Dr Helen Aveyard

Aim:

To explore patients’ and community nurses’ perceptions and experiences of shared decision-making in the home.

Design:

Integrative review.

Data Sources

CINAHL, British Nursing Index, Psycinfo, Medline and Social Services Abstracts were searched for qualitative, quantitative and mixed methods papers published between 1st December 2001 and 31st October 2023.

Review Methods

A systematic search of electronic databases was undertaken using defined inclusion criteria. The included papers were appraised for quality using the Joanna Briggs Institute critical appraisal checklist for qualitative research. Relevant data was extracted and thematically analysed.

Results

14 papers comprising 13 research studies were included. Patients attached great importance to their right to be involved in decision-making and noted feeling valued as a unique individual. Communication and trust between the patient and nurse was perceived as fundamental. However, shared decision-making does not always occur in practice. Nurses described a tension in managing patients’ involvement in decision-making.

Conclusion

The findings demonstrate that although patients and community nurses appreciate participating in shared decision-making within the home, there are obstacles to achieving a collaborative process. This is especially relevant when there are fundamentally different perspectives on the decision being made. More research is needed to gain further understanding of how shared decision-making plays out in practice and to understand the tensions that patients and nurses may experience.

Implications for the profession and/or patient care

This paper argues that shared decision-making is more than the development of a relationship where the patient can express their views (though of course this is important). Shared decision-making requires acknowledgement that the patient has the right to full information and should be empowered to choose between options. Nurses should not assume that shared decision-making in community nursing is easy to facilitate and should recognise the tensions that might exist when true patient choice is enabled.

Aim: to develop and explore the validity of a Patient Reported Experience Measure (PREM) for adult inpatient diabetes care. Method: 27 in-depth interviews were conducted to inform the development of the 42-item PREM which was cognitively tested with ten people. A refined 38-item PREM was piloted with 228 respondents completing a paper (n=198) or online (n=30) version. The performance of the PREM was evaluated by exploring (i) uptake/number of responses, and (ii) survey validity by investigating whether the PREM data were of adequate quality and delivered useful information. Results: the PREM had low drop-out or missing data rates suggesting it was appropriately constructed. Analysis of item frequencies and variances, and problem score calculations concluded that questions provided sufficient score differentiation. Conclusions: This new PREM allows for experiences of inpatient diabetes care to be measured, understood and reported on to help identify priority areas for improving care quality. 

Aim. 
To systematically review and synthesize primary research on experiences and needs of adult informal caregivers of adults at risk of suicide.

Design. 
Systematic review with a data-based convergent synthesis.

Data Sources. 
MEDLINE, PsychINFO and CINAHL were searched in April 2022 and February 2023. English language research focusing on experiences of adult carers of adults was included.

Methods. 
Articles were screened by title (n = 9077) and abstract (n = 132) with additional articles (n = 6) obtained via citation and hand searching. Thirty-one included studies were quality assessed using the Mixed Methods Appraisal Tool and study data were systematically extracted prior to thematic synthesis.

Results. 
Five interconnected themes resulted: transitions; living with fear and uncertainty; changing relationships; interface with healthcare professionals and services; what carers need and want. Caring impacts mental, physical and social wellbeing. Relationships are affected in ways which might not be evident when caring for a minor. Repeated suicidal behaviour is particularly challenging with ongoing hypervigilance contributing to burden, burnout and interpersonal strain. Poor carer support exacerbates negative effects; carers need to feel informed, educated, involved and holistically supported.

Conclusion. 
Timely support for carers is essential. Interventions should address emotional responses, relational changes and effective care recipient support. Longitudinal research is required to understand effects of ongoing caring where there are multiple suicide attempts.

Implications. 
Nurses can provide carers with early support and information and longer term psychosocial interventions. If carers are adequately equipped and supported patient safety and wellbeing will be improved.

Impact. 
Findings of this systematic review include relational changes due to carer hypervigilance reducing autonomy and living with the possibility of suicide. Clinician awareness of the potential for relational shifts will help them prepare and support carers.

Patient or Public Contribution. 
There was no patient or public contribution.

