Caroline McGraw

Older people and medication management: from compliance to concordance

The issue of not taking medicines as prescribed by medical practitioners has a history as long as the medical profession itself. The World Health Organization recently described the problem of patients diagnosed with chronic illnesses not taking their medication as prescribed as ‘a worldwide problem of striking magnitude’. Not taking medicines as prescribed has consequences not only for the individual in terms of therapeutic failure, but also for the wider society. For the individual, failure to take medication as prescribed may result in ill health, poorer quality of life, and reduced life expectancy. For the wider society, consequences include avoidable health care expenditure and the development of drug resistance.

Evaluation of the suitability of root cause analysis frameworks for the investigation of community-acquired pressure ulcers: a systematic review and documentary analysis

AIMS AND OBJECTIVES To evaluate the suitability of root cause analysis frameworks for the investigation of community-acquired pressure ulcers. The objective was to identify the extent to which these frameworks take account of the setting where the ulcer originated as being the persons home rather than a hospital setting. BACKGROUND Pressure ulcers involving full-thickness skin loss are increasingly being regarded as indicators of nursing patient safety failure, requiring investigation using root cause analysis frameworks. Evidence suggests that root cause analysis frameworks developed in hospital settings ignore the unique dimensions of risk in home healthcare settings. DESIGN AND METHODS A systematic literature review and documentary analysis of frameworks used to investigate community-acquired grade three and four pressure ulcers by home nursing services in England. RESULTS No published papers were identified for inclusion in the review. Fifteen patient safety investigative frameworks were collected and analysed. Twelve of the retrieved frameworks were intended for the investigation of community-acquired pressure ulcers; seven of which took account of the setting where the ulcer originated as being the patients home. CONCLUSION This study provides evidence to suggest that many of the root cause analysis frameworks used to investigate community-acquired pressure ulcers in England are unsuitable for this purpose. RELEVANCE TO CLINICAL PRACTICE This study provides researchers and practitioners with evidence of the need to develop appropriate home nursing root cause analysis frameworks to investigate community-acquired pressure ulcers.

Nurses’ perceptions of the root causes of community-acquired pressure ulcers: Application of the Model for Examining Safety and Quality Concerns in Home Healthcare

AIMS AND OBJECTIVES To explore how the context of care influences the development of community-acquired pressure ulcers from the perspective of nurses working in home healthcare settings, to identify and categorise the factors perceived as contributing to the development of these ulcers using the Model for Examining Safety and Quality Concerns in Home Healthcare, and to explore how these risks are managed in practice. BACKGROUND Pressure ulcer reduction is a priority in both hospital and community settings. Evidence suggests the factors affecting safety and performance in community settings are not the same as in hospital. However, research pertaining to pressure ulcer risk management has predominantly been undertaken in hospital settings. DESIGN The study was framed by a qualitative exploratory design. METHODS Semistructured interviews were conducted with a purposive sample of 19 registered nurses recruited from an independent regional tissue viability network and five community nursing provider organisations in London. RESULTS The experiences and perceptions of participants mapped onto the components of the Model for Examining Safety and Quality Concerns in Home HealthCare: patient characteristics, provider characteristics, nature of home healthcare tasks, social and community environment, medical devices and new technology, physical environment, and external environment. Four strategies to address identified risks were established: behavioural interventions, technical interventions, safeguarding interventions and initiatives to promote better integration between health, local authorities and families. CONCLUSION Understanding the complex interplay between people and other elements of the healthcare system is critical to the prevention, management and investigation of pressure ulcers. This study has illuminated these elements from the perspective of nurses working in community settings. RELEVANCE TO CLINICAL PRACTICE Further consideration should be given to the importance of place when both developing risk management strategies for pressure ulcer prevention and learning the lessons from failure.

Multidisciplinary perspectives: Application of the Consolidated Framework for Implementation Research to evaluate a health coaching initiative

Long-term conditions are a leading cause of mortality and morbidity. Their management is founded on a combination of approaches involving government policy, better integration between health and care systems, and individual responsibility for self-care. Health coaching has emerged as an approach to encouraging individual responsibility and enhancing the self-management of long-term conditions. This paper focuses on the evaluation of a workforce initiative in a diverse and socially deprived community. The initiative sought both to improve integration between health and care services for people with long-term conditions, and equip practitioners with health coaching skills. The aim of the study was to contribute an empirical understanding of what practitioners perceive to be the contextual factors that impact on the adoption of health coaching in community settings. These factors were conceptualised using the Consolidated Framework for Implementation Research (CFIR). A stratified purposive sample of 22 health and care practitioners took part in semi-structured telephone interviews. Data were analysed using the CFIR as an analytical framework. The perceptions of trainees mapped onto the major domains of the CFIR: characteristics of the intervention, outer setting, inner setting, characteristics of individuals involved and process of implementation. Individual patient expectations, comorbidities and social context were central to the extent to which practitioners and patients engaged with health coaching. Structural constraints within provider services and the wider NHS were also reported as discouraging initiatives that focused on long-term rewards rather than short-term wins. The authors recommend further research is undertaken both to understand the role of health coaching in disadvantaged communities and ensure the service user voice is heard.