Sharon Hamilton

Assessing organisational readiness for change: use of diagnostic analysis prior to the implementation of a multidisciplinary assessment for acute stroke care

BackgroundAchieving evidence-based practice in health care is integral to the drive for quality improvement in the National Health Service in the UK. Encapsulated within this policy agenda are challenges inherent in leading and managing organisational change. Not least of these is the need to change the behaviours of individuals and groups in order to embed new practices. Such changes are set within a context of organisational culture that can present a number of barriers and facilitators to change. Diagnostic analysis has been recommended as a precursor to the implementation of change to enable such barriers and facilitators to be identified and a targeted implementation strategy developed. Although diagnostic analysis is recommended, there is a paucity of advice on appropriate methods to use. This paper addresses the paucity and builds on previous work by recommending a mixed method approach to diagnostic analysis comprising both quantitative and qualitative data.MethodsTwenty staff members with strategic accountability for stroke care were purposively sampled to take part in semi-structured interviews. Six recently discharged patients were also interviewed. Focus groups were conducted with one group of registered ward-based nurses (n = 5) and three specialist registrars (n = 3) purposively selected for their interest in stroke care. All professional staff on the study wards were sent the Team Climate Inventory questionnaire (n = 206). This elicited a response rate of 72% (n = 148).ResultsA number of facilitators for change were identified, including stakeholder support, organisational commitment to education, strong team climate in some teams, exemplars of past successful organisational change, and positive working environments. A number of barriers were also identified, including: unidisciplinary assessment/recording practices, varying in structure and evidence-base; weak team climate in some teams; negative exemplars of organisational change; and uncertainty created by impending organisational merger.ConclusionThis study built on previous research by proposing a mixed method approach for diagnostic analysis. The combination of qualitative and quantitative data were able to capture multiple perspectives on barriers and facilitators to change. These data informed the tailoring of the implementation strategy to the specific needs of the Trust.

A qualitative study of patients’ perceptions and priorities when living with primary frozen shoulder

Objectives To elucidate the experiences and perceptions of people living with primary frozen shoulder and their priorities for treatment. Design Qualitative study design using semistructured interviews. Setting General practitioner (GP) and musculoskeletal clinics in primary and secondary care in one National Health Service Trust in England. Participants 12 patients diagnosed with primary frozen shoulder were purposively recruited from a GPs surgery, community clinics and hospital clinics. Recruitment targeted the phases of frozen shoulder: pain predominant (n=5), stiffness predominant (n=4) and residual stiffness predominant following hospital treatment (n=2). One participant dropped out. Inclusion criteria: adult, male and female patients of any age, attending the clinics, who had been diagnosed with primary frozen shoulder. Results The most important experiential themes identified by participants were: pain which was severe as well as inexplicable; inconvenience/disability arising from increasing restriction of movement (due to pain initially, gradually giving way to stiffness); confusion/anxiety associated with delay in diagnosis and uncertainty about the implications for the future; and treatment-related aspects. Participants not directly referred to a specialist (whether physiotherapist, physician or surgeon) wanted a faster, better-defined care pathway. Specialist consultation brought more definitive diagnosis, relief from anxiety and usually self-rated improvement. The main treatment priority was improved function, though there was recognition that this might be facilitated by relief of pain or stiffness. There was a general lack of information from clinicians about the condition with over-reliance on verbal communication and very little written information. Conclusions Awareness of frozen shoulder should be increased among non-specialists and the best available information made accessible for patients. Our results also highlight the importance of patient participation in frozen shoulder research.

