Alistair Hewison

An evaluation of the implementation of a programme to improve end-of-life care in nursing homes

The Gold Standards Framework in Care Homes programme aims to improve the quality of end-of-life care for residents. The impact of introducing phase 2 of the programme to homes in England was evaluated. A pre–post survey design was adopted, focusing on indicators identified as markers of good end-of-life care. The 95 homes in phase 2 of the programme were invited to participate in the evaluation. Homes completed a baseline survey of care provision and an audit of the five most recent resident deaths. The survey and audit were repeated post programme completion. Forty-nine homes returned completed pre- and post-surveys, 44 returned pre- and post-data on deaths. Although some staff found completion of the programme challenging, homes that returned pre- and post-data demonstrated improvements in aspects of end-of-life care. There were statistically significant increases in the proportion of residents who died in the care homes and those who had an advanced care plan. Crisis admissions to hospital were significantly reduced. This evaluation indicates that appropriately funded structured programmes have the potential to assist nursing homes improve the provision of end-of-life care to older adults, in line with government health policy.

Men's health, inequalities and policy: contradictions, masculinities and public health in England

The aim of this paper is to consider ‘New’ Labours socio-economic and health policies, discuss how they influence preventive health strategies aimed at men, and identify the implications for managers, researchers and practitioners working to improve public health in the primary care sector in England. Policy, theoretical work and empirical research are analysed, critically, to develop the arguments in the paper. Although men may be perceived as a ‘hard to reach group’, insufficient consideration has been given to how health policy facilitates or restricts successful preventive health work with men. The ‘gender duty’, which has recently been introduced in England, presents an opportunity to build on earlier successful public health work with men. There is some evidence that innovative public health strategies, informed by an understanding of gender, with men are being developed. This may enable primary care trusts to more successfully, and creatively, target and engage men in health improvement activities. However, the current dominant ideology in public health policy in England is grounded in a perspective that emphasises biomedical, neo-liberal and psychological explanations of health and which neglects the relationship between gender and health inequalities. Recognition of the links between gender, poverty, and the concomitant inequalities, is a priority when planning preventive health work with men. If such inequalities are to be redressed, social and economic policies underpinned by values of equity and social justice are needed, incorporating a more nuanced understanding of the role of gender in health.

From conflict to collaboration? Contrasts and convergence in the development of nursing and management theory (2)

Aim  This is the first of two papers which examine the development of theory in the occupations of management and nursing, in order to determine where the similarities and differences lie. Background  The need for the Health Service to be effectively managed was a prominent feature of UK health policy in the 1980s and early 1990s and accounts of the introduction of ‘management methods’ into health care tend to focus on the conflict between management and nursing. More recently, however, the policy emphasis has shifted towards collaborative and co-operative approaches to the provision of health care. Method  An examination of the development of nursing is conducted as the first step in identifying areas of contrast and convergence in the development of nursing and managerial ideologies. In the second paper a similar approach is taken to the history of management. Conclusion  Nursing has been subject to a succession of ideologies aimed at advancing practice, however, many of these approaches have been accepted in an uncritical way. In the second paper the similarities in the development of management thought are examined and the implications this has for nursing management explored.

Co-production in research: some reflections on the experience of engaging practitioners in health research

This article reports the activities undertaken to develop co-production in health research. It is a response to the call for more discussion of the issue made in an earlier issue of this journal. Consideration of the practicalities of undertaking research in this way is an important contribution to the debate.

Rhetoric in policy texts: the role of enthymeme in Darzi's review of the NHS

Political administrations try to present their policies in the best light to justify the ownership of power, and in doing so rely on rhetoric. The documents through which they communicate policy (policy texts) use rhetorical devices to do so. Through these, administrations need to create the impression that they have chosen the best possible course of action, and they also need to create the impression that they are doing something innovative. Both are aspects of entailment, and both are necessary to appeal to multiple constituencies. We illustrate this theoretical argument with analysis of a recent review of NHS policy.

It's been quite a challenge: redesigning end-of-life care in acute hospitals.

OBJECTIVE This paper reports the findings of an interview-based study undertaken to investigate the introduction of end-of-life (EoL) care pathways in three acute trusts, as part of a larger project examining service redesign. The aim was to examine the barriers to and facilitators of change. METHOD Twenty-one in-depth qualitative interviews were conducted with staff working in three National Health Service (NHS) acute hospital trusts. These staff members were involved in end-of-life care, and their accounts were analyzed to identify the key issues when introducing service changes in these settings. RESULTS Thematic analysis revealed five major themes-two of which, leadership and facilitation, and education and training, indicate what needs to be in place if end-of-life care pathways are to be adopted by staff. However, the remaining three themes of difficult conversations, diagnosing dying, and communication across boundaries highlight particular areas of practice and organization that need to be addressed before end-of-life care in hospitals can be improved. SIGNIFICANCE OF RESULTS Organization of end-of-life care in acute hospitals is challenging, and care pathways provide a degree of guidance as to how services can be delivered. However, even when there is effective leadership at all levels of an organization and an extensive program of education for all staff support the use of care pathways, significant barriers to their introduction remain. These include staff anxieties concerning diagnosing dying and discussing dying and end-of-life care planning with patients and their families. It is hoped these findings can inform the development of the proposed new care plans which are set to replace end of life care pathways in England.

