Jill Maben

An open letter to The BMJ editors on qualitative research

Seventy six senior academics from 11 countries invite The BMJ ’s editors to reconsider their policy of rejecting qualitative research on the grounds of low priority. They challenge the journal to develop a proactive, scholarly, and pluralist approach to research that aligns with its stated mission

Using patients' experiences to identify priorities for quality improvement in breast cancer care: patient narratives, surveys or both?

BackgroundPatients’ experiences have become central to assessing the performance of healthcare systems worldwide and are increasingly being used to inform quality improvement processes. This paper explores the relative value of surveys and detailed patient narratives in identifying priorities for improving breast cancer services as part of a quality improvement process.MethodsOne dataset was collected using a narrative interview approach, (n = 13) and the other using a postal survey (n = 82). Datasets were analyzed separately and then compared to determine whether similar priorities for improving patient experiences were identified.ResultsThere were both similarities and differences in the improvement priorities arising from each approach. Day surgery was specifically identified as a priority in the narrative dataset but included in the survey recommendations only as part of a broader priority around improving inpatient experience. Both datasets identified appointment systems, patients spending enough time with staff, information about treatment and side effects and more information at the end of treatment as priorities. The specific priorities identified by the narrative interviews commonly related to ‘relational’ aspects of patient experience. Those identified by the survey typically related to more ‘functional’ aspects and were not always sufficiently detailed to identify specific improvement actions.ConclusionsOur analysis suggests that whilst local survey data may act as a screening tool to identify potential problems within the breast cancer service, they do not always provide sufficient detail of what to do to improve that service. These findings may have wider applicability in other services. We recommend using an initial preliminary survey, with better use of survey open comments, followed by an in-depth qualitative analysis to help deliver improvements to relational and functional aspects of patient experience.

A systematic review of barriers to early presentation and diagnosis with breast cancer among black women

Objective To explore barriers to early presentation and diagnosis with breast cancer among black women. Design Systematic review. Methods We searched multiple bibliographic databases (January 1991–February 2013) for primary research, published in English, conducted in developed countries and investigating barriers to early presentation and diagnosis with symptomatic breast cancer among black women (≥18 years). Studies were excluded if they did not report separate findings by ethnic group or gender, only reported differences in time to presentation/diagnosis, or reported on interventions and barriers to cancer screening. We followed Cochrane and PRISMA guidance to identify relevant research. Findings were integrated through thematic synthesis. Designs of quantitative studies made meta-analysis impossible. Results We identified 18 studies (6183 participants). Delay was multifactorial, individual and complex. Factors contributing to delay included: poor symptom and risk factor knowledge; fear of detecting breast abnormality; fear of cancer treatments; fear of partner abandonment; embarrassment disclosing symptoms to healthcare professionals; taboo and stigmatism. Presentation appears quicker following disclosure. Influence of fatalism and religiosity on delay is unclear from evidence in these studies. We compared older studies (≥10 years) with newer ones (<10 years) to determine changes over time. In older studies, delaying factors included: inaccessibility of healthcare services; competing priorities and concerns about partner abandonment. Partner abandonment was studied in older studies but not in newer ones. Comparisons of healthy women and cancer populations revealed differences between how people perceive they would behave, and actually behave, on finding breast abnormality. Conclusions Strategies to improve early presentation and diagnosis with breast cancer among black women need to address symptom recognition and interpretation of risk, as well as fears of the consequences of cancer. The review is limited by the paucity of studies conducted outside the USA and limited detail reported by published studies preventing comparison between ethnic groups.

The use of focus group interviews in nursing research: Issues and challenges:

Focus group interviews are becoming more widely used as a data collection technique within nursing research. This paper draws on the experience of the authors in conducting a number of focus group interviews while undertaking a study of perceptions of the philosophy and practice of nursing within the context of Project 2000 1. Some of the main issues and challenges to be considered when utilising this method are examined. These include the practicalities of group size, access and sampling, as well as the fundamental issues associated with group interaction. The role of the moderator in maintaining the flow and focus of the group and in ensuring the participation of all group members is addressed, along with an examination of disclosure and validity. Finally, the issues and challenges posed by the analysis of the focus group data are considered. [NT Research 1996; 1 :2, 143-153]

