Alice Coffey

Development and Testing of the Context Assessment Index (CAI)

AIM To test the psychometric properties of the Context Assessment Index (CAI). BACKGROUND We used the Promoting Action on Research Implementation in Health Services Framework (PARIHS) as the theoretical framework for the study. The framework shows the successful implementation of evidence in practice as dependent on the inter-relationship of the nature of the evidence, the quality of the context, and expert facilitation. However, a comprehensive method of assessing context has not yet been available. METHODS A five-stage instrument development and testing methodology was used. Principal components analysis, exploratory factor analysis, and expert panel feedback were used to develop and refine the CAI model. The model was further tested for psychometric properties of internal consistency and test-retest scores. Telephone interviews were conducted with expert nurses to gauge the usability of the instrument. These stages of development and testing resulted in a final 37-item, five-factor CAI model. FINDINGS This 37-item model was accepted as a reasonable explanation of the data. The measures of homogeneity were calculated for each of the five factors to measure internal reliability. The Cronbachs alpha score for the complete questionnaire was estimated at 0.93. All five factors achieved a satisfactory estimated level of internal consistency in scoring, ranging from 0.78 to 0.91. Test-retest scores indicate reliability of the findings, and the feedback from focus group participants suggests that the instrument has practical utility. CONCLUSIONS The CAI provides clinicians with the means to assess and understand the context in which they work and the effect this has on using evidence in practice.

Advance care planning: A systematic review of randomised controlled trials conducted with older adults.

Advance care planning (ACP), involving discussions between patients, families and healthcare professionals on future healthcare decisions, in advance of anticipated impairment in decision-making capacity, improves satisfaction and end-of-life care while respecting patient autonomy. It usually results in the creation of a written advanced care directive (ACD). This systematic review examines the impact of ACP on several outcomes (including symptom management, quality of care and healthcare utilisation) in older adults (>65years) across all healthcare settings. Nine randomised controlled trials (RCTs) were identified by searches of the CINAHL, PubMed and Cochrane databases. A total of 3646 older adults were included (range 72-88 years). Seven studies were conducted with community dwellers and the other two RCTs were conducted in nursing homes. Most studies did not implement a standardised ACD, or measure the impact on quality of end-of-life care or on the death and dying experience. All studies had some risk of bias, with most scoring poorly on the Oxford Quality Scale. While ACP interventions are well received by older adults and generally have positive effects on outcomes, this review highlights the need for well-designed RCTs that examine the economic impact of ACP and its effect on quality of care in nursing homes and other sectors.

Discharging older people from hospital to home: what do we know?

Aims and objectives.  The aim of this literature review was to examine empirical research to date on hospital discharge and illuminate areas in need of further exploration. Background.  Discharging older people from hospital has long been associated with difficulties and complications. With a steady increase in the ageing population in Ireland and their use of acute hospital services, the successful management of hospital discharge is now a central concern to health service management. Methods.  Using a seven-step approach by Stolz et al. [Scandinavian Journal of Caring Sciences (2004) Vol. 18, 111-119] a keyword database search was conducted which revealed 44 studies that matched the authors inclusion criteria. Results.  These studies uncover aspects of the discharge process that are in need of further research, and particularly suggest more rigour in the measurement of hospital discharge outcomes. Relevance to clinical practice.  This review focuses on a very important clinical issue given the predicted increase in the use of acute services by older people and the known vulnerabilities of the interface between hospital and community settings.

