Ailsa M Brotherton

Clinical decision making and the provision of information in PEG feeding: an exploration of patients and their carers’ perceptions

BACKGROUND Government health care policy encourages a culture of patient choice and involvement in decision making, although the complexities and challenges involved in fully engaging patients in clinical decision making can be perceived as barriers to effective communication between the professional and patient. The present study aimed to explore the patients and their carers perceptions of the adequacy of the information provided and their subsequent involvement in the decision making process for percutaneous endoscopic gastrostomy (PEG) tube insertion. METHODS The study used purposive sampling. A cross-sectional qualitative design was utilised using semi-structured interviews, which were tape recorded. Sixteen patients and 27 carers were interviewed. The interviews were then transcribed verbatim and data analysis was undertaken using thematic analysis. RESULTS Only four patients and 11 carers reported having a choice in the decision for PEG placement, with only four patients and 10 carers, respectively, reporting they received sufficient information regarding the PEG. Poor communication, lack of information and inappropriate information, attitudes of health care professionals and exclusion were key themes for patients. CONCLUSIONS Clinicians should develop interdisciplinary and participative practices to agree shared treatment goals and evaluate patient experiences. Consideration should also be given to the use of decision making models; in our opinion, the development of such a model, which supports interdisciplinary and participative approaches to decision making, is urgently required.

Percutaneous Endoscopic Gastrostomy Feeding in Nursing Homes: Relatives' Perceptions

The aim of this study is to explore the experiences of relatives of nursing home residents receiving percutaneous endoscopic gastrostomy feeding. Qualitative methodology using semistructured interviews explores the experiences and perceptions of eight relatives. Data are analyzed using thematic analysis. Four themes are constructed from the data: dependence and resulting disempowerment, having minimal or no involvement in the decision-making process for PEG placement, betrayal, and the losses associated with the social aspects of eating. There is a need for professional education about the psychosocial implications of feeding and an increased level of support for relatives to assist them to develop coping strategies. This will require an expansion of current professional roles to include assessment of individual need, setting of appropriate goals, and the coordination of the provision of multiagency services, likely to include counseling and social support. Further research is required in this field to inform service developments.

Mothers’ Process of Decision Making for Gastrostomy Placement

In this article we present the findings of an exploration of mothers’ discourses on decision making for gastrostomy placement for their child. Exploring in-depth interviews of a purposive sample, we analyzed the mothers’ discourses of the decision-making process to understand how their experiences of the process influenced their subsequent constructions of decision making. Mothers negotiated decision making by reflecting on their personal experiences of feeding their child, either orally or via a tube, and interwove their background experiences with the communications from members of the health care team until a decision was reached. Decision making was often fraught with difficulty, resulting in anxiety and guilt. Experiences of decision making ranged from perceived coercion to true choice, which encompasses a truly child-centered decision. The resulting impact of the decision-making process on the mothers was profound. We conclude with an exploration of the implications for clinical practice and describe how health care professionals can support mothers to ensure that decision-making processes for gastrostomy placement in children are significantly improved.

Dietetic research impact and influence: the power of strong coalitions

The research committee of the British Dietetic Association (BDA) developed its research strategy in 2008, highlighting the BDA’s commitment to leading the research agenda for the dietetic profession through the development of research capacity and capability. The implementation of this strategy sharply focuses on encouraging research involvement at all levels of the dietetic profession, recognising that building strong collaborations is key to designing a system that ensures high-quality research advances dietetic practice at an unprecedented pace and scale. The research strategy has five key components: the research agenda, building research capacity, promoting involvement at every level, the publication of high-quality research and the advancement of dietetic practice (BDA, 2008). The editorial team at the Journal of Human Nutrition and Dietetics is committed to making a significant contribution to the achievement of this strategy and is implementing a strategic approach aiming to maximise the impact and influence of dietetic research, as published within the Journal, to advance dietetic practice. It is imperative that there is a cultural shift that moves the profession away from fragmented and isolated pockets of excellent practice to the development of a framework that facilitates the implementation of leading dietetic research across the whole profession, where there is a robust evidence base to facilitate this. What is needed to create this cultural shift? Taking one of the new sections of the Journal as an example (Clinical Nutrition), the publication of high-quality research is, of course, a crucial first step to achieving this change in culture. Professor Elia, in an Editorial in 2011, described the rekindled interest in nutritional support in cancer as being a result of the research conducted by Burden et al. (2010, 2011); Garth et al. (2010) and Baldwin et al. (2011). Interest in the appropriate use of oral nutritional supplements continues to run high in the dietetic profession, and the results of an analysis aiming to examine the ‘effects on mortality and nutritional indices of dietary counselling given with or without ONS and to explore the heterogeneity in the meta-analyses aiming to characterise the groups most likely to benefit from these interventions’ are likely to fuel more interest in this topic (Baldwin & Weekes, 2012). There is similar interest in clinical decision-making and judgements. Baker & Thompson (2012) utilised the methodology of clinical judgement analysis to explore clinicians ‘likelihood of feeding’ and ‘whether or not they would initiate artificial nutrition support’ in response to a number of patient scenarios. They found that clinicians’ judgements varied substantially and report only moderate agreement with the recommendations of the National Institute for Health and Clinical Excellence and an overestimate of the need for artificial nutrition support. However, publication of the research findings alone is insufficient to effect change. Developing the framework for implementing the research findings at an unprecedented pace and scale right across the profession is, however, much more challenging, not least because of the volume of research published. The new professional practice section of the Journal not only affords a new opportunity to publish primary professional practice research, but also provides examples of where the best available evidence within specialties is used to drive advances in professional practice. Kotter’s eight-step change model offers a potential theoretical perspective on which to build a framework for implementing research into dietetic practice at an unprecedented pace and scale. The steps include creating urgency, forming a powerful coalition, creating a vision for change, communicating the vision, removing obstacles, creating short-term wins, building on the change and anchoring the changes into the corporate (professional) culture (Kotter, 1996). One example of where a coalition of key partners has been brought together with a shared vision and sense of urgency (i.e. to implement research into practice) is the multiprofessional consensus panel of healthcare professionals with expertise and an interest in malnutrition, who met to agree on best practice for identifying and managing malnutrition in the community. The consensus reached by the panel was based on evidence, clinical expertise and experience and accepted best practice. Dietitians, general practitioners (GPs), nurses and pharmacists were represented on the panel and the outcome was the development of a new document: ‘Managing Adult Malnutrition in the Community, including a pathway for the appropriate use of oral nutritional supplements (ONS)’. This pathway (Available at: http://www.malnutritionpathway.co.uk/) provides practical evidence-based guidance for GPs and community healthcare professionals and includes information on how to identify individuals who

Using Emotional Intelligence and NLP Training to Promote and Sustain Relationships within KTPs

The School of Nursing and Caring Sciences at the University of Central Lancashire (UCLan) currently has 3 KTPs at various stages – one is completing year 2 of a 3 year project, another is just starting and one has experienced a delayed start because of initial problems with recruitment of an Associate. Participation in health KTPs is a new endeavour for UCLan because it only became possible to develop projects when eligibility criteria changed 3 years ago. It is also new for our partners.