Health professionals' and service users' perspectives of shared care for monitoring wet age-related macular degeneration: a qualitative study alongside the ECHoES trial

Objectives: To explore the views of eye health professionals and service users on shared community and hospital care for wet or neovascular age-related macular degeneration (nAMD).

Method: Using maximum variation sampling, 5 focus groups and 10 interviews were conducted with 23 service users and 24 eye health professionals from across the UK (consisting of 8 optometrists, 6 ophthalmologists, 6 commissioners, 2 public health representatives and 2 clinical eye care advisors to local Clinical Commissioning Groups). Data were transcribed verbatim and analysed thematically using constant comparative techniques derived from grounded theory methodology.

Results: The needs and preferences of those with nAMD appear to be at odds with the current service being provided. There was enthusiasm among health professionals and service users about the possibility of shared care for nAMD as it was felt to have the potential to relieve hospital eye service burden and represent a more patient-centred option, but there were a number of perceived barriers to implementation. Some service users and ophthalmologists voiced concerns about optometrist competency and the potential for delays with referrals to secondary care if stable nAMD became active again. The health professionals were divided as to whether shared care was financially more efficient than the current model of care. Specialist training for optometrists, under the supervision of ophthalmologists, was deemed to be the most effective method of training and was perceived to have the potential to improve the communication and trust that shared care would require.

Conclusions: While shared care is perceived to represent a promising model of nAMD care, voiced concerns suggest that there would need to be greater collaboration between ophthalmology and optometry, in terms of interprofessional trust and communication.

A patient perspective of pharmacist prescribing: 'crossing the specialisms-crossing the illnesses'

Background: The drive for non-medical prescribing has progressed quickly since the late 1990s and involves a range of healthcare professionals including pharmacists. As part of a commissioned research project, this qualitative element of a larger case study focused on the views of patients of pharmacist prescribers. 

Objective: The aim of this study was to explore patients' perspectives of pharmacists as prescribers. 

Methods: Three pharmacists working as independent prescribers in the clinical areas of (i) hypertension, (ii) cardiovascular/diabetes management, (iii) anticoagulation were recruited to three case studies of pharmacist prescribing in Northern Ireland. One hundred and five patients were invited to participate in focus groups after they had been prescribed for by the pharmacist. Focus groups took place between November 2010 and March 2011 (ethical/governance approvals granted) were audio taped, transcribed verbatim, read independently by two authors and analysed using constant comparative analysis. 

Results: Thirty-four patients agreed to participate across seven focus groups. Analysis revealed the emergence of one overarching theme: team approach to patient care. A number of subthemes related to the role of the pharmacist, the role of the doctor and patient benefits. There was an overwhelming lack of awareness of pharmacist prescribing. Patients discussed the importance of a multidisciplinary approach to their care and recognized limitations of the current model of prescribing. 

Conclusion: Patients were positive about pharmacist prescribing and felt that a team approach to their care was the ideal model especially when treating those with more complex conditions. Despite positive attitudes, there was a general lack of awareness of this new mode of practice.

“It’s very complicated”: a qualitative study of medicines management in intermediate care facilities in Northern Ireland

Background: Intermediate care (IC) describes a range of services targeted at older people, aimed at preventing unnecessary hospitalisation, promoting faster recovery from illness and maximising independence. Older people are at increased risk of medication-related adverse events, but little is known about the provision of medicines management services in IC facilities. This study aimed to describe the current provision of medicines management services in IC facilities in Northern Ireland (NI) and to explore healthcare workers' (HCWs) and patients' views of, and attitudes towards these services and the IC concept. 

Methods: Semi-structured interviews were conducted, recorded, transcribed verbatim and analysed using a constant comparative approach with HCWs and patients from IC facilities in NI. 

Results: Interviews were conducted with 25 HCWs and 18 patients from 12 IC facilities in NI. Three themes were identified: 'concept and reality', 'setting and supply' and 'responsibility and review'. A mismatch between the concept of IC and the reality was evident. The IC facility setting dictated prescribing responsibilities and the supply of medicines, presenting challenges for HCWs. A lack of a standardised approach to responsibility for the provision of medicines management services including clinical review was identified. Whilst pharmacists were not considered part of the multidisciplinary team, most HCWs recognised a need for their input. Medicines management was not a concern for the majority of IC patients. 

