Christopher R Burton

What can management theories offer evidence-based practice? A comparative analysis of measurement tools for organisational context

BackgroundGiven the current emphasis on networks as vehicles for innovation and change in health service delivery, the ability to conceptualise and measure organisational enablers for the social construction of knowledge merits attention. This study aimed to develop a composite tool to measure the organisational context for evidence-based practice (EBP) in healthcare.MethodsA structured search of the major healthcare and management databases for measurement tools from four domains: research utilisation (RU), research activity (RA), knowledge management (KM), and organisational learning (OL). Included studies were reports of the development or use of measurement tools that included organisational factors. Tools were appraised for face and content validity, plus development and testing methods. Measurement tool items were extracted, merged across the four domains, and categorised within a constructed framework describing the absorptive and receptive capacities of organisations.ResultsThirty measurement tools were identified and appraised. Eighteen tools from the four domains were selected for item extraction and analysis. The constructed framework consists of seven categories relating to three core organisational attributes of vision, leadership, and a learning culture, and four stages of knowledge need, acquisition of new knowledge, knowledge sharing, and knowledge use. Measurement tools from RA or RU domains had more items relating to the categories of leadership, and acquisition of new knowledge; while tools from KM or learning organisation domains had more items relating to vision, learning culture, knowledge need, and knowledge sharing. There was equal emphasis on knowledge use in the different domains.ConclusionIf the translation of evidence into knowledge is viewed as socially mediated, tools to measure the organisational context of EBP in healthcare could be enhanced by consideration of related concepts from the organisational and management sciences. Comparison of measurement tools across domains suggests that there is scope within EBP for supplementing the current emphasis on human and technical resources to support information uptake and use by individuals. Consideration of measurement tools from the fields of KM and OL shows more content related to social mechanisms to facilitate knowledge recognition, translation, and transfer between individuals and groups.

End-of-life issues in acute stroke care: a qualitative study of the experiences and preferences of patients and families.

The aims of this qualitative study were to identify patients’ and family members’ experiences of acute stroke and their preferences for end-of-life care. Twenty-eight purposely sampled patients with an acute stroke who had high (n = 13) and low (n = 15) disability were selected from 191 sequential cases admitted to two general hospitals in north-east England. In addition, 25 family members of other stroke patients were recruited. Views about current stroke services and preferences for end-of-life care were elicited in semi-structured interviews. Communication between patients and family members and healthcare professionals was consistently highlighted as central to a positive experience of stroke care. Honesty and clarity of information was required, even where prognoses were bleak or uncertain. Patients and family members appeared to attach as much importance to the style of communication as to the substance of the transfer of information. Where decisions had been made to shift the focus of care from active to more passive support, families, and where possible patients, still wished to be included in ongoing dialogue with professionals. Where patients were thought to be dying, family members were keen to ensure that the death was peaceful and dignified. Families reported few opportunities for engagement in any form of choice over place or style of end-of-life care. No family member reported being offered the possibility of the patient dying at home. Uncertainty about prognosis is inevitable in clinical practice, and this can be difficult for patients and families. Our findings demonstrate the importance of improving communication between patient, family and health professionals for seriously ill patients with stroke in UK hospitals.

Palliative care in stroke : a critical review of the literature.

The aim of this literature review was to identify the palliative care needs of stroke patients. Stroke results in high levels of mortality and morbidity, yet very little is known about the nature and extent of palliative care services that are available to this patient group, and the ways in which such services could be delivered. A critical review of the international literature found only seven papers that attempted to identify the palliative care needs of patients diagnosed with stroke. The results of the review showed that the preferences of stroke patients and their families in relation to palliative care services are largely unknown. The review also indicated the paucity of data in regard to the distinction between provision of palliative care services for patients who die in the acute phase of stroke and for those patients who die later. Establishing reliable assessments of need are central to designing and implementing effective interventions and further research is required in this area. Further data on how the input of palliative care experts and expertise could be of benefit to patients, and the most effective ways these inputs could be targeted and delivered is required. Palliative Medicine 2007; 21: 323—331

The palliative care needs of acute stroke patients: a prospective study of hospital admissions

