NHS Community Research Articles

Senior nurses' control expectations and the development of pressure ulcers.

The aim of this research was to establish whether the attitudes and expectations of senior nursing staff might adversely affect patient outcomes in the prevention of pressure ulcers. The hypothesis was that nursing locus of control affects clinical outcomes in patients. In particular, it affects departmental prevalence of pressure damage. A population of nurses (n = 439) in an acute and community NHS trust were surveyed to test knowledge, control beliefs and value of pressure ulcer prevention relative to prevalence. The research was designed to provide different data against which to test the hypothesis: first, to assess acceptability of nurses' knowledge of prevention and appropriate use of risk assessment and equipment; second, to calculate a mean departmental pressure ulcer prevalence; and third, to measure locus of control and value, which is the focus of this article. There were strong associations between departmental prevalence of pressure ulcers and attitudes of senior nursing staff. For example, the more that ward sisters believed they could control pressure ulcer prevention, the higher the prevalence of ulcers in their department. The more that sisters believed that they could not control prevalence, the lower the prevalence of ulcers. The study shows that failure to account for beliefs, values and expectations of staff could lead to patient harm. It is suggested that it might be counterproductive to put great effort into developing clinical guidelines and refinement of risk assessment methods. The findings have important implications for nursing, and challenge the assumption that nurse leaders are universally beneficial to patients.

Clinical guidelines for the promotion of continence in primary care: community nurses' knowledge, practice and perceptions of their role

Urinary incontinence is a common and debilitating problem. Its prevalence increases with advancing age, and heavy reliance on containment products results in high costs for community services, yet evidence exists that effective treatments can be provided in primary care. This quasi-experimental study compared the knowledge, practice and perceptions of their role by community nurses before (Phase 1) and after (Phase 3) the introduction of evidence-based clinical guidelines for continence care. Local guidelines were developed from nationally published guidelines and introduced into two localities of a community NHS trust (the intervention group) with a supporting educational programme during Phase 2. An audit of patient notes showed statistically significant improvements in assessment details recorded by the intervention group, and in the numbers of patients for whom a treatment plan was identified at Phase 3. Data collected from questionnaires, interviews and focus groups showed that the majority of community nurses in both the intervention and control groups believed that their role should involve the assessment and first-line treatment/management of urinary incontinence. However, limitations in their knowledge of continence care and difficulties in enhancing that knowledge base were identified. Three themes relating to role perceptions emerged from interviews, namely assessment skills, patient capacity and role restrictions. The study raises questions about what may constitute realistic expectations of role development for community nurses. Greater development of multidisciplinary teamworking, including enhancement of the link nurse role to provide co-ordination in continence care, could be a way forward.

Clinical audit in NHS acute and community trusts: a comparative analysis

Clinical audit may undergo organisational change as the new primary care trusts assume responsibility for community health services. Very little has been published, however, about community‐based audit. A survey of audit activities involving clinical audit staff was carried out in seven acute hospital trusts and seven community trusts in south east England in 1997. Audit staff completed survey forms for 65 acute projects and 75 community projects on defined topics. Managers in community trusts were much more likely to initiate audit projects or act as lead investigators than managers in the acute trusts, and they more frequently received copies of project reports. Clinical audit staff in community trusts participated more fully in the various phases of the audit process than staff in the acute trusts. If the best of the conventions for community audit practice are transferred to primary care trusts, the foundations of their clinical governance programmes should be strengthened.

Predicting length of stay in Italian Psychiatric Forensic Hospitals: a survival analysis

Admission to an Italian Forensic Hospital (OPG) results in formal exit from psychiatric care provided by NHS community based psychiatric services. The length of stay in such facilities is often perceived as a factor negatively affecting the opportunity for reintegration in the community. Factors predicting length of stay in OPG were investigated by means of a survival analysis carried out on a cohort of 118 inmates of three OPGs (Castiglione delle Stiviere, Reggio Emilia and Montelupo Fiorentino), who represent the whole forensic population from 3 different geographical areas at 30.06.97; all discharges occurred in the following 18 months were examined. In survival analyses conducted on individual predictors, five variables predicted a longer stay: type of offenses (homicide: 706.6 weeks vs. 307.1 for minor offenses and 194.7 for grievous bodily harm, log-rank = 31.8, p < 0.001), type of admission (RR = 0.98, CI 95% 0.97-0.99, p < 0.001), the diagnosis of schizophrenia (621.9 weeks vs. 398.9 weeks or less for other diagnoses; log rank = 9.08, df = 3, p = 0.028), BPRS thought disturbance score (RR = 0.89, CI 98% 0.81-0.98, p < 0.01), hospital of stay (314.6 weeks in Montelupo Fiorentino vs. 706.6 for Reggio Emilia and 621.9 for Castiglione delle Stiviere; log-rank = 9.64, df = 2, p < 0.001). In a Cox linear regression model three significant factors were selected: type of offenses stype of admission, diagnosis of schizophrenia. Judicial factors are relevant in determining the length of stay in OPG. The diagnosis of schizophrenia seems to play an independent role in predicting a longer stay.