Conclusions: Medicines management services are not integral to IC and medicine-related challenges are frequently encountered. Integration of pharmacists into the multidisciplinary team could potentially improve medicines management in IC.

A qualitative study of community pharmacists’ awareness of and involvement with intermediate care facilities

Rationale, aims and objectives: Intermediate care (IC) describes a range of services targeted at older people, aimed at preventing unnecessary hospitalisation, promoting faster recovery and maximising independence. The introduction of IC has created a new interface between primary and secondary care. Older people are known to be at an increased risk of medication-related problems when transferring between healthcare settings and pharmacists are often not included as part of IC multidisciplinary teams. This study aimed to explore community pharmacists’ (CPs) awareness of IC services and to investigate their views of and attitudes towards the medicines management aspects of such services, including the transfer of medication information.

Method: Semi-structured interviews were conducted, recorded, transcribed verbatim and analysed using a constant comparative approach with CPs practising in the vicinity of IC facilities in Northern Ireland, UK.

Results: Interviews were conducted with 16 CPs. Three themes were identified and named ‘left out of the loop’, ‘chasing things up’ and ‘closing the loop’. CPs felt that they were often ‘left out of the loop’ with regards to both their involvement with local IC services and communication across the healthcare interfaces. As a result, CPs resorted to ‘chasing things up’ as they had to proactively try to obtain information relating to patients’ medications. CPs viewed themselves as ideally placed to facilitate medicines management across the healthcare interfaces (i.e., ‘closing the loop’), but several barriers to potential services were identified.

Conclusion: CPs have limited involvement with IC services. There is a need for improvement of effective communication of patients’ medication information between secondary care, IC and community pharmacy. Increasing CP involvement may contribute to improving continuity of care across such healthcare interfaces, thereby increasing the person-centeredness of service provision.

Improving appropriate polypharmacy for older people in primary care: selecting components of an evidence-based intervention to target prescribing and dispensing.

Background
The use of multiple medicines (polypharmacy) is increasingly common in older people. Ensuring that patients receive the most appropriate combinations of medications (appropriate polypharmacy) is a significant challenge. The quality of evidence to support the effectiveness of interventions to improve appropriate polypharmacy is low. Systematic identification of mediators of behaviour change, using the Theoretical Domains Framework (TDF), provides a theoretically robust evidence base to inform intervention design. This study aimed to (1) identify key theoretical domains that were perceived to influence the prescribing and dispensing of appropriate polypharmacy to older patients by general practitioners (GPs) and community pharmacists, and (2) map domains to associated behaviour change techniques (BCTs) to include as components of an intervention to improve appropriate polypharmacy in older people in primary care.

Methods
Semi-structured interviews were conducted with members of each healthcare professional (HCP) group using tailored topic guides based on TDF version 1 (12 domains). Questions covering each domain explored HCPs’ perceptions of barriers and facilitators to ensuring the prescribing and dispensing of appropriate polypharmacy to older people. Interviews were audio-recorded and transcribed verbatim. Data analysis involved the framework method and content analysis. Key domains were identified and mapped to BCTs based on established methods and discussion within the research team.

Results
Thirty HCPs were interviewed (15 GPs, 15 pharmacists). Eight key domains were identified, perceived to influence prescribing and dispensing of appropriate polypharmacy: ‘Skills’, ‘Beliefs about capabilities’, ‘Beliefs about consequences’, ‘Environmental context and resources’, ‘Memory, attention and decision processes’, ‘Social/professional role and identity’, ‘Social influences’ and ‘Behavioural regulation’. Following mapping, four BCTs were selected for inclusion in an intervention for GPs or pharmacists: ‘Action planning’, ‘Prompts/cues’, ‘Modelling or demonstrating of behaviour’ and ‘Salience of consequences’. An additional BCT (‘Social support or encouragement’) was selected for inclusion in a community pharmacy-based intervention in order to address barriers relating to interprofessional working that were encountered by pharmacists.

Conclusions
Selected BCTs will be operationalised in a theory-based intervention to improve appropriate polypharmacy for older people, to be delivered in GP practice and community pharmacy settings. Future research will involve development and feasibility testing of this intervention.

