Juliet MacArthur

Learning Disability Liaison Nursing Services in south-east Scotland: a mixed-methods impact and outcome study.

BACKGROUND There have been significant concerns about the care and treatment of people with intellectual disabilities (ID) when attending general hospitals, which have led to inquiries that highlight service and systems failures. One response has been the development of Learning Disability Liaison Nursing (LDLN) Services across the UK that aim to ensure that additional, specialist support is available for patients, their carers and general healthcare professionals. METHODS A mixed-methods study to investigate the impact of LDLN Services across four Scottish NHS boards was undertaken. In total, 323 referrals made over 18 months were analysed along with qualitative data drawn from interviews and focus groups with a sample of 85 participants including patients with ID (n = 5), carers (n = 16), primary care healthcare professionals (n = 39) and general hospital professionals (n = 19) and learning disability liaison nurses (n = 6). RESULTS The referral patterns to the four liaison nursing services closely matched the known health needs of adults with ID, with common admissions being due to neurological, respiratory and gastrointestinal issues. The LDLN role was seen to be complex and impacted on three key areas: (i) clinical patient care; (ii) education and practice development; and (iii) strategic organisational developments. Specific patient outcomes were linked to issues relating to capacity and consent to treatment, fostering person-centred adjustments to care, augmenting communication and the liaison nurses acting as positive role models and ambassadors for people with ID. CONCLUSIONS The LDLN Services were valued by stakeholders by achieving person-centred outcomes. With their expert knowledge and skills, the liaison nurses had an important role in developing effective systems and processes within general hospital settings. The outcomes highlight the importance of supporting and promoting LDLN Services and the challenges in delivering the multifaceted elements of the role. There is a need to take account of the complex and multidimensional nature of the LDLN role and the possible tensions between achieving clinical outcomes, education and practice developments and organisational strategic initiatives.

Equality and access to general health care for people with learning disabilities: reality or rhetoric?

This paper contributes to the growing debate relating to meeting the health needs of people with learning disabilities when accessing general health services. It is set within the context of a population that has historically experienced poor care and treatment. This is despite legislation to protect vulnerable groups and clear government policies setting out the need to support people with learning disabilities to lead full and equal lives, providing additional support when needed. The evidence surrounding the health needs of people with learning disabilities is presented, along with the resultant implications for health services. This is set alongside emerging evidence that seeks to address the shortfalls and failings that, in some cases, are known to have contributed to premature and often needless death. Particular focus is given to a study that has evaluated the impact of learning disability liaison nursing services that have been developed to support the care of people with a learning disability to access hospital services. This paper stresses the need to further develop and evolve the research evidence base on what works to improve the health of people with learning disabilities, enhance their experience of care and minimise the risk of harm.

New institutionalisation following acute hospital admission: a retrospective cohort study

Abstract Background institutionalisation following acute hospital admission is common and yet poorly described, with policy documents advising against this transition. Objective to characterise the individuals admitted to a care home on discharge from an acute hospital admission and to describe their assessment. Design and setting a retrospective cohort study of people admitted to a single large Scottish teaching hospital. Subjects 100 individuals admitted to the acute hospital from home and discharged to a care home. Methods a single researcher extracted data from ward-based case notes. Results people discharged to care homes were predominantly female (62%), widowed (52%) older adults (mean 83.6 years) who lived alone (67%). About 95% had a diagnosed cognitive disorder or evidence of cognitive impairment. One-third of cases of delirium were unrecognised. Hospital stays were long (median 78.5 days; range 14–231 days) and transfers between settings were common. Family request, dementia, mobility, falls risk and behavioural concerns were the commonest reasons for the decision to admit to a care home. About 55% were in the acute hospital when the decision for a care home was made and 44% of that group were discharged directly from the acute hospital. Conclusions care home admission from hospital is common and yet there are no established standards to support best practice. Decisions should involve the whole multidisciplinary team in partnership with patients and families. Documentation of assessment in the case notes is variable. We advocate the development of interdisciplinary standards to support the assessment of this vulnerable and complex group of patients.

