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Around 70% of people would prefer to die at home, yet around 50% die in hospital, according to Dying Matters. In collaboration with a local hospice, a literature review was undertaken to address the question: ‘what factors precipitate admission to hospital in the last few days of a person's life for those who had expressed a preference to die at home?’ Four electronic databases were searched, with a date range of 2008 to 2018. After 80 articles were screened, 13 were included in the review. The findings identified a number of barriers experienced by people with non-cancer conditions nearing the end of life and their family carers, which inhibit the transition to end-of-life care. The findings suggest that hospice support for non-cancer patients with a deteriorating health trajectory needs to precede patient and family recognition that end-of-life care is needed.

Aims and Objectives: This paper reports the findings from interviews conducted as part of a wider study on interventions to support dignified care in older people in acute hospital care. The data in this paper present the interview data. Background: Dignity is a complex concept. Despite a plethora of recommendations on how to achieve dignified care it remains unclear how to attain this in practice and what the priorities of patients and staff are in relation to dignity. \ud Design: A purposive sample of older patients and staff took part in semi-structured interviews and gave their insight on the meaning of dignity and examples of what sustains and breaches a patient’s dignity in acute hospital care. \ud Method: Thirteen patients and thirty eight healthcare professionals in a single metropolitan hospital in the UK interviewed. Interviews were transcribed verbatim and underwent a thematic analysis. \ud Results: The meaning of dignity was broadly agreed on by patients and staff. Three broad themes were identified; the meaning of dignity, staffing level and its impact on dignity, and organisational culture and dignity. Registered staff of all healthcare discipline and student nurses report very little training on dignity or care of the older person. \ud Conclusion: There remains inconsistencies in the application of dignified care. Staff behaviour, a lack of training and the organisational processes continue to result in breaches to dignity of older people. Clinical nurses have a major role in ensuring dignified care for older people in hospital.\ud Relevance to clinical practice: There needs to be systematic dignity related training with regular refreshers. This education coupled with measures to change the cultural attitudes in an organisation towards older peoples’ care should result in long term improvements in the level of dignified care. Hospital managers have an important role in changing system to ensure that staff deliver the levels of care they aspire to.

In this article, we explore how the application of organizational psychodynamic theories might improve the understanding of unconscious forces influencing apparently rational and evidence-based processes such as the generation and implementation of health policy. There is a growing body of literature using psychodynamic theories to explore discontinuities in policy-making and the containment of anxiety in organizations. In this article, we focus on the dyadic relationship between policy formation and the media/public response, in particular knee-jerk reactions that can cause ‘U’ turns in policy implementation, and the role of organizational leaders in containing public anxiety. We illustrate this using three contrasting instrumental case examples. Drawing on the seminal work of Isabel Menzies and the psychodynamic literature, we explore how anxiety is manifested in organizations and the role of public institutions as receptacles of public anxiety. We suggest that policy has a latent function of controlling objects into which public anxiety is projected and that we need to understand the sources of this anxiety if more rational policy responses are to ensue. We also explore the implications this has for policy development generally and for the role of senior managers.

Background: Dignity is a concept that applies to all patients. Older patients can be particularly vulnerable to experiencing a loss of dignity in hospital. Previous tools developed to measure dignity have been aimed at palliative and end of life care. No tools for measuring dignity in acute hospital care have been reported. \ud \ud Objectives: To develop tools for measuring patient dignity in acute hospitals.\ud \ud Setting: A large UK acute hospital. We purposively selected 17 wards where at least 50% of patients are 65 or over. \ud \ud Methods: Three methods of capturing data related to dignity were developed: an electronic patient dignity survey (possible score range 6-24); a format for non-participant observations; and individual face-to-face semi-structured patient and staff interviews (reported elsewhere). \ud \ud Results: 5693 surveys were completed. Mean score increased from 22.00 pre-intervention to 23.03 after intervention (p\ud \ud Conclusions: We have developed a simple format for a dignity survey and observations. Overall, most patients reported electronically that they received dignified care in hospital. However, observations identified a high percentage of interactions categorised as neu-tral/basic care, which, while not actively diminishing dignity, will not enhance dignity. There is an opportunity make these interactions more positive.