Substance Use and Misuse : Adolescent Substance Use in the context of the family ; a qualitative study of young people's views on parent child attachments , parenting style and parental substance use

Introduction and Aims. While the role of the family in adolescent substance use has been well documented, few studies have attempted to explore in-depth youth perceptions of how these familial processes/dynamics influence teenage substance use. This paper reports the findings from a study exploring risk and protective factors for teenage substance use within the context of the family as perceived by young people with a view to informing current and future family based prevention and education interventions.
Design and Methods. Data collection took place in nine post-primary schools across Northern Ireland. Nine focus groups using participatory techniques were facilitated with a purposive sample of sixty-two young people (age 13-17 years). Data were transcribed verbatim and analysed using a content/thematic analysis.
Results. Three broad themes/aspects of the family emerged from the data, which may serve to protect or attenuate the risk of substance use among young people. Parent-child attachment was a major theme identified in protecting adolescents from substance use in addition to effective parenting particularly an authoritative style of parenting supplemented by parental monitoring and good parent-child communication to encourage child disclosure. Family substance use was deemed to impact on children’s substance use if exposed at an early age and the harms associated with PSM were discussed in detail.
Discussion and Conclusions. The qualitative approach provides insight into current understanding of youth perceptions of substance use in the context of family dynamics. A number of recommendations are outlined. Family based (preventive) interventions/parenting programmes may benefit from components on effective parenting including authoritative styles, parental monitoring, effective communication, spending time together (building attachments), parent-child conflict, adolescent development and factors which impact on parenting. Parenting programmes tailored to mothers and fathers may be beneficial. School based interventions targeting children/adolescents may be best placed to target children living with parental substance misuse.
Keywords: substance/substance related disorders, focus groups, young people/adolescent,

Adolescent substance use in the context of the family: a qualitative study of young people’s views on parent-child attachments, parenting style and parental substance use

Background: Adolescent substance use can place youth at risk of a range of poor outcomes. Few studies have attempted to explore in-depth young people’s perceptions of how familial processes and dynamics influence adolescent substance use.
Objectives: This paper aimed to explore risk and protective factors for youth substance use within the context of the family with a view to informing family based interventions.
Methods: Nine focus groups supplemented with participatory techniques were facilitated with a purposive sample of sixty-two young people (age 13-17 years) from post-primary schools across Northern Ireland. The data were transcribed verbatim and analysed using thematic analysis.
Results: Three themes emerged from the data: 1) parent-child attachments, 2) parenting style and 3) parental and sibling substance misuse. Parent-child attachment was identified as an important factor in protecting adolescents from substance use in addition to effective parenting particularly an authoritative style supplemented with parental monitoring and strong parent-child communication to encourage child disclosure. Family substance use was considered to impact on children’s substance use if exposed at an early age and the harms associated with parental substance misuse were discussed in detail. Both parent and child gender differences were cross-cutting themes.
Conclusion: Parenting programmes (tailored to mothers and fathers) may benefit young people via components on authoritative styles, parental monitoring, communication, nurturing attachments and parent-child conflict. Youth living with more complex issues, e.g. parental substance misuse, may benefit from programmes delivered beyond the family environment e.g. school based settings.

Prescribing of Psychoactive Drugs for Older People in Nursing Homes: An Analysis of Treatment Culture

Background There is increasing interest in how culture may affect the quality of healthcare services, and previous research has shown that ‘treatment culture’—of which there are three categories (resident centred, ambiguous and traditional)—in a nursing home may influence prescribing of psychoactive medications. Objective The objective of this study was to explore and understand treatment culture in prescribing of psychoactive medications for older people with dementia in nursing homes. Method Six nursing homes—two from each treatment culture category—participated in this study. Qualitative data were collected through semi-structured interviews with nursing home staff and general practitioners (GPs), which sought to determine participants’ views on prescribing and administration of psychoactive medication, and their understanding of treatment culture and its potential influence on prescribing of psychoactive drugs. Following verbatim transcription, the data were analysed and themes were identified, facilitated by NVivo and discussion within the research team. Results Interviews took place with five managers, seven nurses, 13 care assistants and two GPs. Four themes emerged: the characteristics of the setting, the characteristics of the individual, relationships and decision making. The characteristics of the setting were exemplified by views of the setting, daily routines and staff training. The characteristics of the individual were demonstrated by views on the personhood of residents and staff attitudes. Relationships varied between staff within and outside the home. These relationships appeared to influence decision making about prescribing of medications. The data analysis found that each home exhibited traits that were indicative of its respective assigned treatment culture. Conclusion Nursing home treatment culture appeared to be influenced by four main themes. Modification of these factors may lead to a shift in culture towards a more flexible, resident-centred culture and a reduction in prescribing and use of psychoactive medication. 

