Alison J. Tierney

Multidisciplinary teamworking in the care of elderly patients with hip fracture

In spite of the increasing diversification of ward-based teams, there has been little empirical research into the evolution and functioning of multidisciplinary teams in the acute hospital setting. The importance of ‘good teamwork’ and ‘multidisciplinary collaboration’ has been highlighted recently in recommendations for ‘best practice’ in the care of elderly patients with hip fracture. Where any elaboration is offered, however, it concentrates narrowly on the specific component of ‘ortho-geriatric collaboration’. This has also been the focus of research in the field. It is argued in this article that further research into the effectiveness of multidisciplinary teamworking in hip fracture care cannot proceed without first understanding the ways in which teams actually operate in current practice, whether in specialised rehabilitation units or in ordinary orthopaedic wards. An empirical dimension to this discussion is provided by drawing on a recent four-centre study of hip fracture care in Scotland which ...

Is multidisciplinary teamwork the key? A qualitative study of the development of respiratory services in the UK

Summary Objectives Using frameworks, such as the long-term conditions pyramid of healthcare, primary care organizations (PCOs) in England and Wales are exploring ways of developing services for people with long-term respiratory disease. We aimed to explore the current and planned respiratory services and the roles of people responsible for change. Setting A purposive sample of 30 PCOs in England and Wales. Design Semi-structured telephone interviews with the person responsible for driving the reconfiguration of respiratory services. Recorded interviews were transcribed and coded, and themes identified. The association of the composition of the team driving change with the breadth of services provided was explored using a matrix. Results All but two of the PCOs described clinical services developed to address the needs of people with respiratory conditions, usually with a focus on preventing admissions for chronic obstructive pulmonary disease (COPD). Although the majority identified the need to develop a strategic approach to service development and to meet educational needs of primary care professionals, relatively few described clearly developed plans for addressing these issues. Involvement of clinicians from both primary and secondary care was associated with a broad multifaceted approach to service development. Teamwork was often challenging, but could prove rewarding for participants and could result in a fruitful alignment of objectives. The imminent merger of PCOs and overriding financial constraints resulted in a ‘fluid’ context which challenged successful implementation of plans. Conclusions While the majority of PCOs are developing clinical services for people with complex needs (principally in order to reduce admissions), relatively few are addressing the broader strategic issues and providing for local educational needs. The presence of multidisciplinary teams, which integrated primary and secondary care clinicians with PCO management, was associated with more comprehensive service provision addressing the needs of all respiratory patients. Future research needs to provide insight into the structures, processes and inter-professional relationships that facilitate development of clinical, educational and policy initiatives which aim to enhance local delivery of respiratory care.

Mind the gap between policy imperatives and service provision: a qualitative study of the process of respiratory service development in England and Wales

BackgroundHealthcare systems globally are reconfiguring to address the needs of people with long-term conditions such as respiratory disease. Primary Care Organisations (PCOs) in England and Wales are charged with the task of developing cost-effective patient-centred local models of care. We aimed to investigate how PCOs in England and Wales are reconfiguring their workforce to develop respiratory services, and the background factors influencing service redesign.MethodsSemi-structured qualitative telephone interviews with the person(s) responsible for driving respiratory service reconfiguration in a purposive sample of 30 PCOs. Interviews were recorded, transcribed, coded and thematically analysed.ResultsWe interviewed representatives of 30 PCOs with diverse demographic profiles planning a range of models of care. Although the primary driver was consistently identified as the need to respond to a central policy to shift the delivery of care for people with long-term conditions into the community whilst achieving financial balance, the design and implementation of services were subject to a broad range of local, and at times serendipitous, influences. The focus was almost exclusively on the complex needs of patients at the top of the long-term conditions (LTC) pyramid, with the aim of reducing admissions. Whilst some PCOs seemed able to develop innovative care despite uncertainty and financial restrictions, most highlighted many barriers to progress, describing initiatives suddenly shelved for lack of money, progress impeded by reluctant clinicians, plans thwarted by conflicting policies and a PCO workforce demoralised by job insecurity.ConclusionFor many of our interviewees there was a large gap between central policy rhetoric driving workforce change, and the practical reality of implementing change within PCOs when faced with the challenges of limited resources, diverse professional attitudes and an uncertain organisational context. Research should concentrate on understanding these complex dynamics in order to inform the policymakers, commissioners, health service managers and professionals.

The nurse/graduate in nursing: Preliminary findings of a follow-up study of former students of the University of Edinburgh degree/nursing programme

Nursing differs from medicine and some other professions in Britain in that its members do not require to be university graduates. However, a small proportion of the nursing profession is made up of nurses who are also graduates. In Britain there is a variety of combinations by which degree and nursing qualifications can be attained. Firstly, graduates of any discipline can train to become nurses (either on conventional nurse training courses or on special shortened courses). Secondly, someone who is a trained nurse can elect to read for a university degree. Thirdly, there are now opportunities for degree and nursing qualifications to be attained in integrated degree/nursing programmes. The provision of integrated degree/nursing programmes is unique in that the degree is wholly or partly a nursing degree, therefore differing from the other types of combination of the dual qualifications. The first degree/nursing programme in the United Kingdom was started in 1960 by the Department of Nursing Studies at the University of Edinburgh. There are now quite a number of programmes of this type offered in universities and polytechnics throughout the country.

Challenges for Nursing Research in an Era Dominated by Health Service Reform and Cost Containment

Many health care systems around the world are under reform, not least for reason of necessary cost containment. As one of the largest items of a health service budget, the costs of nursing services are attracting particular attention. This behooves the nursing profession, if only in its own interest, to accumulate convincing evidence of the cost-effectiveness of nursing. Nursings research track record in the assessment of the costs, quality, and effectiveness of nursing is assessed in this paper and found to be generally weak. The complexity of such research is acknowledged, the need for research which will insure and demonstrate the highest quality of nursing at the lowest possible cost is presented as a key challernge for nurse researchers in the present era.

