen by staff as ‘difficult’ or ‘demanding’ and seek to manage their relationships with nursing staff accordingly.

The work experiences of staff in a MfOP service impacted directly on patient care experience. Poor ward and patient care climates often lead staff to seek job satisfaction through caring for ‘poppets’, leaving less favoured – and often more complex patients – to receive less personalised care.

Investment in staff well-being and ward climate is essential for the consistent delivery of high-quality care for older people in acute settings.

This paper draws on a narrative review of the literature, commissioned to support the Health Visitor Implementation Plan, and aimed at identifying messages about the knowledge, skills, and abilities needed by health visitors to work within the current system of health care provision.

The scoping study and narrative review used three complementary approaches: a broad search, a structured search, and a seminal paper search to identify empirical papers from the health visitor literature for review. The key inclusion criteria were messages of relevance for practice.

378 papers were reviewed. These included empirical papers from the United Kingdom (UK) from 2004 to February 2012, older research identified in the seminal paper search and international literature from 2000 to January 2016.

The review papers were read by members of the multidisciplinary research team which included health visitor academics, social scientists, and a clinical psychologist managed the international literature. Thematic content analysis was used to identify main messages. These were tabulated and shared between researchers in order to compare emergent findings and to confirm dominant themes.

The analysis identified an ‘orientation to practice’ based on salutogenesis (health creation), human valuing (person-centred care), and viewing the person in situation (human ecology) as the aspirational core of health visitors' work. This was realised through home visiting, needs assessment, and relationship formation at different levels of service provision. A wide range of knowledge, skills, and abilities were required, including knowledge of health as a process and skills in engagement, building trust, and making professional judgments. These are currently difficult to impart within a 45 week health visitor programme and are facilitated through ad hoc post-registration education and training. The international literature reported both similarities and differences between the working practices of health visitors in the UK and public health nurses worldwide. Challenges related to the education of each were identified.

The breadth and scope of knowledge, skills, and abilities required by health visitors make a review of current educational provision desirable. Three potential models for health visitor education are described.

This paper aims to focus on facilitating large-scale quality improvement in health care, and specifically understanding more about the known challenges associated with implementation of lean innovations: receptivity, the complexity of adoption processes, evidence of the innovation, and embedding change. Lessons are drawn from the implementation of The Productive Ward: Releasing Time to Caree programme in English hospitals.

The study upon which the paper draws was a mixed-method evaluation that aimed to capture the perceptions of three main stakeholder groups: national-level policymakers (15 semi-structured interviews); senior hospital managers (a national web-based survey of 150 staff); and healthcare practitioners (case studies within five hospitals involving 58 members of staff). The views of these stakeholder groups were analysed using a diffusion of innovations theoretical framework to examine aspects of the innovation, the organisation, the wider context and linkages.

Although The Productive Ward was widely supported, stakeholders at different levels identified varying facilitators and challenges to implementation. Key issues for all stakeholders were staff time to work on the programme and showing evidence of the impact on staff, patients and ward environments.

To support implementation, policymakers should focus on expressing what can be gained locally using success stories and guidance from “early adopters”. Service managers, clinical educators and professional bodies can help to spread good practice and encourage professional leadership and support. Further research could help to secure support for the programme by generating evidence about the innovation, and specifically its clinical effectiveness and broader links to public expectations and experiences of healthcare.

This paper draws lessons from the implementation of The Productive Ward programme in England, which can inform the implementation of other large-scale programmes of quality improvement in health care.

Patients’ experiences have become central to assessing the performance of healthcare systems worldwide and are increasingly being used to inform quality improvement processes. This paper explores the relative value of surveys and detailed patient narratives in identifying priorities for improving breast cancer services as part of a quality improvement process.

One dataset was collected using a narrative interview approach, (n = 13) and the other using a postal survey (n = 82). Datasets were analyzed separately and then compared to determine whether similar priorities for improving patient experiences were identified.

There were both similarities and differences in the improvement priorities arising from each approach. Day surgery was specifically identified as a priority in the narrative dataset but included in the survey recommendations only as part of a broader priority around improving inpatient experience. Both datasets identified appointment systems, patients spending enough time with staff, information about treatment and side effects and more information at the end of treatment as priorities. The specific priorities identified by the narrative interviews commonly related to ‘relational’ aspects of patient experience. Those identified by the survey typically related to more ‘functional’ aspects and were not always sufficiently detailed to identify specific improvement actions.

