Moral distress experienced by health care professionals who provide home-based palliative care

Health care providers regularly encounter situations of moral conflict and distress in their practice. Moral distress may result in unfavorable outcomes for both health care providers and those in their care. The purpose of this study was to examine the experience of moral distress from a broad range of health care occupations that provide home-based palliative care as the initial step of addressing the issue. A critical incident approach was used in qualitative interviews to elicit the experiences on moral distress from 18 health care providers drawn from five home visiting organizations in south central Ontario, Canada. Most participants described at least two critical incidents in their interview generating a total of 47 critical incidents. Analyses of the critical incidents revealed 11 issues that triggered moral distress which clustered into three themes, (a) the role of informal caregivers, b) challenging clinical situations and (c) service delivery issues. The findings suggest that the training and practice environments for health care providers need to be designed to recognize the moral challenges related to day-to-day practice.

Strategies for Effective Management of Health and Safety in Confined Site Construction

The overall aim of this research is to identify and catalogue the numerous managerial strategies for effective management of health and safety on a confined, urban, construction site. A mixed methods methodology was adopted using interviews and focus group discussions on three selected case studies of confined construction sites. In addition to these, a questionnaire survey was used based on the findings from the interviews and the focus group discussions. The top five key strategies include (1) Employ safe system of work plans to mitigate personnel health and safety issues; (2) Inform personnel, before starting on-site, of the potential issues using site inductions; (3) Effective communication among site personnel; (4) Draft and implement an effective design site layout prior to starting on-site; and (5) Use of banksman (traffic co-ordinator) to segregate personnel from vehicular traffic. The construction sector is one of the leading industries in accident causation and with the continued development and regeneration of our urban centres, confined site construction is quickly becoming the norm - an environment which only fuels accident creation within the construction sector. This research aids on-site management that requires direction and assistance in the identification and implementation of key strategies for the management of health and safety, particularly in confined construction site environments.

A framework for developing evaluation capacity in health care settings.

The purpose of this paper is to provide a framework for developing an effective evaluation practice within health care settings. Three features are reviewed; capacity building, the application of evaluation to program activities and the utilization of evaluation recommendations. First, the organizational elements required to establish effective evaluation practice are reviewed emphasizing that an organization's capacity for evaluation develops over time and in stages. Second, a comprehensive evaluation framework is presented which demonstrates how evaluation practice can be applied to all aspects of a program's life cycle, thus promoting the scope of evidence-based decision making within an organization. Finally, factors which influence the adoption of evaluation recommendations by decision makers are reviewed accompanied by strategies to promote the utilization of evaluation recommendations in organization decision making.

Meeting the supportive needs of family caregivers in palliative care:challenges for health professionals

Caring for a dying relative is demanding, and family caregivers have acknowledged many unmet needs associated with their caregiver role. Consistently, caregivers of dying patients with cancer have reported that they need more support and information from health care professionals. Moreover, a number of palliative care clinicians and researchers have called for interventions to enhance the support offered to family caregivers. However, before researchers can develop and test palliative care interventions directed to families, it is important to identify barriers that may confront health care professionals with regard to the provision of supportive family care. For new interventions to be feasible they must be applicable within the constraints of current palliative care service delivery environments. This paper provides an account of issues that may impinge on optimal transference of supportive strategies from health care professionals to family caregivers of patients receiving palliative care. By acknowledging these barriers to supportive care, researchers and health care professionals can begin to design and implement interventions that are clinically relevant and more likely to be effective.

Adolescents' educational outcomes in a social ecology of parenting, family, and community risks in Northern Ireland

This study examines the influence of social ecological risks within the domains of parenting, family environment, and community in the prediction of educational outcomes for 770 adolescents (49% boys, 51% girls, M = 13.6 years, SD = 2.0) living in a setting of protracted political conflict, specifically working class areas of Belfast, Northern Ireland. Controlling for religious community, age, and gender, youths' lower academic achievement was associated with family environments characterized by high conflict and low cohesion. School behaviour problems were related to greater exposure to community violence, or sectarian and nonsectarian antisocial behaviour. Youths' expectations about educational attainment were undermined by conflict in the family environment and antisocial behaviour in the community, as well as parenting low in warmth and behavioural control. Findings underscore the importance of considering family and community contributions to youths' educational outcomes. Suggestions regarding targeted interventions toward promoting resilience are discussed, such as assessing both child and family functioning, developing multidimensional interventions for parents, and building community partnerships, among others.