Randomised trial of personalised computer based information for patients with schizophrenia

Objectives: To compare use, effect, and cost of personalised computer education with community psychiatric nurse education for patients with schizophrenia.Design: Randomised trial of three interventions. Modelling of costs of alternatives.Participants:...

How Do We Define ‘Best Practice’?: Seeking local professional consensus on exercise instruction for patients

Summary Background It is implicit in professional freedom that tensions will arise in professional practice between generally accepted standards of care and individual practitioners' experienced-based understanding of what constitutes ‘best practice'. The advent of clinical governance in the NHS has opened up the debate about professional standards by making management accountable, overall, for the quality of care provided by NHS trusts. A research study into the effectiveness of videotaped exercise instruction for patients with two common musculoskeletal conditions involved the participation of all practice-based physiotherapists in a single NHS community trust. We outline the rationale for the study, its setting and factors in the study design which made explicit agreement between the physiotherapists a prerequisite. In discussion with them, significant and strongly held differences in approach to exercise for the two conditions emerged, and called for a method of arriving at a consensus. Method Following a review of consensus development methods, we adopted an ad hoc approach incorporating three stages: motivating involvement; identifying and respecting diverse views; and peer-led resolution of conflict. We describe the process of developing a working consensus derived from the existing practice of the physiotherapists. Findings Although agreement sufficient to proceed with the research study was obtained, the compromises made and the limitations of the consensus achieved are recognised. Professional freedom and the individuality of patient care emerged as the issues which concerned many of the physiotherapists. Conclusion The experience of gaining consensus in this context can be related to the impending professional challenges presented by clinical governance. We review current ideas on the development and the limitations of professional consensus on ‘best practice'. For physiotherapy departments electing to lead clinical governance by attempting to develop local professional consensus on ‘best practice' for specific conditions or groups of patients, we suggest a number of strategic approaches.

Clinical supervision and support for nurses: an evaluation study

Clinical supervision and support for nurses: an evaluation study Aim. To assess the effects of clinical supervision and informal support on qualified nurses. Rationale. Earlier small‐scale research studies have provided conflicting evidence about the impact of clinical supervision, hence the need for this larger‐scale study. Design. Survey design drawing on an opportunity sample of 211 qualified nurses from 11 randomly selected hospital and community NHS Trusts in one region in England. Quantitative data collection used the Maslach Burnout Inventory (MBI) and the Nursing in Context Questionnaire (NICQ), while qualitative data were based on written critical incidents. The analysis compared supervized with unsupervized nurses. Findings. The critical incident analysis revealed that supervized nurses continued to use informal support networks as well as their supervision sessions to discuss clinical issues. The MBI found no significant differences in levels of burnout between supervized and unsupervized nurses. However, the NCIQ detected some statistically significant differences, with supervized nurses reporting a more listening and supportive management, coping better at work and feeling that they had better access to support than unsupervized nurses. Closer analysis found that this positive finding was particularly strong among the more junior supervized nurses. Conclusion. Where resources are limited, it is better to concentrate on providing clinical supervision to more junior grades of nurses as a valued form of support during their early years as qualified practitioners.

