David Pontin

Safety in numbers 3: Authenticity, Building knowledge & skills and Competency development & assessment: The ABC of safe medication dosage calculation problem-solving pedagogy

When designing learning and assessment environments it is essential to articulate the underpinning education philosophy, theory, model and learning style support mechanisms that inform their structure and content. We elaborate on original PhD research that articulates the design rationale of authentic medication dosage calculation problem-solving (MDC-PS) learning and diagnostic assessment environments. These environments embody the principles of authenticity, building knowledge and skills and competency assessment and are designed to support development of competence and bridging of the theory-practice gap. Authentic learning and diagnostic assessment environments capture the features and expert practices that are located in real world practice cultures and recreate them in authentic virtual clinical environments. We explore how this provides students with a safe virtual authentic environment to actively experience, practice and undertake MDC-PS learning and assessment activities. We argue that this is integral to the construction and diagnostic assessment of schemata validity (mental constructions and frameworks that are an individuals internal representation of their world), bridging of the theory-practice gap and cognitive and functional competence development. We illustrate these principles through the underpinning pedagogical design of two online virtual authentic learning and diagnostic assessment environments (safeMedicate and eDose™).

Does family-centred neonatal discharge planning reduce healthcare usage? A before and after study in South West England

Objective To implement parent-oriented discharge planning (Train-to-Home) for preterm infants in neonatal care. Design Before and after study, investigating the effects of the intervention during two 11-month periods before and after implementation. Setting Four local neonatal units (LNUs) in South West England. Participants Infants without major anomalies born at 27–33 weeks’ gestation admitted to participating units, and their parents. Train-to-Home intervention A family-centred discharge package to increase parents’ involvement and understanding of their babys needs, comprising a train graphic and supporting care pathways to facilitate parents’ understanding of their babys progress and physiological maturation, combined with improved estimation of the likely discharge date. Main outcome measures Perceived Maternal Parenting Self-Efficacy (PMP S-E) scores, infant length of stay (LOS) and healthcare utilisation for 8 weeks following discharge. Results Parents reported that the Train-to-Home improved understanding of their babys progress and their preparedness for discharge. Despite a lack of change in PMP S-E scores with the intervention, the number of post-discharge visits to emergency departments (EDs) fell from 31 to 20 (p<0.05), with a significant reduction in associated healthcare costs (£3400 to £2200; p<0.05) after discharge. In both study phases, over 50% of infants went home more than 3 weeks before their estimated date of delivery (EDD), though no reduction in LOS occurred. Conclusions Despite the lack of measurable effect on the parental self-efficacy scores, the reduction in ED attendances and associated costs supports the potential value of this approach.

The ED-EQoL: the development of a new quality of life measure for patients with erectile dysfunction.

Purpose: To identify the important issues which have an impact on the quality of life (QoL) of men suffering from erectile dysfunction (ED) and to generate a new ED-specific QoL questionnaire ready to undergo further psychometric testing. Methods: QoL issues relating to ED were generated through in-depth qualitative interviews of 29 patients, literature review and consultation with other healthcare professionals. The issues were formulated into a questionnaire, which was piloted using 40 patients with ED and subsequently refined using well-established principles of questionnaire development. Results: The qualitative interviews revealed numerous psychosocial problems associated with ED, which were operationalised into a 40-item questionnaire. Pilot testing allowed the questionnaire to be reduced to a manageable 15-item final questionnaire while maintaining face and content validity and the potential to discriminate between men with varying degrees of affected QoL. This questionnaire had a Cronbachs α of 0.94. Conclusions: A new ED-specific QoL measure has been developed using appropriate methodology. Qualitative techniques identified a range of psychosocial morbidity in men with ED, leading to a simple but robust instrument with face and content validity. This questionnaire, Erectile Dysfunction – Effect on quality of life (ED-EQoL), has now undergone psychometric testing for validity and reliability.

Issues in prognostication for hospital specialist palliative care doctors and nurses: A qualitative inquiry

Background: Patients with advanced life-limiting diseases have high information needs concerning prognosis yet discussions between patients and healthcare professionals are either avoided or inaccurate due to over-optimism. Available prognostic models are problematic. Literature indicates that hospital specialist palliative care professionals are frequently asked to prognosticate, although their experience of prognostication is unknown. Identifying this experience will support the development of prognosis training for hospital specialist palliative care professionals. Aim: To explore hospital specialist palliative care professionals’ experience of prognostication. Research questions: ‘How do specialist palliative care team members prognosticate?’; ‘How do they view prognostication?’ Design: Qualitative research – focus group interviews. Setting/participants: Three UK hospital specialist palliative care teams. Participants included medical doctors and palliative care nurses. Inclusion/exclusion criteria: member of hospital specialist palliative care team with knowledge and experience of prognostication. Numbers of participants: four hospital specialist palliative medicine consultants, three senior doctors in training, nine clinical nurse specialists. Results: Two major themes: Difficulties of prognostication; Benefits of prognostication. Eleven sub-themes: Difficulties (Non-malignant disease; Communicating uncertainty; Seeking definitive prognosis; Participants’ feelings; Confidence in prognostication; Estimating prognosis; Dealing with reaction of prognosis; Prognostic error); Benefits (Patient informed decision-making prioritizing needs and care; Family-prioritizing commitments; Services accessing funding and services planning patient care). Conclusions: Findings highlight lack of evidence to support practice, and identify the complexity and emotional labour involved in prognostication by hospital specialist palliative care team members, and are used to discuss recommendations for further research and practice.