In praise of compassion

Compassion, in its original meaning in Latin, means ‘with suffering’. Compassion is usually expressed towards others when we experience their suffering, being there with them in some way that makes their pain more bearable (Firth-Cozens and Cornwell, 2009). A simple definition is that it is ‘a deep awareness of the suffering of another coupled with the wish to relieve it’ (Chochinov, 2007). The casual reader of recent reports might be forgiven for thinking that nurses have no interest in compassion. The mainstream media have interpreted the regulator’s shocking and disturbing reports about the quality of care in hospitals in Mid Staffordshire and Maidstone and Tunbridge Wells as poor nursing delivered by insensitive, even bad, nurses. More recently, the Patients Association has fuelled public concern with a report documenting ‘dreadful, neglectful, demeaning, painful and sometimes downright cruel treatment elderly patients had experienced at the hands of NHS nurses’ (Patients Association, 2009). A great many practising nurses share the concern. Nurses’ and ex-nurses’ own accounts of poor experiences of care feature regularly in the nursing press. In interviews and evidence (Dawoud and Maben, 2008; Maben and Griffiths, 2008) over and over again a wide range of nurses suggested that the essence of nursing, being with patients, performing essential but intimate care, where relationships are forged and built has been passed over to health care assistants. The broad consensus seems to hold: compassion once seen as ‘the essence of caring and therefore the essence of nursing’ is no longer ‘always the central focus of nursing practice’ (Chambers and Ryder, 2009).

Economic evaluation of nurse staffing and nurse substitution in health care: A scoping review

OBJECTIVE Several systematic reviews have suggested that greater nurse staffing as well as a greater proportion of registered nurses in the health workforce is associated with better patient outcomes. Others have found that nurses can substitute for doctors safely and effectively in a variety of settings. However, these reviews do not generally consider the effect of nurse staff on both patient outcomes and costs of care, and therefore say little about the cost-effectiveness of nurse-provided care. Therefore, we conducted a scoping literature review of economic evaluation studies which consider the link between nurse staffing, skill mix within the nursing team and between nurses and other medical staff to determine the nature of the available economic evidence. DESIGN Scoping literature review. DATA SOURCES English-language manuscripts, published between 1989 and 2009, focussing on the relationship between costs and effects of care and the level of registered nurse staffing or nurse-physician substitution/nursing skill mix in the clinical team, using cost-effectiveness, cost-utility, or cost-benefit analysis. Articles selected for the review were identified through Medline, CINAHL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and Google Scholar database searches. REVIEW METHODS After selecting 17 articles representing 16 unique studies for review, we summarized their main findings, and assessed their methodological quality using criteria derived from recommendations from the guidelines proposed by the Panel on Cost-Effectiveness in Health Care. RESULTS In general, it was found that nurses can provide cost effective care, compared to other health professionals. On the other hand, more intensive nurse staffing was associated with both better outcomes and more expensive care, and therefore cost effectiveness was not easy to assess. CONCLUSIONS Although considerable progress in economic evaluation studies has been reached in recent years, a number of methodological issues remain. In the future, nurse researchers should be more actively engaged in the design and implementation of economic evaluation studies of the services they provide.

Evaluating the clinical appropriateness of nurses’ prescribing practice: method development and findings from an expert panel analysis

Background: The number of nurses independently prescribing medicines in England is rising steadily. There had been no attempt systematically to evaluate the clinical appropriateness of nurses’ prescribing decisions. Aims: (i) To establish a method of assessing the clinical appropriateness of nurses’ prescribing decisions; (ii) to evaluate the prescribing decisions of a sample of nurses, using this method. Method: A modified version of the Medication Appropriateness Index (MAI) was developed, piloted and subsequently used by seven medical prescribing experts to rate transcripts of 12 nurse prescriber consultations selected from a larger database of 118 audio-recorded consultations collected as part of a national evaluation. Experts were also able to give written qualitative comments on each of the MAI dimensions applied to each of the consultations. Analysis: Experts’ ratings were analysed using descriptive statistics. Qualitative comments were subjected to a process of content analysis to identify themes within and across both MAI items and consultations. Results: Experts’ application of the modified MAI to transcripts of nurse prescriber consultations demonstrated validity and feasibility as a method of assessing the clinical appropriateness of nurses’ prescribing decisions. In the majority of assessments made by the expert panel, nurses’ prescribing decisions were rated as clinically appropriate on all nine items in the MAI. Conclusion: A valid and feasible method of assessing the clinical appropriateness of nurses’ prescribing practice has been developed using a modified MAI and transcripts of audio-recorded consultations sent to a panel of prescribing experts. Prescribing nurses in this study were generally considered to be making clinically appropriate prescribing decisions. This approach to measuring prescribing appropriateness could be used as part of quality assurance in routine practice, as a method of identifying continuing professional development needs, or in future research as the expansion of non-medical prescribing continues.