Background We explored the potential impact of staff opinions and service provision upon patient's willingness to recruit to a clinical trial studying the effects of extended treatment time (TT) on haemodialysis (HD), six hours versus four hours for a period of twenty-four weeks. Methods We conducted a local survey of dialysis nurses and a national survey of multidisciplinary HD staff opinions to extended TT including clinical benefits, tolerance to, prescription and ability to accommodate extended TT on in-centre HD programmes. Results The survey was completed by 56/134 (42%) local nurses and the national survey by 15/72 (21%) of dialysis providers across the UK (35% nurses and 75% other healthcare professionals). The majority of respondents felt extended TT was clinically beneficial but only 42% of nurses would recommend extended TT compared to 95% of non-nursing healthcare professionals (p < 0.0001). Although 45% of nurses felt that it was well tolerated, non-nursing healthcare professionals suggested this was significantly higher at 75% (p

Aims To identify education priorities for practice nursing across eight London Clinical Commissioning Groups (CCGs); to identify the education, training, development and support needs of practice nurses in undertaking current and future roles. Background The education needs of practice nurses have long been recognised but their employment status means that accessing education requires the support of their GP employer. This study scopes the educational requirements of the practice nurse workforce and working with educational providers and commissioners describes a coherent educational pathway for practice nurses. Method A survey of practice nurses to scope their educational attainment needs was undertaken. Focus groups were carried out which identified the education, training, development and support needs of practice nurses to fulfil current and future roles. Findings A total of 272 respondents completed the survey. Practice nurses took part in three focus groups (n=34) and one workshop (n=39). Findings from this research indicate a practice nurse workforce which lacked career progression, role autonomy or a coherent educational framework. Practice nurses recognised the strength of their role in building relationship-centred care with patients over an extended period of time. They valued this aspect of their role and would welcome opportunities to develop this to benefit patients. Conclusion This paper demonstrates an appetite for more advanced education among practice nurses, a leadership role by the CCGs in working across the whole system to address the education needs of practice nurses, and a willingness on the part of National Health Service education commissioners to commission education which meets the education needs of the practice nurse workforce. Evidence is still required, however, to inform the scope of the practice nurse role within an integrated system of care and to identify the impact of practice nursing on improving health outcomes and care of local populations.

Background The 30-Item-Birth-Satisfaction-Scale (30-item-BSS) was developed to evaluate women's experiences of childbirth. Objective To thematically analyse the qualitative responses to questions comprising the 30-item BSS questionnaire, to identify whether the qualitative responses are in anyway harmonized with experiences reported within the quantitative portion of the 30-item-BSS. Study design The focus of our enquiry was the analysis of secondary data from (n = 115) completed 30-item-BSS questionnaires in which respondents provided textual comments to the quantitative questions in order to draw separate qualitative analysis of birth satisfaction. Line-by-line thematic coding was conducted to classify each written comment into a theme. Themes representing birth satisfaction were subsequently analysed using constant comparative analysis to differentiate birth satisfaction classifications that range from high to low, Exceptional, Good, Satisfactory, Unsatisfactory. Participants The completed questionnaires (30-tem-BSS) from a convenience sample of postnatal women (< 10 days postpartum) who had delivered a healthy term infant. Findings The experiences for childbirth were ultimately classified as Exceptional for 4 women, Good for 39 women, Satisfactory for 55 women, and Unsatisfactory for 17 women. Key conclusions We found that qualitative data synchronized favorably with data from the quantitative aspect of the BSS. Implications for practice Two versions of the BSS are available: (1) The psychometrically valid and reliable 10-item-BSS from which scores can be correlated with other validated measures, and (2) The 30-item-BSS designed to assess individual women's experiences prior to in-depth qualitative work. Both scales are available from the second author.

Aim: To identify the appropriate service provider attendees of emergency departments (EDs) and walk-in centres (WiCs) in North East London and to match this to local service provision and patient choice.\ud Design: An anonymous patient survey and a retrospective analysis of a random sample of patient records were performed. A nurse consultant, general practitioner (GP) and pharmacist used the presenting complaints in the patients’ records to independently stream the patient to primary care services, non-National Health Services or ED. Statistical analysis of level of agreement was undertaken. A stakeholder focus group reviewed the results.\ud Subjects and setting Adult health consumers attending ED and urgent care services in North East London.\ud Results The health user survey identified younger rather than older users (mean age of 35.6 years – SD 15.5), where 50% had not seen a health professional about their concern, with over 40% unable to obtain a convenient or emergency appointment with their GP. Over a third of the attendees were already receiving treatment and over 40% of these saw their complaint as an emergency. Over half of respondents expected to see a doctor, one-quarter expected to see a nurse and only 1% expected to see a pharmacist across both services, although WiCs are nurse-led services. More respondents expected a prescription from a visit to a WiC, whereas in the ED a third of respondents sought health advice or reassurance.\ud Conclusion: A number of unscheduled care strategies are, or have just been, developed with the emphasis on moving demand into community-based services. Plurality of services provides service users with a range of alternative access points but can cause duplication of services and repeat attendance. Managing continued increase in emergency and unscheduled care is a challenge. The uncertainties in prospective decision making could be used to inform service development and delivery.

