Investigating and implementing change within the primary health care nursing team

Primary care is developing rapidly with significant impacts on the nursing team. Such changes have brought inter-professional team-working into sharper focus, particularly community care and collaborative working. This paper: examines the nursing roles within a general practice; describes the perspectives of service users; identifies areas of change; clarifies core and specialist skills; defines new roles among the primary health care nursing team; proposes a new model of working; and identifies appropriate education. The project was set in a general practice in south-west England and used an action research methodology. The objectives were to create a change in practice and to develop and refine existing theory to underpin nursing roles. Throughout the research regular team meetings allowed reflection and discussion about research findings and progress. Data were collected from multiple sources, including team workshops, patient focus group interviews, and individual interviews with GPs, practice managers and area managers. Reflective diaries and a patient survey were also used. The analysis of the quantitative and qualitative data collected from patients formed a basis for practice development and facilitated the team's reflection on the areas of change. Overall high satisfaction with services and care was expressed in the patient interviews and the questionnaire. The themes from the data highlighted areas important for patients and helped in shaping the new roles and responsibilities for team members. Regarding the team perspective, the data indicated many areas that could be considered for development. The community nursing team decided to concentrate on three key areas: child health, leg ulcer management, and cardiovascular health. The research concludes that action research presents some problems and challenges but is a useful approach to developing team-working in primary health care.     

Appreciating and developing compassionate care in an acute hospital setting caring for older people

dewar b. & MacKay R. (2010) Appreciating and developing compassionate care in an acute hospital setting caring for older people. International Journal of Older People Nursing
5 , 299–308
doi: 10.1111/j.1748-3743.2010.00251.x Background. There is increasing emphasis in policy, research and practice on the importance of caring in health care. Indeed there is much debate about how to enhance the caring cultures within which health care is provided. This paper argues that a proper systematic analysis of caring practice that works well in care environments may help us to move towards a realistic model for the future which supports staff, patients and families to give and receive compassionate care. Aim. The aim of the project was to explore, develop and articulate strategies that enhanced compassionate relationship centred care in an acute hospital setting, caring for older people. Methods. Appreciative action research informed the development and evaluation of the project. A range of data generation activities were used to examine what worked well. Following detailed analysis key processes emerged as being central to delivery of compassionate care. Specific action projects were implemented and evaluated to enhance these processes necessary for compassionate caring. Findings. Data from the project helped to articulate the special and often hidden acts that make up compassionate care. In relation to the process of ‘knowing who I am and what matters to me’ data provided evidence of the value of this process and the potential impact to care. In addition data about the process of doing appreciative action research helped to realise its application and relevance in the health care setting. Conclusions. Findings from this work suggest that there are a number of significant processes that help people to deliver compassionate care. These need to be articulated, shared more widely across practice, policy and education so that we can build on this excellent practice. Implications for practice. Appreciative action research adopted in this project is an important methodology to supporting practitioners to identify what it is they do well and develop practice to try to make the best caring practice happen most of the time. Academics, policy makers and practitioners should consider the approach of appreciative action research as key to supporting developments in care.     

Enhancing the quality of nursing care in methadone substitute clinics using action research: a process evaluation

Title. Enhancing the quality of nursing care in methadone substitute clinics using action research: a process evaluation Aim. This paper is a report of a study to answer the research question: can participative action research help to halt the deterioration in methadone substitution treatment and develop new care strategies which are better geared toward the patients’ needs? Background. In the Netherlands, methadone substitute treatment has been the main medical treatment for heroin addiction since the early 1980s. Although effective at first, this methadone provision has deteriorated during the last 15 years. Over time, nursing staff have had to restrict their activities to simply dispensing methadone and have not been able to develop any other interventions, such as outreach care. Method. A participative action research process was used in two outpatient methadone substitute treatment clinics. Using the four stages of the cooperative inquiry design of Heron and the knowledge development model of Johns, a diagnosis of all the bottlenecks was made and innovative care strategies were implemented. Reflection meetings were held to offer nursing staff maximum benefit in improving the quality of nursing care. Findings. Action research partially succeeded in enhancing care strategies. Of the two clinics involved in the study, one improved both its care organization and patient‐centred outcome. The other managed to improve the organization of the care. Conclusion. Participative strategies can be, but are not always, a helpful method for enhancing professional care in addictions nursing. By setting out attainable goals in daily practice, some nurses were able to become active change agents. The development of knowledge is inextricably connected with the growth of new care strategies. Chronic opiate users can benefit from the expansion of professional nursing knowledge.     