Early supported discharge for elderly trauma patients: a report on a preliminary study

To cope with increasing numbers of elderly patients in acute orthopaedic units, various schemes have been introduced to expedite early rehabilitation and discharge. This paper reports a study undertaken in a large Scottish teaching hospital in order to assess the potential and requirements for a local scheme of early supported discharge for elderly trauma patients. Over a four-month period, data were collected from and about elderly patients (70+) admitted from home to the orthopaedic unit (overall sample of 282, detailed subsample of 100). Existing arrangements were shown to allow the apparently satisfactory direct discharge home of a substantial proportion (45%) of these patients in spite of their age (mean 80.2 years) and the fact that previous frailty was common and many (59%) lived alone. Findings of the study suggested that the number of discharges directly home could be increased with improved early rehabilitation, better pain control, systematic discharge planning, occupational therapy input and stronger links between the orthopaedic ward and the community services. Early clinical predictions of individual potential for direct discharge were unreliable. In a Scheme of Early Supported Discharge now in operation following the preliminary study, all patients admitted directly from home are considered.

Theatre gowns: a survey of the extent of user protection

This paper describes a survey of contamination by blood and other body fluids to theatre staff during general and orthopaedic surgery. Fourteen surgeons completed questionnaires following 243 operations, providing information describing the extent of contamination. Recommendations are made for more extensive precautions to be taken when operating on patients considered to be at high-risk of carrying human immunodeficiency virus (HIV). Further assessment of the reliability and comfort of impermeable gowns is required.

Comments on: “A comparative analysis of lay-caring and professional (nursing) caring relationships”

It was with some trepidation that I took up the Editor-in-Chief’s invitation to write a commentary, 15 years on, on this much-cited past paper, [International Journal of Nursing Studies 24(2) (1987) 155–165]. I recalled the difficulty I remember having in ‘getting my head round’ Alison Kitson’s doctoral research work when I first heard her speak on it in the early 1980s. Even now I find the research literature on ‘caring’ to be generally difficult to read and digest. And so, approaching this task filled me with the kind of apprehension which students experience when faced with a tricky essay topic which, left to themselves, would not have been of their own choosing! A major part of my difficulty with the literature on this topic arises from confused and inconsistent use of the words ‘caring’ and ‘care’ and, in particular, with their detachment from the words ‘nurse’ and ‘nursing’. Even the title of Kitson’s article reminds me of this recurrent problem in its hyphenation of ‘lay-caring’ but not of its counterpart. Frequently, or so it seems to me, the words ‘care’ and ‘caring’ are used interchangeably, ignoring the proper part of speech in the usage of ‘care’, ‘caring’ or the verb, ‘to care’. This will seem pedantic, but look up the different parts of speech under ‘care’ in any dictionary; and while you are at it, also look up ‘nurse/nursing’. You will find, I think, that recourse to the straightforward lay definition of these terms is more instructive than some of the lengthy discussions that preface articles on ‘caring’ in the professional literature. My esteemed writing partner, Nancy Roper, contends that the words ‘care’ and ‘caring’, which crept into increasing use in the nursing literature in the 1970s, have succeeded only in displacing the words ‘nursing’ and ‘nurse’ from our professional vocabulary. We will lose our way, she contends, both in practice and in academe, if we insist on referring to ‘caring’ instead of ‘nursing’. I may simply have been brainwashed successfully by Nancy, but I now support her position wholeheartedly. The only time I now add ‘care’ to the word ‘nursing’ is when I want to distinguish nursing care from medical (or other) care. ‘Caring’ may be synonymous with ‘nursing’, or at least integral to it, but ‘caring’ is not the prerogative of the nursing profession. Try out the Roper regime of sticking to the word ‘nursing’. But enough of this general comment—albeit pertinent—and on to my commentary on Kitson’s paper, that being the specific task I was set. I have structured my comments to respond directly to the four questions that the Editor-in-Chief suggested might be asked in the course of a re-view of this IJNS paper.

HipMod: Development of a Multi-Agent Audit-Based Computer Simulation of Hip Fracture Care

This paper describes the development of a computer simulation of the care of hip fracture, a common and serious injury with a complex journey of care. The project made use of a national, evidence-based guideline on hip fracture care, together with data from a national hip fracture audit and from service and research sources. To overcome the recognized limitations of such data in the modelling of care, clinicians from different specialties and disciplines working on hip fracture care participated by means of multi-agent-based modelling techniques. The model followed the journey of care (admission, surgery, rehabilitation, discharge or death), and, by incorporating the clinical reasoning of experienced practitioners, was developed to reflect the realities of day-to-day clinical decision-making. It was evaluated in terms of the credibility of its outputs with clinical participants, and by formal statistical comparisons of its outputs with real outcomes from comparable groups of patients in the national audit. The model was used to explore the impact of guideline compliance on care and resource use. Further modelling might serve to explore the implications of different service configurations for hip fracture care; to support service planning for demographic change; and to assist clinical training.

Teaching medical ethics: University of Edinburgh

The Edinburgh Medical Group Research Project is unique in Britain. Part of its function is to experiment with teaching medical ethics both inside and outside of the Medical School. The papers which follow have been written by two full-time reseach fellows working with the Project and two of the professional advisers, one nursing and one medical. Together they give a picture of the wide scope of exerimental teaching taking place in Edinburgh and present some preliminary results from these experiments.