BACKGROUND despite a mortality rate of approximately 30% in acute stroke, little is known about the palliative care needs of this group of patients. DESIGN prospective study of 191 acute stroke patients admitted to hospital in England. Biographical, medical and stroke-related data were collected. Participants completed the Sheffield Profile for Assessment and Referral to Care (SPARC), a screening tool for referral to specialist palliative care. FINDINGS over 50% reported moderate to significant fatigue-related problems. Approximately 50% reported symptom-related problems (e.g. pain) or psychological distress (e.g. anxiety). Approximately 25% had concerns about death or dying, and 66% had concerns about dependence and disability. Over 50% were worried about the impact of stroke on family members. There were significant main effects of dependence (Barthel Index) (F(1,123) = 12.640 P = 0.001) and age (F(4,123) = 3.022 P = 0.020), and a significant three-factor interaction between dependence, age and co-morbidities (F(9,123) = 2.199 P = 0.026) in predicting total SPARC scores. CONCLUSIONS acute stroke patients have a high prevalence of palliative care needs. Acute stroke services should use the SPARC for needs assessment. Priority for assessment should be given to patients with a score of <15/20 on the Barthel Index, a tool already used in most stroke services.

Yoga for reducing perceived stress and back pain at work

BACKGROUND Stress and back pain are two key factors leading to sickness absence at work. Recent research indicates that yoga can be effective for reducing perceived stress, alleviating back pain, and improving psychological well-being. AIMS To determine the effectiveness of a yoga-based intervention for reducing perceived stress and back pain at work. METHODS Participants were recruited from a British local government authority and randomized into a yoga group who received one 50 min Dru Yoga session each week for 8 weeks and a 20 min DVD for home practice and a control group who received no intervention. Baseline and end-programme measurements of self-reported stress, back pain and psychological well-being were assessed with the Perceived Stress Scale, Roland Morris Disability Questionnaire and the Positive and Negative Affect Scale. RESULTS There were 37 participants in each group. Analysis of variance and multiple linear regression showed that in comparison to the control group, the yoga group reported significant reductions in perceived stress and back pain, and a substantial improvement in psychological well-being. When compared with the control group at the end of the programme, the yoga group scores were significantly lower for perceived stress, back pain, sadness and hostility, and substantially higher for feeling self-assured, attentive and serene. CONCLUSIONS The results indicate that a workplace yoga intervention can reduce perceived stress and back pain and improve psychological well-being. Larger randomized controlled trials are needed to determine the broader efficacy of yoga for improving workplace productivity and reducing sickness absence.

Mental health crisis and respite services: service user and carer aspirations

There is emerging evidence that crisis resolution services can provide alternatives to hospital admission, reducing demand on inpatient beds. Following a public consultation exercise in Lancashire (England), a team of nurses undertook a study, using interactive research methodology, to gain an understanding of how users and carers define a crisis and what range of crisis services, resources and interventions service users and carers thought would help avoid unnecessary hospital admission. Data collection comprised postal questionnaires and 24 group meetings with service users and carers, which were held during 2006. Data were analysed, and seven themes were identified: (1) definitions of a crisis; (2) access to services; (3) interventions; (4) range of services required (before, during and after crisis); (5) place of treatment; (6) recovery and rehabilitation; and (7) community support. We conclude that expressed preferences of service users and carers for pre-emptive services that are delivered flexibly will present a challenge for service commissioners and providers, particularly where stringent access criteria are used. Home-based pre-emptive services that reduce the need for unnecessary hospital treatment may avoid progression to social exclusion of service users.

The organisational context of nursing care in stroke units: A case study approach.

BACKGROUND Internationally the stroke unit is recognised as the evidence-based model for patient management, although clarity about the effective components of stroke units is lacking. Whilst skilled nursing care has been proposed as one component, the theoretical and empirical basis for stroke nursing is limited. We attempted to explore the organisational context of stroke unit nursing, to determine those features that staff perceived to be important in facilitating high quality care. DESIGN A case study approach was used, that included interviews with nurses and members of the multidisciplinary teams in two Canadian acute stroke units. A total of 20 interviews were completed, transcribed and analysed thematically using the Framework Approach. Trustworthiness was established through the review of themes and their interpretation by members of the stroke units. FINDINGS Nine themes that comprised an organisational context that supported the delivery of high quality nursing care in acute stroke units were identified, and provide a framework for organisational development. The study highlighted the importance of an overarching service model to guide the organisation of care and the development of specialist and advanced nursing roles. Whilst multidisciplinary working appears to be a key component of stroke unit nursing, various organisational challenges to its successful implementation were highlighted. In particular the consequence of differences in the therapeutic approach of nurses and therapy staff needs to be explored in greater depth. Successful teamwork appears to depend on opportunities for the development of relationships between team members as much as the use of formal communication systems and structures. A co-ordinated approach to education and training, clinical leadership, a commitment to research, and opportunities for role and practice development also appear to be key organisational features of stroke unit nursing. Recommendations for the development of stroke nursing leadership and future research into teamwork in stroke settings are made.