Feeling the cold: implications for nurse managers arising from the financial pressures in health care in England

AIM The purpose of this short paper is to identify some of the implications and opportunities nurse managers in England face as a result of the current global economic recession. BACKGROUND Government borrowing and poor global economic conditions have combined to create a pound175 billion budget deficit in the UK. The National Health Service in England will be required to make substantial savings in order to help offset this shortfall. KEY ISSUES This is a brief critical commentary which examines some of the challenges and opportunities for nurse managers in England. It draws on a number of sources to identify key issues concerning nursing management arising from the financial pressures facing health care. CONCLUSION The next few years are going to be very difficult for nurses and their managers, however, the current situation also presents opportunities to advance the contribution and influence of nursing and nursing management. IMPLICATIONS FOR NURSING MANAGEMENT What nurse managers do next will be crucial in shaping the NHS response to the financial storm and the future nature of health care in England.

Patients-people-place: developing a framework for researching organizational culture during health service redesign and change

BackgroundOrganizational culture is considered by policy-makers, clinicians, health service managers and researchers to be a crucial mediator in the success of implementing health service redesign. It is a challenge to find a method to capture cultural issues that is both theoretically robust and meaningful to those working in the organizations concerned. As part of a comparative study of service redesign in three acute hospital organizations in England, UK, a framework for collecting data reflective of culture was developed that was informed by previous work in the field and social and cultural theory.MethodsAs part of a larger mixed method comparative case study of hospital service redesign, informed by realist evaluation, the authors developed a framework for researching organisational culture during health service redesign and change. This article documents the development of the model, which involved an iterative process of data analysis, critical interdisciplinary discussion in the research team, and feedback from staff in the partner organisations. Data from semi-structured interviews with 77 key informants are used to illustrate the model.ResultsIn workshops with NHS partners to share and debate the early findings of the study, organizational culture was identified as a key concept to explore because it was perceived to underpin the whole redesign process. The Patients-People-Place framework for studying culture focuses on three thematic areas (‘domains’) and three levels of culture in which the data could be organised. The framework can be used to help explain the relationship between observable behaviours and cultural artefacts, the values and habits of social actors and the basic assumptions underpinning an organization’s culture in each domain.ConclusionsThis paper makes a methodological contribution to the study of culture in health care organizations. It offers guidance and a practical approach to investigating the inherently complex phenomenon of culture in hospital organizations. The Patients-People-Place framework could be applied in other settings as a means of ensuring the three domains and three levels that are important to an organization’s culture are addressed in future health service research.

Qualitative critical incident study of patients’ experiences leading to emergency hospital admission with advanced respiratory illness

Objectives The high volume of emergency admissions to hospital is a challenge for health systems internationally. Patients with lung cancer and chronic obstructive pulmonary disease (COPD) are frequently admitted to hospital as emergency cases. While the frequency of emergency admission has been investigated, few studies report patient experiences, particularly in relation to the decision-making process prior to emergency admission. We sought to explore patient and carer experiences and those of their healthcare professionals in the period leading up to emergency admission to hospital. Setting 3 UK hospitals located in different urban and rural settings. Design Qualitative critical incident study. Participants 24 patients with advanced lung cancer and 15 with advanced COPD admitted to hospital as emergencies, 20 of their carers and 50 of the health professionals involved in the patients’ care. Results The analysis of patient, carer and professionals’ interviews revealed a detailed picture of the complex processes involved leading to emergency admission to hospital. 3 phases were apparent in this period: self-management of deteriorating symptoms, negotiated decision-making and letting go. These were dynamic processes, characterised by an often rapidly changing clinical condition, uncertainty and anxiety. Patients considered their options drawing on experience, current and earlier advice. Patients tried to avoid admission, reluctantly accepting it, albeit often with a sense of relief, as anxiety increased with worsening symptoms. Conclusions Patients with advanced respiratory illness, and their carers, try to avoid emergency admission, and use logical and complex decision-making before reluctantly accepting it. Clinicians and policy-makers need to understand this complex process when considering how to reduce emergency hospital admissions rather than focusing on identifying and labelling admissions as ‘inappropriate’.

The importance of clinical leadership in service redesign : Experience in three English National Health Service Hospitals

Purpose – The way change occurred at a strategic level and in four clinical services in three hospitals was examined. The purpose of this paper is to report how the hospitals designed and delivered change at organisational and clinical service level to improve services for patients, and the role of clinical leadership in this process. Design/methodology/approach – A comparative case study involving semi-structured interviews was undertaken. These involved a range of senior managers in 2009 (n=77), 2011 (n=21) and 2012 (n=29). Interviews with staff involved directly in service delivery were also carried out in 2011 (n=92). The interviews were recorded digitally, transcribed verbatim, and analysed thematically using the Framework Method. Findings – The value of, and approach taken to clinical leadership varied across the hospitals and over time. This was affected by the culture and priorities of the organisation. Some strategies for developing clinical leadership were developed, however they were limited. I...