Dr Nicola Carey
Academic and research departmentsFaculty of Health and Medical Sciences.
Nicola is a Reader and lead for the Long Term Conditions and Ageing Cluster within the School of Health Sciences. Nicola is a qualified nurse who has worked in a variety of posts across the country in primary care as both a practice nurse and nurse practitioner. She also spent two years in the United States whilst undertaking her Master's in Public Health in community health education and was involved in several national and state level projects including the Youth Risk Behaviour Survey. Her research interests include quality improvement, workforce development, non-medical prescribing and patient self-management. She has significant experience in the conduct and management of multi-site studies and mixed methods research.
She has also previously worked as a member of the HTA pharmaceutical panel and the NIHR grant awarding body Research for Patients Benefit (RfPB) and is Vice-Chair for the Association of Prescribers.
Areas of specialism
Nicola has been involved in a number of projects in non-medical prescribing including: diabetes, dermatology, paediatrics and the development of multi-professional prescribing. The findings from this research have provided support for revised prescribing regulation and assisted service providers to understand how non-medical prescribing can be used in service redesign.
Nurse Independent & Supplementary Prescribing (V300)
Research methods, Transforming Services for Quality
Supervision: MSc Dissertation, PhD
Background. The use of medicines is an important component of the care of patients with diabetes. However, education and support is equally important to the successful management of this group. These are areas of care in which nurses have traditionally been involved. Evidence suggests that combining nursing skills with prescribing may result in shared decision-making and increased medicines concordance.
Design and methods. A collective case study of nine practice settings across England in which nurses prescribed medicines for people with diabetes. Data comprised of semi structured interviews (n = 31), patient questionnaires (n = 131) and video-taped observations of nurse consultations (n = 35). Data analysis included thematic analysis and descriptive statistics. Data were collected between October 2007?September 2008.
Results. Nurses demonstrated good communication skills, which they integrated with the ability to prescribe. Questionnaire and video data confirmed an exchange of information between nurse and patient about aspects of self-care and medicines management. Additional benefits included improved efficiency, supported by patient satisfaction with access and waiting times. Nurses were inconsistent in explaining the risks and benefits of treatments and side-effects and exploring the use of non-prescribed herbal or over-the-counter medicine.
Conclusion. The care nurses are able to provide to people with diabetes is optimised through prescribing. Further evidence is required to evaluate nurse prescribing from the patient?s perspective. Our findings will be of interest to those keen to develop the prescribing role for nurses involved in diabetes service delivery.
Relevance to clinical practice. Prescribing is a valuable development through which nurses are able to encourage self-care and work towards shared-decision making with patients in a way that supports national guidance on the care of people with diabetes.
Background. Nurse-led services enhance care and improve outcomes for patients with diabetes. Research indicates that care delivered by nurse prescribers can improve efficiency and support new ways of working. There is no evidence reported that explores nurses and team member views on how nurse prescribing is being used in diabetes services.
Method. A collective case study of nine practice settings across England in which nurses prescribed medicines for patients with diabetes. A thematic analysis of semi-structured interview data collected during 2007 and 2008. Participants were qualified nurse prescribers, administrative staff, doctors and non-prescribing nurses.
Findings. Nurse prescribing was reported to enhance and support a variety of models of diabetes care. It enabled nurses to work more independently and provide a more streamlined service. Maintaining a team approach ensured that nurses continued to learn and maintained good relationships with doctors.
Conclusion. Nurse prescribing is being successfully used to support and develop more streamlined services for patients with diabetes. Individual and organisational factors, as well as the interpretation of policy initiatives are reported to influence how prescribing is used in practice. Understanding the implications of these forces is important if the full potential of this new and developing role is to be realised.
Relevance to clinical practice. Nurses have an important role to play in the medicines management of patients with diabetes. Nurse prescribing supports and enhances established diabetes services. Prescribing allows nurses to develop diabetes services around the needs of the individual and introduce new ways of working such as the single review process.
Objective: To explore the views patients with diabetes have about their consultations with nurse prescribers and any impact this may have on their medications management.
Design: A qualitative study involving semi-structured interviews and thematic analysis.
Setting: Six primary care sites in which nurses prescribed medications for patients with diabetes in England. Data was collected in 2009.
Participants: Interviews took place with 41 patients with diabetes from the case loads of 7 nurse prescribers.
