Dr Olga Kozlowska

Commentary on: Sushko K, Strachan P, Butt M, Nerenberg K, Sherifali D. Supporting self- management in women with pre- existing diabetes in pregnancy: a mixed- methods sequential comparative case study. BMC nursing. 2024 Jan 2;23(1):1.

Background: Nursing staff engage readily with patients and associates in mental health/forensic inpatient settings. These settings are known to have instances of workplace violence directed toward staff and such violence includes racism. Racism is a form of workplace violence that must be better understood and supported within this complex setting. Completing a systematic review to coalesce preexisting research and suggested interventions can be beneficial to supporting nurses. Methods: Systematic review following
PRISMA guidelines. CINAHL, PsycInfo, Medline, British Nursing Database, and Web of Science databases were searched. Reviewers screened the papers for inclusion (29 articles out of 7146 were selected for inclusion) and completed the quality appraisal using the Mixed Methods Appraisal Tool. Subsequently, data extraction was completed, and findings were summarised through narrative synthesis. Results: The way racism was conceptualised impacted how data was collected, reported, and interpreted; racism was silenced or exposed depending on how studies were undertaken. If exposed, evidence indicated racism
is a problem but is not always acknowledged or acted upon. Some evidence determined racism led to negative work-related outcomes. The literature provided limited examples of interventions. These included changing education/orientation for staff, openly discussing racist events and better planning for patients amongst colleagues and management. Conclusion: Increasing diversity within the workforce requires more research exploring and addressing issues related to racism towards nurses. Narratives of racism being normalised and embedded in mental health/forensic settings need to be challenged.

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. 

Background and objectives: People living with dementia have historically been excluded from qualitative research and their voices ignored due to the perception that a person with dementia is not able to express their opinions, preferences and feelings. Research institutions and organizations have contributed by adopting a paternalistic posture of overprotection. Furthermore, traditional research methods have proven to be exclusionary towards this group. The objective of this paper is to address the issue of inclusion of people with dementia in research and provide an evidence-based framework for dementia researchers based on the five principles of human rights: Participation, Accountability, Non-discrimination and equality, Empowerment and Legality (PANEL).

Design: This paper adapts the PANEL principles to the research context, and uses evidence from the literature to create a framework for qualitative research in people with dementia. This new framework aims to guide dementia researchers in designing studies around the needs of people with dementia, to improve involvement and participation, facilitate research development and maximize research outcomes.

Results: A checklist is presented with questions related to the five PANEL principles. These questions cover ethical, methodological and legal issues that researchers may need to consider while developing qualitative research for people with dementia.

Conclusions: The proposed checklist offers a series of questions and considerations to facilitate the development of qualitative research in patients with dementia. It is inspired by current human rights work of recognized dementia researchers and organisations who have been directly involved in policy development. Future studies need to explore its utility in improving participation, facilitating ethics approvals and ensuring that outcomes are relevant to people with dementia. ​​​​​​​

Mental health nurses working in inpatient settings are at increased risk of being assaulted by patients. Systematic reviews have synthesised predominantly quantitative evidence relating to the prevalence, contributing factors, effects and adverse outcomes of violence towards mental health nurses. This article details a systematic review that used a meta-aggregative approach to provide a synthesis of qualitative evidence on the experiences of mental health nurses who have been assaulted by patients in inpatient settings. The review found that mental health nurses consider violence against them to be a significant and unacceptable issue that can have significant and pervasive effects on their personal and professional lives. Nurses may avoid or suppress their emotions following an assault, finding it challenging to share and
report their experiences. Mental health nurses’ perceptions of factors that contribute to and can prevent violence and assault included the environment, workforce, relationships, gender and restrictive practice. By focusing on findings generated through the use of qualitative research methods, this literature review enhances the depth of existing evidence, bringing the voice of nurses who have been assaulted to current understanding.

The purpose of this paper is to examine how faculty staff on health and social care programmes  support students with mental health issues.
The study used a qualitative survey design to gain in-depth information on faculty staff experiences. Seventy-one faculty staff at two universities in the South East of England out of an eligible population of 115 staff responded to an anonymous online questionnaire which were thematically analysed.
The findings indicated that faculty staff were dealing with uncertainties in providing support to students with mental health needs. They reported tensions between their academic, professional and pastoral roles. There was a wide recognition that supporting students was physically and emotionally demanding for faulty staff and especially challenging when their roles and expectations were unclear. This was compounded by lack of explicit guidelines and an apparent severed connection between faculty staff and student support services
A need for clearly defined roles and responsibilities for faculty staff in supporting students with mental health needs including a review of their pastoral role were identified.  The study reinforces the need for effective collaborative arrangements and collective decision making and clearer procedures in the planning and implementation of students’ personal support plans. A concerted  effort into adopting a transpersonal approach which incorporates mental health staff awareness training, restorative spaces for reflection and supportive pathways for faculty staff.
This paper provides rare empirical evidence of faculty staff views on their role in supporting students with mental health needs on health and social care porgrammes.