A new research agenda: improving health care in general hospitals

Aim and objectives. To set out the research required to improve the health of people with learning disabilities in general hospital settings. The objectives are: (i) to share service developments in a mapping exercise to provide a picture of current work in this area, and (ii) to identify practice issues and experiences that can contribute to a broader research agenda. Background. It is recognized that people with learning disabilities are high users of all healthcare systems and have different pattern of health needs that often go unidentified, with some requiring general hospital care. The research evidence base in this area of practice needs to be developed to promote and improve health care. Method. A facilitated focus group design was employed at a conference event to identify areas for research in the future and determined that action is required on four broad research fronts. Results. Research is required to establish core principles of care, service developments, practical care measures and influencing change in practice. Conclusion. Research collaborations need to be established to support activity in this area and requires action in the future. Relevance to clinical practice. The evidence base and understanding of the high and differing pattern of health needs of people with learning disabilities continues to evolve and develop, with considerable scope to identify new areas for research. A conference approach was used to identify research questions to improve the care of this group in general hospital settings and offers a model that may be helpful in defining new areas of enquiry in the future.     

Implementation of evidence‐based health care using action research: An emancipatory approach

The aim of the study is to discuss the emancipatory approach to action research as an appropriate methodology for workers' meaningful implementation of evidence‐based health care. Implementation of evidence‐based health care using action research is well supported by the literature. There are various approaches to action research, and they are coherent with the objectives and methods elected to develop the investigation. It is not clear which approach of action research is responsible for meaningful worker engagement in changing praxis. This is a discussion paper based on our experiences and supported by literature on collective health. Health care is defined as a social praxis, dependent upon the capitalist mode of production in which health workers engage themselves in a labour process that has negative (as alienation) as well as positive (as creativity) meanings. Emancipatory changes of social praxis through implementation of evidence‐based health care require that participants understand the positive and negative meanings of their work and engage health workers in a conscious and intentional collaborative educational process. Implementation of evidence‐based health care through emancipatory action research is capable of overcoming alienation and changing social practice through a participatory meaningful process of knowledge translation.     

Using the stages of change model to improve communication about advance care planning

TOPIC: Advance care planning (ACP) is a term intended to describe the dynamic process of discussing wishes for future medical care. PURPOSE: To demonstrate how a behavior change model can be used to enhance ACP. SOURCES: Authors' personal experience, workshops, literature review. CONCLUSIONS: Incorporating behavioral change theory helps develop workable interventions and provides strategies for nurses to approach patients appropriately about planning for future medical care.     

Transforming a conservative clinical setting: ICU nurses' strategies to improve care for patients' relatives through a participatory action research

This study focuses on change strategies generated through a dialogical–reflexive–participatory process designed to improve the care of families of critically ill patients in an intensive care unit (ICU) using a participatory action research in a tertiary hospital in the Balearic Islands (Spain). Eleven professionals (representatives) participated in 11 discussion groups and five in‐depth interviews. They represented the opinions of 49 colleagues (participants). Four main change strategies were created: (i) Institutionally supported practices were confronted to make a shift from professional‐centered work to a more inclusive, patient‐centered approach; (ii) traditional power relations were challenged to decrease the hierarchical power differences between physicians and nurses; (iii) consensus was built about the need to move from an individual to a collective position in relation to change; and (iv) consensus was built about the need to develop a critical attitude toward the conservative nature of the unit. The strategies proposed were both transgressive and conservative; however, when compared with the initial situation, they enhanced the care offered to patients' relatives and patient safety. Transforming conservative settings requires capacity to negotiate positions and potential outcomes. However, when individual critical capacities are articulated with a new approach to micropolitics, transformative proposals can be implemented and sustained.     

