Sally Corbett

Reconceptualizing models of delirium education: findings of a Grounded Theory study

BACKGROUND Effectiveness of educational interventions targeted at improving delirium care is limited by implementation barriers. Studying factors which shape learning needs can overcome these knowledge transfer barriers. This in-depth qualitative study explores learning needs of hospital staff relating to care needs of the confused older patients. METHODS Fifteen research participants from across the healthcare spectrum working within an acute care setting were interviewed. Five focus groups were undertaken with patients, carers, and mental health specialists. A Grounded Theory methodology was adopted and data were analyzed thematically in parallel to collection until theoretical saturation was reached. RESULTS Eight categories of practice gap emerged: ownership of the confused patient, negative attitudes, lack of understanding of how frightened the patient is in hospital, carer partnerships, person-centered care, communication, recognition of cognitive impairment and specific clinical needs (e.g. capacity assessments). Conceptually, the learning needs were found to be hierarchically related. Moreover, a vicious circle relating to the core learning needs of ownership, attitudes and patients fear emerged. A patient with delirium may be frightened in an alien environment and then negatively labeled by staff who subsequently wish for their removal, thereby worsening the patients fear. DISCUSSION These findings reconceptualize delirium education approaches suggesting a need to focus interventions on core level practice gaps. This fresh perspective on education, away from disease-based delirium knowledge toward work-based patient, team and practice knowledge, could lead to more effective educational strategies to improve delirium care.

Developing effective educational approaches for Liaison Old Age Psychiatry teams: a literature review of the learning needs of hospital staff in relation to managing the confused older patient.

BACKGROUND Deficiencies in the knowledge, skills and attitudes of all healthcare professionals working within the general hospital contribute towards the suboptimal care of older hospitalized patients with confusion. In the U.K., policy dictates that Liaison Old Age Psychiatry teams deliver effective education to general hospital clinical staff. The purpose of this paper is to review the literature concerning the learning needs of healthcare professionals in relation to managing confusion in the older patient in order to inform effective educational approaches for Liaison Old Age Psychiatry teams. METHODS A broad range of medical and educational databases were searched. Identified English language studies were selected for further analysis if they had a specific educational focus in the hospital setting and then further subdivided into intervention and naturalistic studies. The impact of intervention studies was evaluated by Kirkpatricks system. Learning needs, as determined from the naturalistic studies, were mapped to identify themes. RESULTS 13 intervention studies were identified. Despite a high level of effectiveness for educational interventions, it was unclear what the active components were. A further 23 naturalistic studies were identified; their findings focused on knowledge gaps, diagnostic behaviors and experiences, attitudes and training issues. Few studies specifically researched learning needs or the educational role of liaison teams. Conspicuous by its absence was reference to relevant educational theories. CONCLUSIONS The findings of this review can be incorporated in the planning of local curricula by Liaison Teams in order to design educational strategies. There is a need for further research, especially studies exploring the learning needs of all healthcare professionals.

Describing clinical teachers' characteristics and behaviours using critical incidents and repertory grids.

Context  Completion of a rating questionnaire is the method used most frequently to evaluate a teachers performance. Questionnaires that largely assess ‘high‐inference’ teaching characteristics, such as ‘enthusiasm’ and ‘friendliness’, require the observer to make a judgement about the teacher but do not describe what the teacher actually did and so have limited use in providing feedback. Measures of ‘low‐inference’ teaching behaviours (i.e. those that are concrete and observable), such as frequency, amount or types of verbal interaction, do not demonstrate how these are linked to good teaching.

Illness perceptions in people with acute bacterial gastro-enteritis.

Functional gastro-intestinal disorders (FGID) like irritable bowel syndrome (IBS) are common and can develop after gastroenteritis. Illness representations may be important influences on the development of post-infectious FGIDs. Here, we studied both the relationship between prior chronic symptoms (FGIDs) and illness perception during an acute illness (bacterial gastro-enteritis) as well as the relationship between illness perception during an acute illness (bacterial gastro-enteritis) and the subsequent development of chronic abdominal symptoms. Two hundred and seventeen people with recent gastro-enteritis completed a questionnaire asking about gut symptoms consistent with a diagnosis of IBS, functional dyspepsia or functional diarrhoea and the Illness Perception Questionnaire. Those without a prior FGID were followed up and completed a similar gut questionnaire at six months. People with a prior FGID had significantly more symptoms and scored significantly higher on the timeline and consequence scores than those without. People who developed a FGID had a non-significantly higher number of symptoms and higher consequence and timeline scores than those who did not. Neither comparative group differed in the control/cure scores or causation scores. The implications of the findings are discussed.