Background:
People with intellectual disabilities are more likely to have diabetes and may require
additional support to manage it. Insulin treatment is complex and there are health
inequalities facing people with intellectual disabilities which affect optimal diabetes
management. This review aimed to identify barriers and facilitators to managing
diabetes with insulin for adults with intellectual disabilities.

Method:
PPI was integral to the development of the research question. A systemised review
was conducted across CINAHL, the British Nursing Index and MEDLINE.
Thematic analysis was used to synthesise data and PRISMA guidelines were
followed.

Results:
Barriers and facilitators to managing diabetes with insulin for people with intellectual
disabilities were identified in relation to three key themes: 1. The individual, 2. Other
people, 3. Environmental/social factors.

​​​​​​​Conclusions:
People with intellectual disabilities who use insulin, require education, support, and a
person-centred approach to facilitate supported self-management. More training for
their supporters is needed and further research is
recommended.

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.

This article describes and reflects upon ethical dilemmas encountered during the data collection phase of a doctoral study exploring the experiences of mental health nurses who have been assaulted by patients in secure settings. It considers the researcher's position as an ‘insider’ and highlights the potential for this status to influence assumptions, conflicts and decisions in relation to ethical considerations. The projection of the researcher's own emotional experience onto participants is recognised to be a significant factor, emphasising the importance of reflection and reflexivity during the process. The dilemmas discussed are situated in and influenced by the context of the COVID-19 pandemic.

The delivery of care for people with diabetes is a growing challenge with rapid growth in the numbers of people affected and increases in complexity of the management of the disease with more money being spent on diabetes than ever.

The system by which diabetes care is delivered in the UK is often fragmented and involves multiple providers across primary, community and specialist services which are managed by separate organizations, driven by different priorities, outcome measures and budgets, and supported by incompatible IT systems.

To improve the fragmentation of diabetes services, integrated care has been proposed as a solution. In essence, diabetes integration is the whole health community joining in partnership to own the health outcomes of patients with diabetes in their local area. This article examines what integration means to diabetes care, ranging from generalist to specialist diabetes care, describes the five key pillars of the integration of diabetes care and summarises key data sets which can be used.

Aims and objectives: To review interventions and strategies designed to progress UK clinical academic career pathways in nursing and identify barriers and facilitators to aid wider implementation.

Background: For over a decade, the UK political agenda has promoted the entry of nurses into clinical academic roles. Partnerships between the National Health Service and academia are known to increase nursing recruitment, retention and quality of care. However, there remains a lack of nurses working in these partnership roles.

Design: A systematised review was conducted. An electronic database search was carried out in PubMed, CINAHL, the British Nursing Database, and PsychInfo for articles published between Sept 2006 to June 2020. A narrative approach to data synthesis was used and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed.

Results: Ten papers were included in the review. The authors reported a range of programmes, pathways and toolkits. Pathway outcome measures included numbers of nurses recruited onto clinical academic programmes, clinical academic programmes completed, nursing research outputs, impact on clinical practice and impact on nursing recruitment. Barriers and facilitators to pathway development included funding, clinical and research time constraints, infrastructure, strong and strategic clinical-academic leadership and effective partnership working. The quality of the included studies was mixed; more high quality, evidence-based programmes need to be developed and rigorously evaluated. 

Conclusions: The findings can inform nursing clinical academic research pathway development internationally, by identifying key drivers for success. Sustained and cohesive implementation of clinical academic research pathways is lacking across the UK.

Background: Disparities in diabetes care are prevalent, with significant inequalities observed in access to, and outcomes of, healthcare. A population health approach offers a solution to improve the quality of care for all with systematic ways of assessing whole population requirements and treating and monitoring sub-groups in need of additional attention. Description of the care practice: Collaborative working between primary, secondary and community care was introduced in seven primary care practices in one locality in England, UK, caring for 3560 patients with diabetes and sharing the same community and secondary specialist diabetes care providers. Three elements of the intervention included 1) clinical audit, 2) risk stratification, and 3) the multi-disciplinary virtual clinics in the community. Methods: This paper evaluates the acceptability, feasibility and short-term impact on primary care of implementing a population approach intervention using direct observations of the clinics and surveys of participating clinicians. Results and discussion: Eighteen virtual clinics across seven teams took place over six months between March and July 2017 with organisation, resources, policies, education and approximately 150 individuals discussed. The feedback from primary care was positive with growing knowledge and confidence managing people with complex diabetes in primary care. Conclusion: Taking a population health approach helped to identify groups of people in need of additional diabetes care and deliver a collaborative health intervention across traditional organisational boundaries.

