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Aims: Studies of health services reveal a focus on provision of scheduled care at the expense of patient need, placing the health service in a position of power and the patient as passive recipient. This secondary qualitative analysis of a focused ethnography draws on the Foucauldian concept of power as pervasive and relational, to examine how an imbalance of power is manifested in situations where people with both cancer and dementia are being treated for cancer. Design: Secondary qualitative analysis of a focused ethnographic study.Data Sources: In the original study, qualitative data were gathered from observation and interviews with people with cancer and dementia (n = 2), caregivers (n = 7) and staff (n = 20). The study was conducted in the outpatient departments of two teaching hospitals in England between January 2019 and July 2021. Data from all sources were analysed for this secondary analysis using constant comparison.Results: The principal theme was balance, encapsulating the competing priorities involved in delivering cancer treatment. There was tension between maintaining safety and ensuring an individual's right to treatment, and difficulty reconciling the needs of the system with the needs of individuals.Conclusion: The pervasive nature of power can be harnessed to enhance the agency of people with cancer and dementia by incorporating principles of shared decision making.

Failures in fundamental care (e.g. nutrition or pain-relief) for hospitalised patients can have serious consequences, including avoidable deaths. Policy rhetoric of ‘shared decision-making’ fails to consider how structural constraints and power dynamics limit patient agency in nursing staff-patient interactions. Goffman's concepts of face work, the presentation of self and the Total Institution shaped our analysis of interview and focus group data from hospital patients. Patients avoided threatening ‘good’ patient and staff face by only requesting missed care when staff face was convincing as ‘caring’ and ‘available’ (‘engaged’). Patients did not request care from ‘distracted’ staff (‘caring’ but not ‘available’), whilst patient requests were ignored in Total Institution-like ‘dismissive’ interactions. This meant patients experienced missed care with both ‘distracted’ and ‘dismissive’ staff. Patients with higher support needs were less able to carry out their own missed care to protect staff face, so experienced more serious care omissions. These findings show that many elements of the Total Institution survive in modern healthcare settings despite attempts to support individualised care. Unless nursing staff can maintain face as ‘engaged’ (despite organisational constraints that can reduce their capacity to do so) patient participation in care decisions will remain at the level of rhetoric.

IntroductionPeople with dementia have poorer cancer outcomes than those without, and experience inequalities in access to, and quality of, care. Outpatient environments, where radiotherapy, chemotherapy and immunotherapy cancer treatments typically take place, have largely been excluded from research. This study was conducted to understand provision of treatment and support and experiences of care for people with dementia undergoing cancer treatment in the outpatient setting.Materials and methodsUsing observation, interviews and document analysis, data were collected to scrutinise the cultural environment of ambulatory care, comprising the physical fabric of the care setting; interactions, behaviours and perceptions of those in the care setting; and the organizational, clinical and interactional processes involved in care delivery. The study was conducted in the outpatient oncology departments of two large teaching hospitals in England between January 2019-July 2021.ResultsData were gathered from a wide range of sources, including 15 hours of observation, and interviews with patients (n=2), caregivers (n=7) and staff (n=20). Evidence from this study suggests the cultural environment of the outpatient care setting reflects and supports the standardised processing of people for cancer treatment. Dementia introduces a wider set of care requirements not catered for by this standardised treatment model and associated processes. Data showed the needs of patients with dementia could be addressed most effectively when individualised, as opposed to standardised care, was offered.ConclusionThere is work to be done in outpatient cancer services to ensure responsiveness to individual patient need. This could be achieved by having an established way (or ways) of eliciting needs, preferences and expectations, a belief that a person’s needs and expectations are legitimate, and that effort should be made to address them, with the ability to accommodate these needs and expectations.Patient or public contributionpatients and caregivers were involved in the study design and development of study materials including the interview topic guide. They also assisted with discussion and clarification of study findings.

IntroductionEstablishing methods to evaluate interactions between hospital staff and patients with a dementia is vital to inform care delivery. This study aimed to assess the validity of Quality of Interactions Schedule (QuIS) ratings in relation to the care experiences of people with a dementia in a general hospital setting.MethodsFour hundred and ninety face‐to‐face interactions between staff and patients with a dementia (n = 107) on six medicine for older people wards in a UK National Health Service hospital were observed and rated using QuIS and the Psychological Well‐Being in Cognitively Impaired Persons (PWB‐CIP) tool. We also invited patient ratings for longer interactions (n = 217). Analyses explored associations between QuIS ratings, PWB‐CIP ratings and patient ratings.ResultsWhen QuIS was rated negative, the mean researcher‐rated patient psychological well‐being was lower (PWB = 7.9 out of maximum score of 10) than when QuIS was non‐negative (PWB = 8.8, p = 0.036). Negative QuIS ratings were associated with negative ratings on seven out of ten individual PWB‐CIP items. When QuIS was rated negative, the associated patient rating was 4% less likely to be ‘happy’. The patient was also 4% more likely to rate the interaction as ‘kind’. Patients struggled to participate in care ratings.ConclusionsSome patients found responding to researcher questions difficult or not relevant, reflecting the need for development of more suitable methods in this field. Our findings of an association between lower quality QuIS‐rated interactions and lower psychological well‐being lend support to the use of QuIS with patient populations that include people with a dementia.