Results: Findings are reported under three themes; the nurse consultation style, benefits of the nurse prescriber consultation and views on involvement and decision-making. Key aspects of the nurse consultation style were a non-hurried approach, care and rapport, approachability, continuity, and providing clear information based on specialist knowledge. Many benefits were described, including improved access to appropriate advice and medication, greater understanding and ability to self-manage, ability to address problems and improved confidence, trust and wellbeing. While patients were happy with the amount of information received and involvement they had decisions about their treatment, there was some controversy over the consistency of information provided on side-effects of treatment.
Conclusions: The study provides new knowledge about what patients with diabetes value and benefit from in respect to care provided by nurse prescribers. Continuity of relationship, flexibility over consultation length, nurses? interpersonal skills and specialist diabetes knowledge were identified as crucial to good quality care. Patients require that nurse prescribers are skilled in providing a person-centred approach and have access to specialist training. The level of information and involvement offered to patients should reflect patients? requirements.
Objective. To improve the knowledge and understanding that formal care workers have on the significance of skin changes and to improve earlier identification and management of pressure ulceration.
Background. Evidence suggests that there is a continuing rise in the elderly population with co-morbidities and the risk of them developing pressure damage is increased. Formal care workers are ideally placed to help identify and alert healthcare professionals about these high risk patients yet current education provision is ad hoc and lacks standardisation.
Design. An insider approach to action research was adopted to develop and evaluate an education intervention on pressure ulceration to formal care workers from 10 residential homes and 6 private care agencies.
Methods. An education intervention was delivered to 250 participants following which a questionnaire was utilised to evaluate the session including verbal and written feedback from the participants. A pre and post intervention audit was conducted to assess the impact on pressure ulcer prevalence in November 2014 and May 2015.add dates
Results. The sessions were evaluated by 86% participants who completed questionnaires, with an average score of 4.95/5. Many of the participants had previously received no training on this subject. There was an overall 29% reduction of all pressure ulcers with a 57% reduction of pressure ulcers across the residential homes.
Conclusion. This paper reports on the results from the evaluation of an educational intervention on the prevention and early identification of pressure damage, delivered to formal care workers who support patients either in residential care or in their own home.
Relevance to clinical practice. Formal care workers are an under-utilised group and could potentially have an impact on the early identification pressure damage or those patients at high risk, improving the quality and cost effectiveness of pressure ulcer management
Women with diabetes are at increased risk of adverse maternal and fetal outcomes. Preconception care can improve pregnancy outcomes and is paramount to minimise complications, but, current provision is sub-optimal. Mobile technology, particularly smartphones and apps have the potential to improve preconception care provision but research is lacking in this area. The need to use modern technologies to improve preconception care knowledge and awareness led to the development of a Preconception and Diabetes Information app in stage A of this study.
The aim of this paper, stage B of the study, is to explore the feasibility and acceptability of the Preconception and Diabetes Information app to improve preconception care knowledge and attitudes in women with diabetes, and explore the potential for wider implementation.
A mixed methods study design adopting a quasi-experimental approach will assess women?s knowledge and attitudes related to preconception care, and level of patient activation (knowledge and confidence for self-management of health) before and after the 3 month intervention period. A log of activity will be used to determine engagement with the app and semi-structured interviews will explore women?s experiences.
This is the first study to explore the acceptability and feasibility of a Preconception and Diabetes Information app for women with diabetes. The app has potential to change the way preconception care is delivered, improve pregnancy outcomes and be widely implemented in both developed and developing countries. This is important given the considerable shortfalls in current preconception care services in the United Kingdom and around the world.
The study aim was to investigate the experiences of couples starting infertility investigations and treatments. Using an ethnographic methodology with a longitudinal design, involving iterative rounds of observation and interviews with the same participants.
The findings show couples were resistant to becoming fertility patients and starting treatments, and this was often connected to the meaning that infertility had for them. The discomfort and challenge of this transition, previously described as ?mazing?, was not always recognised or fully appreciated by the healthcare staff involved with the couples. ARTs are becoming ubiquitous and this has increased the mazing undertaken by couples because of the necessity for multiple treatment cycles. The commercialisation of fertility treatments, often including payment for cycles, is also unhelpful for couples? decision-making. Couples are jointly involved in negotiating treatments and future planning, but clinics focus almost exclusively on the female partner. The ?journey? retains its open-ended quality because treatments, belying their promise and hope, do not usually resolve the uncertainty of infertility.