One aspect of the implementation of patient-centred care is the improvement of consultations between service users and practitioners, and this can be done through 'communicative action'. This article explains how observing video recordings of consultations in a walk-in centre can help service users and practitioners better understand each other's conversations and interactions.

Primary care organizations (PCOs) in the National Health Service in England and Wales are required to purchase most hospital-based health care for their populations. This ‘quasi-market’ in health care can be seen as ‘relational’, characterized by an emphasis on cooperative long-term relationships rather than on true competition. The English government has recently introduced new market mechanisms as a response to the perceived weakness of the relational market. This article draws on three qualitative case studies of PCOs to investigate whether PCO personnel interviewed in 2005/6 concurred with that perception of weakness. Overall, relationships between PCOs and hospital services providers were regarded as unbalanced in favour of the latter, despite a shared framework of central government policy. Commissioners were seen as generally weak, and providers were judged to be generally unresponsive to PCOs’ wishes. Top–down pressure by governments on PCOs and providers of hospital services was more important than commissioning power in shaping hospital services. It remains to be seen whether the remarketization strategy succeeds in strengthening the commissioning function in primary care.

This article examines the contribution of Professional Executive Committees (PECs) to Primary Care Trusts (PCTs). It looks at the balance of clinical and corporate discussions in PEC meetings, and how their contribution and functions are perceived by PEC members and other PCT personnel.

The role of boards in the public sector is unclear, particularly at a time of increased control of services by central government. This paper looks at the case of primary health care organizations, which are responsible for providing or commissioning the health care required by their local populations. Documentary analysis of board papers from 15 such organizations showed that boards are more likely to discuss `second order' functions (finance, governance, administration) than clinical and service issues. In general, they appear to avoid a challenging style in their relationships with officers. Interviews with officers and board members of three organizations found that the possibility that boards might challenge did affect how business is conducted, even though in reality challenge was rare. However, the contribution of boards outside board meetings was also valued, in the work of subcommittees, strategy planning sessions, etc. Though the boards are in no sense representative and their importance in setting strategy and monitoring performance somewhat overshadowed by central government's activity in these areas, they nevertheless do have some authority, which both checks and supports officers.

As patients increasingly care for themselves at home, they require accessible information to enable informed self-care. This article describes the development of an educational electronic application (app) designed for use by patients at risk of pressure ulcers, and their carers. The app can be downloaded to Windows, Android or Apple smartphones or tablets. The app is based on the current pressure ulcer prevention and management guidelines from the National Pressure Ulcer Advisory Panel and the National Institute for Health and Care Excellence, and is designed to educate patients and carers about how to prevent a pressure ulcer, how to recognise a pressure ulcer, and what to do if they suspect they are developing a pressure ulcer. We hope the app will be used to help with educational conversations among patients, carers and healthcare professionals.

We explored the potential impact of staff opinions and service provision upon patient's willingness to recruit to a clinical trial studying the effects of extended treatment time (TT) on haemodialysis (HD), six hours versus four hours for a period of twenty-four weeks.We conducted a local survey of dialysis nurses and a national survey of multidisciplinary HD staff opinions to extended TT including clinical benefits, tolerance to, prescription and ability to accommodate extended TT on in-centre HD programmes.The survey was completed by 56/134 (42%) local nurses and the national survey by 15/72 (21%) of dialysis providers across the UK (35% nurses and 75% other healthcare professionals). The majority of respondents felt extended TT was clinically beneficial but only 42% of nurses would recommend extended TT compared to 95% of non-nursing healthcare professionals (p0.0001). Although 45% of nurses felt that it was well tolerated, non-nursing healthcare professionals suggested this was significantly higher at 75% (p0.05). The negative impact on service provision was agreed by 83% of nurses with the need to facilitate shifts within a finite time period and pressure to find session spaces being cited.There is conflict between the understanding that extended TT is clinically beneficial and its prescriptiondelivery to patients. Enrolment to studies examining HD delivery strategies may be influenced by service provision and staff attitudes. In centre HD has been designed to maximise patient throughput and we may need to consider more flexible settings in which to deliver longer treatment time: Home HD maybe a solution.