Embedding compassionate care in local NHS practice: Developing a conceptual model through realistic evaluation

The aim of this study was to critically analyse the impact of the ‘Leadership in Compassionate Care Programme’ and offer a conceptual model of factors that can embed compassionate care in contemporary health care environments. This three-year initiative (2008–2011) was designed to embed compassionate care in both practice and pre-registration education. Using a realistic evaluation approach this longitudinal qualitative study involved data collection in eight participating wards. The ‘level of adoption’ of the Programme varied across the wards, which pointed to key context and mechanisms that were influential in embedding compassionate care. Contextual factors that promoted adoption of the Programme were stability, support and leadership. The most important mechanisms were appreciative inquiry coupled with skilled facilitation. Powerful practice development techniques focused on articulating and demonstrating values; giving patients, relatives and staff a voice to express their experiences and emotions; and instituting effective feedback mechanisms. In the high adopting wards the main outcomes included personalisation of patient care, an increased sense of involvement for relatives and ‘caring conversations’ becoming an accepted part of working practice. Embedding and sustaining compassionate care demands strategic vision and investment in a local infrastructure that supports relationship-centred care, practice development and effective leadership at all levels.

Special Collection Editorial: Clinical Academic Careers

Editing the Journal of Research in Nursing’s first online collection of published papers with an accompanying editorial (See: http://jrn.sagepub.com/site/virtual_special_issue/ specialcollectionsclinicalcareers2.xhtml) has presented the opportunity to reflect on the progress of clinical academic careers in nursing and midwifery over nearly 20 years and deliberate key messages. My professional interest stems from a practice-based role to forge a clinical academic career in one Health Board in Scotland. What is evident from the selected papers is that there has been a clear shift in the United Kingdom (UK) in emphasis from nursing research being the province of a comparatively small number of academic institutions to emergent models based on partnerships centred on the improvement of patient outcomes through the conduct and implementation of applied research (Gerrish, 2010; Latter et al., 2009). There is no doubt that publication of the Finch Report (UKCRC, 2007) with its recommendations for clinical academic research training and career progression has presented a watershed in this analysis. What is important to recognise is that the Dame Janet Finch’s principal driver was not clinical academic careers per se, but the ‘urgent’ need for an evidence base that would focus on prevention, selfmanagement and the management of chronic conditions in the community (Finch, 2009: 103). More recently, MacLeod Clarke (2014) reinforced this message in her call for clinical academic leadership focused on moving the discipline forward through strengthening the role of nursing interventions in improving outcomes and enhancing patient benefit. Back in 1997, while in the role of a Regional Nurse Director, Christine Beasley, the former Chief Nursing Officer for England, looked towards the new millennium as presenting an opportunity for nursing research. This was in response to the recent publication of the Culyer Report (NHS Research & Development Task Force, 1994) with its focus on the way that funds were allocated for research and development. She presented an example of a strategic approach to building nursing research capacity that in many ways mirrored the future model proposed in the Finch Report (UKCRC, 2007), along with recognition of the need for a greater focus on primary care research. Her concluding remarks continue to

Embedding Compassionate Care: A Leadership Programme in the National Health Service in Scotland

This chapter presents the findings from a 3-year research study examining the impact of the Leadership in Compassionate Care (LCC) Programme undertaken in Scotland. The study led to the development of a conceptual model for strengthening organisational capacity for the delivery of compassionate care. This model recognises compassionate care as focussing on meeting the needs of patients, relatives and staff. The study revealed that embedding and sustaining compassionate care were strongly influenced by work environment and organisational context; these two elements are examined in terms of their impact on the sustained adoption of the LCC Programme’s aims. Findings suggest that establishing a sustained culture of compassionate care demands strategic vision and investment in a local infrastructure that supports relationship-centred care, practice development and effective leadership at all levels. The most influential aspects of organisational context were strategic buy-in, leadership style, support from charge nurses and clinical nurse managers and an appreciative facilitation approach by the LCC Programme team.

