Learning, development, and support needs of community palliative care clinical nurse specialists

Background: The palliative care clinical nurse specialist (PC-CNS) is a core member of the specialist palliative care team. According to professional policy, the role has four specific components: clinical practice, education, research, and leadership and management. Little is known about how to support staff in this role. Aim: The aim of this study was to explore what learning, development, and support PC-CNSs in one hospice need to enable them to fulfil all components of their role. Design: Using a descriptive exploratory approach, semi-structured interviews were undertaken with a purposive sample of community PC-CNSs from a hospice in Northern Ireland. Interviews were audio-recorded, transcribed verbatim, and thematically analysed. Findings: Seventeen interviews were analysed and three themes identified: influence of organisational culture, influence of the individual, and learning and development solutions. Conclusions: Participants reported that the PC-CNS role was stressful. They identified that the organisational culture and indeed individuals themselves influenced the learning and development support available to help them fulfil the four components of the role. Working relationships and stability within teams affected how supported individuals felt and had implications for managers in meeting the needs of staff while balancing the needs of the service.

‘All illness is personal to that individual’: a qualitative study of patients’ perspectives on treatment adherence in bronchiectasis

Background: Adherence to treatment is low in bronchiectasis and is associated with poorer health outcomes. Factors affecting adherence decisions have not been explored in patients with bronchiectasis. 

Objective: We aimed to explore patients' perspectives on adherence, factors affecting adherence decision making and to develop a conceptual model explaining this decision-making process in adults with bronchiectasis. 

Methods: Adults with bronchiectasis participated in one-to-one semi-structured interviews. Interviews were audio-recorded, transcribed verbatim and analysed independently by two researchers using thematic analysis. Data from core themes were extracted, categorized into factors affecting adherence decision making and used to develop the conceptual model. 

Results: Participants' beliefs about treatment, the practical aspects of managing treatment, their trust in health-care professionals and acceptance of disease and treatment were important aspects of treatment adherence. The conceptual model demonstrated that adherence decisions were influenced by participants' individual balance of barriers and motivating factors (treatment-related, disease-related, health-care-related, personal and social factors). 

Conclusion: Adherence decision-making in bronchiectasis is complex, but there is the potential to enhance adherence by understanding patients' specific barriers and motivators to adherence and using this to tailor adherence strategies to individual patients and treatments. © 2014 John Wiley & Sons Ltd.

Caught in a 'spiral': barriers to healthy eating and dietary health promotion needs from the perspective of unemployed young people and their service providers

The number of young people in Europe who are not in education, employment or training (NEET) is increasing. Given that young people from disadvantaged backgrounds tend to have diets of poor nutritional quality, this exploratory study sought to understand barriers and facilitators to healthy eating and dietary health promotion needs of unemployed young people aged 16-20 years. Three focus group discussions were held with young people (n=14). Six individual interviews and one paired interview with service providers (n=7). Data were recorded, transcribed verbatim and thematically content analysed. Themes were then fitted to social cognitive theory (SCT). Despite understanding of the principles of healthy eating, a ‘spiral’ of interrelated social, economic and associated psychological problems was perceived to render food and health of little value and low priority for the young people. The story related by the young people and corroborated by the service providers was of a lack of personal and vicarious experience with food. External, environmental factors such as the proliferation and proximity of fast food outlets and the high perceived cost of ‘healthy’ compared to ‘junk’ food rendered the young people low in self-efficacy and perceived control to make healthier food choices. Agency was instead expressed through consumption of junk food and substance abuse. Both the young people and service providers agreed that for dietary health promotion efforts to succeed, social problems needed addressed and agency encouraged through (individual and collective) active engagement of the young people themselves.