Evaluating the systematic implementation of the ‘Let Me Decide’ advance care planning programme in long term care through focus groups: staff perspectives

BackgroundThe ‘Let Me Decide’ Advance Care Planning (LMD-ACP) programme offers a structured approach to End-of-Life (EoL) care planning in long-term care for residents with and without capacity to complete an advance care directive/plan. The programme was implemented in three homes in the South of Ireland, with a view to improving quality of care at end of life. This paper will present an evaluation of the systematic implementation of the LMD-ACP programme in the homes.MethodsFocus groups were conducted with 15 Clinical Nurse Managers and two Directors of Nursing where the programme had been implemented. A semi-structured topic guide was used to direct questions that addressed implementation process, challenges implementing advance care planning, advantages/disadvantages and recommendations for the future. Data was analysed using manifest content analysis.ResultsFive key categories emerged, with 16 corresponding subcategories. These subcategories emerged as a result of 37 codes. Key benefits of the programme included enhancing communication, changing the care culture, promoting preference-based care and avoiding crisis decision making. Establishing capacity among residents and indecision were among the main challenges reported by staff.DiscussionA number of recommendations were proposed by participants and included multi-disciplinary team involvement, and a blended approach to education on the topic. According to participants relationships with residents deepened, there was a more open and honest environment with family, end of life care focused more on symptom management, comfort and addressing spiritual care needs as opposed to crisis decision making and family conflict.ConclusionThe introduction of the LMD-ACP programme enhanced the delivery of care in the long-term care sites and led to a more open and positive care environment.

Clinical unity and community empowerment: the use of smartphone technology to empower community management of chronic venous ulcers through the support of a tertiary unit

Background Chronic ulcers affect roughly 60,000 Irish people, at a total cost of €600,000,000, or €10,000 per patient annually. By virtue of their chronicity, these ulcers also contribute a significant burden to tertiary outpatient vascular clinics. Objective We propose utilizing mobile phone technology to decentralise care from tertiary centres to the community, improving efficiency and patient satisfaction, while maintaining patient safety. Methods Bespoke mobile software was developed for Apples iPhone 4 platform. This allowed for the remote collection of patient images prospectively and their transmission with clinical queries, from the primary healthcare team to the tertiary centre. Training and iPhones were provided to five public health nurses in geographically remote areas of the region. Data were uploaded securely and user end software was developed allowing the review and manipulation of images, along with two way communication between the teams. Establishing reliability, patients were reviewed clinically as well as remotely, and concordance analysed. Qualitative data were collected through focus group discussion. Results From October to December 2011 eight patients (61–83 yrs, mean 75.3 yrs) with chronic venous ulceration and their five public health nurses were recruited. Data were transmitted using 3 G, Edge, GPRS and WiFi, at a mean speed of 69.03 kps. Concordance was 100% for wound bed assessment, 80% for skin integrity/colour and 60% for exudate assessment. Focus group analysis explored the concept, practicalities and future applications of the system. Conclusions With an evolving national data network, the secure transmission of clinical images is a safe alternative to regular clinic appointments for patients with chronic venous ulceration. With further development, and packaged as a freely downloadable application, this has the potential to support the community care of chronic wounds.

Incontinence: prevalence, management, staff knowledge and professional practice environment in rehabilitation units

Background.  Bladder and bowel incontinence is a major health care problem, which adversely affects the lives of many individuals living at home or in health service facilities. Current approaches to continence care emphasize comfort, safety and reduction of risk, rather than detailed individualized assessment and management. The literature illustrates a gap between evidence and actual practice and emphasizes the context of care as being a key element for successful implementation of evidence based practice. Aims.  To identify prevalence of bowel and bladder incontinence and its management, investigate continence knowledge and describe the professional practice environment within a rehabilitation unit for older people. Method.  An integrated evaluation of continence prevalence, staff knowledge and the work environment was adopted. Results.  Findings revealed a high incidence of incontinence (60% urinary, 3% faecal, 37% mixed) a lack of specific continence assessment and specific rationale for treatment decisions or continuation of care. The focus was on continence containment rather than on proactive management. Staff demonstrated a reasonable knowledge of incontinence causation and treatment as measured by the staff knowledge audit. The evaluation of the work environment indicated a low to moderate perception of control over practice (2.39), autonomy in practice (2.87), nurse doctor relationship (2.67) and organizational support (2.67).