Background: To date, there is a wealth of evidence that patients have been invited to take an active role in prompting handwashing of hospital staff, but there is insufficient evidence on what happens in practice and whether this is acceptable to both staff and patients. Objective: To understand the role of patient involvement in the promotion of hand hygiene among nurses in the hospital setting. Methods: This qualitative interpretive study comprised of focus group discussions conducted with nurses (n = 36) and interviews with patients (n = 21). Data from nurses were analysed using inductive thematic analysis. Data from patients were analysed by critical incident analysis. Results: Experiences from nurses and patients can be summarised into 4 themes (1) both nurses and patients acknowledged the patients’ right to ask, (2) both groups reported concerns that asking about hand hygiene could have an adverse impact on the nurse-patient relationship, (3) patients reported negative reactions from nurses when promoting handwashing, and (4) patients reported that the promotion of hand hygiene was not only offensive and upsetting for nurses, but also embarrassing for patients. Conclusions: Findings from this study suggest that patients are expected to adopt a passive role in infection control and remain silent when observing non-compliance to hand hygiene within the hospital setting, to avoid being embarrassed, offensive and upsetting to nurses.

Aim. 
To explore how nurses' use of electronic health records impacts on the quality of nurse–patient interactions and communication.

Design. 
An integrative review.

Data sources. 
MEDLINE®, CINAHL®, PscyINFO, PubMed, BNI and Cochrane Library databases were searched for papers published between January 2005 and April 2022.

Review methods. 
Following a comprehensive search, the studies were appraised using a tool appropriate to the study design. Data were extracted from the studies that met the inclusion criteria relating to sample characteristics, methods and the strength of evidence. Included empirical studies had to examine interactions or communication between a nurse and patient while electronic health records were being used in any healthcare setting. Findings were synthesized using a thematic approach.

Results. 
One thousand nine hundred and twenty articles were initially identified but only eight met the inclusion criteria of this review. Thematic analysis revealed four key themes, indicating that EHR: impedes on face-to-face communication, promotes task-orientated and formulaic communication and impacts on types of communication patterns.

Conclusion. 
Research examining nurse–patient interactions and communication when nurses' use electronic health records is limited but evidence suggests that closed nurse–patient communications, reflecting a task-driven approach, were predominantly used when nurses used electronic health records, although some nurses were able to overcome logistical barriers and communicate more openly. Nurses' use of electronic health records impacts on the flow, nature and quality of communication between a nurse and patient.

Impact. 
The move to electronic health records has taken place largely without consideration of the impact that this might have on nurse–patient interaction and communication. There is evidence of impact but also evidence of how this might be mitigated. Nurses must focus future research on examining the impact that these systems have, and to develop strategies and practice that continue to promote the importance of nurse–patient interactions and communication.

Patient or Public contribution. 
Studies examined within this review included patient participants that informed the analysis and interpretation of data.

Background: Informed consent prior to nursing care procedures is an established principle which acknowledges the right of the patient to authorise what is done to him or her; consent prior to nursing care should not be assumed. Nursing care procedures have the potential to be unwanted by the patient and hence require an appropriate form of authorisation that takes into consideration the relationship between the nurse and patient and the ongoing nature of care delivery.

Research question: How do nurses obtain consent from patients prior to nursing care?.

Design: Critical incident technique and the collection of critical happenings.

Participants: 17 participants who were all qualified nurses took part in in-depth interviews.

Ethical considerations: Ethical approval was obtained from the university ethics committee.

Findings: Information giving is a key component prior to nursing care procedures. Nurses provide information to patients as a routine aspect of care delivery, and do so even when the patient is unable to communicate themselves. Whilst some participants described how information giving might be rushed or overlooked at times, it is clearly an established part of nursing care and is provided to ensure the patient knows what to expect when care is delivered. What is less clear is the extent to which information is given in order to seek the consent - rather than merely inform the patient - about nursing care.

Conclusion: Implied consent is often an appropriate way in which consent is obtained prior to nursing care procedures. It takes into account the ongoing care provision and the relationship that exists between the nurse and patient. However implied consent should not be assumed. Nurses need to ensure that information is given not only to inform the patient about a procedure but to enable the patient to give his or her consent and to find an alternative way forward if the patient withholds their consent.