How much is '5-a-day'? A qualitative investigation into consumer understanding of fruit and vegetable intake guidelines

BACKGROUND: Despite the known health benefits of fruit and vegetables (FV), population intakes remain low. One potential contributing factor may be a lack of understanding surrounding recommended intakes. The present study aimed to explore the understanding of FV intake guidelines among a sample of low FV consumers.

METHODS: Six semi-structured focus groups were held with low FV consumers (n = 28, age range 19-55 years). Focus groups were recorded digitally, transcribed verbatim and analysed thematically using nvivo (QSR International, Melbourne, Australia) to manage the coded data. Participants also completed a short questionnaire assessing knowledge on FV intake guidelines. Descriptive statistics were used to analyse responses.

RESULTS: The discussions highlighted that, although participants were aware of FV intake guidelines, they lacked clarity with regard to the meaning of the '5-a-day' message, including what foods are included in the guideline, as well as what constitutes a portion of FV. There was also a sense of confusion surrounding the concept of achieving variety with regard to FV intake. The sample highlighted a lack of previous education on FV portion sizes and put forward suggestions for improving knowledge, including increased information on food packaging and through health campaigns. Questionnaire findings were generally congruent with the qualitative findings, showing high awareness of the '5-a-day' message but a lack of knowledge surrounding FV portion sizes.

CONCLUSIONS: Future public health campaigns should consider how best to address the gaps in knowledge identified in the present study, and incorporate evaluations that will allow the impact of future initiatives on knowledge, and ultimately behaviour, to be investigated.

‘Potentially inappropriate or specifically appropriate?’ Qualitative evaluation of general practitioners views on prescribing, polypharmacy and potentially inappropriate prescribing in older people

Background: Potentially inappropriate prescribing (PIP) is common in older people in primary care, as evidenced by a significant body of quantitative research. However, relatively few qualitative studies have investigated the phenomenon of PIP and its underlying processes from the perspective of general practitioners (GPs). The aim of this paper is to explore qualitatively, GP perspectives regarding prescribing and PIP in older primary care patients.

Method: Semi-structured qualitative interviews were conducted with GPs participating in a randomised controlled trial (RCT) of an intervention to decrease PIP in older patients (≥70 years) in Ireland. Interviews were conducted with GP participants (both intervention and control) from the OPTI-SCRIPT cluster RCT as part of the trial process evaluation between January and July 2013. Interviews were conducted by one interviewer and audio recorded. Interviews were transcribed verbatim and a thematic analysis was conducted.

Results: Seventeen semi-structured interviews were conducted (13 male; 4 female). Three main, inter-related themes emerged (complex prescribing environment, paternalistic doctor-patient relationship, and relevance of PIP concept). Patient complexity (e.g. polypharmacy, multimorbidity), as well as prescriber complexity (e.g. multiple prescribers, poor communication, restricted autonomy) were all identified as factors contributing to a complex prescribing environment where PIP could occur, as was a paternalistic-doctor patient relationship. The concept of PIP was perceived to be of variable usefulness to GPs and the criteria to measure it may be at odds with the complex processes of prescribing for this patient population.

Conclusions: Several inter-related factors contributing to the occurrence of PIP were identified, some of which may be amenable to intervention. Improvement strategies focused on improved management of polypharmacy and multimorbidity, and communication across primary and secondary care could result in substantial improvements in PIP.