Nursing Interventions for Improving Nutritional Status and Outcomes of Stroke Patients: Descriptive Reviews of Processes and Outcomes

BACKGROUND Stroke produces many effects that impact eating. Nutrition is fundamental for recovery and rehabilitation, but the nursing nutritional role and associated outcomes have not been delineated. AIMS (1) To identify nursing interventions intended to improve nutritional status and related outcomes of stroke survivors, and (2) To examine the outcomes of identified nursing interventions on nutrition-related outcomes, including dietary intake, functional status, complications, activities of daily living, mortality, and quality of life for stroke survivors. METHODS A modified version of Cochrane literature searching and review methods was used to identify studies that described and evaluated nursing nutritional interventions for adult stroke patients in hospital and community settings. A minimum of 10 years content of seven databases and nine journals was searched to March 2011. Findings were presented descriptively. RESULTS In total 27 papers from 26 studies were included: 5 randomized controlled trials, 5 clinical trials, 6 quasi-experiments, 4 case studies, and 6 qualitative/observational studies. Stroke nursing nutritional care encompassed screening of nutritional status and swallowing function; assessment of nutritional characteristics and preferences; referral; mealtime organization, supervision and monitoring; mealtime assistance and feeding skills. Nurses individualized care, coordinated or managed meal delivery and enteral feeding systems, were responsible for the dining environment and conduct of mealtimes; they taught staff, patients, and carers. There was little indication of integrated or psychosocial nursing nutritional care, or concepts, theories or models of nursing nutritional care. Many interventions were described but not evaluated. Little high quality evidence was of available. CONCLUSIONS This review indicated the parameters of nursing nutritional care, and provided a framework for future research. A functional, supportive, and educational nursing nutritional role was described but little evidence was of sufficient quality to support policy and practice development or inform education. Nutritional care was revealed as an essential but under-recognized element of stroke nursing.

Evaluation of a complex healthcare intervention to increase smoking cessation in pregnant women: interrupted time series analysis with economic evaluation.

Objectives To evaluate the effectiveness of a complex intervention to improve referral and treatment of pregnant smokers in routine practice, and to assess the incremental costs to the National Health Service (NHS) per additional woman quitting smoking. Design Interrupted time series analysis of routine data before and after introducing the intervention, within-study economic evaluation. Setting Eight acute NHS hospital trusts and 12 local authority areas in North East England. Participants 37 726 records of singleton delivery including 10 594 to mothers classified as smoking during pregnancy. Interventions A package of measures implemented in trusts and smoking cessation services, aimed at increasing the proportion of pregnant smokers quitting during pregnancy, comprising skills training for healthcare and smoking cessation staff; universal carbon monoxide monitoring with routine opt-out referral for smoking cessation support; provision of carbon monoxide monitors and supporting materials; and an explicit referral pathway and follow-up protocol. Main outcome measures Referrals to smoking cessation services; probability of quitting smoking during pregnancy; additional costs to health services; incremental cost per additional woman quitting. Results After introduction of the intervention, the referral rate increased more than twofold (incidence rate ratio=2.47, 95% CI 2.16 to 2.81) and the probability of quitting by delivery increased (adjusted OR=1.81, 95% CI 1.54 to 2.12). The additional cost per delivery was £31 and the incremental cost per additional quit was £952; 31 pregnant women needed to be treated for each additional quitter. Conclusions The implementation of a system-wide complex healthcare intervention was associated with significant increase in rates of quitting by delivery.

Intermittent fasting interventions for the treatment of overweight and obesity in adults aged 18 years and over: a systematic review and meta-analysis