Commentary on: Kennedy ARogers ABowen Ret al. Implementing, embedding and integrating self-management support tools for people with long term conditions in primary care nursing: a qualitative study. Int J Nurs Stud 2014;51:1103-13. Implications for practice and research Self-management support for patients with long-term conditions is not seen as a priority within the current structures and procedures of primary care nursing. The few nurses who implement aspects of self-management support have been confident enough to disrupt the prevailing system and spend time on hidden work. However, they could only initiate conversations and were not able to sustain interactions sufficiently to support lifestyle change. Supporting patients with lifestyle changes necessary to self-manage long-term conditions requires changes in primary care nursing.

This paper describes the NewCan practice framework that is designed to enable professionals from a range of agencies (health care, education, social services) to utilise evidence on risk and protective factors in child and adolescent mental heath (CAMH) in order that they can: . assess the child and family needs using a common evidence base and shared language to communicate across all agencies involved in the care of the child; . enhance local capacity to respond to the needs of these children by identify ing resources/services available locally which can enhance protective factors and reduce risk; . develop a plan of intervention shared by all agencies involved in the care of the child, including the child’s contribution and that of their family/carers to the realisation of the plan. The framework was designed to help practitioners across agencies to identify the most effective combination of universal, targeted and clinical services for each child/family and community that can be configured to respond to the risk and protective factors within the local socio-cultural context. This paper describes the development of the framework and includes some preliminary experiences from professionals and parents who have used the framework in practice.

Background. The 1990 NHS Community Care Act established a requirement for hospital discharge policies and procedures in the United Kingdom to be developed in collaboration with local government authorities in order to ensure supported discharge for those in need. Aims. The aim of the study reported in this paper was to track decisions about hospital discharge in relation to outcomes for a sample of medical patients and their carers, identified as at risk of experiencing unsuccessful discharge processes. Methods. Themed unstructured interviews were conducted in three different hospitals with 30 patients identified as at risk of unsuccessful discharge and their carers pre- and postdischarge. Hospital, community and social care staff involved in the care of the patient were also interviewed. Findings. Patients and carers were constantly negotiating their social roles, seeking to juggle appropriate identities and limited resources to maintain their own and each others’ dignity and quality of life. When the negotiation process was destabilized (for example, by exacerbation of chronic disease, withdrawal of some resource, or the experience of additional stressors – not necessarily health-related), then either or both parties sought a way out. In all the cases examined the result was admission to hospital – usually, but not always, mediated by community professionals. Conclusions. The effective discharge of patients from hospital needs to move from a functional focus on symptom management to a negotiation of quality of life that seeks to promote health for all parties involved.

Lack of funding for research capacity-building in nursing and allied health research has been a long-standing issue (Rafferty et al., 2002; Scott, 2002). More recently, limited moneys have been made available in the form of doctoral and post-doctoral awards from the Health Foundation and the Department of Health, largely to prepare nurses and allied health professionals for a career in research. However, little attention has been given to the capacity-building required for practitioners who may now have research as a core component of their work: nurse consultants and research and development nurses working in NHS and primary care trusts, for example. These practitioner researchers tend not to have previously benefited from the luxury of full-time funding and have learnt their research skills through higher education courses — Master's or part-time PhDs — or 'on the job' experience. This paper reports findings of a three-year study, the CELEC [Central and East London Education Consortium (now the North East London Workforce development Confederation)] Action Research Project: Care for Older People, that focused on the development and evaluation of seven lead R&D nurses: Care for Older People. These posts were appointed at Whitley Council (Nurse) Grade I or Research and Analogous Staff Grade II, depending on whether the lead R&D nurses preferred their contract to be with the NHS or the university. It was anticipated that the project might prepare some practitioners for a future role as nurse consultants. The paper reflects on the lessons learnt from this project, in particular the lead R&D nurses' education and support needs. Although findings mainly relate to their work as action researchers, they are likely to be of wide interest given that nurse consultants are expected to engage in this form of practice development. Action research is concerned with improving practice. It seeks to do research with and for people, rather than research on them (Meyer, 2000). It is thus ideally suited for practitioners who may, in addition to their role in research, also have responsibility for developing services. The findings may also be of interest to lecturer practitioners, who might choose to use action research as a means of facilitating work-based learning.