A process evaluation of a cluster randomised trial to reduce potentially inappropriate prescribing in older people in primary care (OPTI-SCRIPT study)

Background
The OPTI-SCRIPT cluster randomised controlled trial (RCT) found that a three-phase multifaceted intervention including academic detailing with a pharmacist, GP-led medicines reviews, supported by web-based pharmaceutical treatment algorithms, and tailored patient information leaflets, was effective in reducing potentially inappropriate prescribing (PIP) in Irish primary care. We report a process evaluation exploring the implementation of the intervention, the experiences of those participating in the study and lessons for future implementation.

Methods
The OPTI-SCRIPT trial included 21 GP practices and 196 patients. The process evaluation used mixed methods. Quantitative data were collected from all GP practices and semi-structured interviews were conducted with GPs from intervention and control groups, and a purposive sample of patients from the intervention group. All interviews were transcribed verbatim and analysed using a thematic analysis.

Results
Despite receiving a standardised academic detailing session, intervention delivery varied among GP practices. Just over 70 % of practices completed medicines review as recommended with the patient present. Only single-handed practices conducted reviews without patients present, highlighting the influence of practice characteristics and resources on variation. Medications were more likely to be completely stopped or switched to another more appropriate medication when reviews were conducted with patients present. The patient information leaflets were not used by any of the intervention practices. Both GP (32 %) and patient (40 %) recruitment rates were modest. For those who did participate, overall, the experience was positively viewed, with GPs and patients referring to the value of medication reviews to improve prescribing and reduce unnecessary medications. Lack of time in busy GP practices and remuneration were identified as organisational barriers to future implementation.

Conclusions
The OPTI-SCRIPT intervention was positively viewed by both GPs and patients, both of whom valued the study’s objectives. Patient information leaflets were not a successful component of the intervention. Academic detailing and medication reviews are important components in changing PIP, and having patients present during the review process seems to be a more effective approach for decreasing PIP.

Barriers and facilitators to cooking from 'scratch' using basic or raw ingredients: A qualitative interview study

Background: Previous research has highlighted an ambiguity in understanding cooking related terminology and a number of barriers and facilitators to home meal preparation. However, meals prepared in the home still include convenience products (typically high in sugars, fats and sodium) which can have negative effects on health. Therefore, this study aimed to qualitatively explore: (1) how individuals define cooking from ‘scratch’, and (2) their barriers and facilitators to cooking with basic ingredients.
Methods: 27 semi-structured interviews were conducted with participants (aged 18-58 years) living on the island of Ireland, eliciting definitions of ‘cooking from scratch’ and exploring the reasons participants cook in a particular way. The interviews were professionally transcribed verbatim and Nvivo 10 was used for an inductive thematic analysis.
Results: Our results highlighted that although cooking from ‘scratch’ lacks a single definition, participants viewed it as optimal cooking. Barriers to cooking with raw ingredients included: 1) time pressures; (2) desire to save money; (3) desire for effortless meals; (4) family food preferences; and (5) effect of kitchen disasters. Facilitators included: 1) desire to eat for health and well-being; (2) creative inspiration; (3) ability to plan and prepare meals ahead of time; and (4) greater self-efficacy in one’s cooking ability.
Conclusions: Our findings contribute to understanding how individuals define cooking from ‘scratch’, and barriers and facilitators to cooking with raw ingredients. Interventions should focus on practical sessions to increase cooking self-efficacy; highlight the importance of planning ahead and teach methods such as batch cooking and freezing to facilitate cooking from scratch.

Ethical reasoning through simulation: a phenomenological analysis of student experience

Background
Medical students transitioning into professional practice feel underprepared to deal with the emotional complexities of real-life ethical situations. Simulation-based learning (SBL) may provide a safe environment for students to probe the boundaries of ethical encounters. Published studies of ethics simulation have not generated sufficiently deep accounts of student experience to inform pedagogy. The aim of this study was to understand students’ lived experiences as they engaged with the emotional challenges of managing clinical ethical dilemmas within a SBL environment.

Methods
This qualitative study was underpinned by an interpretivist epistemology. Eight senior medical students participated in an interprofessional ward-based SBL activity incorporating a series of ethically challenging encounters. Each student wore digital video glasses to capture point-of-view (PoV) film footage. Students were interviewed immediately after the simulation and the PoV footage played back to them. Interviews were transcribed verbatim. An interpretative phenomenological approach, using an established template analysis approach, was used to iteratively analyse the data.