Background

Antimicrobial stewardship (AMS) has traditionally been the domain of doctors and pharmacists but there is a growing recognition that successful stewardship incorporates a multidisciplinary approach that includes nursing staff. This literature review explores nurses’ perceptions of their role in antimicrobial stewardship within the hospital environment and provides new insights to inform future practice.

Methodology

An integrative literature review was undertaken. Five academic databases were searched, which identified six relevant studies. Whittemore and Knafl's method for conducting an integrative review was followed. ENTREQ guidelines have been adhered to.

Findings

Two themes were identified: nurses’ working in partnership with other professionals and engagement in education.

Discussion

Antimicrobial stewardship illustrates the role of the nurse within the wider multidisciplinary team regarding wider patient safety issues and the need for education to enhance this role.

Relevance to clinical practice

Nurses have a clear role to play in antimicrobial stewardship but need to be fully cognisant of the issues involved. Further clarity on how nurses should enact this role in their complex working environments is required. It is essential that both student and qualified nurses are able to speak up in order to maximise patient safety, fulfil their professional duty and promote the overall effectiveness of AMS if they witness poor antibiotic management practices.

Aims

To, firstly, explore student and academic nurse perceptions of classroom content about the assessment and identification of pressure injuries across skin tone diversity and, secondly, to describe the impact of classroom content on student nurse understanding of pressure injury in people with dark skin tones.

Design

Qualitative case study employing focus groups and semi-structured interviews.

Methods

Five higher education institutions in the United Kingdom were purposively chosen. At each of the five-case sites, one focus group with student nurses and one semi-structured interview with a nurse academic were conducted between May 2018 and April 2019. The participants’ narratives were transcribed verbatim and analysed via thematic analysis.

Results

Classroom learning was predominately framed through a white lens with white normativity being strongly reinforced through teaching and learning activities. This reinforcement of white normativity was evidenced through two main themes: (i) dominance of whiteness in the teaching and learning of pressure injuries in undergraduate nurse education and (ii) the impact and implications for student nurses of whiteness as the norm in pressure injury teaching.

Conclusion

Nurses responsible for the design and delivery of teaching and learning experiences for nursing students need to ensure meaningful teaching and learning experiences. This learning should assist future nurses to interrogate their complicity in a system of white dominance.

Impact

Nurse education delivered today influences and shapes nurses of the future. Nurses are the cornerstone of healthcare and play a significant role in the delivery of equitable healthcare. Nurse academics have a duty of care to inform and highlight health inequities in nursing and ultimately to enhance equity in care.

Literature reviews generally analyse and synthesis the evidence (or lack thereof) in a particular topic area and they are an increasingly popular form of scholarly activity. The scoping review is a popular literature review approach that has been adopted across the social and health sciences over the last fifteen years. With this upsurge in use, differences of opinion about how to analyse and report scoping reviews has also grown. Drawing on work carrying out a scoping review on oral health and child maltreatment, we put forward a structured approach to analysis and reporting of such reviews: the PAGER (Patterns, Advances, Gaps, Evidence for practice and Research recommendations) framework. In this article, we reflect on the strengths and limitations of the framework, drawing on examples, laying out the methodological processes, and making suggestions as to how it might improve reporting. The article makes a contribution to efforts that seek to improve the reporting and utility of scoping reviews in health and social research.

Nurses in primary care are often the first point of access for those seeking health care, and it is well known that accessing health services can be difficult for some, especially those on a low income. A charity initiative has been developed in a low-income area in England to help such individuals, wherein volunteers help local residents to access local services and support. This study explores the experiences of service users in order to understand their perceptions and feelings about the service, using an instrumental case study method with semi-structured interviews. Qualitative data were collected from six service users and transcribed by the researcher for subsequent thematic analysis. The participants' experiences were characterised by reduced social isolation, reduced emotional distress, improved mobility and transport options, improved confidence and control over life, and effective management of memory issues. Various aspects of advocacy and empowerment were also observed. Further, the coping strategies used by the participants while facing the challenges of social isolation and ageing were highlighted. The findings provide important insight into the support needs of populations on low income, the ways in which they access healthcare and how the volunteer service can best support them.