Our analysis suggests that whilst local survey data may act as a screening tool to identify potential problems within the breast cancer service, they do not always provide sufficient detail of what to do to improve that service. These findings may have wider applicability in other services. We recommend using an initial preliminary survey, with better use of survey open comments, followed by an in-depth qualitative analysis to help deliver improvements to relational and functional aspects of patient experience.

Supplementary prescribing (SP) is a drug therapy management model implemented in the United Kingdom since 2003. It is a voluntary partnership between an independent prescriber; a supplementary prescriber, for example, nurse or pharmacist; and the patient, to implement an agreed patient-specific clinical management plan (CMP).

To investigate pharmacist prescribers' views and experiences of the early stages of SP implementation.

A qualitative, longitudinal study design was used. A purposive, maximum variability sample of 16 pharmacist supplementary prescribers, trained in Southern England, participated. Eleven were hospital pharmacists, owing to the overrepresentation of hospital pharmacists in the first cohort. Two semistructured interviews were conducted with each participant, at 3 and 6 months after their registration as prescribers. The Framework approach was used for data collection, management, and analysis.

Three typologies of pharmacists' experiences were identified: “a blind alley”, “a stepping stone” and “a good fit”. Despite some delays in its implementation, SP was seen as a step forward. Some participants also believed that it improved patient care and pharmacists' integration in the health care team and increased their job satisfaction. However, there was a concern that SP, as first implemented, was bureaucratic and limited pharmacists' freedom in their decision making. Hence, pharmacists were more supportive of the then imminent introduction of a pharmacist independent prescribing (IP) role.

Despite challenges, the SP role represented a step forward for pharmacists in the United Kingdom. It is possible that pharmacist SP can coexist with IP in the areas suitable for CMP use. Elsewhere, SP is likely to become more of a “stepping stone” to an IP role than the preferred model for pharmacist prescribing. Future research needs to objectively assess the outcomes of pharmacist SP, preferably in comparison with IP, to inform decision making among pharmacists regarding the adoption of such an innovative role.

An association between quality of care and staffing levels, particularly registered nurses, has been established in acute hospitals. Recently an association between nurse staffing and quality of care for several chronic conditions has also been demonstrated for primary care in English general practice. A smaller body of literature identifies organisational factors, in particular issues of human resource management, as being a dominant factor. However the literature has tended to consider staffing and organisational factors separately.

We aim to determine whether relationships between the quality of clinical care and nurse staffing in general practice are attenuated or enhanced when organisational factors associated with quality of care are considered. We further aim to determine the relative contribution and interaction between these factors.

We used routinely collected data from 8409 English general practices. The data, on organisational factors and the quality of clinical care for a range of long term conditions, is gathered as part of “Quality and Outcomes Framework” pay for performance system. Regression models exploring the relationship of staffing and organisational factors with care quality were fitted using MPLUS statistical modelling software.

Higher levels of nurse staffing, clinical recording, education and reflection on the results of patient surveys were significantly associated with improved clinical care for COPD, CHD, Diabetes and Hypothyroidism after controlling for organisational factors. There was some evidence of attenuation of the estimated nurse staffing effect when organisational factors were considered, but this was small. The effect of staffing interacted significantly with the effect of organisational factors. Overall however, the characteristics that emerged as the strongest predictors of quality of clinical care were not staffing levels but the organisational factors of clinical recording, education and training and use of patient experience surveys.

Organisational factors contribute significantly to observed variation in the quality of care in English general practices. Levels of nurse staffing have an independent association with quality but also interact with organisational factors. The observed relationships are not necessarily causal but a causal relationship is plausible. The benefits and importance of education, training and personal development of nursing and other practice staff was clearly indicated.

Research on Indian nurses has focused on their participation as global migrant workers for whom opportunities abroad act as an incentive for many to migrate overseas. However, little is known about the careers of Indian nurses, or the impact of a globalized health care market on nurses who remain and on the profession itself in India.

To explore nurses’ accounts of entry into nursing in the context of the globalisation of the nursing profession in India, and the salience of ‘migration’ for nurses’ individual careers.

Qualitative interview study (n = 56).

The study drew on interviews with 56 nurses from six sites in Bangalore, India. These included two government hospitals, two private hospitals, a Christian mission hospital, a private outpatient clinic and two private nursing colleges. Participants were selected purposively to include nurses from Christian and Hindu backgrounds, a range of home States, ages and seniority and to deliberately over-recruit (rare) male nurses.