Results
Four main themes emerged from the analysis: (1) ‘Authentic on all levels?’, (2)‘Letting the emotions flow’, (3) ‘Ethical alarm bells’ and (4) ‘Voices of children and ghosts’. Students recognised many explicit ethical dilemmas during the SBL activity but had difficulty navigating more subtle ethical and professional boundaries. In emotionally complex situations, instances of moral compromise were observed (such as telling an untruth). Some participants felt unable to raise concerns or challenge unethical behaviour within the scenarios due to prior negative undergraduate experiences.

Conclusions
This study provided deep insights into medical students’ immersive and embodied experiences of ethical reasoning during an authentic SBL activity. By layering on the human dimensions of ethical decision-making, students can understand their personal responses to emotion, complexity and interprofessional working. This could assist them in framing and observing appropriate ethical and professional boundaries and help smooth the transition into clinical practice.

Situation Background Assessment Recommendation (SBAR): Undergraduate Perspectives

Situation Background Assessment and Recommendation (SBAR): Undergraduate Perspectives C Morgan, L Adams, J Murray, R Dunlop, IK Walsh. Ian K Walsh, Centre for Medical Education, Queen’s University Belfast, Mulhouse Building, Royal Victoria Hospital, Grosvenor Road, Belfast BT12 6DP Background and Purpose: Structured communication tools are used to improve team communication quality.1,2 The Situation Background Assessment and Recommendation (SBAR) tool is widely adopted within patient safety.3 SBAR effectiveness is reportedly equivocal, suggesting use is not sustained beyond initial training.4-6 Understanding perspectives of those using SBAR may further improve clinical communication. We investigated senior medical undergraduate perspectives on SBAR, particularly when communicating with senior colleagues. Methodology: Mixed methods data collection was used. A previously piloted questionnaire with 12 five point Lickert scale questions and 3 open questions was given to all final year medical students. A subgroup also participated in 10 focus groups, deploying strictly structured audio-recorded questions. Selection was by convenience sampling, data gathered by open text questions and comments transcribed verbatim. In-vivo coding (iterative, towards data saturation) preceded thematic analysis. Results: 233 of 255 students (91%) completed the survey. 1. There were clearly contradictory viewpoints on SBAR usage. A recurrent theme was a desire for formal feedback and a relative lack of practice/experience with SBAR. 2. Students reported SBAR as having variable interpretation between individuals; limiting use as a shared mental model. 3. Brief training sessions are insufficient to embed the tool. 4. Most students reported SBAR helping effective communication, especially by providing structure in stressful situations. 5. Only 18.5% of students felt an alternative resource might be needed. Sub analysis of the themes highlighted: A. Lack of clarity regarding what information to include and information placement within the acronym, B. Senior colleague negative response to SBAR C. Lack of conciseness with the tool. Discussion and Conclusions: Despite a wide range of contradictory interpretation of SBAR utility, most students wish to retain the resource. More practice opportunities/feedback may enhance user confidence and understanding. References: (1) Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Quality & Safety in Health Care 2004 Oct;13(Suppl 1):85-90. (2) d'Agincourt-Canning LG, Kissoon N, Singal M, Pitfield AF. Culture, communication and safety: lessons from the airline industry. Indian J Pediatr 2011 Jun;78(6):703-708. (3) Dunsford J. Structured communication: improving patient safety with SBAR. Nurs Womens Health 2009 Oct;13(5):384-390. (4) Compton J, Copeland K, Flanders S, Cassity C, Spetman M, Xiao Y, et al. Implementing SBAR across a large multihospital health system. Jt Comm J Qual Patient Saf 2012 Jun;38(6):261-268. (5) Ludikhuize J, de Jonge E, Goossens A. Measuring adherence among nurses one year after training in applying the Modified Early Warning Score and Situation-Background-Assessment-Recommendation instruments. Resuscitation 2011 Nov;82(11):1428-1433. (6) Cunningham NJ, Weiland TJ, van Dijk J, Paddle P, Shilkofski N, Cunningham NY. Telephone referrals by junior doctors: a randomised controlled trial assessing the impact of SBAR in a simulated setting. Postgrad Med J 2012 Nov;88(1045):619-626.