Purpose. Integration of health services involves multiple interdependent leaders acting at several
levels of their organisation and across organisations. This paper explores the complexities of
leadership in an integrated care project and aims to understand what leadership arrangements are
needed to enable service transformation.
Design/Methodology/Approach. This case study analysed system and organisational leadership
on a project aiming to integrate primary and specialist care. To explore the former, the national
policy documents and guidelines were reviewed. To explore the latter, the official documents from
the transformation team meetings and interview data from seventeen healthcare professionals and
commissioners were analysed using thematic analysis with the coding framework derived from
the comprehensive and multilevel framework for change.
Findings. Although integration was supported in the narratives of the system and organisational
leaders, there were multiple challenges: 1) insufficient support by the system level leadership for
the local leadership, 2) insufficient organisational support for (clinical) leadership within the
transformation team, and 3) insufficient leadership within the transformation team due to
disruptions caused by personnel changes, roles ambiguity, conflicting priorities, and insufficient
resources.
Practical implications. This study provides insights into the interdependencies of leadership
across multiple levels and proposes steps to maximise the success of complex transformational
projects.
Value. This study’s practical findings are useful for those involved in the bottom-up integrated
projects, especially the transformation teams’ members. The case study highlights the need for a
toolkit enabling local leaders to operate effectively within the system and organisational leadership
contexts. 

Services for diabetes mellitus are currently often delivered across primary, community and specialist services managed by separate organizations, driven by different priorities, outcome measures and budgets, and supported by incompatible IT systems. Integrated care has been proposed as a solution to improve the fragmentation of diabetes services. Integrated diabetes care is the coordination of services around a patient supported by integration of the health system. In essence, diabetes integration is the whole health community joining in partnership to own the health outcomes of people with diabetes in their local area. This article examines what integration means to diabetes care, ranging from generalist to specialist diabetes care.

The care of people with dementia within the hospital setting is challenging for healthcare professionals. Hospital design and services are not optimized for people with dementia, owing to the lack of preparation of healthcare professionals and the busy environment of the acute hospital. The peri-operative environment may present particular difficulties but little is known about the experience and care of people with dementia in this setting. The aim of this review was to examine the care of surgical patients who have dementia and their family members in peri-operative environments and describe strategies adopted by healthcare professionals. A systematic search of the following databases was completed: BNI, CINAHL, PubMED and PsychINFO in accordance with PRISMA guidelines. Data were extracted and analysed within a thematic analysis framework as described by Braun and Clarke. Ten papers based on eight studies were included, five (n = 355,010 participants) containing quantitative data and five reporting qualitative data (n = 395 participants). People with dementia who go undergo surgery experienced higher adverse post-operative outcomes such as respiratory problems or urinary tract infections. The key elements in surgical care for people with dementia included: health assessment throughout the surgical trajectory (pre-, intra- and post-operative) and the resources used by healthcare professionals in the peri-operative care. Healthcare professionals reported difficulties in the completion of health assessments due to the cognitive status of people with dementia and a lack of skills in dementia management. The use of restraints was still a common practice and a source of conflict. Dementia-specific training and guidelines focused on the care of surgical patients who have dementia in peri-operative environments are required to improve care and post-operative outcomes. More research is required to develop effective interventions to improve care and decrease the risk of complications for people with dementia in the peri-operative care environment.

The Local Enhanced Service (LES) is a popular commissioning tool to boost the quality of health care. Primary care providers are invited to participate in the LES and offered financial incentives. There are many LESs for Diabetes across the UK, creating opportunities for comparing their variation in content and determining best practice. However, little is known about the individual LESs and their outcomes. Calling on mostly unpublished Clinical Commissioning Groups’ documents, this paper discusses the current practice in Diabetes LESs and highlights a need for their systematic evaluation.

Many national policies propose integration between primary and specialist care to improve the care of people with long-term conditions. There is an increasing need to understand how to practically implement such service redesign. This paper reviews the literature on the barriers to, and facilitators of, integrating primary and specialist healthcare for people with long-term conditions in the UK, with the aim of informing the development and implementation of similar initiatives in integration. MEDLINE and CINAHL databases were searched and 14 articles discussing factors hindering or enabling integration were identi-fied. The factors were extracted and synthesised and key lessons were tabulated. Successful integration of care requires synchronised changes on different levels, a well-resourced team, a welldefined and evidence-based service, agreed and articulated new roles and responsibilities, and a willingness among healthcare professionals to co-work and co-learn. Barriers to successful implementation of integrated care include a lack of commitment across organisations, limited resources, poorly functioning information technology (IT), poor coordination of fi nances and care pathways, conflicting objectives, and conflict within teams. The examples of integrated working provide insights into problems and solutions around interorganisational and interprofessional working that will guide those planning integration in the future.