Bolivian health and social care professionals' experiences of decision-making in oncology and palliative care

In the UK, end-of-life care strategies recommend patients and families are involved in decision making around treatment and care. In Bolivia, such strategies do not exist, and access to oncology services depends on finance, geography, education and culture. Compared to more developed countries, the delivery of oncology services in Latin America may result in a higher percentage of patients presenting with advanced incurable disease. The objective of this study was to explore decision-making experiences of health and social care professionals who cared for oncology and palliative care patients attending the Instituto Oncológico Nacional, Cochabamba (Bolivia). Patients were predominantly from the Quechua tradition, which has its own ethnic diversity, linguistic distinctions and economic systems. Qualitative data were collected during focus groups. Data analysis was conducted using Interpretative Phenomenological Analysis. Three interrelated themes emerged: (i) making sense of structures of experience and relationality; (ii) frustration with the system; and (iii) the challenges of promoting shared decision making. The study uncovered participants' lived experiences, emotions and perceptions of providing care for Quechua patients. There was evidence of structural inequalities, the marginalisation of Quechua patients and areas of concern that social workers might well be equipped to respond to, such as accessing finances for treatment/care, education and alleviating psychological or spiritual suffering.

Peer assisted learning in health education.

There are many forms of Peer Assisted Learning (PAL). There are well-established theoretical models as to why PAL is proven to be effective across educational sectors. To maximise gains from PAL careful consideration needs to be given to the roles of peers. Evidence suggests that PAL projects with clearly defined roles for interaction result in strongest outcomes. Effect Sizes (ES) from meta-analyses of peer assisted learning indicate ES of between 0.25-0.50. Outcomes can be social and emotional as well as academic. PAL generally requires adaptation of existing resources and can be cost-effective to implement compared to other educational developments.

Exploring lay views on physical activity and their implications for public health policy. A case study from East Belfast

It is now recognised that inactive lifestyles underpin much of the disease burden evident in the richer nations of the world. Indeed, the WHO has identified physical inactivity as a 'global public health problem' and has established minimum physical activity (PA) targets for people at different stages of the life-course. Yet, according to WHO, just under 1/3 of working age adults across the globe meet those targets and it is not at all clear how the disjunction between the recommendations of policy makers and the behaviour of ordinary people might be surmounted. Using an opportunity to examine the impact of an urban regeneration project on community residents in East Belfast (Northern Ireland) this paper examines the views of some 113 people on how to increase rates of PA in an area of multiple deprivation. The results of the analysis suggest that lay people rarely consider PA as a discrete issue, or one that centres on individuals and their motivation, but rather as one component in a complex web of concerns, processes and events that include such things as the actions of neighbours and relatives, material and political environments, vandalism, violence, and the weather. We explore and unravel the nature of those concerns using novel methods of content analysis that generate 'issue webs'. Particular attention is paid to the ways in which lay people conceptualize 'activity' and to the manner in which they point to ways of encouraging activity that are rooted in everyday life rather than in the corpocentric, agent-centred and often sport dominated strategies favoured by local policy makers. Our results support those who argue that interventions to increase rates of PA need to move beyond behavioural approaches that focus on individuals and consider the social, political and material contexts in which 'activity' occurs.

Falls prevention and support:: translating research, integrating services and promoting the contribution of service users for quality and innovative programmes of care