Background Lower nurse staffing levels are associated with increased hospital mortality. Older patients with cognitive impairments (CI) have higher mortality rates than similar patients without CI and may be additionally vulnerable to low staffing. Objectives To explore associations between registered nurse (RN) and nursing assistant (NA) staffing levels, mortality and readmission in older patients admitted to general medical/surgical wards. Research design Retrospective cohort. Participants All unscheduled admissions to an English hospital of people aged ≥75 with cognitive screening over 14 months. Measures The exposure was defined as deviation in staffing hours from the ward daily mean, averaged across the patient stay. Outcomes were mortality in hospital/within 30 days of discharge and 30-day re-admission. Analyses were stratified by CI. Results 12,544 admissions were included. Patients with CI (33.2%) were exposed to similar levels of staffing as those without. An additional 0.5 RN hours per day was associated with 10% reduction in the odds of death overall (odds ratio 0.90 [95% CI 0.84–0.97]): 15% in patients with CI (OR 0.85 [0.74–0.98]) and 7% in patients without (OR 0.93 [0.85–1.02]). An additional 0.5 NA hours per day was associated with a 15% increase in mortality in patients with no impairment. Readmissions decreased by 6% for an additional 0.5 RN hours in patients with CI. Conclusions Although exposure to low staffing was similar, the impact on mortality and readmission for patients with CI was greater. Increased mortality with higher NA staffing in patients without CI needs exploration.

At the time of writing (11th April 2020) there are 1.72 million Covid‐19 infections and 104,889 deaths worldwide. In the UK the first recorded death was on the 5th of March 2020 and in just 37 days 9,875 deaths in hospital have been recorded. The 10th of April saw the highest number of UK daily deaths (980) to date. These UK figures do not include those who died in care homes or in the community. Similar death rates have been experienced in China earlier this year (3,339) and are rising globally with particularly high death rates in the US (18,761 with over half of deaths in New York State), Italy (18,939), Spain (16,353) and France (13,197). As the Coronavirus disease 2019 (Covid-19) pandemic takes hold, nurses are on the front line of health and social care in the most extreme of circumstances. We reflect during a moment in time (week three of lockdown in the UK and week 5/6 across Europe) to highlight the issues facing nurses at this unprecedented time. At the bedside 24 hours a day seven days a week, in similar outbreaks, nurses have had the highest levels of occupational stress and resulting distress compared to other groups (Cheong and Lee, 2004, Maunder et al., 2006, Nickell et al., 2004). Nurses are already a high-risk group, with the suicide rate among nurses 23% higher than the national average (ONS 2017). Despite this, the RCN (Royal College of Nursing in the UK) has reported that nurses feel “repeatedly” ignored by their employers when they raise concerns about their mental health (Mitchell 2019). A focus on personal responsibility for psychological health and well-being and an over-emphasis on nurses being ‘resilient’ in the face of under-staffing and often intense emotional work is consistently challenged by nurses and nurse academics (Traynor 2018). Treating resilience as an individual trait is seen to ‘let organisations off the hook’ (Traynor 2018); yet has often been the focus of organisational strategies to date. This does not work at the best of times and certainly is not appropriate now in these most difficult of circumstances. Here we discuss the stressors and challenges and present evidence-informed guidance to address the physical and psychological needs of nurses during the Covid-19 pandemic. We stress the importance of peer and team support to enable positive recovery after acutely stressful and emotionally draining experiences, and outline what managers, organisations and leaders can do to support nurses at this most critical of times.

Purpose: over half of individuals diagnosed with cancer are aged over 70 years, and more than 75% of those with cancer report at least one other medical condition. Having multiple conditions alongside cancer in old age may lower functional status, greater likelihood of treatment complications and less favourable prognoses. This qualitative study explored how older people with long-term chronic conditions manage their health and meet their health-related goals after they have completed treatment for cancer. Methods: one-to-one face-to-face qualitative interviews were conducted with 8 older people and 2 informal caregivers based in the UK. Older adults were eligible to participate if they were over 70 and had completed primary cancer treatment with curative intent and had at least one other chronic health condition. A semi-structured interview schedule developed a priori based on Shippee’s cumulative complexity model was used. We aimed to explore experiences that could influence self-management, utilisation of healthcare services and health outcomes. A framework analysis was used to describe and interpret the data. Results: four overarching themes were identified in the analysis. These themes related to factors that influenced the everyday health-related workload and capacity of the participants. These factors included their health, resources, and opportunities, as well their motivation and sense of perceived control over their lives. Conclusions: fragmented healthcare systems and relationships with healthcare professionals also influenced the participants’ self-management of their health. Our findings highlight the interaction between an individuals’ needs, capacity, treatment burden, and the services and resources available to them. These findings support calls to promote person-centred care to better support older adults to manage their health.

Introduction: Involuntary relocation when care homes close can be detrimental to residents’ health and well-being and is associated with increased mortality. There is little formal evidence to support whether planning can mitigate the impact of such moves. This study aimed to understand the experiences of a whole care home relocation where staff and residents relocated together using existing published guidance.Methods: A longitudinal qualitative research study using individual face-to-face semi-structured interviews was conducted between August 2018 and August 2019. Baseline interviews were conducted 6–8 weeks after relocation with follow-up interviews 10–12 months later. Interviews were recorded, transcribed and analysed using framework analysis.Results: 27 interviews were conducted; 19 baseline interviews (4 residents, 7 family members, 8 staff) and 8 follow-up interviews (2 residents, 2 family members, 4 staff). Participants’ feelings about the relocation were mixed: some reported apprehension before the move but others excitement. Residents and families felt variably involved in planning the move, whereas staff expressed lack of involvement. Time, family support and continuity of care helped participants settle in. The new environment shaped participants’ experiences and abilities to adjust, especially the lack of a homely feeling with the new home, the larger size and changes in staff organisation and management.Conclusions: Despite implementation of existing guidance, relocation was still challenging for residents, staff and family members. Future relocations should increase involvement of staff in the planning and design of the home; offer continuous support to those involved; and ensure continuity of care and management style.