Background: Focus group discussions for data collection in nursing research has increased. Data from focus groups provides rich in-depth understanding of a phenomenon, which can inform clinical practice. Guidance on facilitating focus groups has been developed, however there is a lack of guidance on techniques of translating, analysing and presenting focus group data from countries with linguistic differences. Aim: To explore contemporary examples of translating, analysing and presenting focus group data from countries with linguistic differences and provide an in-depth example of the decision making process from one study with focus group data from two countries. Methods: A discussion paper to guide recommendations for focus group data analysis from countries with linguistic differences. Discussion: The experience from undertaking focus groups across two countries and contemporary nursing research has highlighted the need for a clear rationale and transparency in the reporting of translating, analysing and presentation of data. Detailed and transparent reporting needs to include not only the translation process, but when this occurred, either pre
or post analysis, and when or if the data was amalgamated. Implications for research/practice: There is a clear need for evidence-based guidance on the reporting of translation, transcription and analysis of focus group data from countries with linguistic difficulties.

Stories enable us to explore hidden experiences (East et al 2010) or ‘unknown unknowns’ and are a way for people who have been through illness to share their experiences (Frank 2016). Much research is dependent on human memory (Barusch 2011) and qualitative research in particular relies on people telling stories or accounts to describe their experiences (Palacios et al 2015). Nursing research especially focuses on people's experiences of health and illness (Bonis 2008). Qualitative research can inform and facilitate positive change in health research (Streubert & Carpenter 2011) and focuses on the “meaning rather than the measurement” (Holloway & Biley 2011 p.968). One of the ways meaning can be explored is through asking people about their experiences. Participants are often invited to share their stories with researchers via interviews, focus groups or other means, and their memory is crucial to communicating these. The nature of much nursing research can be described as sensitive (Dempsey et al 2016). Here again memory plays a role, participants are asked to draw on memories of experiences that may be distressing or that may raise unanticipated issues for them. These can have serious consequences and remembering these events can trigger thoughts and emotions which can lead to Post-Traumatic Stress Disorder (PTSD) (McNally 2010). As a concept, memory is rarely discussed or described within qualitative nursing research. Rather, it is taken for granted and there is little acknowledgement that memory is much more complex than a simple storage and retrieval system. A discussion of the implications of this for qualitative nursing research is therefore timely. Furthermore, specific considerations on how to support participants recalling negative or traumatic events are pertinent. 

Background. Nursing research is dedicated to improving care, but research into end of life care can be challenging because of a possible reluctance by researchers to invite bereaved people to take part in studies.

Aim. To use a focused mapping approach to explore the recruitment to studies of grieving and bereaved people.

Discussion. There is no ‘gold standard’ method of recruitment and no best way to approach participants. The outcome of each method, measured by the percentage of potential participants recruited, appears to be unrelated to the approach used.

Conclusion. There is no evidence that participation in research harms those who have recently been bereaved, but there is evidence of benefits from participating.

Implications for practice. Researchers should not feel they need to protect the bereaved from participating in research and can invite bereaved individuals to join a study without worrying about causing them harm.

Background

In this paper we discuss the emergence of many different methods for doing a literature review. Referring back to the early days, when there were essentially two types of review; a Cochrane systematic review and a narrative review, we identify how the term systematic review is now widely used to describe a variety of review types and how the number of available methods for doing a literature review has increased dramatically. This led us to undertake a review of current practice of those doing a literature review and the terms used to describe them.

Method

We undertook a focused mapping review and synthesis. Literature reviews; defined as papers with the terms review or synthesis in the title, published in five nursing journals between January 2017–June 2018 were identified. We recorded the type of review and how these were undertaken.

Results

We identified more than 35 terms used to describe a literature review. Some terms reflected established methods for doing a review whilst others could not be traced to established methods and/or the description of method in the paper was limited. We also found inconsistency in how the terms were used.