Falls are a significant threat to the safety, health and independence of older citizens. Despite the substantial evidence that is available around effective falls prevention programmes and interventions, their translation into falls reduction programmes and policies has yet to be fully realised. While hip fracture rates are decreasing, the number and incidence of fall-related hospital admissions among older people continue to rise. Given the demographic trends that highlight increasing numbers of older people in the UK, which is broadly reflected internationally, there is a financial and social imperative to minimise the rate of falls and associated injuries. Falling is closely aligned to growing older (Slips, Trips and Falls Update: From Acute and Community Hospitals and Mental Health Units in England and Wales, Department of Health, HMSO, London, 2010). According to the World Health Organization, around 30% of older people aged over 65 and 50% of those over 80 will fall each year (Falls Fact Sheet Number 344, WHO, Geneva, 2010). Falls happen as a result of many reasons and can have harmful consequences, including loss of mobility and independence, confidence and in many cases even death (Cochrane Database Syst Rev 15, 2009, 146; Slips, Trips and Falls Update: From Acute and Community Hospitals and Mental Health Units in England and Wales, Department of Health, HMSO, London, 2010; Falling Standards, Broken Promises: Report of the National
Audit of Falls and Bone Health in Older People 2010, Health Care Quality
Improvement Partnership, London, 2011). What is neither fair nor correct is the
common belief by old and young alike that falls are just another inconvenience to put up with. The available evidence justifiably supports the view that well-organised services, based upon national standards and expert guidance, can prevent future falls among older people and reduce death and disability from fractures. This paper will draw from the UK, as an exemplar for policy and practice, to discuss the strategic direction of falls prevention programmes for older people and the partnerships that need to exist between researchers, service providers and users of services to translate evidence to the clinical setting. Second, it will propose some mechanisms for disseminating evidence to healthcare professionals and other stakeholders, to improve the quality and capacity of the clinical workforce.

Effects of a demand-led evidence briefing service on the uptake and use of research evidence by commissioners of health services: protocol for a controlled before and after study

Background: Clinical Commissioning Groups (CCGs) are mandated to use research evidence effectively to ensure optimum use of resources by the National Health Service (NHS), both in accelerating innovation and in stopping the use of less effective practices and models of service delivery. We intend to evaluate whether access to a demand-led evidence service improves uptake and use of research evidence by NHS commissioners compared with less intensive and less targeted alternatives. 

Methods/design: This is a controlled before and after study involving CCGs in the North of England. Participating CCGs will receive one of three interventions to support the use of research evidence in their decision-making:1) consulting plus responsive push of tailored evidence; 2) consulting plus an unsolicited push of non-tailored evidence; or 3) standard service unsolicited push of non-tailored evidence. Our primary outcome will be changed at 12 months from baseline of a CCGs ability to acquire, assess, adapt and apply research evidence to support decision-making. Secondary outcomes will measure individual clinical leads and managers’ intentions to use research evidence in decision making. Documentary evidence of the use of the outputs of the service will be sought. A process evaluation will evaluate the nature and success of the interactions both within the sites and between commissioners and researchers delivering the service. 

Discussion: The proposed research will generate new knowledge of direct relevance and value to the NHS. The findings will help to clarify which elements of the service are of value in promoting the use of research evidence.Those involved in NHS commissioning will be able to use the results to inform how best to build the infrastructure they need to acquire, assess, adapt and apply research evidence to support decision-making and to fulfil their statutory duties under the Health and Social Care Act.

Connectivity and Physical Activity: Using Footpath Networks to Measure the Walkability of Built Environments

There is now a strong body of research that suggests that the form of the built environment can influence levels of physical activity, leading to an increasing interest in incorporating health objectives into spatial planning and regeneration policies and projects. There have been a number of strands to this research, one of which has sought to develop “objective” measurements of the built environment using Geographic Information Science (GIS) involving measures of connectivity and proximity to compare the relative “walkability” of different neighbourhoods. The development of the “walkability index” (e.g. Leslie et al 2007, Frank et al 2010) has become a popular indicator of spatial distribution of those features of the built environment that are considered to have the greatest positive influence on levels of physical activity. The success of this measure is built on its ability to succinctly capture built environment correlates of physical activity using routinely available spatial data, which includes using road centre lines as a basis of a proxy for connectivity.

This paper discusses two key aspects of the walkability index. First, it follows the suggestion of Chin et al (2008) that the use of a footpath network (where available), rather than road centre lines, may be far more effective in evaluating walkability. This may be particularly important for assessing changes in walkability arising from pedestrian-focused infrastructure projects, such as greenways. Second, the paper explores the implication of this for how connectivity can be measured. The paper takes six different measures of connectivity and first analyses the relationships between them and then tests their correlation with actual levels of physical activity of local residents in Belfast, Northern Ireland. The analysis finds that the best measurements appear to be intersection density and metric reach and uses this finding to discuss the implications of this for developing tools that may better support decision-making in spatial planning.