Objective: To examine the effectiveness of intermittent energy restriction in the treatment for overweight and obesity in adults, when compared to usual care treatment or no treatment. Introduction: Intermittent energy restriction encompasses dietary approaches including intermittent fasting, alternate day fasting, and fasting for two days per week. Despite the recent popularity of intermittent energy restriction and associated weight loss claims, the supporting evidence base is limited. Inclusion criteria: This review included overweight or obese (BMI ≥25 kg/m2) adults (≥18 years). Intermittent energy restriction was defined as consumption of ⩽800 kcal on at least one day, but no more than six days per week. Intermittent energy restriction interventions were compared to no treatment (ad libitum diet) or usual care (continuous energy restriction ∼25% of recommended energy intake). Included interventions had a minimum duration of 12 weeks from baseline to post outcome measurements. The types of studies included were randomized and pseudo-randomized controlled trials. The primary outcome of this review was change in body weight. Secondary outcomes included: i) anthropometric outcomes (change in BMI, waist circumference, fat mass, fat free mass); ii) cardio-metabolic outcomes (change in blood glucose and insulin, lipoprotein profiles and blood pressure); and iii) lifestyle outcomes: diet, physical activity, quality of life and adverse events. Methods: A systematic search was conducted from database inception to November 2015. The following electronic databases were searched: MEDLINE, Embase, CINAHL, Cochrane Library, ClinicalTrials.gov, ISRCTN registry, and anzctr.org.au for English language published studies, protocols and trials. Two independent reviewers evaluated the methodological quality of included studies using the standardized critical appraisal instruments from the Joanna Briggs Institute. Data were extracted from papers included in the review by two independent reviewers using the standardized data extraction tool from the Joanna Briggs Institute. Effect sizes were expressed as weighted mean differences and their 95% confidence intervals were calculated for meta-analyses. Results: Six studies were included in this review. The intermittent energy restriction regimens varied across studies and included alternate day fasting, fasting for two days, and up to four days per week. The duration of studies ranged from three to 12 months. Four studies included continuous energy restriction as a comparator intervention and two studies included a no treatment control intervention. Meta-analyses showed that intermittent energy restriction was more effective than no treatment for weight loss (−4.14 kg; 95% CI −6.30 kg to −1.99 kg; p ⩽ 0.001). Although both treatment interventions achieved similar changes in body weight (approximately 7 kg), the pooled estimate for studies that investigated the effect of intermittent energy restriction in comparison to continuous energy restriction revealed no significant difference in weight loss (−1.03 kg; 95% CI −2.46 kg to 0.40 kg; p = 0.156). Conclusions: Intermittent energy restriction may be an effective strategy for the treatment of overweight and obesity. Intermittent energy restriction was comparable to continuous energy restriction for short term weight loss in overweight and obese adults. Intermittent energy restriction was shown to be more effective than no treatment, however, this should be interpreted cautiously due to the small number of studies and future research is warranted to confirm the findings of this review.

Weight-loss interventions for overweight/obese adults with chronic musculoskeletal pain: a mixed methods systematic review protocol.

REVIEW QUESTION/OBJECTIVE The objective of this mixed methods review is to develop an aggregated synthesis of qualitative and quantitative data on weight-loss interventions for overweight/obese adults with chronic musculoskeletal pain in an attempt to derive conclusions and recommendations useful for clinical practice and policy decision making.The objective of the quantitative component of this review is to quantify the effectiveness of weight-loss interventions on weight, pain and physical and/or psychosocial function in overweight/obese adults with chronic musculoskeletal pain.The objectives of the qualitative component of this review are to explore the perceptions and experiences of overweight/obese adults with chronic musculoskeletal pain of the link between their weight and pain, and the effectiveness and appropriateness of weight-loss interventions and sustainability of weight-loss efforts.

Developing workable research methods: Lessons from a pilot study with vulnerable participants and complex assessments

Following acute stroke, deterioration in nutritional status and weight loss is common; few studies have investigated this, perhaps due to difficulties with recruitment and completion of complex assessments with stroke patients. This study reports the feasibility of a study protocol to determine predictors of nutritional intake in stroke patients. The aim of the study was to test the feasibility of a protocol to measure taste and smell function, and explore links with dietary intake following stroke. Patients were recruited from one Acute Stroke Unit in 2007/8. Data were collected at three time-points and entailed standardised validated assessments of taste and smell function, diet, appetite and mood state. Recruitment of this vulnerable population to a demanding assessment schedule was challenging. Of a cohort of 166 admissions, six were recruited and complete data collected from four participants. Slow recruitment was largely due to exacting inclusion criteria and rapid hospital discharge. Those who completed all assessments reported the schedule as tolerable and acceptable. This study illustrated the difficulties of recruiting this vulnerable population. Identification of reasons for slow recruitment facilitated development of measures to address them. It was possible to format a complex and lengthy assessment schedule to be acceptable to vulnerable participants.