Introduction: The Quality of Interactions Schedule (QuIS) is an observational tool to assess the quality of staff-patient interactions in a healthcare context. QuIS is a promising measure for the evaluation of compassionate care, particularly where care is being delivered to patient populations, such as older people, who may be excluded from self-completion data collection methods. This study investigates the content validity of QuIS in identification of negative staff-patient interactions in acute care.Methods: Staff-patient interactions (n = 1598) on adult inpatient units with a high proportion of older patients in two UK National Health Service hospitals were observed and rated using QuIS. When rating interactions as negative quality, observers recorded brief field notes to explain the rating. Content analysis was used to develop categories of negative interaction type. These categories were compared with the QuIS negative interaction definitions.Results: Eighty-eight negative ratings were accompanied by a field note that could be used in the analysis. Five interaction categories were identified: Patient calls for help, call not acknowledged; Staff focused on task and appear to ignore/not hear patient; Patient-led interactions appear dismissed or ignored; Patient prevented from doing something without explanation; Staff interact with each other or talk to relatives, not including patient. There was clear association between the derived categories and QuIS guidance for negative ratings.Conclusion: These findings support the validity of QuIS data in relation to measurement of interaction quality in acute care settings. Extending the research to a wider range of settings would be useful.

BackgroundThere is little research examining resistance, refusal or rejection of care by people living with dementia within acute hospital wards despite the prevalence of dementia in adult hospital populations.ObjectivesTo explore the ways in which resistance to care manifests within the acute setting and is understood, classified and subsequently managed by ward staff.DesignEthnographySettingAcute medical units and trauma and orthopaedic wards in five NHS hospitals in England and Wales.ParticipantsPeople living with dementia and nursing team members (registered nurses and healthcare assistants) on participating wards.MethodsObservational fieldwork and ethnographic interviews collected over a period of 20 months (155 days of non-participant observation (minimum 2 h, maximum 12 h, total hours: 680) focusing on staff delivering care to patients with dementia. Interviewees included patients, visitors, and staff working on and visiting the ward. Data collection and analysis drew on the theoretical sampling and constant comparison techniques of grounded theory.ResultsWe found that resistance to care by people living with dementia was a routine and expected part of everyday care in the participating acute hospital settings. The timetabled rounds of the ward (mealtimes, medication rounds, planned personal care) significantly shaped patient and staff experiences and behaviours. These routinized ward cultures typically triggered further patient resistance to bedside care. Institutional timetables, and the high value placed on achieving efficiency and reducing perceived risks to patients, dictated staff priorities, ensuring a focus on the delivery of essential everyday planned care over individual patient need or mood in that moment. Staff were thus trapped into delivering routines of care that triggered patterns of resistance.ConclusionsNursing staff struggle to respond to the needs of people living with dementia in acute care settings where the institutional drivers of routines, efficiency and risk reduction are not mediated by clinical leadership within the ward. Cycles of resistance in response to organisationally mandated timetables of care can result in poor care experiences for patients, and emotional and physical burnout for staff. More research is needed into how institutional goals can be better aligned to recognise the needs of a key hospital population: people living with dementia.

Policymakers advocate for integrated care as a solution to care fragmentation. In the case of older adults, informal carers (especially ‘dutiful daughters’) play a significant role in integrating and coordinating care. Ludlow and colleagues examine how the role of informal carers in integrating care across services and systems is reflected in policy (the blunt-end of the system) and the experiences of dutiful daughters (the sharp-end) in England and Australia. They present the findings from content analysis of key policy documents, as well as four case accounts of dutiful daughters. The authors found that unpaid carers, and the gender imbalance of caregiving, were largely invisible in the policy documents, accentuating the disconnect between policymakers’ vision for integrated care and the accomplishment of integration on the ground.

BackgroundOlder people are more likely to be living with cancer and multiple long-term conditions, but their needs, preferences for treatments, health priorities and lifestyle are often not identified or well-understood. There is a need to move towards a more comprehensive person-centred approach to care that focuses on the cumulative impact of a number of conditions on daily activities and quality of life. This paper describes the intervention planning process for CHAT& PLANTM, a structured conversation intervention to promote personalised care and support self-management in older adults with complex conditions.MethodsA theory-, evidence- and person-based approach to intervention development was undertaken. The intervention planning and development process included reviewing relevant literature and existing guidelines, developing guiding principles, conducting a behavioural analysis and constructing a logic model. Optimisation of the intervention and its implementation involved qualitative interviews with older adults with multimorbidity (n = 8), family caregivers (n = 2) and healthcare professionals (HCPs) (n = 20). Data were analysed thematically and informed changes to the intervention prototype.ResultsReview findings reflected the importance of HCPs taking a person-centred (rather than disease-centred) approach to their work with older people living with multimorbidity. This approach involves HCPs giving health service users the opportunity to voice their priorities, then using these to underpin the treatment and care plan that follow. Findings from the planning stage indicated that taking a structured approach to interactions between HCPs and health service users would enable elicitation of individual concerns, development of a plan tailored to that individual, negotiation of roles and review of goals as individual priorities change. In the optimisation stage, older adults and HCPs commented on the idea of a structured conversation to promote person-centred care and on its feasibility in practice. The idea of a shared, person-centred approach to care was viewed positively. Concerns were raised about possible extra work for those receiving or delivering care, time and staffing, and risk of creating another "tick-box" exercise for staff. Participants concluded that anyone with the appropriate skills could potentially deliver the intervention, but training was likely to be required to ensure correct utilisation and self-efficacy to deliver to the intervention.ConclusionsCHAT&PLAN, a structured person-centred conversation guide appears acceptable and appealing to HCPs and older adults with multimorbidity. Further development of the CHAT&PLAN intervention should focus on ensuring that staff are adequately trained and supported to implement the intervention.