Evaluating prescribing competencies and standards used in nurse independent prescribers’ prescribing consultations An observation study of practice in England

Background Independent prescribing of medicines by nurses is widely considered to be part of advanced nursing practice, and occurs within an episode of patient care that can be completed independently by a nurse. Nurse prescribers therefore require the competencies necessary to manage a consultation—such as history taking and diagnostic skills—and subsequently need to decide on any appropriate medicine to be prescribed. Safe prescribing should also involve an accurate, legible and comprehensive written prescription and documentation of the consultation in the patient’s records. However, the extent to which nurse independent prescribers use prescribing competencies and standards in practice had not been researched prior to this study. Aim To describe the frequency with which nurses use a range of prescribing competencies in their prescribing consultations, in order to provide a measure of the quality and safety of nurses’ independent prescribing practices. Design and methods Across 10 case study sites, 118 nurse independent prescribers’ prescribing consultations were analysed using non-participant observation and a structured checklist of prescribing competencies. Documentary analysis was also undertaken of a) prescriptions written (n =132) by nurses and b) the record of the prescribing episode in patient records (n =118). Sample and setting 118 prescribing consultations of 14 purposively selected nurse independent prescribers working in primary and secondary care trust case study sites in England. Findings Nurse independent prescribers were issuing a prescription every 2.82 consultations; nurses used a range of assessment and diagnosis competencies in prescribing consultations, but some were employed more consistently than others; nurses almost universally wrote full and accurate prescription scripts for their patients; nurses recorded each of their prescribing consultations, but some details of the consultation and the prescription issued were not always consistently recorded in the patient records. Conclusion The findings from this observation study provide evidence about the quality and safety of nurses’ prescribing consultations in England.

One size fits all? Mixed methods evaluation of the impact of 100% single-room accommodation on staff and patient experience, safety and costs

Background and objectives There is little strong evidence relating to the impact of single-room accommodation on healthcare quality and safety. We explore the impact of all single rooms on staff and patient experience; safety outcomes; and costs. Methods Mixed methods pre/post ‘move’ comparison within four nested case study wards in a single acute hospital with 100% single rooms; quasi-experimental before-and-after study with two control hospitals; analysis of capital and operational costs associated with single rooms. Results Two-thirds of patients expressed a preference for single rooms with comfort and control outweighing any disadvantages (sense of isolation) felt by some. Patients appreciated privacy, confidentiality and flexibility for visitors afforded by single rooms. Staff perceived improvements (patient comfort and confidentiality), but single rooms were worse for visibility, surveillance, teamwork, monitoring and keeping patients safe. Staff walking distances increased significantly post move. A temporary increase of falls and medication errors in one ward was likely to be associated with the need to adjust work patterns rather than associated with single rooms per se. We found no evidence that single rooms reduced infection rates. Building an all single-room hospital can cost 5% more with higher housekeeping and cleaning costs but the difference is marginal over time. Conclusions Staff needed to adapt their working practices significantly and felt unprepared for new ways of working with potentially significant implications for the nature of teamwork in the longer term. Staff preference remained for a mix of single rooms and bays. Patients preferred single rooms.

Uneven development: comparing the indigenous health care workforce in Saudi Arabia, Bahrain and Oman.

INTRODUCTION A global shortage of health care workers has led to an increase in international migration, often from low-income ‘sending’ countries in Africa, India and the Phillipines (Lorenzo et al., 2007; Seboni, 2009; Hamada et al., in press) to high income ‘receiving’ countries including the UK and the US (Bach, 2007; Brush and Sochalski, 2007; Smith et al., 2006). In the Middle East, many countries have come to rely on international recruitment to staff their burgeoning health care facilities but they are now forced to compete with other countries in an increasingly global market. Here we explore workforce issues in three Gulf states: Saudi Arabia, Bahrain and Oman, which have had different degrees of success in recruiting indigenous health care workers.We suggest that historical, social and religious forces create challenges to women’s participation in the labour market in the Gulf states and impede local health workforce recruitment.