The challenge of documenting managed care cost savings and performance

It is not too late for managed care to turn this situation around because the debate over health care reform and managing change is ongoing. It remains to be seen whether managed care companies will support independent third parties (i.e., researchers) in analyzing proprietary data and making value judgments about their effectiveness. There is a perception among managed care organizations that potentially negative findings could damage them in the marketplace. Nonetheless, smart organizations use negative findings as new opportunity targets for service improvement and product refinement. To what extent will managed care companies voluntarily release accurate data on performance factors in order for researchers to conduct cross-company analyses? Perhaps competitive markets such as managed care are not consistent with voluntary data sharing. On the other hand, mandatory reporting will not ensure data accuracy either. It is up to the managed care industry itself to develop a cooperative approach to data collection, analysis, and dissemination.     

Development of a peer education programme for advance end-of-life care planning

AIM: to develop and evaluate an education programme to help older people find out about treatment and care choices at the end of life. DESIGN: an action research approach was used to develop an education booklet about end-of-life care. A programme of qualitative evaluation ran alongside the project. It comprised a combination of methods, including face-to-face and telephone interviews and questionnaires with those who took part in the small group discussions. SAMPLE: the research team consisted of five academic researchers and eight people recruited from voluntary groups representing older adults to act as community advisors in developing the programme. The booklet was tested in small group discussions with members of the general public. Five community advisors volunteered to act as 'peer educators' and helped to lead the small group discussions after receiving a 3-day training course to prepare them for their role. The project took place in Sheffield. RESULTS: the education discussions and the related booklet were perceived as acceptable in providing information about a sensitive issue. Peer educators felt that the training course prepared them well. Community advisors felt that they were treated as equal members of the research team. This project has served as a useful pilot study of the education programme that has now been extended to other areas of the UK.     

Implementing audit in palliative care: an action research approach

AIM: To investigate the factors that influence the successful implementation of audit in a palliative care setting. BACKGROUND: Quality assurance is a necessary component of contemporary health care. In the past, palliative care has not generally been subject to systems of audit and quality management. However in recent years the need for all health care organizations to have clear policies and procedures for maintaining quality has become more pressing. METHOD: An action research project was conducted to investigate the implementation of audit in a palliative care setting, which involved the application and modification of the Support Team Assessment Scale (STAS). FINDINGS: A collaborative approach was adopted and this facilitated the identification of factors vital to successful introduction of the audit methodology into the unit. These included effective teamwork, the input of an external facilitator, good relationships with management and prompt and relevant feedback on progress. The use of STAS was fully integrated into the work of the unit and a robust programme of audit has been established. CONCLUSIONS: Combining the cyclical nature of action research methodology and the audit process with Lewin's change theory provided a clear conceptual framework for the research. This approach would be applicable in a range of health care settings to bring about improvements in quality management.     

Developing a framework for primary palliative care services

Practice and empirical data indicate concerns regarding the delivery of primary palliative care, particularly the provision of a multidisciplinary approach. A collaborative study was undertaken between an academic unit and primary care practice to evaluate current care provision and explore methods of developing services. A two-phase study was carried out over a period of 18 months using an action research approach, in order to facilitate concurrent service evaluation, change in practice, and the involvement of professionals in research and practice development. The first phase highlighted the need to enhance primary palliative care services; a number of practice changes were identified and implemented during the second phase and evaluated using quantitative and qualitative methods. Data demonstrated the enhancement of services, benefits to patient care and professional working and the viability of an innovative model of palliative care delivery - that of a surgery-based clinic for palliative care patients and carers. A framework for the provision of multidisciplinary palliative care in the community was developed.     