OBJECTIVE: Many older people with cancer live with multimorbidity. Little is understood about the cumulative impact of old age, cancer and multimorbidity on self-management. This qualitative systematic review and synthesis aimed to identify what influences self-management from the perspective of older adults living with cancer and multimorbidity.METHODS: Six databases were systematically searched for primary qualitative research reporting older adults' experiences of living with cancer and multimorbidity (eg, Medline, Embase, and CINAHL). A thematic synthesis was guided by Shippee's model of cumulative complexity. Text labelled as results in the included papers was treated as data.RESULTS: Twenty-eight studies were included. While the included studies varied in their focus, our analysis highlighted a number of important themes consistent across the studies. Health conditions with the greatest negative impact on independent living assumed the greatest importance, sometimes meaning their cancer was a low priority. Self-management practices seen as likely to interfere with quality of life were deprioritized unless viewed as necessary to maintain independence. When burden outweighed capacity, people were reluctant to ask for help from others in their social network. The contribution of formal healthcare services to supporting self-management was relatively peripheral.CONCLUSIONS: Old age and multimorbidity together may complicate self-management after cancer, threatening health and well-being, creating burden and diminishing capacity. Older adults prioritized self-management practices they considered most likely to enable them to continue to live independently. The protocol was registered with Prospero (CRD42018107272).

Bridges and colleagues offer important insight into how elements of context can be identified and mobilized in planned improvement efforts targeted at health care coordination and delivery. Their analysis of the implementation journey of a compassionate care intervention targeted at hospital ward nursing teams highlights the implications for intervention design and implementation. The authors show how the degree of impact and sustainability of such interventions is highly context-specific and mediated by factors across micro- and meso-level boundaries. They conclude that design and implementation of care interventions should include the identification and mobilization of contextual elements that bear directly on individual health care professionals’ capacity to provide the nature and quality of care desired.

Purpose of review: the current review draws attention to the need for longer term management of multiple conditions in older adults with cancer.Recent findings: older people living with and beyond cancer are more likely than younger people to have higher prevalence of multimorbidity leading to an overall increase in illness and treatment burdens, limiting health-related quality of life (QoL), and capacity to self-manage. Older age presents a higher risk of cancer treatment side-effects and development or progression of other conditions, leading to worsening health, long-lasting functional problems, and social isolation. Although many prioritize functional independence and continuance of valued activities over survival, older people living with multimorbidity are more likely to experience poor physical functioning during and beyond cancer treatment.Summary: cancer treatment decisions and survivorship plans should be developed in the context of other conditions and in line with the individual's priorities for continued QoL. More research is needed to guide service development and clinical practice in this important area.

ObjectivesThere is currently no overview of supportive interventions developed for older people having cancer treatment. The aims and objectives, methods, and outcomes of interest of existing supportive interventions have not been evaluated. To understand how health services might meet the needs of older people undergoing cancer treatment, a scoping review was undertaken to identify and characterise supportive interventions developed for this patient group.Materials and methodsThis scoping review examined supportive interventions (services, programs, tools or policies) applied during diagnosis or treatment that address physical, psychological, social or spiritual needs of older patients. A systematic search of the following electronic databases was undertaken August–October 2017 (updated March 2019): AMED; CINAHL; EMBASE; Medline; PsychINFO.ResultsSixty-two papers met the inclusion criteria. The review established that existing interventions to support older people having treatment for cancer are diverse in aim, and the evaluation methodology and outcome measure selection vary considerably. The interventions rarely target complex issues such as multimorbidity, frailty, or the impact of other geriatric syndromes in addition to cancer.ConclusionWe suggest that future research should focus on patient populations with complex needs, including addressing comorbidity and age-associated conditions such as dementia.