This paper looks at the development of logistic regression models to predict readmissions for medical patients on their initial admission to hospital. The design of our study was a retrospective analysis of a large dataset drawn from a range of secondary sources - medical, nursing, therapy and social care records. Three northern hospitals and related community health districts and social care organizations in the UK participated. Records of 1,192 patients discharged from medical wards during the period April 1992-March 1995 were analysed. Readmission within six weeks of discharge was the main outcome measure.Four logistic regression equations were produced. Three individual site equations were calculated and classification levels for readmission of 17-22 per cent were achieved. Component factors that differed in importance were age, GP contact, social services contact, marital status and living status. The weakest equation was the equation that encompassed patients from all three sites, which classified 7 per cent of readmissions. It is possible to develop equations that will explain readmission for a fifth of medical patients on admission to individual hospitals. Further exploratory work needs to be undertaken to explore reasons for differences between districts and develop more generalizable predictive equations.

This paper presents findings from a study that investigated the relationship between research and practwice on a Nursing Development Unit (NDU) in a hospital in the UK. The over-arching aim of the NDU was to promote individualised patient care. This requires the experiences and life goals of the patient, including the patient's and family construction of risk, to inform the care planning process. Two projects, undertaken by nurses on the ward, one on inpatient self-medication and the other on the management of falls, are analysed as case studies in order to address the questions: (1) How do nurses develop and research patient-centred care? (2) What are the implications of their choice of methodology in relation to their stated aims of individualising care? The paper demonstrates how conventions about research methodology and outcomes dominated the nurses' interpretation of research, the hospital research agenda and the literature on the research topics. These conventions shaped the construction of risk an...

This paper provides a description of a 'whole system' research model developed in Canada and adapted for use in the United Kingdom. The model tests the assumption that service utilization across the whole system is driven by a complex mix of psychosocial factors, rather than disease characteristics, of the population and, second, that proactive, integrated and communitybased packages of care are equally or more effective and less expensive than fragmented services. The methodology uses large-scale, cross-sectional surveys of a diverse range of population groups accessing health and social services. Data were collected on measures of psychosocial resource, functional ability and service utilization. The relationship between psychosocial resources, functional ability and service utilization is analysed. This paper describes the research model, the theories informing the model and the application of the model to two diverse population groups: patients with chronic obstructive pulmonary disease and single par...

Coping strategies used by hospitalized stroke patients: implications for continuity and management of care¶ This paper describes findings from an English study into the perceptions of multi-professional practice given by stroke patients, their informal carers and hospital staff. Unstructured interviews were conducted with nine stroke patients and eight informal carers. Case studies were developed from the interview data which formed the basis of a questionnaire designed to ascertain the aims of care for the case studies and the location of professional responsibility for meeting these aims. This was returned by 31 respondents from a range of professional backgrounds. The findings indicate that patients and carers sought out relationships with staff and other patients in order to gain information to help them understand their uncertain futures. Professional staff were reluctant to pass specific information on to patients as it might be misleading in each individual case. The uncertainty surrounding individual recovery means that supportive relationships initiated by patients and carers may need to be recognized and nurtured.

This paper discusses sampling in qualitative research, describing the principles and how different researchers have described their sampling techniques. The example of a research project in which the authors were involved ( 1 ) is used to show how a range of quantitative and qualitative sampling techniques can be combined, highlighting some of the problems. In particular, where theoretical sampling was required, we found that a systematic way of identifying theoretically useful sampling units was needed, and so a method of selection which we have called matrix sampling was devised, whereby informed and coherent choices could be made.

This paper describes the epidemiological and demographic trends underpinning the current shift to primary health care heralded by the Community Care Act. It suggests that the health service is increasingly treating people suffering from long-term disability. Hospitals no longer provide an appropriate setting for the management of long-term disability as hospital-based practitioners cannot integrate treatment modalities into the everyday life experiences of the patient. Community care introduces a social dimension to the traditional medical model of health. The paper examines the information needs generated by both the social model and the medical model of health and considers the types of information required by each model. It concludes by discussing the potential for librarians to influence health care provision via the type of information they make available to practitioners.

