Julienne Meyer

Using qualitative methods in health related action research

This is the last in a series of three articles

The experience of living at home with frailty in old age: A psychosocial qualitative study

BACKGROUND With enhanced longevity, many people in late old age find themselves frail and living at home, often alone. Whilst conceptualisations vary, frailty is often used in clinical practice as a directional term, to refer to older people at particular risk of adverse health outcomes and to organise care. Investigation of the experience of being frail is a complementary and necessary addition to international research endeavours clearly to define, predict and measure frailty. Currently, there is little empirical work exploring how people over time manage being frail. OBJECTIVE The study aimed to understand the experience over time of home-dwelling older people deemed frail, in order to enhance the evidence base for person-centred approaches to frail elder care. DESIGN The study design combined psychosocial narrative approaches and psycho-dynamically informed observation. Data on the experience of 15 frail older people were collected by visiting them up to four times over 17 months. These data were analyzed using psychosocial analytical methods that combined case based in-depth staged analysis of narratives with psycho-dynamically informed interpretations of observational data. SETTING The study was carried out in the homes of the participants; all lived in a socio-economically diverse area of inner London. PARTICIPANTS 15 participants were purposively selected for living at home, being aged 85 or older and regarded as frail by a clinical multi-disciplinary intermediate care team. RESULTS The findings challenge the negative terms in which frailty in older age is viewed in the predominant models. Rather, frailty is understood in terms of potential capacity - a state of imbalance in which people experience accumulated losses whilst working to sustain and perhaps create new connections. CONCLUSION This study suggests that holding together loss and creativity is the ordinary, but nonetheless remarkable, experience of frail older people. For frail older people, the presence of others to engage with their stories, to recognise and value the daily rituals that anchor their experience and to facilitate creative connections is vital if they are to retain capacity and quality of life whilst being frail.

EXPLORING SYMPTOMS IN PATIENTS MANAGED WITHOUT DIALYSIS: A QUALITATIVE RESEARCH STUDY

Little is known about the prevalence and burden of symptoms in patients managed without dialysis. This study was the result of a larger study exploring the experiences of 30 such patients and their trajectories to death. Data were analysed relating to symptoms once the patients had been referred to a Renal Supportive Care Service based in the East End of London, UK. A high symptom prevalence was found with 30 different symptoms reported at first consultation. Widely reported symptoms impacting on daily living included breathlessness, oedema, pruritus, nausea and vomiting and pain. Findings indicate that as symptoms escalate and death approaches, some symptoms, such as fluid overload and lethargy become difficult to treat indicating that death is close. This new knowledge can help staff as they attempt to determine when the end of life is approaching in order to support and care for patients appropriately. This paper highlights a need for effective identification and management of symptoms as they arise and further exploration of the effects of these symptoms on daily living.

Developing theory and practice: Creation of a Community of Practice through Action Research produced excellence in stroke care

Much emphasis is placed on expert knowledge like evidence-based stroke guidelines, with insufficient attention paid to processes required to translate this into delivery of everyday good care. This paper highlights the worth of creating a Community of Practice (CoP) as a means to achieve this. Drawing on findings from a study conducted in 20002002 of processes involved in establishing a nationally lauded high quality Stroke Unit, it demonstrates how successful development of a new service was linked to creation of a CoP. Recent literature suggests CoPs have a key in implementing evidence-based practice; this study supports this claim whilst revealing for the first time the practical knowledge and skills required to develop this style of working. Findings indicate that participatory and democratic characteristics of Action Research are congruent with the collaborative approach required for developing a CoP. The study is an exemplar of how practitioner researchers can capture learning from changing practice, thus contributing to evidence-based healthcare with theoretical and practical knowledge. Findings are relevant to those developing stroke services globally but also to those interested in evidence-based practice.

Action research in health-care practice: Nature, present concerns and future possibilities

This paper begins by defining what is meant by action research and locates it as a form of a new paradigm of research. Next it describes some present-day concerns about its use in health-care practice and then goes on to describe a vision of research policy and practice which suggests that action research may have a greater role to play in the next millennium. In conclusion, a cautious and pragmatic approach to the use of action research is advocated which is based on rigorous, systematic and visible methods of data collection, analysis and verification of findings.