Beliefs of students about growing older and perceptions of working in gerontology Educators in health and social care could do more to overcome the stereotypical views that deter trainees from choosing a career in the specialty, say Alice Coffey and colleagues

An ageing population that is increasing does not necessarily mean an increase in people who require health and social care. However, it is predicted that a wide range of such services is likely to be needed. This demand is set against a shortage of skilled healthcare professionals and a lack of interest in working with older people. There is a particular shortage of skilled gerontological workers in the developed world, made worse by a perceived lack of professional esteem, economic reward and poor working environments in the specialism. Most studies recommend education to enable individuals to develop accurate knowledge about the ageing process and interest in working with older people. There is a discrepancy in the literature as to whether health and social care workers hold positive or negative attitudes towards older people. As attitudes are strongly linked with perceptions of working with older people, this article presents a review of the literature and discussion on attitudes of health and social care students to ageing and perceptions of working with older people.

Transitional care interventions: Relevance for nursing in the community

OBJECTIVES The coordination and integration of health care is compromised by complex challenges related to transitions between care settings, greater prevalence of chronic health conditions, and older individuals with increasing levels of dependency. Transitional care incorporates a broad range of services designed to provide care continuity. This systematic review aims to synthesize and present findings regarding the relevance of transitional care interventions to community nursing. DESIGN AND SAMPLE A systematic search of electronic databases was conducted as part of a larger review to identify evidence-based interventions to support a model to guide nursing and midwifery in the community in Ireland. All relevant empirical studies published in English between 2010 and 2015 were included. MEASURES Studies were assessed based on inclusion criteria. The Cochrane Risk of Bias and AMSTAR tools were used to assess the methodological quality of studies. Key themes and concepts were extracted and synthesized. RESULTS Transitional care interventions had significant positive effects in reducing all-cause readmissions, mortality, and heart failure-related rehospitalizations. CONCLUSION Effective transitional care requires excellent communication between acute and primary care providers. This has implications for integration and organization of care across settings and nursing competence.

Measuring staff perception of end-of-life experience of older adults in long-term care

BACKGROUND Quality of dying and death receive far less attention than quality of life. Measuring the quality of care at end-of-life (EOL) in long-term care (LTC) is essential, to ensure high standards. METHODS A questionnaire measuring staff perception of their patients end of life experience (SPELE) was developed. Content validity (CVI) was assessed by a panel of experts, and piloting was conducted with dyads of healthcare assistants (n=15) and nurses (n=15). RESULTS The SPELE captures facets of the quality of the death and dying experience from healthcare staffs perspective. Good group inter-rater reliability was observed among subscales. One exception was the pain and symptom experience scale. Kappa values showed little agreement between nurses and healthcare assistants for certain symptoms, including pain. CONCLUSION Further testing of the questionnaire is required. However it is described as a useful mechanism to enable researchers and clinicians to explore quality of care at EOL.

The factors to be considered when evaluating bedside handover

AIM This paper sought to identify the factors that should be considered in the study of bedside handover at the change of nursing shift. BACKGROUND The introduction of bedside handover at the change of nursing shift has been linked to increased patient safety; bedside handover is not a simple change of location but a fundamental change in nursing practice. METHOD An integrative review of the literature was performed, to identify factors that should be considered when exploring and describing the process and content of nursing handover when performed at the patient bedside. RESULTS Nursing handover conducted at the patients bedside is different to other forms of clinical handover in that the patient is part of the process. A dedicated tool is required to comprehensively study and understand the complexities of the bedside handover at the change of nursing shift. CONCLUSION The factors identified in this literature review should be used to develop a tool to study the phenomenon that is nursing bedside handover. IMPLICATIONS FOR NURSING MANAGEMENT Handover at the change of nursing shift is a high risk, high volume nursing practice, therefore the introduction of bedside handover should be systematically studied.