Background: Current projections indicate that the UK faces a 252% increase in people aged over 65 with one or more long term conditions (LTC) by 2050. Nurses, managing their own caseloads and clinics, working across sectors and organisational boundaries and as part of a wider multi-disciplinary team, are frequently seen as key to managing this growing demand. However, the evidence base informing the nursing role in managing LTC, the most effective configuration of the multi-disciplinary team and the policy evidence relating to the infrastructure required to support cross organisational working, remains weak. Objectives: To explore, identify and characterise the origins, processes and outcomes of effective chronic disease management models and the nursing contributions to such models. Design: Case study whole systems analysis using qualitative interview methods. Settings: Two community matron services, two primary care (GP) practice nursing services, two hospital based specialist nursing services were purposefully sampled from across England and Wales. Participants: Selection criteria were derived using a consensus conference. The nurses in the service, all patients and carers on the caseload, members of the multi-disciplinary team and stakeholders were invited to participate. Methods: Semi-structured interviews with all participants, thematic analysis within a whole system framework. Results: The study found high levels of clinical nursing expertise which in the case of the community matrons was meeting the aim of reducing hospital admissions. Both the primary care and hospital nurse specialist indicate similar levels of clinical expertise which was highly valued by medical colleagues and patients. Patients continued to experience fragmented care determined by diagnostic categories rather than patient need and by the specific remit of the clinic or service the patient was using. Patient data systems are still organised around the impact on services and prevalence of disease at an individual level and not around the patient experience of disease. Conclusion: Nurses are making a major contribution to meeting the policy objectives for long term conditions. Primary care nurses and hospital nurse specialists do broadly similar roles. The scope of the nursing roles and services studied were idiosyncratic, opportunistic and reactive, rather than planned and commissioned on an analysis of local population need. © 2012 Elsevier Ltd.

Background: The global response to the rise in prevalence of chronic disease is a focus on the way services are managed and delivered, in which nurses are seen as central in shaping patient experience. However, there is relatively little known on how patients perceive the changes to service delivery envisaged by chronic care models. Objectives: The PEARLE project aimed to explore, identify and characterise the origins, processes and outcomes of effective chronic disease management models and the nursing contributions to the models. Design, settings and participants Case study design of seven sites in England and Wales ensuring a range of chronic disease management models. Participants included over ninety patients and family carers ranging in age from children to older people with conditions such as diabetes, respiratory disease, epilepsy, or coronary heart disease. Methods: Semi-structured interviews with patients and family carers. Focus groups were conducted with adolescents and children. A whole systems approach guided data collection and data were thematically analysed. Results: Despite nurses' role and skill development and the shift away from the acute care model, the results suggested that patients had a persisting belief in the monopoly of expertise continuing to exist in the acute care setting. Patients were more satisfied if they saw the nurse as diagnostician, prescriber and medical manager of the condition. Patients were less satisfied when they had been transferred from an established doctor-led to nurse-led service. While nurses within the study were highly skilled, patient perception was guided by the familiar rather than most appropriate service delivery. Most patients saw chronic disease management as a medicalised approach and the nursing contribution was most valued when emulating it. Conclusions: Patients' preferences and expectations of chronic disease management were framed by a strongly biomedical discourse. Perceptions of nurse-led chronic disease management were often shaped by what was previously familiar to the patient. At a strategic level, autonomous nursing practice requires support and further promotion to wider society if there is to be a shift in societal expectation and trust in the nurse's role in chronic disease management. © 2011 Elsevier Ltd.

Background: Knowledge is recognized as a crucial organizational resource, which it has been suggested, increases in value through use. However, tensions exist between applying generalized scientific and academic knowledge to practice and incorporating local, experiential and tacit understanding in our knowledge base for practice. Knowledge management and transfer are frequently advocated as the means to increase service capacity within existing resource levels. In the NHS knowledge management and transfer tends to adopt a social constructivist approach, which favours the application of scientific evidence to practice, consequently the tacit and experiential knowledge of practitioners and service users is often excluded from formal knowledge-transfer processes. Aim: This paper describes a systematic process that was used to formalize tacit nursing knowledge in child and adolescent mental health (CAMH) and link it into the pre-existing scientific and academic literature. Method: The paper goes on to describe how this process was modified and transferred to work with parents of children referred to CAMH services. Findings: The paper illustrates the differing strands of pre-existing scientific and academic knowledge valued by nurses and parents. It highlights how involving service users in identifying scientific and academic knowledge that they find useful can focus attention on strands of pre-existing knowledge previously overlooked by professionals and service providers and thus enhance the value of this knowledge as an organizational resource. The paper also demonstrates how the tacit and experiential knowledge of nurses and services users can be transformed into more formalized knowledge, which can then be incorporated into organizational knowledge-transfer processes.