Clinical supervision and support for nurses: an evaluation study

To assess the effects of clinical supervision and informal support on qualified nurses. Earlier small-scale research studies have provided conflicting evidence about the impact of clinical supervision, hence the need for this larger-scale study. Survey design drawing on an opportunity sample of 211 qualified nurses from 11 randomly selected hospital and community NHS Trusts in one region in England. Quantitative data collection used the Maslach Burnout Inventory (MBI) and the Nursing in Context Questionnaire (NICQ), while qualitative data were based on written critical incidents. The analysis compared supervized with unsupervized nurses. The critical incident analysis revealed that supervized nurses continued to use informal support networks as well as their supervision sessions to discuss clinical issues. The MBI found no significant differences in levels of burnout between supervized and unsupervized nurses. However, the NCIQ detected some statistically significant differences, with supervized nurses reporting a more listening and supportive management, coping better at work and feeling that they had better access to support than unsupervized nurses. Closer analysis found that this positive finding was particularly strong among the more junior supervized nurses. Where resources are limited, it is better to concentrate on providing clinical supervision to more junior grades of nurses as a valued form of support during their early years as qualified practitioners.

Dementia in people with learning disability: a preliminary study into care staff knowledge and attributions

SummaryThe present paper describes the findings of a pilot study funded by the NHS Executive Primary and Community Care Research Initiative Small Projects Scheme that investigated the knowledge and attributions of dementia held by care staff who work with older adults with learning disability. Meetings took place with 21 members of care staff identified as keyworkers to older adults with learning disability living in residential houses provided by Solihull Healthcare NHS Trust, Solihull, UK. The results suggest that staff have knowledge of ageing at a similar level to that of college students. Forgetfulness was the sign that they would most expect to see if they thought someone was suffering from dementia. When a change in behaviour was attributed to dementia, it was most likely to be viewed as ‘stable, uncontrollable’ with staff feeling pessimistic about being able to change the behaviour.

The value of the facilities management function in the UK NHS community health-care sector.

This paper stresses the importance of the strategic integration of the organisational facilities management function as being an essential prerequisite towards facilities and organisational effectiveness. The impact of both the strategic and operational facilities management function on community health-care facility users is also documented. The value of the facilities management function in terms of other health-care related organisational core deliverables is also observed. Mechanisms for general organisational facilities management improvement are identified and a number of facilities management performance measuring tools outlined.

Brief Communication

Brief Communication

Reviews : Meningitis (information video). Copies can be obtained from the authors: Dr Rosemary Jones and Dr Fiona Finley, Consultant Community Paediatricians, Bath and West Community NHS Trust, Bath NHS House, Child Health Department, Newbridge Hill, Bath BA1 3QE. Telephone (01225) 731500

Reviews : Meningitis (information video). Copies can be obtained from the authors: Dr Rosemary Jones and Dr Fiona Finley, Consultant Community Paediatricians, Bath and West Community NHS Trust, Bath NHS House, Child Health Department, Newbridge Hill, Bath BA1 3QE. Telephone (01225) 731500

Clinical Governance and User Involvement

Clinical governance is high on the Government's agenda for improving quality in health and social care. It was introduced to ensure fair access to effective, prompt and high quality care for all users, regardless of geographical area. An integral aspect of this initiative is the involvement of users. This paper presents current government policy on clinical governance, a working definition and an exploration of the value of user involvement. It gives an example of establishing a strategy for user involvement, from Bedfordshire and Luton Community NHS Trust, where the first author is a non-executive member of the Trust Board. It suggests methods that occupational therapists can use to involve users in various aspects of the service. The authors propose that, for occupational therapists, the whole culture of involving users must shift from being passive to being proactive. Occupational therapists are well placed to be pioneers in this agenda and must move forward in involving users, in order to create modern, dependable and user-friendly health and social care.

Primary care professionals’ knowledge and attitudes on speech disfluency in pre-school children

Early intervention in fluency disorders such as stammering is desirable but this depends on early referral of disfluent children to speech and language therapists. The willingness to refer young disfluent children depends on, among other things, the knowledge and attitudes of primary care practitioners who are likely to be the main sources of referral. A postal questionnaire survey was carried out of all general practitioners (GPs) and health visitors (HVs) in the area of the former Highland Community NHS Trust to elicit this information. The results indicated that these professionals were more likely to refer young disfluent children to speech and language therapy if they themselves had received some post-graduate training about this disorder. More GPs than HVs were uncertain about the natural history of the disorder and about whether young disfluent children should be enrolled for therapy. GPs were more inclined to believe that there were personality traits characteristic of those who stammer and they were also more influenced by waiting lists in their decisions about referral. It would seem that some primary care professionals may have beliefs about stammering which were acquired in their training and which have not been updated. Appropriate post-graduate training seems to increase referral numbers. Training programmes that meet the needs of primary care professionals should be supported and evaluated.