Reflections on implementing an evidence-based educational intervention in residential aged care

BackgroundThe aged care sector has been subjected to ongoing public criticism about the quality and standards of care Reflections on implementing an evidenced based educational intervention in residential aged care. It is important for educators and researchers to work in partnership with staff in this sector to empower them and enhance care. This paper reports the implementation of a specifically designed educational intervention, the Tri-focal Education Program (TEP).AimTo explore whether implementing the TEP had any impact on staffs’ perceptions of the work environment, work competence, and organisational culture in a residential aged care facility.MethodsThe TEP was delivered by a nurse educator who worked with staff to develop and role model the desired practice changes. A pre (n = 52) and post (n = 33) survey, comprising two validated instruments, was used to explore the impact of the implementation of the TEP from the staff perspective.FindingsStaff reported positive perceptions of their work environment on the pre-survey and there were no significant changes post-intervention.DiscussionThere are multiple explanations for this result. It could be that a low response rate, combined with high pre-test scores, created a ceiling effect that made it difficult to demonstrate any significant post-test changes.ConclusionA more bipartisan, action research approach to the implementation of the TEP may have empowered staff, encouraged them to engage more fully with the research, and feel safe to respond accurately to the survey. Given that staff felt rushed to deliver care, a longer implementation phase that introduces change in a more gradual way may reduce the potential burden on staff.     

Improving networks between acute care nurses and an aged care assessment team

Background. Acute care nurses have an important role in the discharge planning of older people from hospital to home. However, few nurses understand the changing aged care system or the consequences of poor referral on the lives of older people postdischarge. Aims and objectives. This paper reports the findings of a research project, which aimed to investigate the possibilities for facilitating the transition of older people from hospital to home through improving the working relationship between nurses and members of a multidisciplinary aged care assessment team (ACAT). Design and methods. The paper reports one action research cycle from a larger project. Action research was chosen because its focus on knowledge development and action leads to practical solutions to clinical problems. The research approach included interactive forums designed to facilitate effective collaboration between the nurses and ACAT in the discharge planning of older people. Data collection strategies included audiotapes of ACAT research discussions, field notes, policy documents, referral forms and an evaluation tool. Results and conclusions. The findings illustrate that ward nurses have, at best, a limited knowledge and understanding of the aged care system, its function, or how to access services. They need assistance to develop their knowledge of services available to support older people following discharge. The conduct of interactive forums, which utilize a case study approach, facilitated such knowledge development and empowered the nurses to become more involved in discharge planning. Participation in the forums also facilitated new collaborative partnerships between the nurses and ACAT, which enhanced effective discharge planning. Relevance to clinical practice. The paper outlines practical strategies to support collaboration between ward nurses and community providers and/or multi disciplinary assessment services. It provides a list of key considerations for the development of effective ward/community networks to facilitate the discharge of older people.     

Spiritual care of families in the intensive care unit

OBJECTIVES: There is growing recognition of the importance of spiritual care as a quality domain for critically ill patients and their families, but there is a paucity of research to guide quality improvement in this area. Our goals were to: 1) determine whether intensive care unit (ICU) family members who rate an item about their spiritual care are different from family members who skip the item or rate the item as "not applicable" and 2) identify potential determinants of higher family satisfaction with spiritual care in the ICU. DESIGN: Cross-sectional study, using data from a cluster randomized trial aimed at improving end-of-life care in the ICU. SETTING: ICUs in ten Seattle-area hospitals. SUBJECTS: A total of 356 family members of patients dying during an ICU stay or within 24 hrs of ICU discharge. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Family members were surveyed about spiritual care in the ICU. Chart abstractors obtained clinical variables including end-of-life care processes and family conference data. The 259 of 356 family members (73%) who rated their spiritual care were slightly younger than family members who did not rate this aspect of care (p = .001). Multiple regression revealed family members were more satisfied with spiritual care if a pastor or spiritual advisor was involved in the last 24 hrs of the patient's life (p = .007). In addition, there was a strong association between satisfaction with spiritual care and satisfaction with the total ICU experience (p < .001). Ratings of spiritual care were not associated with any other demographic or clinical variables. CONCLUSIONS: These findings suggest that for patients dying in the ICU, clinicians should assess each family's spiritual needs and consult a spiritual advisor if desired by the family. Further research is needed to develop a comprehensive approach to ICU care that meets not only physical and psychosocial but also spiritual needs of patients and their families.     