Treatments for infertility, including ARTs, are portrayed as straightforward, however this study finds that couples, particularly during the early stages from first GP referral, are reluctant to engage with medical fertility pathways and do not find the processes ?routine?. By acknowledging this, and showing an interest in the personal and social context of their patients? infertility, clinical staff can demonstrate they are listening to their patients. Couples may find this altered communication helps improve their experiences of fertility treatments.
Patient redirection can help reduce service demand by providing information about more appropriate services. There is no evidence available regarding the effect of nurse-led patient redirection in an urgent care centre setting.
Develop and evaluate a nurse led patient self-care and redirection first (SCARF) intervention in an urgent care centre.
Adopting a prospective observational design, the intervention was delivered to an opportunity sample of patients attending a South London Hospital Urgent Care Centre, June-July 2014, evaluated through patient interviews 5-10 days after initial attendance.
118/1,710 people who attended the urgent care centre participated of whom 81 (69%) were redirected to other services (n=64) (e.g. pharmacist/ GP) or self-care at home (n=17) and 38 transferred to the emergency department. Of 110 (93.2%) participants who completed the questionnaire 97.2% were satisfied. Only 2 accessed different services to those recommended. 72.2% (n=85) reported they would not re-attend the urgent care centre for a similar condition.
Treating minor ailments in an urgent care centre is inefficient use of resources. A nurse led self-care and redirection intervention can help re-direct patients with minor ailments to more appropriate services. Further evaluation of the intervention on service demand and costs is required.
Self-management interventions have become increasingly popular in the management of long term health conditions; however, little is known about their impact on psychological well-being in people with Multiple Sclerosis (MS).
To examine the effectiveness of self-management interventions on improving depression, anxiety and health related quality of life in people with MS.
A structured literature search was conducted for the years 2000 to 2016. The review process followed the PRISMA guidelines, and is registered with PROSPERO (no. CRD42016033925).
The review identified 10 RCT trials that fulfilled selection criteria and quality appraisal. Self-management interventions improved health-related quality of life in 6 out of 7 studies, with some evidence of improvement in depression and anxiety symptoms.
Although the results are promising more robust evaluation is required in order to determine the effectiveness of self-management interventions on depression, anxiety and quality of life in people with MS. Evaluation of the data was impeded by a number of methodological issues including incomplete content and delivery information for the intervention and the exclusion of participants representing the disease spectrum. Recommendations are made for service development and research quality improvement.
Physical health needs of people with intellectual disabilities are often overlooked. Inadequate physical health skills (assessment, monitoring) of healthcare professionals working in intellectual disabilities is a barrier to equitable care. Recent reports have called for initiatives to improve training through quality improvement programmes.
An integrative review was undertaken to 1) identify physical health training needs of healthcare professionals 2) identify challenges of implementing quality improvement skills training.
Six electronic databases were searched (January 1990-March 2015) and included if they described the physical health assessment/monitoring skills of healthcare professionals and quality improvement programmes designed to impact the physical health of adults with intellectual disabilities. Articles were appraised using the Mixed Methods Appraisal Tool (MMAT).
668 articles were identified, of which 14 were included in the review. Literature was sparse with none reporting training needs of healthcare professionals in intellectual disabilities. Identified training needs of mainstream healthcare professionals included physical assessment, communication, general and syndrome specific knowledge, and health promotion. Quality improvement studies were of limited quality, under evaluated and poorly reported. Lack of staff engagement, role confusion and sustainability were barriers to quality improvement implementation.
Physical health skills of healthcare professionals are key to improving care for people with intellectual disabilities. However, quality improvement is poorly implemented in this area of practice. In order to better meet the needs of this group better implementation and evaluation of intellectual disabilities quality improvement programmes is required.
Making best use of existing skills to increase service capacity is a global challenge. The aim was to systematically review physiotherapy and podiatrist prescribing and medicines management activity, including evidence of impact on patient care, levels of knowledge and attitudes towards extended medicines role.
A search of MEDLINE, CINAHL, and Cochrane databases, using terms to identify prescribing and medicines management across a range of roles, was conducted from January 1985 to May 2016 for physiotherapy, and January 1968 to May 2016 for podiatry. Hand searching of citations and databases from professional organisations was undertaken. Data were extracted and analysed descriptively, and quality appraised by 2 reviewers using the mixed methods appraisal tool.