OP56 Evaluation of the implementation of a complex intervention (babyClear©) to promote increased smoking cessation rates among pregnant women

Background Rates of smoking at delivery are higher in the North East than in the rest of England (21% vs 13% in 2011/12). The babyClear© approach was commissioned in 2012/13 to support the full implementation of NICE guidance, and rolled out to all localities in the North East. The intervention package included training for staff in maternity and stop smoking services (SSS) and a new referral pathway for pregnant smokers. Systematic identification of smokers and opt-out referral to SSS, with intensive follow up, was emphasised. We aimed to evaluate its impact on referral rates, quit rates and birthweight, and estimate its cost-effectiveness. Methods Data from all maternity units in the north east of England for deliveries between Jan 2013 and Sept 2014 were linked with SSS referral data. We used a mixed-effects modelling approach to analyse the effect of the intervention on referral to SSS and on the probability of quitting smoking before delivery, using a before and after design. We used a linear mixed-effects model to investigate the impact of quitting during pregnancy on birthweight. Costs of delivering the intervention over five years were estimated. Results 37,726 singleton deliveries, including 10,594 smokers, were analysed. Referrals to SSS increased by 2.5 fold (95% CI 2.2–2.8) by month four after implementation. The odds of quitting during pregnancy nearly doubled (adjusted OR 1.8, 95% CI 1.5–2.2). Quit rates were higher in women who were referred to SSS (aOR 3.2, 95% CI 3.0–3.7) or who set a quit date (aOR 4.2, 95% CI 3.5–4.9). Quit rates were lower among women living in deprived areas (aOR 0.5, 95% CI 0.4–0.6). Birthweight was 6.5% (95% CI 5.8%–7.2%) higher among babies of women who quit during pregnancy compared with those who continued smoking, equivalent to 200 g increase for a reference term birth. Quitters’ babies were slightly lighter than babies of non smokers (1.4%, 95% CI 0.1–1.9%; 46 g lower for reference birth). 30 pregnant women (9 pregnant smokers) needed to be treated for each additional quit, at an estimated additional cost of £57 to £938 per quit. Conclusion Implementation of a system wide intervention to promote smoking cessation in pregnancy, focussed on systematic identification of pregnant smokers and opt-out referral to SSS, substantially increased quit rates, improved birth weight among pregnant quitters and was highly cost effective.

Early intervention programs using volunteers for child development and nutrition: a mixed methods systematic review protocol

REVIEW QUESTION/OBJECTIVE The overall aim of this mixed methods systematic review is to explore the effectiveness and experience of early intervention programs using volunteers, peer supporters and community champions with the aim of improving one or more of the following outcomes of children from conception to two years:Specifically the review questions are.

Rapid discharge from hospital in the last days of life: an evaluation of key issues and the discharge sister role.

BACKGROUND When the time comes, most people wish to die at home. Nevertheless, many deaths occur in hospital, often because of delays in the discharge process. This study explored the issues surrounding rapid discharge from hospital in the final days of life, and evaluated the contribution of a discharge sister role. METHODS A qualitative design was used, incorporating focus groups and interviews with key stakeholders. A total of 75 staff and 7 carers participated. RESULTS Participants highlighted the small window of opportunity available to facilitate a rapid but safe discharge from hospital. Early recognition of the last days of life was vital as was the availability of a skilled health professional, such as the discharge sister, to coordinate the patients journey from hospital to preferred place of death. CONCLUSIONS Rapid discharge is challenging and requires high levels of skill. The discharge sister navigated complex organisational systems to facilitate rapid discharge for those who might otherwise have died in hospital.