Background The acute hospital setting has become a key site of care for people living with dementia. The Department of Health and Social Care recognises that as many as one in four acute hospital beds in the UK will be occupied by a person living with dementia at any given time. However, people living with dementia are a highly vulnerable group within the hospital setting. Following an acute admission, their functional abilities can deteriorate quickly and significantly. Detailed research is required to understand the role and needs of health-care staff caring for this patient population and to explore what constitutes ‘good care’ for people living with dementia within the acute setting. Objectives The focus of this study was a common but poorly understood phenomenon within the acute setting: refusal and resistance to care. Our research questions were ‘How do ward staff respond to resistance to everyday care by people living with dementia being cared for on acute hospital wards?’ and ‘What is the perspective of patients and their carers?’. Design This ethnography was informed by the symbolic interactionist research tradition, focusing on understanding how action and meaning are constructed within a setting. In-depth evidence-based analysis of everyday care enabled us to understand how ward staff responded to the care needs of people living with dementia and to follow the consequences of their actions. Setting This ethnography was carried out on 155 days (over 18 months) in 10 wards within five hospitals across England and Wales, which were purposefully selected to represent a range of hospital types, geographies and socioeconomic catchments. Participants In addition to general observations, 155 participants took part directly in this study, contributing to 436 ethnographic interviews. Ten detailed case studies were also undertaken with people living with dementia. Results We identified high levels of resistance to care among people living with dementia within acute hospital wards. Every person living with dementia observed within an acute hospital ward resisted care at some point during their admission. Limitations Limitations identified included the potential for the Hawthorne or researcher effect to influence data collection and establishing the generalisability of findings. Conclusions Ward staff typically interpreted resistance as a feature of a dementia diagnosis, which overshadowed the person. However, resistance to care was typically a response to ward organisation and delivery of care and was typically rational to that person’s present ontology and perceptions. In response, nurses and health-care assistants used multiple interactional approaches that combined highly repetitive language with a focus on completing essential care on the body, which itself had a focus on the containment and restraint of the person in their bed or at their bedside. These approaches to patient care were a response to resistance but also a trigger for resistance, creating cycles of stress for patients, families and ward staff. The findings have informed the development of simple, no-cost innovations at the interactional and organisational level. A further study is examining continence care for people living with dementia in acute hospital settings. Funding The National Institute for Health Research Health Services and Delivery Research programme.

Background There is no recent synthesis of primary research studies into older people's experiences of hospital care. Objective To synthesise qualitative research findings into older people's experiences of acute health care. Design Systematic procedures for study selection and data extraction and analysis. Comparative thematic approach with meta-ethnographic features for synthesis. Data sources Worldwide grey and published literature written in English between January 1999 and December 2018 identified from databases: CINAHL, Medline, British Nursing Index, EMBASE Psychiatry, International Bibliography of the Social Sciences, PsychINFO, and AgeInfo. Review methods Systematic review and synthesis of 61 qualitative studies and two systematic reviews describing older patients’ experiences of care in acute hospital settings. Results The physical and social environment of the hospital positioned many older patients as insignificant and powerless to influence the care they received. Patients subjugated their needs to those of staff and other patients, holding back information and requests for help. Patient knowledge of the time-based schedules for care, and experiences of waiting for care and of staff limiting their time with them served to reinforce patients’ feelings of insignificance and powerlessness, reflecting the perceived primacy of bureaucratic organisation of care over individual needs and preferences. Highly negative experiences would result if these aspects of context were not mediated by individualised relational work by staff, nursing staff in particular. Some groups of patients were at particular risk of negative experiences: people with dementia and/or delirium; people with difficulty communicating, hearing or understanding; people from ethnic minority groups, especially where there was a language difference; people with low functional/physical ability; people with low literacy; and people without regular visitors and/or family support. Three key features of care consistently mediated negative feelings and were linked to more positive experiences were: “maintaining identity: see who I am”, “building relationships: connect with me”, and “partnering in care: involve me”. Conclusion Older people's care experiences in hospital may be negative in the absence of relational work by nurses to maintain people's identity, establish caring connections and ensure that individual patient needs, preferences and values are honoured in the care that is delivered. Relational care by nurses can mediate powerful institutional drivers that may otherwise result in negative experiences and poor care. Organisational and service-wide commitment are needed to create the culture and context in which relational care can flourish. Tweetable abstract: Synthesis of qualitative research on older ppl's hospital experiences: hospital's physical and social environment positions older ppl as insignificant and powerless. Highly negative experiences result if impact of context not mediated by individualised relational work by nurses.

BackgroundConcerns about the degree of compassion in health care have become a focus for national and international attention. However, existing research on compassionate care interventions provides scant evidence of effectiveness or the contexts in which effectiveness is achievable.ObjectivesTo assess the feasibility of implementing the Creating Learning Environments for Compassionate Care (CLECC) programme in acute hospital settings and to evaluate its impact on patient care.DesignPilot cluster randomised trial (CRT) and associated process and economic evaluations.SettingSix inpatient ward nursing teams (clusters) in two English NHS hospitals randomised to intervention (n = 4) or control (n = 2).ParticipantsPatients (n = 639), staff (n = 211) and visitors (n = 188).InterventionCLECC is a workplace educational intervention focused on developing sustainable leadership and work team practices (dialogue, reflective learning, mutual support) theorised to support the delivery of compassionate care. The control setting involved no planned staff team-based educational activity.Main outcome measuresQuality of Interaction Schedule (QuIS) for staff–patient interactions, patient-reported evaluations of emotional care in hospital (PEECH) and nurse-reported empathy (as assessed via the Jefferson Scale of Empathy).Data sourcesStructured observations of staff–patient interactions; patient, visitor and staff questionnaires and qualitative interviews; and qualitative observations of CLECC activities.ResultsThe pilot CRT proceeded as planned and randomisation was acceptable to teams. There was evidence of potential contamination between wards in the same hospital. QuIS performed well, achieving a 93% recruitment rate, with 25% of the patient sample cognitively impaired. At follow-up there were more positive (78% vs. 74%) and fewer negative (8% vs. 11%) QuIS ratings for intervention wards than for control wards. In total, 63% of intervention ward patients achieved the lowest possible (i.e. more negative) scores on the PEECH connection subscale, compared with 79% of control group patients. These differences, although supported by the qualitative findings, are not statistically significant. No statistically significant differences in nursing empathy were observed, although response rates to staff questionnaire were low (36%). Process evaluation: the CLECC intervention is feasible to implement in practice with medical and surgical nursing teams in acute care hospitals. Strong evidence of good staff participation was found in some CLECC activities and staff reported benefits throughout its introductory period and beyond. Further impact and sustainability were limited by the focus on changing ward team behaviours rather than wider system restructuring. Economic evaluation: the costs associated with using CLECC were identified and it is recommend that an impact inventory be used in any future study.LimitationsFindings are not generalisable outside hospital nursing teams, and this feasibility work is not powered to detect differences attributable to the CLECC intervention.ConclusionsUse of the experimental methods is feasible. The use of structured observation of staff–patient interaction quality is a promising primary outcome that is inclusive of patient groups often excluded from research, but further validation is required. Further development of the CLECC intervention should focus on ensuring that it is adequately supported by resources, norms and relationships in the wider system by, for instance, improving the cognitive participation of senior nurse managers. Funding is being sought for a more definitive evaluation.Trial registrationCurrent Controlled Trials ISRCTN16789770.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 6, No. 33. See the NIHR Journals Library website for further project information. The systematic review reported inChapter 2was funded by the NIHR Collaboration for Leadership in Applied Health Research and Care Wessex, the University of Örebro and the Karolinska Institutet.