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,

Life after Stroke: Coping mechanisms among African Caribbean Women

In the UK stroke is the third most common cause of death for women and the incidence in African Caribbean women is higher than the general population. Stroke burden has major consequences for the physical, mental and social health of African Caribbean women. In order to adjust to life after stroke individuals affected employ a range of strategies which may include personal, religious (church) or spiritual support (i.e. prayer), individual motivation, or resignation to life with a disability. This study explored these areas through the coping mechanisms that African Caribbean women utilised post stroke in the context of stroke recovery and lifestyle modification efforts needed to promote healthy living post stroke. A qualitative approach using Interpretative Phenomenological Analysis was adopted. Eight women were recruited into the study. Semi structured in-depth interviews were audio recorded and were transcribed verbatim. Data were analysed using a four-stage framework: familiarisation, sense making, developing themes and data refinement and analysis. Three main themes on coping emerged: the need to follow medical rules to manage stroke, strength and determination, and the use of religion and faith to cope with life after stroke. These findings illustrate both a tension between religious beliefs and the medical approach to stroke and highlight the potential benefits that religion and the church can play in stroke recovery. Implications for practice include acknowledgement and inclusion of religion and church based health promotion in post stroke recovery.

Kids just wanna have fun: Children's experiences of a weight management programme

Objectives: To explore children's accounts of their experiences of the UK‘s largest childhood obesity programme, MEND (Mind, Exercise, Nutrition…Do it!) (See www.mendprogramme.org). Design: Semi-structured interviews were conducted with children who had completed the MEND obesity programme. Interviews were transcribed verbatim and analysed using Interpretative Phenomenological Analysis (IPA). Method Fourteen children spanning diverse areas of London comprised this study (eight male, six female), aged between 11 and 14 years and in secondary school. Participants were interviewed a year after completing one of the London-based MEND obesity programmes. Results: This article focuses on the most common and striking theme to emerge from the original dataset (The complete analysis may be found in L. Watson, Unpublished doctoral thesis): Fun. Subthemes were: ‘going with the flow’; active participation in activities that led to new experiences (‘actually doing it’ – seeing the fun side); the importance of others in the experience of fun (‘you do games in unity’ – ‘it's not as fun on your own’). Conclusion: Children have fun when engaged in interactive and varied activities with opportunity for individual feedback and improvement. When designing childhood obesity programmes, conditions that optimise children's experience of fun should be emphasised over didactic and risk-heavy information pertaining to childhood obesity.

L'analyse de la cohérence et de la cohésion dans la restitution orale et dans la restitution écrite par un jeune francophone du premier cycle secondaire diagnostiqué dysphasique