1316 papers were identified, and 21 included in the review. No studies were identified that reported prescribing and no studies specific to podiatry met the inclusion criteria. Physiotherapists were highly involved in administering medicines, providing medicines advice, and recommending new medicines. Patient satisfaction, cost and outcomes were equivalent when comparing physiotherapist-led injection therapy to traditional care. Pharmacology knowledge was variable and unmet training needs identified.
Medicines management practices were identified in physiotherapy and positive outcomes of extended scope physiotherapy. There was a lack of evidence regarding podiatric practice. Review of educational preparation for medicines management is recommended along with evaluation of medicines management practice.
Women with diabetes are at increased risk of adverse maternal and fetal outcomes. Preconception care can minimise risk of complications and improve outcomes, but current provision is inadequate. Mobile technology, particularly smartphone apps, could improve preconception care provision but research is lacking in this area.
The study aimed to critically appraise the literature with respect to PCC educational interventions and highlight limitations of current interventions, and to develop a Preconception and Diabetes Information (PADI) app for women with type 1 or 2 diabetes and explore the system?s feasibility and acceptability.
A systematic review of the literature and a 2-phase mixed methods study design, (1) development and (2) feasibility and acceptability, were used. The app was developed via a co-design approach with women with diabetes, healthcare professionals and an app development company. A 3-month pre- and post-intervention study assessed preliminary outcome estimates (preconception care knowledge, attitudes and behaviours), user acceptability was also explored. Data collection methods included focus groups, semi-structured interviews and questionnaires.
The systematic review showed that PCC educational interventions had a positive effect on patient and behavioural outcomes, however, PCC uptake was low and the use of eHealth for PCC of women with DM was still in its infancy. The 2-phase mixed methods study design indicated a high level of enthusiasm and interest towards a preconception care app that could overcome shortfalls in current preconception care service provision. Improvements were recorded in knowledge of pregnancy planning and pregnancy-related risks, perceived benefits and self-efficacy to seek preconception care, and patient activation measure, following the 3-month app usage. Participants found the PADI app acceptable (satisfaction rating was 72%), useful and informative. Usage was episodic and influenced by functionality (manual data input) and personal factors (pregnancy intention, time/memory and conflicting priorities) that participants felt could be overcome via personalisation, automation, improved interactivity and daily reminders.
This is the first study to explore the acceptability and feasibility of a preconception care app for women with diabetes. It has positive implications in terms of overcoming barriers to preconception care provision and uptake, and changing preconception behaviours. In order that the contribution of the PADI app can be fully realised, further evaluation is required.
With life expectancy continuing to rise in the United Kingdom there is an increasing public health
focus on the maintenance of physical independence among all older adults. Identifying interventions that improve
physical outcomes in pre-frail and frail older adults is imperative.
A systematic review of the literature 2000 to 2017 following PRISMA guidelines and registered with
PROSPERO (no. CRD42016045325).
Ten RCT trials fulfilled selection criteria and quality appraisal. The study quality was moderate to good.
Interventions included physical activity; nutrition, physical activity combined with nutrition. Interventions that
incorporated one or more physical activity components significantly improved physical outcomes in pre-frail and/or
frail older adults.
Physical activity interventions are key to maintaining independence in pre-frail and frail older adults.
A lack of consensus regarding the definition of frailty, and an absence of core measures to assess this means any
attempt to create an optimal intervention will be impeded. This absence may ultimately impact on the ability of
older and frail adults to live well and for longer in the community.
Aim: The aim of this paper is to explore the views and experiences of clinicians and women with diabetes regarding the use of a mobile app for preconception care.
Method: An exploratory study was conducted. Data were collected using focus group and interviews with 19 participants, comprising 10 clinicians and 9 women with type 1 or 2 diabetes. Data were analysed thematically.
Findings: Women with diabetes and clinicians highlighted the inadequacy and challenges of current preconception care service provision and expressed a high level of enthusiasm and interest, towards a preconception care app that could support preconception care delivery for women with diabetes and overcome barriers to preconception care service provision and uptake.
Conclusion: The acceptability of mobile health technology to both women and clinicians creates an important opportunity to overcome existing barriers to service provision, delivery and uptake, and improve both maternal and fetal outcomes for women with diabetes.