ObjectiveCompassionate care continues to be a focus for national and international attention, but the existing evidence base lacks the experimental methodology necessary to guide the selection of effective interventions for practice. This study aimed to evaluate the Creating Learning Environments for Compassionate Care (CLECC) intervention in improving compassionate care.SettingWard nursing teams (clusters) in two English National Health Service hospitals randomised to intervention (n=4) or control (n=2). Intervention wards comprised two medicines for older people (MOPs) wards and two medical/surgical wards. Control wards were both MOPs.ParticipantsData collected from 627 patients and 178 staff. Exclusion criteria: reverse barrier nursed, critically ill, palliative or non-English speaking. All other patients and all nursing staff and Health Care Assistant HCAs were invited to participant, agency and bank staff were excluded.InterventionCLECC, a workplace intervention focused on developing sustainable leadership and work-team practices to support the delivery of compassionate care. Control: No educational activity.Primary and secondary outcome measuresPrimary—Quality of Interaction Schedule (QuIS) for observed staff–patient interactions. Secondary—patient-reported evaluations of emotional care in hospital (PEECH); nurse-reported empathy (Jefferson Scale of Empathy).ResultsTrial proceeded as per protocol, randomisation was acceptable. Some but not all blinding strategies were successful. QuIS observations achieved 93% recruitment rate with 25% of patient sample cognitively impaired. At follow-up there were more total positive (78% vs 74%) and less total negative (8% vs 11%) QuIS ratings for intervention wards versus control wards. Sixty-three per cent of intervention ward patients scored lowest (ie, more negative) scores on PEECH connection subscale, versus 79% of control. This was not a statistically significant difference. No statistically significant differences in nursing empathy were observed.ConclusionsUse of experimental methods is feasible. The use of structured observation of staff–patient interaction quality is a promising outcome measure inclusive of hard to reach groups.Trial registration numberISRCTN16789770.

Aims and objectivesTo identify the potential benefits of dementia specialist nursing and to inform the implementation of roles to support people with dementia during hospital admission.BackgroundExtended stays and adverse events mean that hospital admissions are costly for people with dementia, and patient experiences and outcomes can be poor. Specialist nurses have been identified as having potential to enhance care quality, reduce excess stays and reduce costs, but the evidence base for dementia specialist nurse roles has not previously been synthesised.DesignScoping review.Data sourcesCochrane Library, Campbell Collaboration, Clinical Evidence, Evidence-Based Medicine, York Centre for Reviews and Dissemination, PubMed, Medline, CINAHL and PsycInfo databases and internet searches and personal libraries/expert consultation to identify grey literature.MethodsInitial scoping searches were used to inform more focused systematic searches. Studies directly evaluating dementia nurse specialist roles or giving evidence of effectiveness of interventions/services that could be delivered by them to improve core outcomes were identified by one reviewer and verified by a second reviewer.ResultsWhile direct evidence for the effectiveness of these roles is lacking, a number of areas were identified in which a nurse specialist role could make a contribution, including preventing adverse events and improving patient experiences and outcomes. There is a considerable body of evidence for the effectiveness of these interventions although the volume of evidence for specific interventions is not always significant.ConclusionsThe evidence indicates that a skilled dementia specialist nurse, undertaking a clearly defined role, and working directly with people with dementia and their carers for a significant proportion of the time, could benefit people with dementia in hospitals and their family carers.Relevance to clinical practiceClear guidance for the development and implementation of dementia specialist nurse roles in acute hospital settings.