Interviews covered how and why nurses entered nursing, their training and career paths to date, plans for the future, their experiences of providing nursing care and attitudes towards migration. Data analysis drew on grounded theory methods.

Nursing is traditionally seen as a viable career particularly for women from Christian communities in India, where it has created inter-generational ‘nurse families’. In a globalizing India, nursing is becoming a job ‘with prospects’ transcending traditional caste, class and gender boundaries. Almost all nurses interviewed who intended seeking overseas employment envisaged migration as a short term option to satisfy career objectives – increased knowledge, skills and economic rewards – that could result in long-term professional and social status gains ‘back home’ in India. For others, migration was not part of their career plan: yet the increases in status that migration possibilities had brought were crucial to framing nursing as a ‘suitable job’ for a growing number of entrants.

The possibility of migration has facilitated collective social mobility for Indian nurses. Migration possibilities were important not only for those who migrate, but for improving the status of nursing in general in India, making it a more attractive career option for a growing range of recruits.

To synthesize evidence and knowledge from published research about nurses’ experiences of nurse-patient relationships with adult patients in general,acute inpatient hospital settings.

While primary research on nurses’ experiences has been reported, it has not been previously synthesized.

Meta-ethnography

Published literature from Australia, Europe, and North America,written in English between January 1999–October 2009 was identified from databases: CINAHL, Medline, British Nursing Index and PsycINFO.

Qualitative studies describing nurses’ experiences of the nurse-patient relationship in acute hospital settings were reviewed and synthesized using the meta-ethnographic method.

Sixteen primary studies (18 papers) were appraised as high quality and met the inclusion criteria. The findings show that while nurses aspire to develop therapeutic relationships with patients, the organizational setting at a unit level is strongly associated with nurses’ capacity to build and sustain these relationships.The organizational conditions of critical care settings appear best suited to forming therapeutic relationships, while nurses working on general wards are more likely to report moral distress resulting from delivering unsatisfactory care. General ward nurses can then withdraw from attempting to emotionally engage with patients.

The findings of this meta-ethnography draw together the evidence from several qualitative studies and articulate how the organizational setting at a unit level can strongly influence nurses’ capacity to build and sustain therapeutic relationships with patients. Service improvements need to focus on how to optimize the organizational conditions that support nurses in their relational work with patients.

Releasing Time to Care: The Productive Ward™ (RTC) is a method for conducting continuous quality improvement (QI). The Saskatchewan Ministry of Health mandated its implementation in Saskatchewan, Canada between 2008 and 2012. Subsequently, a research team was developed to evaluate its impact on the nursing unit environment. We sought to explore the influence of the unit’s existing QI capacity on their ability to engage with RTC as a program for continuous QI.

We conducted interviews with staff from 8 nursing units and asked them to speak about their experience doing RTC. Using qualitative content analysis, and guided by the Organizing for Quality framework, we describe the existing QI capacity and impact of RTC on the unit environment.

The results focus on 2 units chosen to highlight extreme variation in existing QI capacity. Unit B was characterized by a strong existing environment. RTC was implemented in an environment with a motivated manager and collaborative culture. Aided by the structural support provided by the organization, the QI capacity on this unit was strengthened through RTC. Staff recognized the potential of using the RTC processes to support QI work. Staff on unit E did not have the same experience with RTC. Like unit B, they had similar structural supports provided by their organization but they did not have the same existing cultural or political environment to facilitate the implementation of RTC. They did not have internal motivation and felt they were only doing RTC because they had to. Though they had some success with RTC activities, the staff did not have the same understanding of the methods that RTC could provide for continuous QI work.

RTC has the potential to be a strong tool for engaging units to do QI. This occurs best when RTC is implemented in a supporting environment. One size does not fit all and administrative bodies must consider the unique context of each environment prior to implementing large-scale QI projects. Use of an established framework, like Organizing for Quality, could highlight the distinctive supports needed in particular care environments to increase the likelihood of successful engagement.

There is increasing international interest in universal, health promoting services for pregnancy and the first three years of life and the concept of proportionate universalism. Drawing on a narrative review of literature, this paper explores mechanisms by which such services might contribute to health improvement and reducing health inequalities.