La présente recherche porte sur la cohérence et la cohésion qu'il existe dans l'expression orale d'un jeune dysphasique du premier cycle du secondaire et dans la production écrite effectuée par celui-ci. Compte tenu du problème de langage parlé que présente entre autres la dysphasie, le risque de trouver le même problème est possiblement présent dans la production écrite. Cela a des répercussions au niveau scolaire dans l'expression de ses idées, l'apprentissage de l'écriture, peut-être même dans la compréhension de ce qu'il écoute et lit. Non seulement, cela a-t-il des conséquences dans les résultats académiques, mais aussi dans les relations sociales avec ses pairs et ses enseignants puisqu'il ne saisit pas certains énoncés du langage tels que des jeux de mots ou des métaphores. De plus, il a de la difficulté à exprimer clairement ses idées et ses opinions. Ces obstacles à l'expression orale et celle écrite peuvent éventuellement marginaliser le jeune dysphasique et le démotiver. Des études ont mis en évidence qu'il existe une relation entre le langage parlé et l'apprentissage de l'écriture : si le jeune dysphasique éprouve des difficultés à s'exprimer oralement, il en sera de même dans la production écrite. Toutefois, d'autres études démontrent que l'apprentissage de l'écriture aide à améliorer le langage oral. Toutes ces études ont été effectuées sur de jeunes enfants au niveau préscolaire ou au primaire; elles ont été faites à partir de textes narratifs restitués par des jeunes n'ayant par de problème de langage. Notre recherche, qui est exploratoire et descriptive, concerne des jeunes du premier cycle du secondaire et la collecte de données s'est faite à partir d'un texte courant. Elle visait deux objectifs spécifiques : premièrement, analyser la cohérence et la cohésion dans la restitution orale et celle écrite d'un sujet tout-venant et dans celles d'un jeune dysphasique; et deuxièmement, décrire les relations entre les restitutions des deux sujets. Pour ce faire, la collecte de données s'est déroulée de la manière suivante : nous avons demandé à deux jeunes de deuxième et troisième secondaires, l'un, tout-venant et l'autre, dysphasique, de restituer ce qu'ils se rappelaient de l'écoute d'un texte à dominante descriptive laquelle leur a été faite à tour de rôle. Dans un premier temps, ils devaient rappeler oralement le contenu du texte lu, et dans un deuxième temps, ils devaient écrire ce dont ils se souvenaient du même texte. Une fois les restitutions orales transcrites sous forme de Verbatim, elles ont été, tout comme les restitutions écrites, décrites et comparées entre elles selon les critères suivants : la cohérence (intégration et hiérarchisation et la cohésion (récurrence, coréférence, contiguïté sémantique et connecteurs). Les résultats obtenus montrent d'abord que les restitutions orales et écrites présentent des similitudes quant à la cohérence et la cohésion. Les restitutions écrites sont légèrement plus détaillées, c'est-à-dire quelques idées ont été ajoutées ou précisées. Par exemple, dans la restitution orale, comme dans celle écrite, le sujet tout-venant mentionne que les fourmis d'Argentine pourraient être "dangereuses pour les arbres fruitiers". Dans sa restitution écrite, il ajoute comme informations que ces insectes "aiment le sucre" et qu'elles "vont dans les maisons". Les observations montrent aussi une différence entre les restitutions du jeune toutvenant et celles du jeune dysphasique. Ce dernier rappelle les informations du texte de façon cohérente et presque complète alors que le sujet tout-venant ne restitue que les informations de la première partie, et ce, de la façon la plus simple, soit par l'énumération sans connecteurs autres que ceux de l'énumération. Par contre, le sujet tout-venant maîtrise les procédés cohésifs mieux que le sujet dysphasique. Quant à ce dernier, il semble mieux réussir à l'écrit qu'à l'oral. La compréhension des informations de façon globale et, peut-être, le type de texte influencent les résultats dans le rappel des informations. Le sujet dysphasique peut restituer les idées, et ce, de façon structurée s'il saisit bien l'idée globale du texte qu'il lui a été lu, mais la microstructure est moins maîtrisée, sauf l'utilisation des connecteurs qui a probablement un lien plus étroit - que les autres procédés cohésifs - avec la cohérence et la compréhension des idées. Donc, à partir de l'analyse des restitutions orale et écrite, il semble que le trouble de langage aurait des répercussions au niveau des procédés de la cohésion, sauf dans le cas des connecteurs. L'utilisation de ceux-ci et les procédés de cohérence sont maîtrisés par le jeune dysphasique qui a compris le contenu du texte qui lui a été lu.

Patients’ Views: Peer Support Worker On Inpatient Wards

Purpose: To explore patients’ experiences of intentional mental health peer support (PS) Design/methodology/approach: Seven in depth interviews were carried out by an independent researcher with individual inpatients who volunteered via a PS worker following leaflet and poster distribution explaining the research on the two wards. Each recorded interview of thirteen questions was transcribed verbatim by the researcher and analysis identified common themes across the interviews. Findings: An overarching theme of communication with patients was identified together with six main themes: person centeredness, practical support, building connections, emotional support, modelling hope, and recovery interventions. There were no negative comments expressed by interviewees. Research limitations/implications: Small scale qualitative research allows in-depth exploration of experiences which is valuable in informing the further development of peer support. Originality/value: There are very few published reports of inpatient experiences of peer support in inpatient settings.

Role Ambiguity and Perceived Organizational Politics in Wolf Recovery: Washington State Wildlife Agency Personnel Perspectives

Thesis (Master's)--University of Washington, 2015-12

Facilitating self-directed learning: the nurse educators' perspective

The concept of self-directed learning was examined from the nurse educators' perspective. One structured interview, lasting between one and one-and-a half hours, was conducted with each of 14 nurse educators in two community college continuing education programs in nursing. One community college program encourages selfdirected learning; the other encourages self-study and active participation in the teaching/learning process. All 14 interviews were tape-recorded and transcribed verbatim. Verbatim transcripts were analyzed for themes, patterns, and relationships utilizing analyst-constructed typologies. six prerequisites or necessary conditions for facilitating self-directed learning in a community college continuing education program in nursing were identified. ~he crucial issue in facilitating self-directed learning was found to be the issue of teacher-control.