Conclusion

We have identified a proliferation of terms used to describe doing a literature review; although it is not clear how many distinct methods are being used. Our review indicates a move from an era when the term narrative review was used to describe all ‘non Cochrane’ reviews; to a time of expansion when alternative systematic approaches were developed to enhance rigour of such narrative reviews; to the current situation in which these approaches have proliferated to the extent so that the academic discipline of doing a literature review has become muddled and confusing. We argue that an ‘era of consolidation’ is needed in which those undertaking reviews are explicit about the method used and ensure that their processes can be traced back to a well described, original primary source.

This literature review was conducted to describe the range of organisations and informal groups providing peer support to personal budget users in the UK between the launch of direct payments in 1997 and 2016. Forty-five research reports included relevant evidence. This has been aggregated to show how peer networks supported individual users, as well as to describe their wider role in policy development and implementation. Despite their diversity, the support they provided often had common characteristics. Peer networks fostered collaboration, enhanced communication, built confidence amongst people who were entitled to a personal budget, and applied specialist knowledge that was often derived from the lived experience of network members. None of these characteristic was exclusive to peer networks. However, they may have been more deeply culturally embedded here than in other settings, which perhaps accounts for the positive experiences of support reported in the research literature.

Background. Assistant practitioners have knowledge and skills beyond the level of traditional support workers, and work in many clinical settings. However, some assistant practitioners lack a clearly defined role and may be under-used due to issues around accountability and uncertainty about their purpose. This paper explores the assistant practitioner role from the perspectives of assistant practitioners and registered nurses. Methods. This study aimed to explore the role of the assistant practitioner from the perspectives of assistant practitioners and registered nurses in two NHS hospital trusts in Oxfordshire, United Kingdom. Six qualitative focus groups were undertaken between February–March 2017. Ethical approval was obtained (FREC 2016/05) and written consent was provided by participants. Data was analysed thematically analysed using the Framework method. Results. Nineteen participants (assistant practitioners, n = 12; registered nurses, n = 7) were recruited using convenience sampling. Emerging themes related to ‘fluctuating roles and responsibilities of assistant practitioners’, ‘role differences between registered nurses and assistant practitioners’, ‘working relationships’, ‘supervision’ and ‘redefining nursing pathways’. The Results and Discussion sections highlight a lack of role clarity and blurring of boundaries between the roles of assistant practitioners and registered nurses, with many tasks undertaken by both. This lack of ownership of ‘nurse-specific’ roles by registered nurses was evident and clear differences were only encountered with regard to accountability. The development of the Nursing Associate role provides managers with the opportunity to redefine staff banding hierarchies to ensure that clinical staff are aware of their role capabilities and limitations and are practicing safely, whilst promoting career development and progression pathways. Conclusion. Addressing issues around role clarity can benefit professional development, satisfaction, role identity and ownership for registered nurses and assistant practitioners, by recognising the individual and collective value they bring to the clinical team. The findings can help inform the development of the Nursing Associate role.

Background. Inflammatory Bowel Disease is a chronic, untreatable condition represented by two illnesses, Crohn's and Ulcerative Colitis. Despite high incidence in well-developed industrialised countries, and the significant impact of symptoms on patient's quality of life, little is known about living with Inflammatory Bowel Disease.

Aim. To explore the patients' experiences of living with Inflammatory Bowel Disease.

Design. A qualitative systematic review.

Data sources. CINAHL, Medline, British Nursing Index and PsycINFO were searched using the following keywords: Inflammatory Bowel Disease AND experiences. We have limited the search to studies published in English from 2000 to 2017.

Review method. Thematic synthesis.

Results. Data from 23 studies, identified that fatigue, incontinence and uncertainty about future, body image, and lack of information from healthcare professionals dominated the experiences of those living with Inflammatory Bowel Disease. Also, patients living with Inflammatory Bowel Disease were reluctant to disclose their illness due to lack of public awareness and stigma surrounding symptoms. From these, an overarching theme has been identified: Living in isolation and exclusion.

Conclusion. Patients with Inflammatory Bowel Disease face a variety of problems, often their priorities and those of healthcare professionals differ greatly. Healthcare professionals have little evidence needed to provide adequate, holistic care to this group. With a rise in the Inflammatory Bowel Disease population in newly industrialised countries it is estimated that the condition is turning into a global disease, potentially making long term care unsustainable. More evidence is needed to understand the concerns of this group.