Effective health care for older people living and dying in care homes: A realist review

BackgroundCare home residents in England have variable access to health care services. There is currently no coherent policy or consensus about the best arrangements to meet these needs. The purpose of this review was to explore the evidence for how different service delivery models for care home residents support and/or improve wellbeing and health-related outcomes in older people living and dying in care homes.MethodsWe conceptualised models of health care provision to care homes as complex interventions. We used a realist review approach to develop a preliminary understanding of what supported good health care provision to care homes. We completed a scoping of the literature and interviewed National Health Service and Local Authority commissioners, providers of services to care homes, representatives from the Regulator, care home managers, residents and their families. We used these data to develop theoretical propositions to be tested in the literature to explain why an intervention may be effective in some situations and not others. We searched electronic databases and related grey literature. Finally the findings were reviewed with an external advisory group.ResultsStrategies that support and sustain relational working between care home staff and visiting health care professionals explained the observed differences in how health care interventions were accepted and embedded into care home practice. Actions that encouraged visiting health care professionals and care home staff jointly to identify, plan and implement care home appropriate protocols for care, when supported by ongoing facilitation from visiting clinicians, were important. Contextual factors such as financial incentives or sanctions, agreed protocols, clinical expertise and structured approaches to assessment and care planning could support relational working to occur, but of themselves appeared insufficient to achieve change.ConclusionHow relational working is structured between health and care home staff is key to whether health service interventions achieve health related outcomes for residents and their respective organisations. The belief that either paying clinicians to do more in care homes and/or investing in training of care home staff is sufficient for better outcomes was not supported.

Interprofessional care co-ordinators: the benefits and tensions associated with a new role in UK acute health care

While more flexible models of service delivery are being introduced in UK health and social care, little is known about the impact of new roles, particularly support worker roles, on the work of existing practitioners. This action research study aimed to explore the impact of one such new role, that of interprofessional care co-ordinators (IPCCs). The general (internal) medical service of a UK hospital uses IPCCs to provide support to the interprofessional team and, in doing so, promote efficiency of acute bed use. Using a range of methods, mainly qualitative, this action research study sought to explore the characteristics and impact of the role on interprofessional team working. While the roles flexibility, autonomy and informality contributed to success in meeting its intended objectives, these characteristics also caused some tensions with interprofessional colleagues. These benefits and tensions mirror wider issues associated with the current modernisation agenda in UK health care.

Provision of NHS generalist and specialist services to care homes in England: review of surveys

BACKGROUND The number of beds in care homes (with and without nurses) in the United Kingdom is three times greater than the number of beds in National Health Service (NHS) hospitals. Care homes are predominantly owned by a range of commercial, not-for-profit or charitable providers and their residents have high levels of disability, frailty and co-morbidity. NHS support for care home residents is very variable, and it is unclear what models of clinical support work and are cost-effective. OBJECTIVES To critically evaluate how the NHS works with care homes. METHODS A review of surveys of NHS services provided to care homes that had been completed since 2008. It included published national surveys, local surveys commissioned by Primary Care organisations, studies from charities and academic centres, grey literature identified across the nine government regions, and information from care home, primary care and other research networks. Data extraction captured forms of NHS service provision for care homes in England in terms of frequency, location, focus and purpose. RESULTS Five surveys focused primarily on general practitioner services, and 10 on specialist services to care home. Working relationships between the NHS and care homes lack structure and purpose and have generally evolved locally. There are wide variations in provision of both generalist and specialist healthcare services to care homes. Larger care home chains may take a systematic approach to both organising access to NHS generalist and specialist services, and to supplementing gaps with in-house provision. Access to dental care for care home residents appears to be particularly deficient. CONCLUSIONS Historical differences in innovation and provision of NHS services, the complexities of collaborating across different sectors (private and public, health and social care, general and mental health), and variable levels of organisation of care homes, all lead to persistent and embedded inequity in the distribution of NHS resources to this population. Clinical commissioners seeking to improve the quality of care of care home residents need to consider how best to provide fair access to health care for older people living in a care home, and to establish a specification for service delivery to this vulnerable population.

Calling for an international dialogue on quality of life in care homes

meyer j. & owen t. (2008) International Journal of Older People Nursing 3, 291-294
Calling for an international dialogue on quality of life in care homes.

Relationships, expertise, incentives, and governance: Supporting care home residents' access to health care: An interview study from England

Objectives To explore what commissioners of care, regulators, providers, and care home residents in England identify as the key mechanisms or components of different service delivery models that support the provision of National Health Service (NHS) provision to independent care homes. Methods Qualitative, semistructured interviews with a purposive sample of people with direct experience of commissioning, providing, and regulating health care provision in care homes and care home residents. Data from interviews were augmented by a secondary analysis of previous interviews with care home residents on their personal experience of and priorities for access to health care. Analysis was framed by the assumptions of realist evaluation and drew on the constant comparative method to identify key themes about what is required to achieve quality health care provision to care homes and resident health. Results Participants identified 3 overlapping approaches to the provision of NHS that they believed supported access to health care for older people in care homes: (1) Investment in relational working that fostered continuity and shared learning between visiting NHS staff and care home staff, (2) the provision of age-appropriate clinical services, and (3) governance arrangements that used contractual and financial incentives to specify a minimum service that care homes should receive. Conclusion The 3 approaches, and how they were typified as working, provide a rich picture of the stakeholder perspectives and the underlying assumptions about how service delivery models should work with care homes. The findings inform how evidence on effective working in care homes will be interrogated to identify how different approaches, or specifically key elements of those approaches, achieve different health-related outcomes in different situations for residents and associated health and social care organizations.