Sally Brearley

Getting ready for user involvement in a systematic review.

Objective  This paper aims to support the critical development of user involvement in systematic reviews by explaining some of the theoretical, ethical and practical issues entailed in ‘getting ready’ for user involvement.

Physician associates and GPs in primary care: a comparison

Background Physician associates [PAs] (also known as physician assistants) are new to the NHS and there is little evidence concerning their contribution in general practice. Aim This study aimed to compare outcomes and costs of same-day requested consultations by PAs with those of GPs. Design and setting An observational study of 2086 patient records presenting at same-day appointments in 12 general practices in England. Method PA consultations were compared with those of GPs. Primary outcome was re-consultation within 14 days for the same or linked problem. Secondary outcomes were processes of care. Results There were no significant differences in the rates of re-consultation (rate ratio 1.24, 95% confidence interval [CI] = 0.86 to 1.79, P = 0.25). There were no differences in rates of diagnostic tests ordered (1.08, 95% CI = 0.89 to 1.30, P = 0.44), referrals (0.95, 95% CI = 0.63 to 1.43, P = 0.80), prescriptions issued (1.16, 95% CI = 0.87 to 1.53, P = 0.31), or patient satisfaction (1.00, 95% CI = 0.42 to 2.36, P = 0.99). Records of initial consultations of 79.2% (n = 145) of PAs and 48.3% (n = 99) of GPs were judged appropriate by independent GPs (P<0.001). The adjusted average PA consultation was 5.8 minutes longer than the GP consultation (95% CI = 2.46 to 7.1; P<0.001); cost per consultation was GBP £6.22, (US

Handbook of service user involvement in nursing and healthcare research

10.15) lower (95% CI = −7.61 to −2.46, P<0.001). Conclusion The processes and outcomes of PA and GP consultations for same-day appointment patients are similar at a lower consultation cost. PAs offer a potentially acceptable and efficient addition to the general practice workforce.

People and Teams Matter in Organizational Change: Professionals’ and Managers’ Experiences of Changing Governance and Incentives in Primary Care

Service USer involvemenT in nUrSing & HealTHcare reSearcH Handbook of Service USer involvemenT in nUrSing & HealTHcare reSearcH H a n d bo o k o f er v ic e U er in v o lv em en T in n U r in g & H ea TH c a r e r eSea r c H Elizabeth Morrow annette boaz Sally brearley fiona Ross This book fills an important niche in the market providing practical expert advice on service user (patients, carers and the public) involvement in nursing and healthcare research. an invaluable guide for anyone working or involved in nursing and healthcare research, this book provides a step-by-step guide to the principles and process of involvement, including understanding the rationale for involvement, designing involvement, working with service users, and evaluating what has been achieved.

Nurse case management and general practice: implications for GP consortia

OBJECTIVES To explore the experiences of governance and incentives during organizational change for managers and clinical staff. STUDY SETTING Three primary care settings in England in 2006-2008. STUDY DESIGN Data collection involved three group interviews with 32 service users, individual interviews with 32 managers, and 56 frontline professionals in three sites. The Realistic Evaluation framework was used in analysis to examine the effects of new policies and their implementation. PRINCIPAL FINDINGS Integrating new interprofessional teams to work effectively is a slow process, especially if structures in place do not acknowledge the painful feelings involved in change and do not support staff during periods of uncertainty. CONCLUSIONS Eliciting multiple perspectives, often dependent on individual occupational positioning or place in new team configurations, illuminates the need to incorporate the emotional as well as technocratic and system factors when implementing change. Some suggestions are made for facilitating change in health care systems. These are discussed in the context of similar health care reform initiatives in the United States.

Physician assistants in English primary care teams: A survey.

BACKGROUND Case management is widely promoted as a means of ensuring continuity of care, improving patient outcomes, and achieving efficient management of resources. Community matrons have been introduced recently as specialists in the case management of patients with multiple complex problems. AIM To understand how nurse case managers are seen by GPs and NHS managers. SETTING (1) Telephone interviews with 41 community nurse managers recruited from 10 English strategic health authorities and two Welsh health boards; (2) face-to-face interviews with 12 nurse case managers, 12 GPs and five NHS community service managers in three study sites with different population and practitioner characteristics. METHOD Semi-structured individual interviews, by telephone or face to face. RESULTS Attitudes among GPs to nurse case managers were shaped by perceptions of the quality of community nursing on the one hand and the perceived benefit of case management as a method of reducing hospital use on the other. The dominant mood was scepticism about the ability of nurse case managers to reduce hospital admissions. Community matrons were seen as staff who were imposed on local health services, sometimes to detrimental effect. CONCLUSION The introduction of case management and community matrons may disrupt existing communities of practice and be perceived negatively, at least in areas where good working relationships between nurses and GPs have developed. Commissioners should be aware of the potential resistance to changes in skill mix and role in nursing services, and promote innovation in ways that minimise disruption to functional communities of practice.