It is being increasingly recognised that nursing needs to be constructively and critically informed by a body of scientific knowledge, and that practitioners need to develop active and independent learning styles which enable them to access, use and evaluate such knowledge. This approach has led to many teachers reexamining their approaches to teaching and learning, with an increasing emphasis upon cultivating lifelong learning and in providing students with the skills to facilitate this process. It is against this backdrop that the authors developed a comprehensive information skills package for student nurses undertaking an ENB Diploma in Nursing Science/Registered General Nurse Course (ENB Pilot Scheme Course). The package was designed specifically for use within the Newcastle Polytechnic Library though with modifications, it could be used in other venues. This paper explores the rationale and structure of the package and its subsequent implementation and evaluation.

Background: Various initiatives have been tried to improve the quality of primary care in England and Wales in the last fifteen years. Such initiatives can be divided into quality improvement (QI) and quality assurance (QA). Purpose: This paper looks at three contrasting models, drawn from data from 48 semistructured interviews with personnel from three primary care organisations (PCOs): two primary care trusts in England and one Local Health Board in Wales. Findings: The first model was collegiate, a voluntary doctor-led initiative begun during the period of GP fundholding. The second is clinical governance, a current government-imposed system administered by PCO officers, which has attracted limited engagement from GPs. The third is the Quality and Outcomes Framework of the new GP contract, which was generally described positively, although the process of administering it was experienced as bureaucratic. Discussion: The three models correspond with three organisational types: networks (which use peer relationships to achieve goals), hierarchy (which use ‘top-down’ requirements and monitoring) and market (which use contracts). Although doctors have traditionally preferred network-style arrangements, the success of these arrangements in sustained QA and QI has been questionable. The importance of hierarchical arrangements is inevitable, given the functions and constitution of PCOs, and the risk that GPs will disengage is similarly inevitable. However, it is important that PCO officers find ways to engage GPs as much as possible in quality initiatives if patient services are to improve.

Susan Procter,1 Fiona Brooks,2 Patricia Wilson,3 Carolyn Crouchman,1 Sally Kendall21Faculty of Society and Health, Buckinghamshire New University, High Wycombe, UK; 2Centre for Research in Primary and Community Care (CRIPACC), University of Hertfordshire, Hatfield, UK; 3Centre for Health Services Studies, University of Kent, Canterbury, UKAim: To describe the role of school nursing in leading and coordinating a multidisciplinary networked system of support for children with asthma, and to analyze the strengths and challenges of undertaking and supporting multiagency interprofessional practice.Background: The growth of networked and interprofessional collaborations arises from the recognition that a number of the most pressing public health problems cannot be addressed by single-discipline or -agency interventions. This paper identifies the potential of school nursing to provide the vision and multiagency leadership required to coordinate multidisciplinary collaboration.Method: A mixed-method single-case study design using Yin's approach, including focus groups, interviews, and analysis of policy documents and public health reports.Results: A model that explains the integrated population approach to managing school-age asthma is described; the role of the lead school nurse coordinator was seen as critical to the development and sustainability of the model.Conclusion: School nurses can provide strategic multidisciplinary leadership to address pressing public health issues. Health service managers and commissioners need to understand how to support clinicians working across multiagency boundaries and to identify how to develop leadership skills for collaborative interprofessional practice so that the capacity for nursing and other health care professionals to address public health issues does not rely on individual motivation. In England, this will be of particular importance to the commissioning of public health services by local authorities from 2015.Keywords: leadership, multiagency, public health, school nursing, whole systems

This paper describes the development and evaluation of a nurse-led interagency community outreach service for patients with chronic obstructive pulmonary disease. The service improved the quality of life of the patients who accessed it. However, difficulties in maintaining the service arose from the historical structure of care delivery and policy frameworks.