Using liminality to understand mothers’ experiences of long-term breastfeeding: ‘Betwixt and between’, and ‘matter out of place’

Breastmilk is widely considered as the optimum nutrition source for babies and an important factor in both improving public health and reducing health inequalities. Current international/national policy supports long-term breastfeeding. UK breastfeeding initiation rates are high but rapidly decline, and the numbers breastfeeding in the second year and beyond are unknown. This study used the concept of liminality to explore the experiences of a group of women breastfeeding long-term in the United Kingdom, building on Mahon-Daly and Andrews. Over 80 breastfeeding women were included within the study, which used micro-ethnographic methods (participant observation in breastfeeding support groups, face-to-face interviews and online asynchronous interviews via email). Findings about women’s experiences are congruent with the existing literature, although it is mostly dated and from outside the United Kingdom. Liminality was found to be useful in providing insight into women’s experiences of long-term breastfeeding in relation to both time and place. Understanding women’s experience of breastfeeding beyond current usual norms can be used to inform work with breastfeeding mothers and to encourage more women to breastfeed for longer.

Family presence during resuscitation: Validation of the risk–benefit and self-confidence scales for student nurses

Background. There is increasing debate about the advantages and disadvantages of family-witnessed resuscitation. Research about the views of healthcare providers depends upon reliable tools to measure their perceptions. Two tools have been developed for use with nurses (26-item cost-benefit tool, 17-item self-confidence tool). Objectives. Firstly, to validate these tools for use with student nurses in the UK. Secondly, to report on the perceived risks and benefits reported by student nurses, and their self-confidence in dealing with this situation. Methods. A sample of 79 student nurses were invited to complete the tools. Item-total correlations and Cronbach’s α were used to determine internal consistency. Factor analysis was computed to assess construct validity. The correlation between the two scales was explored. Results. 69 students completed a questionnaire. Very few had experience of family-witnessed resuscitation. Mean total scores were 3.16 (standard deviation 0.37; range 2.04–4.12) on the risk-benefit scale and 3.14 (standard deviation 0.66; range 1.94–4.82) on the self-confidence scale. Four of the original items were removed from the risk-benefit scale (Cronbachs α 0.86; 95% confidence interval ≥0.82). None were removed from the self-confidence scale (Cronbachs α 0.93; 95% confidence interval ≥0.91). There was a significant correlation between the two scales (r = 0.37, p = 0.002). Conclusions. There is growing evidence that these tools are valid and reliable for measuring student nurses’ perceptions about family-witnessed resuscitation.

Number of readmissions was similar for hospital at home and traditional hospital care for children with moderate illness.

Patients 399 moderately ill children (mean age 25.7 mo, 60% boys) who had breathing difficulties (n=202); diarrhoea with or without vomiting (n=125); or a feverish illness (n=72); and were likely to require ≥ 24 hours of nursing observation. Exclusion criteria were child unsuitability as judged by the general practitioner (GP), assessing physician, or nurse; child unwillingness or inability to participate; no telephone access; or registration with a GP outside the health authority. 389 children (97%) completed the trial.

Developing nursing competence: Future proofing nurses for the changing practice requirements of 21st century healthcare

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Consult, Negotiate, and Involve: Evaluation of an Advanced Communication Skills Program for Health Care Professionals:

Effective communication is central to children, young people, and their families’ experiences of health care. Most patient complaints in developed health care systems result from ineffective communication, including inadequate information provision, not feeling listened to, failure to value patients concerns, and patients not feeling involved in care decisions. Advanced communication skills training is now embedded within cancer care policy in the United Kingdom and now features prominently within cancer education in many countries. Here, we share findings from a research evaluation of an advanced communication skills training program dedicated to health professionals caring for children and young people with cancer. We evaluated participants’ (n = 59) perceptions of the program, impact on their skills, knowledge, competence, and confidence. An appreciative inquiry design was adopted; data included interviews, precourse-postcourse evaluations, e-mail blog survey, and 360-degree reflective work records. The framework approach underpinned data analysis and triangulation of data sets. Key findings highlighted good and poor practice in health professionals’ engagement with children, young people, and their families; the purpose of communicating effectively was not always consistent with collaborative working. Attending a program helped participants expand their knowledge of communication theories and strategies. Participants valued using simulated scenarios to develop their skills and were keen to use their new skills to enhance care delivery. Our emphasis within this evaluation, however, remained on what was communicated, when and how, rather than to what effect. The impact of programs such as these must now be evaluated in terms of patient benefit.

An interactive monitoring device reduced asthma symptoms and functional limitations in inner city children with asthma.

Patients 134 children who were 8–16 years of age (mean age 12 y, 57% boys, 76% African-American), had a diagnosis of persistent asthma, had an English speaking caregiver, and had a telephone at home. Exclusion criteria were involvement in other asthma or drug efficacy studies or behaviour modification research, mental or physical challenges that made it difficult to use the Health Buddy, or comorbid conditions affecting quality of life. Follow up was 96% at 6 weeks and 91% at 12 weeks.