Board editorial: Care homes as a setting for research and policy development:

In many countries around the world, there are increasingly more care home than acute hospital beds. In the United Kingdom (UK) the figure is three times higher (Laing, 2015). That is why this focus edition, examining the work of care homes, is of particular importance to nursing and makes the need for high quality research compelling. Gone are the days when older people admitted themselves for companionship. In care homes, both those with and without on-site nursing, residents are considerably frailer on admission than 10 years ago, and often have significant palliative care needs from advanced, progressive, incurable disease(s) (Kinley et al., 2014). Four inter-related themes have emerged from international contributions from Austria, Australia, England, the Netherlands, Norway, Scotland and Spain. These are:

New care home admission following hospitalisation: how do older people, families and professionals make decisions about discharge destination? A case-study narrative analysis

AIMS AND OBJECTIVES To gain an in-depth understanding of the decision-making processes involved in the discharge of older people admitted to hospital from home and discharged to a care home, as described in the case records. BACKGROUND The decision for an older person to move into a care home is significant and life-changing. The discharge planning literature for older people highlights the integral role of nurses in supporting and facilitating effective discharge. However, little research has been undertaken to explore the experiences of those discharged from hospital to a care home or the processes involved in decision-making. METHOD A purposive sample of 10 cases was selected from a cohort of 100 individuals admitted to hospital from home and discharged to a care home. Cases were selected to highlight important personal, relational and structural factors thought to affect the decision-making process. Narrative case studies were created and were thematically analysed to explore the perspectives of each stakeholder group and the conceptualisations of risk which influenced decision-making. RESULTS Care home discharge decision-making is a complex process involving stakeholders with a range of expertise, experience and perspectives. Decisions take time and considerable involvement of families and the multidisciplinary team. There were significant deficits in documentation which limit the understanding of the process and the patients voice is often absent from case records. The experiences of older people, families and multidisciplinary team members making care home decisions in the hospital setting require further exploration to identify and define best practice. IMPLICATIONS FOR PRACTICE Nurses have a critical role in the involvement of older people making discharge decisions in hospital, improved documentation of the patients voice is essential. Health and social care systems must allow older people time to make significant decisions about their living arrangements, adapting to changing medical and social needs.

Review: ‘Gaps, mishaps and overlaps’. Nursing documentation: How does it affect care?

The reviewed study, a small-scale study into nursing documentation in an acute NHS hospital in England, raises serious issues for policy, practice and the wider profession in terms of the effectiveness of existing systems, efficient use of the nursing resource and accountability of individual practitioners. The title ‘gaps, mishaps and overlaps’ is a wellconstructed summary of the key findings and has the potential to frame some fundamental questions to shape nurses’ thinking about their professional responsibilities for record keeping (Nursing and Midwifery Council, 2009). The need for improved communication, care planning and record keeping are regular themes in investigations (Parliamentary and Health Service Ombudsman, 2015; Scottish Public Service Ombudsman, 2016) and inquiries (Francis, 2013) into poor practice. A consistent theme is of a failure of record keeping in terms of them being contemporaneous, accurate and full. The potential link between poor documentation and the quality of care delivery is exemplified in the findings from one Ombudsman’s report into failure of care for a patient with dementia:

Review: Developing the delirium care pathways

Delirium in older people is an issue of international relevance and one that has a well established evidence base in terms of prevention, recognition, diagnosis and management. As the authors rightly state, despite this, under-recognition or misdiagnosis leads to continued high incidence rates, which has significant consequences for patients, families and healthcare providers. The background to this initiative echoes other examples of poor implementation of evidence, despite the publication of guidelines, toolkits and care pathways – a key example of this being pre-operative fasting (Crenshaw, 2011). What is striking in the premise to this paper is the fact that the original clinical practice guideline for the management of delirium in older people (Clinical Epidemiology and Health Service Evaluation Unit, 2006) was 121 pages long, which the authors claim to be a key issue in poor local implementation. The fact that the Australian Commonwealth Government recognised this limitation should be seen as a positive response from policy makers, along with their stipulation for the development of three delirium care pathways: community, acute care and care home. The key strength of the reviewed study is the detailed outline of the iterative and inductive process undertaken and the emphasis on a collaborative approach between the Ministry of Health and an academic institution. While the focus here is delirium, the process adopted carries relevance for a wide range of conditions. The key elements of success point clearly towards the importance of appropriate stakeholder engagement during all three stages of the project. From a policy perspective the reviewed study gives insight into the role of government in influencing published guidelines. While the project team produced their own final version, the Ministry of Health, as project sponsor, made the final decision to retain a generic nature within the pathways that would allow for some flexibility in local implementation, for example through not specifying a single delirium assessment tool. This stands in contrast to the approach taken in some other countries, for example in Scotland the improving the