Arsenic in Rice Grown in Low-Arsenic Environments in Bangladesh

It has previously been reported that rice grown in regions of Bangladesh with low-arsenic (As) concentrations in irrigation water can have relatively high concentrations of As within their grains. This study aims to determine how widespread this issue is, and determine the seasonal variation in grain As in these regions. Levels of As were measured in shallow tube well (STW) water, soils, and rice grains collected during the Boro (dry) and Aman (wet) seasons from six Upazilas (sub-districts) of Bangladesh where As levels in groundwater were known to be low. In all the Upazilas, the As concentrations in STW water were <50 mu g L-1. The As levels in soil samples collected from the Upazilas ranged between 0.2-4.0 mgkg(-1) in the sam-ples collected during the Boro season, and 0.4-5.7 mg kg(-1) in the samples collected in the Aman season. Levels of As in both Boro and Aman rice grain varied widely: in Boro 0.02-0.45 mg kg(-1), and in Aman 0.01-0.29 mg kg(-1). Additionally, a household survey of dietary habits was also conducted in one Upazila by estimating As ingestion by 15 head female members. On average, the women consumed 3.1 L of water, 1.1 kg of cooked rice, and 42 g dry weight of curry per day. The total As ingestion rates ranged from 31.1-129.3 mu g day(-1) (mean 63.5 mu g kg(-1)). These findings indicate that the major route of As ingestion in low groundwater As areas of Bangladesh is rice, followed by curry and then water.

Knowledge Exchange, Spatial Analysis & Healthy Urban Environments (KESUE): Project Report

The Knowledge Exchange, Spatial Analysis and Healthy Urban Environments (KESUE) project has extended work previously undertaken by a QUB team of inter-disciplinary researchers engaged with the Physical Activity in the Regeneration of Connswater (PARC) project (Tully et al, 2013). The PARC project focussed on parts of East Belfast to assess the health impact of the Connswater Community Greenway. The KESUE project has aimed to extend some of the tools used initially in East Belfast so that they have data coverage of all of Belfast and Derry-Londonderry. The purpose of this has been to enable the development of evidence and policy tools that link features of the built environment with physical activity in these two cities. The project has used this data to help shape policy decisions in areas such as physical activity, park management, public transport and planning.

Working with a range of local partners who part-funded the project (City Councils in Belfast and Derry-Londonderry, Public Health Agency, Belfast Healthy Cities and Department of Regional Development), this project has mapped all the footpaths in the two cities (covering 37% of the NI population) and employed this to develop evidence used in strategies related to healthy urban planning. Using Geographic Information Systems (GIS), the footpath network has been used as a basis for a wide range of policy-relevant analyses including pedestrian accessibility to public facilities, site options for new infrastructure and assessing how vulnerable groups can access services such as pharmacies. Key outputs have been Accessibility Atlases and maps showing how walkability of the built environment varies across the two cities.

In addition to generating this useful data, the project included intense engagement with potential users of the research, which has led to its continued uptake in a number of policies and strategies, creating a virtuous circle of research, implementation and feedback. The project has proved so valuable to Belfast City Council that they have now taken on one of the researchers to continue the work in-house.

People with intellectual disabilities: promoting quality end of life care

Background: Internationally concerns have been highlighted about the quality of palliative care that people with intellectual disability receive. It has also been evidenced that people with intellectual disabilities are seldom referred to hospice and palliative care services. 

Aims: This study aimed to explore the experience of health and social care professionals in providing palliative care to people with intellectual disabilities. 

Methods An exploratory, qualitative design was used. A purposive sample of thirty health and social care professionals, working in intellectual disability and palliative care services, who had provided end-of-life care to adults with intellectual disabilities, were recruited to the study following informed consent. They were asked to reflect on a case scenario of a person with intellectual disability to whom they had provided end of life care. A semi-structured interview technique, with open questions and prompts, was used to explore their experiences and insights. The narrative from the case scenarios were content analysed using a recognised framework. 

Results: Three themes emerged from the data within the case scenarios: Identifying end of life care needs, meeting support needs and empowerment in partnership. Examples of good practice and issues in practice were apparent. 

Conclusion/ Discussion: This study contributes to the developing international evidence base to enhance end of life care for people with intellectual disabilities and provides further insights into this area of practice. Funder: HSC Research and Development Doctoral Fellowship Scheme