The aim of the study was to explore and compare the development of continence services in two contrasting trusts. The first was a community trust which had initiated a top-down purchaser-led continence service. The second was a combined acute and community trust which had introduced a bottom-up, organic continence service based on staff development. The research used a qualitative, interpretative design. Evidence-based guidelines for female urinary incontinence (FUI) were analysed and key organizational features elicited. These were used to frame and analyse 20 semi-structured interviews with a range of community-based professionals who provided a service to women suffering from urinary incontinence. The interviews identified practitioner knowledge and awareness of the evidence pertaining to the management and treatment of FUI and also the features of the organizational structure of service provision in their locality which facilitated or constrained the implementation of evidence-based treatment in this area. The findings suggest that evidence-based guidelines were more closely adhered to in practice, in the trust using organic approaches to service development. Top-down, purchaser led approaches were more prescriptive and circumscribed the scope of professional practice. This adversely affected access to services for women suffering from urinary incontinence. Organic approaches to service development produce more flexible, responsive services. It is difficult, however, to integrate this approach with strategic planning as the flexibility required maybe incompatible with managerial responsibilities for defining roles and organizational functions.

This study aimed to provide an in-depth understanding of the process of hospital discharge experienced by the carers of patients ‘at risk’ of unsuccessful discharge from medical wards in three hospitals in the North of England. Background. The Community Care Act and the Carers Recognition and Services Act placed responsibility on service providers to ensure the smooth discharge of patients from hospital making sure that appropriate community services are in place to support the patient and their informal carer following discharge from hospital. The study, from which this paper is taken, identified patients at risk of unsuccessful discharge and tracked the experiences of the patient and their carer through the discharge process. For the purpose of the study unsuccessful discharge is defined as unplanned readmission within 6 weeks of discharge or extended length of stay. Design. The study combined qualitative and quantitative methods to identify factors leading to unsuccessful discharge. Logistic regression was used retrospectively with the records of 1500 patients to identify factors predicting unsuccessful discharge. A sample of medical patients predicted to be at risk of unsuccessful discharge, their formal and informal carers, were followed through the discharge process using qualitative techniques to look at decision-making and outcomes related to discharge. Findings. This paper presents findings relating to patient/carer experiences of the discharge process. It explores the obligate moral climate in which the role of carer is negotiated between professionals, patients, family members, friends and neighbours and the differing assumptions about duty associated with caring roles in hospital and in family and community settings. Conclusion. The discussion adopts a critical theory perspective to examine the contradictions confronting practitioners, patients and carers arising from hospital policies which promote cost-effective and efficient use of expensive technical resources while simultaneously seeking to identify and meet the needs of patients and carers for care.

Developing a concept analysis of control for use in child and adolescent mental health nursing The need to help children and young people with significant mental health problems develop a sense of personal control in their everyday lives, in a manner which does not endanger themselves or others, was recognized by nurse practitioners working in an English regional multidisciplinary child and adolescent mental health residential unit. A concept analysis of control was undertaken and used to develop a framework for analysing control. This deductive framework was modified iteratively by nurses who developed new knowledge from a qualitative exploration of current practice and the application of the evolving framework to practice problems. The paper describes this process and highlights three main findings: (i) the evolving attributes of the concept analysis helped nurses steer a course through the complexities of practice; (ii) the research highlighted and enabled nurses to confront the paradoxical nature of control; (iii) the process enabled nurses to recognize the mutuality of feelings aroused simultaneously when both the nurse and the child are challenged to maintain personal control.

Practice development: ambiguity in research and practice Practice development activity occupies an ambiguous position in relation to both clinical practice and research. In practice, it is seen at times as an added extra to normal work despite arguably being an inherent part of professional practice. In research, it fails to demonstrate the rigour of being generalisable because of its explicit location in a specific care environment. The study reported in this paper explored the implications of this ambiguity for practitioners who seek to develop health care practice. Ten focus groups were held with health care researchers and practitioners concerning the processes of developing practice in the North East of England. The results demonstrate how people manage themselves and the uncertainty that surrounds the use of research in clinical practice. The paper argues for an appreciation of reflexive forms of research, such as action and practitioner research, which do not disassociate research and practice and in which practitioners have a role in knowledge creation as well as knowledge implementation.

Providing a good care experience and making a difference to children and families is at the core of health visiting practice. Sonya Wallbank and Susan Procter discuss the importance of understanding what is meant by compassionate care.