Collaboration and Co-Production of Knowledge in Healthcare: Opportunities and Challenges

Over time there has been a shift, at least in the rhetoric, from a pipeline conceptualisation of knowledge implementation, to one that recognises the potential of more collaboration, co-productive approaches to knowledge production and use. In this editorial, which is grounded in our research and collective experience, we highlight both the potential and challenge with collaboration and co-production. This includes issues about stakeholder engagement, governance arrangements, and capacity and capability for working in a co-productive way. Finally, we reflect on the fact that this approach is not a panacea, but is accompanied by some philosophical and practical challenges.

Does self-efficacy influence recovery and well-being in osteoarthritis patients undergoing joint replacement? A systematic review:

Objective: To investigate the role of self-efficacy in functional recovery and well-being outcomes in osteoarthritis patients, undergoing hip or knee replacement surgery. Data sources: Studies were identified using MEDLINE via PUB med, PsycINFO and CINAHL from inception to July 2013. Methods: Three search strategies that combined key terms of ‘self-efficacy’, ‘functional recovery’, ‘well-being’ and ‘joint replacement’ were applied. Titles and abstracts were screened for eligibility and, accordingly, potentially eligible studies were retrieved for review. Included studies were assessed in terms of their quality, and data were extracted by two independent reviewers. A narrative synthesis of results was conducted. Results: In total, 836 articles were identified and after electronic de-duplication, 708 articles remained. After screening 15 articles were retrieved as potentially eligible and eight articles were included in the review. Of the eight studies (n = 967 patients), seven had a prospective design and all studies were considered of good quality. No fully conclusive evidence for the influence of self-efficacy upon functional recovery outcomes was found. When the timing of self-efficacy measurement was examined, post-operative self-efficacy was found to be related to functional recovery outcomes. Conclusion: Presurgical self-efficacy was the least consistent predictor of functional outcomes while postoperative self-efficacy was more consistently associated with recovery outcomes such as longer distance ambulation, exercise repetition and frequency, walking speed and disability.

Collective action for implementation: a realist evaluation of organisational collaboration in healthcare

BackgroundIncreasingly, it is being suggested that translational gaps might be eradicated or narrowed by bringing research users and producers closer together, a theory that is largely untested. This paper reports a national study to fill a gap in the evidence about the conditions, processes and outcomes related to collaboration and implementation.MethodsA longitudinal realist evaluation using multiple qualitative methods case studies was conducted with three Collaborations for Leadership in Applied Health Research in Care (England). Data were collected over four rounds of theory development, refinement and testing. Over 200 participants were involved in semi-structured interviews, non-participant observations of events and meetings, and stakeholder engagement. A combined inductive and deductive data analysis process was focused on proposition refinement and testing iteratively over data collection rounds.ResultsThe quality of existing relationships between higher education and local health service, and views about whether implementation was a collaborative act, created a path dependency. Where implementation was perceived to be removed from service and there was a lack of organisational connections, this resulted in a focus on knowledge production and transfer, rather than co-production. The collaborations’ architectures were counterproductive because they did not facilitate connectivity and had emphasised professional and epistemic boundaries. More distributed leadership was associated with greater potential for engagement. The creation of boundary spanning roles was the most visible investment in implementation, and credible individuals in these roles resulted in cross-boundary work, in facilitation and in direct impacts. The academic-practice divide played out strongly as a context for motivation to engage, in that ‘what’s in it for me’ resulted in variable levels of engagement along a co-operation-collaboration continuum. Learning within and across collaborations was patchy depending on attention to evaluation.ConclusionsThese collaborations did not emerge from a vacuum, and they needed time to learn and develop. Their life cycle started with their position on collaboration, knowledge and implementation. More impactful attempts at collective action in implementation might be determined by the deliberate alignment of a number of features, including foundational relationships, vision, values, structures and processes and views about the nature of the collaboration and implementation.