The use of HoNOS in the evaluation of partial hospitalization in mental health day care

Objectives: the North Mersey Community NHS Trust commissioned an evaluation of a new partial hospitalization service following the restructuring of the mental health day units. The study was undertaken to examine the profile of people with serious mental illness and subsequent changes in in-patient admissions and duration of hospital stay.Method: baseline characteristics of the total population of day unit patients were assessed by Health of the Nation Outcome Scales (HoNOS) ratings and compared with similar populations elsewhere. A review of hospital admission statistics was undertaken.Results: total HoNOS scores reported were low in all day units, indicative of post hospital admission stability. ‘Other mental health problems’ was the highest ranked item. The mean score of 1.9 concealed a minority of people requiring further intervention to address secondary mental health needs. Admissions reduced by 4.3% and admission days by 18.9% at 6 months from the commissioning date. This might signify a small effect for partial hospitalization.Summary of findings: the findings provide a baseline for monitoring trends in the day-patient profile. Recommendations for dissemination of evidence-based practice and investment in psycho-social intervention training are identified.

Discharge and follow-up for people with stroke: what happens and why.

To assess the quality of the process of discharge from hospital and follow-up services for people with stroke. A criterion-based process audit and basic outcome measures, combined with surveys of patients' satisfaction and staff opinion of the service. All units treating stroke patients in a health care district including an acute and a community NHS trust, and 23 participating GP practices. Process audit: documented notes of 98 stroke patients admitted and discharged over a four-month period. Patient satisfaction survey: 93 surviving stroke patients. Staff opinion survey: general practitioners, hospital doctors, therapists and nurses treating stroke patients throughout the district. A poor level of service was found. The main shortcomings were poor communication and liaison and a narrow focus of rehabilitation which concentrated on the assessment and provision of basic home care and activities of daily living (ADL) required to obtain discharge. There was a paucity of provision beyond this most basic level and little follow-up after discharge. Pass rates against agreed criteria were: communication between staff and patients/carers 47%, liaison between staff 44%, assessment of home-based needs 48%, assessment of domestic skills 15.5%. Fifty-one per cent of patients were referred for follow-up therapy and of these 72% started follow-up therapy within six weeks of discharge, only 27% had any follow-up assessment of activity levels and well-being. Patients were dissatisfied with the information, support services and therapy they received. The main reasons for the shortcomings were lack of awareness of the services provided, professionals' low expectations of patients' abilities, and limitations of community-based therapy services. Evidence from other publications suggests that these results do not indicate a service that is any worse than other districts, rather it represents the poor deal offered to stroke patients. By comprehensively assessing several aspects of the service together this methodology has been able to reveal these inadequacies and the reasons for them.

The value of the facilities management function in the UK NHS community health‐care sector

This paper stresses the importance of the strategic integration of the organisational facilities management function as being an essential prerequisite towards facilities and organisational effectiveness. The impact of both the strategic and operational facilities management function on community health‐care facility users is also documented. The value of the facilities management function in terms of other health‐care related organisational core deliverables is also observed. Mechanisms for general organisational facilities management improvement are identified and a number of facilities management performance measuring tools outlined.

The Use of an Ethical Advisory Group in a Learning Disability Service

The paper examines the concept of an interprofessional ethical advisory group and the contribution which it might make towards improving care provision for people with learning disabilities. It describes briefly the policy and professional practice background and outlines the aims and functions of such a group, focusing upon that established within the Southern Derbyshire Community NHS Trust.

An audit of drug incidents in learning disability group homes.

The implementation of clinical governance (Department of Health, 1997) requires the review of practice by consideration of complaints and clinical incidents. A systematic review of the clinical incident forms in group homes for those with learning disabilities, within an NHS community trust, highlighted issues for concern. This led to an audit being conducted of drug administration procedures involving examination of records and observation of practice. It demonstrated that there was general adherence to the trust's policies. The audit stimulated debate, and a number of potential areas for action were identified. The review of drug administration with clients who have learning difficulties raised wider questions about the scarcity of evidence in this area to support practice, the culture of client-centred homes and whether monitoring systems are sufficiently robust.

Trainee satisfaction before and after the Calman reforms of specialist training: questionnaire survey

Objectives: To evaluate the impact of the Calman reforms of higher specialist training on trainee satisfaction.Design: Questionnaire surveys using portable electronic survey units, two years apart.Setting: Postgraduate, teaching, district general,...