Background Despite concerns about the degree of compassion in contemporary healthcare, there is a dearth of evidence for health service managers about how to promote compassionate healthcare. This paper reports on the implementation of the Creating Learning Environments for Compassionate Care (CLECC) intervention by four hospital ward nursing teams. CLECC is a workplace educational intervention focused on developing sustainable leadership and work-team practices designed to support team relational capacity and compassionate care delivery.\ud \ud Objectives To identify and explain the extent to which CLECC was implemented into existing work practices by nursing staff, and to inform conclusions about how such interventions can be optimised to support compassionate care in acute settings.\ud \ud Methods Process evaluation guided by normalisation process theory. Data gathered included staff interviews (n=47), observations (n=7 over 26 hours) and ward manager questionnaires on staffing (n=4).\ud \ud Results Frontline staff were keen to participate in CLECC, were able to implement many of the planned activities and valued the benefits to their well-being and to patient care. Nonetheless, factors outside of the direct influence of the ward teams mediated the impact and sustainability of the intervention. These factors included an organisational culture focused on tasks and targets that constrained opportunities for staff mutual support and learning.\ud \ud Conclusions Relational work in caregiving organisations depends on individual caregiver agency and on whether or not this work is adequately supported by resources, norms and relationships located in the wider system. High cognitive participation in compassionate nursing care interventions such as CLECC by senior nurse managers is likely to result in improved impact and sustainability.

We are good at reinventing the wheel in older people's nursing, where we often find ourselves struggling with the same practice issues regardless of care setting. Frequently, the starting point is to develop a local solution.

Background There is a lack of consensus on how the practices of health care workers may be assessed and measured in relation to compassion. The Quality of Interactions Schedule (QuIS) is a promising measure that uses independent observers to assess the quality of social interactions between staff and patients in a healthcare context. Further understanding of the relationship between QuIS and constructs such as person-centred care would be helpful to guide its future use in health research. Objective This study aimed to assess the validity of QuIS in relation to person-centred care measured using the CARES® Observational Tool (COT™). Methods 168 nursing staff-patient care interactions on adult inpatient units in two acute care UK National Health Service hospitals were observed and rated using QuIS and COT™. Analyses explored the relationship between summary and individual item COT™ scores and the likelihood of a negative (lower quality) QuIS rating. Results As the degree of person-centred care improved, QuIS negative ratings generally decreased and positive social ratings increased. QuIS-rated negative interactions were associated with an absence of some behaviours, in particular staff approaching patients from the front (relative risk (RR) 3.7), introducing themselves (RR 3.1), smiling and making eye contact (RR 3.4), and involving patients in their care (RR 3.7). Conclusion These findings provide further information about the validity of QuIS measurements in healthcare contexts, and the extent to which it can be used to reflect the quality of relational care even for people who are unable to self-report.

Background People with dementia have poorer cancer outcomes than those without. Little information exists concerning implications of comorbid cancer-dementia for people having cancer treatment in an ambulatory care setting. The purpose of this focused ethnography is to characterise the environment, behaviour and processes that comprise the setting, and to explore what constitutes ‘good care’ in this context. Trial design The aim of this focused ethnography is to establish an empirically-based conceptual foundation to inform development of innovations to improve the way treatment and support is offered to people with dementia having cancer treatment. Objectives include: Understanding the physical fabric of the ambulatory care environment, and how this shapes patterns of behaviour and processes; Understanding the actions of those involved in the receipt or provision of care for people with dementia having cancer treatment, through exploration of interactions, perceptions, and language. Understanding the processes involved in care delivery, and how these shape treatment and support offered to patients. Identify characteristics that constitute ‘good care’ and gain an understanding of barriers and facilitators. Identify which aspects of the ambulatory care setting are amenable to modification to meet the needs of this complex population. This project will allow formation of a rich picture of the cultural context in which behaviour, environment and processes are situated, and identify ways in which the organisation of care might be structured to provide a person-centred service for people with dementia. Participants: Participation will be invited from people with dementia having cancer treatment (n ≤ 10), informal carers (n ≤ 10), and staff members (oncologists, nurses, radiographers, support workers, administrative staff, and allied health professionals) (n ≤ 30). Methods: Data will be collected via observations, interviews and document analysis. Data will be analysed using constant comparison, informed by the analytic tradition of grounded theory (Glaser & Strauss 1967), to allow the researchers to establish an empirically-based conceptual and theoretical foundation that is grounded in the original data. Legal entity responsible for the study Naomi Farrington. Funding National Institute for Health Research, United Kingdom. Disclosure All authors have declared no conflicts of interest.

Aims and objectives: To examine, through the lens of Social Cognitive Theory, the process of change when developing a preparation programme for patients awaiting Total Knee Replacement Surgery.\ud \ud Background: Social Cognitive Theory has been used extensively in occupational psychology to explain and change human actions. It has not been widely used to examine the actions of clinical teams when developing practice.\ud \ud Design: Action research.\ud \ud Methods: Four action cycles were undertaken to develop an information booklet and multidisciplinary Knee Clinic at an acute hospital for patients waiting for Total Knee Replacement Surgery. The process of change, led by a staff and service user Project Management Group, was examined through fieldnotes, interviews, observation and a reflective diary. The data were analysed using the theoretical framework of Bandura’s Social Cognitive Theory.\ud \ud Results: The change process was influenced by personal, environmental and behavioural factors. Self-efficacy and outcomes expectations of staff and service users varied and impacted the level of their involvement in the study. Environmental factors influenced the scope of the project. The behaviour of the Project Management Group facilitated change through the development of team working and involvement in the action cycles. The results of this initiative achieved clinical changes which had not occurred during previous attempts at service development.\ud \ud Conclusion: Social Cognitive Theory is an appropriate and useful theoretical framework both for retrospective analysis and to inform planning of practice changes within the clinical setting.