Doing More with Less in Health Care: Findings from a Multi-Method Study of Decommissioning in the English National Health Service

Ensuring that health care teams have a mix of skilled professionals to meet patient need, safely and effectively, is a priority in all health services. The United Kingdom, like a number of other countries, have been exploring the contribution physician assistants, who are well established in the United States of America, can make to health care teams including primary care. This study investigated the employment of physician assistants in English primary care and their contribution through an electronic, self report, survey. Sixteen physician assistants responded, who were working in a variety of types of general practice teams. A range of activities were reported but the greatest proportion of their time was described as seeing patients in booked surgery appointments for same day/urgent appointments. The scope of the survey was limited and questions remain as to patient and professional responses to a new professional group within English primary care.

What aspects of intentional rounding work in hospital wards, for whom and in what circumstances? A realist evaluation protocol

In the context of an austere financial climate, local health care budget holders are increasingly expected to make and enact decisions to decommission (reduce or stop providing) services. However, little is currently known about the experiences of those seeking to decommission. This paper presents the first national study of decommissioning in the English National Health Service drawing on multiple methods, including: an interview-based review of the contemporary policy landscape of health care decommissioning; a national online survey of commissioners of health care services responsible for managing and enacting budget allocation decisions locally; and illustrative vignettes provided by those who have led decommissioning activities. Findings are presented and discussed in relation to four themes: national-local relationships; organisational capacity and resources for decommissioning; the extent and nature of decommissioning; and intended outcomes of decommissioning. Whilst it is unlikely that local commissioners will be able to ‘successfully’ implement decommissioning decisions unless aspects of engagement, local context and outcomes are addressed, it remains unclear what ‘success’ looks like in terms of a decommissioning process.

Realist synthesis of intentional rounding in hospital wards: exploring the evidence of what works, for whom, in what circumstances and why

Introduction Intentional rounding (IR) is a structured process whereby nurses in hospitals carry out regular checks, usually hourly, with individual patients using a standardised protocol to address issues of positioning, pain, personal needs and placement of items. The widespread implementation of IR across the UK has been driven by the recommendations of the Francis Inquiry although empirical evidence of its effectiveness is poor. This paper presents a protocol of a multimethod study using a realist evaluation approach to investigate the impact and effectiveness of IR in hospital wards on the organisation, delivery and experience of care from the perspective of patients, their family members and staff. Methods and analysis The study will be conducted in four phases. Phase 1: theory development using realist synthesis to generate hypotheses about what the mechanisms of IR may be, what particular groups may benefit most or least and what contextual factors might be important to its success or failure which will be tested in subsequent phases of the study. Phase 2: a national survey of all NHS acute trusts to explore how IR is implemented and supported across England. Phase 3: case studies to explore how IR is implemented ‘on the ground’, including individual interviews with patients, family members and staff, non-participant observation, retrieval of routinely collected patient outcomes and cost analysis. Phase 4: accumulative data analysis across the phases to scrutinise data for patterns of congruence and discordance and develop an overall evaluation of what aspects of IR work, for whom and in what circumstances. Ethics and dissemination The study has been approved by NHS South East Coast—Surrey Research Ethics Committee. Findings will be published in a wide range of outputs targeted at key audiences, including patient and carer organisations, nursing staff and healthcare managers.

Taking data seriously: the value of actor-network theory in rethinking patient experience data:

Background Intentional rounding (IR) is a structured process whereby nurses conduct one to two hourly checks with every patient using a standardised protocol. Objective A realist synthesis of the evidence on IR was undertaken to develop IR programme theories of what works, for whom, in what circumstances and why. Methods A three-stage literature search and a stakeholder consultation event was completed. A variety of sources were searched, including AMED, CINAHL, MEDLINE, PsycINFO, HMIC, Google and Google Scholar, for published and unpublished literature. In line with realist synthesis methodology, each study’s ‘fitness for purpose’ was assessed by considering its relevance and rigour. Results A total of 44 papers met the inclusion criteria. To make the programme theories underpinning IR explicit, we identified eight a priori propositions: (1) when implemented in a comprehensive and consistent way, IR improves healthcare quality and satisfaction, and reduces potential harms; (2) embedding IR into daily routine practice gives nurses ‘allocated time to care’; (3) documenting IR checks increases accountability and raises fundamental standards of care; (4) when workload and staffing levels permit, more frequent nurse–patient contact improves relationships and increases awareness of patient comfort and safety needs; (5) increasing time when nurses are in the direct vicinity of patients promotes vigilance, provides reassurance and reduces potential harms; (6) more frequent nurse–patient contact enables nurses to anticipate patient needs and take pre-emptive action; (7) IR documentation facilitates teamwork and communication; and (8) IR empowers patients to ask for what they need to maintain their comfort and well-being. Given the limited evidence base, further research is needed to test and further refine these propositions. Conclusions Despite widespread use of IR, this paper highlights the paradox that there is ambiguity surrounding its purpose and limited evidence of how it works in practice.