Evaluation of a model of nursing care for older patients using participatory action research in an acute medical ward

Aims and objectives. The main aim of this study was to improve the quality of nursing care for older acutely ill hospitalized medical patients through developing, implementing and evaluating a new model of care using a participatory action research process. Background. One of the challenges of nursing today is to meet the health‐care needs of the growing older population. It is important to consider what quality of nursing care means to older patients if nurses are to address gaps between their own perceptions and those of older patients themselves and to consider conceptual models of care appropriate for older patients care in order to improve the quality of care provided. Design. This study is a mixed method triangulated study, involving the use of both quantitative and qualitative methods through participatory action research methodology to establish an evidence‐base for an evolving model of care. Methods. The model was tested on 60 acutely ill patients aged at least 65 years. The medical ward nurses selected a key reference group including the researcher to facilitate the participatory action research process to develop, implement and evaluate a new model of care based on Orem's self‐care model incorporating the Nurses Improving Care to Health System Elders Faculty (Am J Nurs 1994; 94:21) medication protocol to improve the nursing care provided for acutely ill older patients. Results. The participatory action research process resulted in improved heath‐care outcomes for the patients, such as significant improvements in activities of daily living capabilities between admission to discharge, significant improvements in knowledge levels regarding their medication regimes, as well as increased satisfaction with nursing care activities as perceived by older patients and nursing staff. The implementation of educational sessions during the model of care improved the older patient's functional activities and knowledge levels of their medication regime prior to discharge. In addition, by repeatedly explaining procedures, nurses became more involved with their individual patient's care, developing a patient‐centred care relationship based on Orem's self‐care model. Conclusions. This study demonstrates the efficacy of a new model of nursing care in improving the quality of nursing care for older patients in the acute medical ward setting. Relevance to clinical practice. This study is significant because of its evidence‐base and demonstrates how the participatory action research process empowered nurses to make sustainable changes to their practice. The nurses in the study wanted to affect change. The planned change was not dictated by management, but was driven by the clinical nursing staff at the ‘grass roots’ level. Therefore, being involved in the decision‐making process provided an incentive to actively implement change.     

The safe use of syringe drivers for palliative care: an action research project

A palliative care team in north Scotland identified serious drug errors occurring in the local health-care trust. These were connected with the use of variable rate syringe drivers (IVAC P100) to deliver pain and symptom management rather than the more suitable Graseby MS26. An action research approach was taken to effecting change. An educational workshop was set up which 23 nurses attended. Clinical support was provided and 3 months later an evaluation was carried out. Of the 13 nurses who had used an MS26, most were able to correctly follow the process of setting up the driver and had made appropriate observations, but drug calculations were a problem. Change was stated to have taken place in seven clinical areas but the degree of change was variable. Facilitators and obstacles to the change process are identified and recommendations made for the next round in the action research cycle.     

Reflecting the scope and work of palliative care teams today: an action research project to modernise a national minimum data set

The Minimum Data Set (MDS) for UK specialist palliative care services was developed in 1995 to provide annual data on palliative care services. Data collected is used for local and national purposes including service management, monitoring and audit, the commissioning of services and the development of national policy. The emergence of Payment by Results and HealthCare Resource Groups, which will have an impact on the funding processes, together with identified limitations of the current MDS resulted in a project to revise the MDS. An action research approach was used for the project and had distinctive phases including modifying the MDS, a pilot phase and an expert panel consultation. Modifications to all the sections of the MDS and changes to terminology were made. The action research approach enabled revisions made based upon a national consensus and met the changing provision of specialist palliative care services for the UK.     

Using large data sets in long-term care to measure and improve quality

The authors explore the evolution, potential uses, and limitations of four existing large data sets in long-term care: Minimum Data Set (MDS), Outcome Assessment and Information Set (OASIS), Online Survey and Certification Reporting System (OSCAR), and Consumer Surveys. They also describe the emerging Federal Nursing Home Quality Initiative and its potential for future research. All four existing large data sets have potential to be used to improve quality of care. Their utility is presently diminished because providers are not using the data for formal continuous quality improvement. However, the Center for Medicare and Medicaid Services (CMS) is currently engaged in a series of special studies designed to build and sustain a culture of continuous quality improvement in nursing homes and to make continuous, measurable improvement a growing part of the care of Medicare beneficiaries in those settings. These CMS studies, all of which will draw on the four existing large data sets in long-term care, offer the potential to develop, explicate and test theory about the assumed causal relationships between structure and process variables and related health care outcomes in long-term care.