Compassion has been identified as an essential element of nursing and is increasingly under public scrutiny in the context of demands for high quality health care. While primary research on effectiveness of interventions to support compassionate nursing care has been reported, no rigorous critical overview exists.To systematically identify, describe and analyse research studies that evaluate interventions for compassionate nursing care; assess the descriptions of the interventions for compassionate care, including design and delivery of the intervention and theoretical framework; and to evaluate evidence for the effectiveness of interventions.Published international literature written in English up to June 2015 was identified from CINAHL, Medline and Cochrane Library databases. Primary research studies comparing outcomes of interventions to promote compassionate nursing care with a control condition were included. Studies were graded according to relative strength of methods and quality of description of intervention. Narrative description and analysis was undertaken supported by tabulation of key study data including study design, outcomes, intervention type and results.25 interventions reported in 24 studies were included in the review. Intervention types included staff training (n=10), care model (n=9) and staff support (n=6). Intervention description was generally weak, especially in relation to describing participants and facilitators, and the proposed mechanisms for change were often unclear. Most interventions were associated with improvements in patient-based, nurse-based and/or quality of care outcomes. However, overall methodological quality was low with most studies (n=16) conducted as uncontrolled before and after studies. The few higher quality studies were less likely to report positive results. No interventions were tested more than once.None of the studies reviewed reported intervention description in sufficient detail or presented sufficiently strong evidence of effectiveness to merit routine implementation of any of these interventions into practice. The positive outcomes reported suggest that further investigation of some interventions may be merited, but high caution must be exercised. Preference should be shown for further investigating interventions reported as effective in studies with a stronger design such as randomised controlled trials.

Objectives Although older people can experience complex health and social care needs alongside a primary cancer diagnosis, little is understood about how cancer treatment decisions are made for this population. This study aimed to investigate how cancer treatment decisions are formulated for older people with complex health and social care needs and the factors that shape these processes. Design Qualitative study involving semistructured interviews and non-participant observations. Framework approach used for data analysis. Setting Breast and colorectal cancer services in five English NHS hospital trusts. Participants Interviews: purposive sample of 22 clinicians directly involved in a face-to-face clinical role with patients regarding cancer treatment and care, maximising variation across clinical roles, tumour types and trusts. Observations: purposive sample of five cancer multidisciplinary meetings, maximising variation across location, team size and tumour type. Results The initial stages of cancer treatment decision-making are team-based, medically dominated and focused on the cancer. For patients with complex health and social care needs that extend beyond cancer pathology, later and less visible stages in the decision-making process are more haphazard and may result in less effective and workable treatment plans, as individual clinicians struggle to devise and deliver these plans without breaching time-based targets. Conclusions Service targets that focus resources solely on the presenting disease can disadvantage older patients with complex health and social care needs that extend beyond this primary diagnosis. Care should be taken to ensure time-based targets do not disincentivise thorough and timely assessment that can lead to the formulation of treatment plans tailored to individual needs and circumstances.

Background People with medically unexplained physical symptoms (MUPS) are helped by interventions that combine physical and psychological explanations and treatment. Traditional acupuncture may offer such a perspective, but its use for these patients has not been investigated. Aim To ascertain how patients with MUPS perceive and experience five-element acupuncture treatment. Design and setting A longitudinal qualitative interview study, nested in a randomised controlled trial was carried out in four general practices in socioeconomically diverse areas of London. Method A purposive sample of 20 trial participants was interviewed twice, at the start and the end of 6 months of acupuncture treatment. Semi-structured interviews were transcribed, coded, and analysed thematically, summarising both across-case as themes and within-case individual vignettes. Results Acupuncture, initially accepted as ‘just another referral’ — one like many others that had been tried and proved unsuccessful — was valued for the amount of time allotted with a caring practitioner who listened and responded, as well as for the interactive and holistic nature of the sessions. These attributes encouraged many patients to take an active role in their treatment, including making cognitive or behavioural lifestyle changes. Interviewees cited a wide range of changes in their health that spanned physical, psychological, and social dimensions. These were largely positive and included an increase in physical and/or mental energy, as well as feelings of greater personal control, calmness, and relaxation. Three interviewees reported worsening health but did not ascribe this to acupuncture. Conclusion Many patients who were treated with five-element acupuncture perceived a range of positive effects and appeared to take on a more active role in consultations and self-care.

Objective: To explore older people’s and their relatives’ views on and experiences of acute health care.\ud \ud Design: Systematic procedures were used for study selection and data extraction and analysis. A comparative thematic approach to synthesis was taken with a number of features adopted from the literature on meta-ethnography.\ud \ud Data sources: Worldwide grey and published literature written in English between January 1999 and June 2008 identified from databases: CINAHL, Medline, British Nursing Index, EMBASE Psychiatry, International Bibliography of the Social Sciences, PsychINFO, and AgeInfo.\ud \ud Review methods: We conducted a systematic review and synthesis of qualitative studies describing older patients’ and/or their relatives’ experiences of care in acute hospital settings. 42 primary studies and 1 systematic review met the inclusion criteria.\ud \ud Results: A number of themes emerged. The quality of technical care is often taken for granted by older patients, and good or bad experiences are described more in terms of relational aspects of care. Older patients in hospital may feel worthless, fearful or not in control of what happens, especially if they have impaired cognition, or communication difficulties. Three key features of care consistently mediated these negative feelings and were linked to more positive experiences: “creating communities: connect with me”, “maintaining identity: see who I am” and “sharing decision-making: include me”.\ud \ud Conclusion: These findings highlight the perspectives of older people and their relatives on the delivery of personalized and dignified care in acute settings. They lend support to previous calls for relationship-centred approaches to care and provide a useful experience-based framework for practice for those involved in care for older people.