Through a narrative review of empirical literature, to identify: (1) What are the key components of health visiting practice? (2) How are they reflected in implementing the universal service/provision envisaged in the English Health Visitor Implementation Plan (HVIP)?

The paper draws upon a scoping study and narrative review.

We used three complementary approaches to search the widely dispersed literature: (1) broad, general search, (2) structured search, using topic-specific search terms, (3) seminal paper search. Our key inclusion criterion was information about health visiting practice. We included empirical papers from United Kingdom (UK) from 2004 to February 2012 and older seminal papers identified in search (3), identifying a total of 348 papers for inclusion. A thematic content analysis compared the older (up to 2003) with more recent research (2004 onwards).

The analysis revealed health visiting practice as potentially characterized by a particular ‘orientation to practice.’ This embodied the values, skills and attitudes needed to deliver universal health visiting services through salutogenesis (health creation), person-centredness (human valuing) and viewing the person in situation (human ecology). Research about health visiting actions focuses on home visiting, needs assessment and parent–health visitor relationships. The detailed description of health visitors’ skills, attitudes, values, and their application in practice, provides an explanation of how universal provision can potentially help to promote health and shift the social gradient of health inequalities.

Identification of needs across an undifferentiated, universal caseload, combined with an outreach style that enhances uptake of needed services and appropriate health or parenting information, creates opportunities for parents who may otherwise have remained unaware of, or unwilling to engage with such provision. There is a lack of evaluative research about health visiting practice, service organization or universal health visiting as potential mechanisms for promoting health and reducing health inequalities. This paper offers a potential foundation for such research in future.

(i) To synthesise the evidence-base for Schwartz Center Rounds® (Rounds) to assess any impact on healthcare staff and identify key features; (ii) to scope evidence for interventions with similar aims, and compare effectiveness and key features to Rounds.

Systematic review of Rounds literature; scoping reviews of comparator interventions (Action Learning Sets; After Action Reviews; Balint Groups; Caregiver Support Programme; Clinical Supervision; Critical Incident Stress Debriefing; Mindfulness-Based Stress Reduction; Peer Supported Storytelling; Psychosocial Intervention Training; Reflective Practice Groups; Resilience Training).

PsychINFO, CINAHL, MEDLINE, and EMBASE, internet search engines; consultation with experts.

Empirical evaluations (qualitative or quantitative); any healthcare staff in any healthcare setting; published in English.

The overall evidence base for Rounds is limited. We developed a composite definition to aid comparison with other interventions from 41 documents containing a definition of Rounds. Twelve (ten studies) were empirical evaluations. All were of low/moderate quality (weak study designs including lack of control groups). Findings showed the value of Rounds to attenders, with a self-reported positive impact on individuals, their relationships with colleagues and patients, and wider cultural changes. The evidence for the comparative interventions was scant and also low/moderate quality. Some features of Rounds were shared by other interventions, but Rounds offer unique features including being open to all staff and having no expectation for verbal contribution by attenders : Evidence of effectiveness for all interventions considered here remains limited. Methods that enable identification of core features related to effectiveness are needed to optimise benefit for individual staff members and organisations as a whole. A systems approach conceptualising workplace wellbeing as arising from both individual and environmental/structural factors, and comprising interventions both for assessing and improving the wellbeing of healthcare staff, is required. Schwartz Rounds could be considered as one strategy to enhance staff wellbeing.

In 2011–2012, we carried out a programme of research to inform the Department of Health's strategy for strengthening health visiting services in England. Our research included a study of parents' views of their experiences with health visiting services in two geographical areas in England. Here, we draw upon data from this work to illustrate valuable aspects of family support outside the home reported in parents' accounts of their experiences of health visiting. We also explore the usefulness of relational autonomy as a theoretical lens for understanding the mechanisms through which this support operates.

We draw upon data from semi-structured interviews with 44 parents across two ‘Early Implementer Sites’ of the ‘new service vision’ in England. Our thematic analysis of the data was informed by grounded theory principles.

Parents valued being able to attend child health clinics and group activities outside the home; this helped them to avoid social isolation and to identify, choose and use the forms of advice and support that best suited them. We suggest that health visiting outside the home and children's centres services may also foster parental autonomy, especially when this is understood in relational terms.

Health visiting outside the home and children's centres services are an important complement to health visiting in the home; both dimensions of family support should be available in the community. Relational readings of autonomy can help illuminate the ways in which these services can foster (or undermine) parents' autonomy.