Deconstructing dementia and delirium hospital practice: using cultural historical activity theory to inform education approaches

Older patients with dementia and delirium receive suboptimal hospital care. Policy calls for more effective education to address this though there is little consensus on what this entails. The purpose of this clarification study is to explore how practice gaps are constructed in relation to managing the confused hospitalised older patient. The intent is to inform educational processes in the work-place beyond traditional approaches such as training. Adopting grounded theory as a research method and working within a social constructionist paradigm we explored the practice gaps of 15 healthcare professionals by interview and conducted five focus groups with patients, carers and Liaison mental health professionals. Data were thematically analysed by constant comparison and theoretical sampling was undertaken until saturation reached. Categories were identified and pragmatic concepts developed grounded within the data. Findings were then further analysed using cultural historical activity theory as a deductive lens. Practice gaps in relation to managing the confused older patient are determined by factors operating at individual (knowledge and skill gaps, personal philosophy, task based practice), team (leadership, time and ward environmental factors) and organisational (power relationships, dominance of medical model, fragmentation of care services) levels. Conceptually, practice appeared to be influenced by socio-cultural ward factors and compounded by a failure to join up existing “patient” knowledge amongst professionals. Applying cultural historical activity theory to further illuminate the findings, the central object is defined as learning about the patient and the mediating artifacts are the care relationships. The overarching medical dominance emerges as an important cultural historical factor at play and staff rules and divisions of labour are exposed. Lastly key contradictions and tensions in the system that work against learning about the patient are identified. Cultural historical activity theory can be used to advance understanding of practice gaps in order to develop a broader transformative approach to dementia and delirium practice and education. Structural changes at an individual, team and systems level resulting from this novel understanding of practice complexity are proposed. Contradictions can be used as foci for expansive learning. Lastly, interprofessional education (formal and informal) is advocated to further knotwork and improve the care of the older confused patient.

Learning about the Patient: an innovative interprofessional dementia and delirium education programme

Patients with confusion (delirium and dementia) in the general hospital environment are more likely to have negative health outcomes compared with other patients. Poor team and individual practice is partly responsible for this, and a training gap has been described. We report an innovative interprofessional teaching intervention that is founded on robust medical education research findings, and has the potential to improve staff practice.

Contemporary experience of stress in UK foundation level doctors.

1.How the doctor appraises a stressful situation is crucial 2.Participants were interviewed about workplace stressors, how they coped, and how stress affected them 3.Doctors identified a lack of available senior support as a significant mediator of stress 4.A culture change is needed, where stress is not stigmatised but recognised as a facet of learning

Early Supported Discharge/Hospital At Home For Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Review and Meta-Analysis.

abstract A systematic review and meta-analysis was performed to assess the safety, efficacy and cost of Early Supported Discharge (ESD) and Hospital at Home (HAH) compared to Usual Care (UC) for patients with acute exacerbation of COPD (AECOPD). The structure of ESD/HAH schemes was reviewed, and analyses performed assuming return to hospital during the acute period (prior to discharge from home treatment) was, and was not, considered a readmission. The pre-defined search strategy completed in November 2014 included electronic databases (Medline, Embase, Amed, BNI, Cinahl and HMIC), libraries, current trials registers, national organisations, key respiratory journals, key author contact and grey literature. Randomised controlled trials (RCTs) comparing ESD/HAH to UC in patients admitted with AECOPD, or attending the emergency department and triaged for admission, were included. Outcome measures were mortality, all-cause readmissions to 6 months and cost. Eight RCTs were identified; seven reported mortality and readmissions. The structure of ESD/HAH schemes, particularly selection criteria applied and level of support provided, varied considerably. Compared to UC, ESD/HAH showed a trend towards lower mortality (RRMH = 0.66; 95% CI 0.40–1.09, p = 0.10). If return to hospital during the acute period was not considered a readmission, ESD/HAH was associated with fewer readmissions (RRMH = 0.74, 95% CI: 0.60–0.90, p = 0.003), but if considered a readmission, the benefit was lost (RRMH = 0.84; 95% CI 0.69–1.01, p = 0.07). Costs were lower for ESD/HAH than UC. ESD/HAH is safe in selected patients with an AECOPD. Further research is required to define optimal criteria to guide patient selection and models of care.

Developing a long‐term condition's information service in collaboration with third sector organisations

BACKGROUND People with long-term conditions need to be signposted to high quality information and advice to understand and manage their condition. Information seeking tools combined with third sector information could help address their information needs. OBJECTIVE To describe the development and implementation of an information service for people living with long-term conditions at one NHS acute trust in the Northeast of England. METHODS An information service was trialled using bespoke information models for three long-term conditions in collaboration with third sector organisations. These guided people to relevant, timely and reliable information. Both clinician and service user questionnaires were used to evaluate satisfaction with the service. RESULTS Appropriately designed information models can be used interchangeably across all services. Between 75% and 91% of users agreed that they were satisfied with various aspects of the service. Generally, users received relevant, understandable and high quality information at the right time. Nearly all health professionals (94-100%) felt the service was accessible, provided high quality information and did not significantly impact on their consultation time. CONCLUSION The developed information service was well received by service users and health professionals. Specifically, the use of information prescriptions and menus facilitated access to information for people with long-term conditions.

A reflective process used to develop a health professional led colitis self‐management programme

People with colitis experiencing poor quality of life and attending hospital out‐patients were invited to a self‐management course, based on patient‐centred and experiential learning philosophies, with self‐efficacy as the model for health behaviour change. The course was facilitated by a health psychologist and gastro‐intestinal (GI) specialist research nurse and consisted of six sessions each lasting two‐and‐a‐half hours. Twelve complete courses were delivered at six hospital sites. After each session reflections were recorded by the facilitators in a diary. For two of these courses a reflective diary was also kept by a participant observer. After the completion of these two courses, the facilitator and participant diaries were analysed together using the framework method allowing critical reflection and perspective transformation. There was concordance between diaries about events and problems, but sometimes perspectives and interpretation differed leading to insights about the role of the health professional educator.