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Objective: To determine the views of Avon's general practitioners about the general practice proposals within the government's white paper Working for Patients., Design: Postal questionnaire survey., Setting: A county in south west England., Subjects: All general practitioner principals (n = 537) under contract with Avon Family Practitioner Committee., Measurements and Main Results: 492 doctors (92%) responded to the survey. More than three quarters of the respondents were opposed to the government's proposals on budgets for specific surgical procedures, prescribing, and diagnostic tests; and between 63% and 93% felt negative about advantages that might accrue from the proposals. Over three quarters of general practitioners were in favour of family practitioner committees monitoring work load, prescribing, and referrals. General practitioners in large, potentially budget holding practices held similar views to doctors in smaller practices., Conclusions: Avon's general practitioners substantially reject most of the government's proposals about general practice in the white paper Working for Patients.

Background: There is growing evidence that spending time with or in nature can be beneficial for health and wellbeing. Emerging evidence suggests potential benefits for staff and service users in healthcare settings, yet little is known about how to put Nature-based approaches (NBAs) into practice within the Child and Adolescent Mental Health Services (CAMHS) setting. The CAMHS Goes Wild project in Southwest England aimed to explore the implementation of NBAs within CAMHS, examining staff attitudes and understanding to identify potential benefits and challenges through a mixed methods study., Methods: The study involved three phases of data collection: an online survey with two waves, the first wave prior to the training, and the second four months post-training, and semi-structured interviews. Data collection was designed to fit around NatureWell training, attended by sixty-four CAMHS staff, which took place alongside the study. All participants were sampled from one NHS Trust and the study was open to both those who had attended the NatureWell training and those who had not. Data were synthesised to produce an understanding of staff attitudes towards NBAs and perceived barriers and facilitators to the implementation of this approach., Results: Ninety-seven staff responded to the wave 1 survey and 57 responded to the wave 2 survey. Fourteen staff members were interviewed. Data synthesis generated three themes: Tension between the culture of CAMHS and NBAs (Theme 1) and the need for buy-in and governance support (Theme 2). Theme three described the potential benefits of NBAs for staff and service users in CAMHS and is presented in a separate paper. The first two themes are presented in this paper., Conclusions: The implementation of NBAs in mental health service settings for CYP presents both significant challenges and opportunities. Our findings suggest multiple barriers to implementation, often in the form of organisational or cultural factors, such as the risk averse nature of the service. Our work also elucidates several potential facilitators which may address or mitigate some of these barriers. These potential enablers, such as harnessing the role of firsthand experience, warrant further exploration in the implementation of NBAs in CAMHS., (© 2024. The Author(s).)

WHAT IS KNOWN ON THE SUBJECT?: Emergency departments (ED) are key settings to support and manage suicidal crisis; thus, ED staff are often the first point of contact for people in suicidal crisis. Despite this, some ED staff receive little training and/or education on how to best support such patients., What the Paper Adds to Existing Knowledge: Previous research focuses on one staffing role (e.g. triage nurses) whereas this paper includes staff working across the ED pathway. Administrative staff have often been excluded from research, despite representing a key part of the clinical pathway and being a person's initial contact with the ED. Overall findings demonstrate that staff experience a lack of confidence, training and burnout due to regularly supporting people in suicidal crisis. Staff also perceive there to be a negative ED culture, which often leads to poor attitudes towards suicidal crisis. The main challenges reported are an increase in working pressures, unavailability of resources and staff retention. Findings build upon previous research to highlight key challenges different staff face along the clinical pathway and the implications this can have on a patient's journey and follow-up care provided. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Findings are of particular importance and relevance to ED managers, and more broadly NHS England. Negative ED culture, poor staff attitudes and confidence can have a detrimental impact on both staff health and wellbeing, as well as a patient's journey throughout the ED, resulting in repeat presentations and absconding as appropriate support is not received. Policymakers need to consider staff burnout and lack of resources in mental health care strategies, and training programmes should be developed to improve culture and confidence among ED staff and managers to improve care for people attending EDs in suicidal crisis., Abstract: INTRODUCTION: Emergency departments (EDs) are often the first point of contact for people in suicidal crisis. Yet, previous work has tended to focus on only one type of staffing role, failing to account for different staff perspectives along the clinical pathway., Aims: To explore and synthesise the perspectives of ED administrative (i.e. receptionists), medical (triage nurses) and mental health staff (liaison psychiatrists) working with people presenting in suicidal crisis., Method: Qualitative study guided by thematic analysis of semi-structured interviews with 23 ED staff across six EDs in Cheshire and Merseyside, England., Results: Findings demonstrate that staff experience a lack of confidence, training and burnout due to regularly supporting people in suicidal crisis. The main challenges reported are an increase in working pressures, unavailability of resources and staff retention., Discussion: Staff felt unequipped to deal with suicide-related presentations. Organisational support is perceived to be lacking, with increased staffing pressures and poor service availability. This lack of support was linked to job dissatisfaction., Implications for Practice: Findings are of particular relevance to individual EDs and NHS England. Addressing the challenges staff are reporting can have positive implications for staff wellbeing, as well as a patient's experience and journey throughout the ED., (© 2023 The Authors. Journal of Psychiatric and Mental Health Nursing published by John Wiley & Sons Ltd.)

Background: A common factor in the abuse of people with intellectual disabilities in residential settings has been the failure of care staff and frontline managers to recognise poor practice at an early stage and prevent its development into a culture of abuse. In this context, staff understandings of abuse and poor practice in residential services for people with intellectual disabilities were explored., Method: Semi-structured interviews (n = 56) were undertaken with care staff and frontline managers working across England. Interviews included the use of vignettes, based on real-life experiences of people with intellectual disabilities, to prompt discussion., Results: Staff struggled to define either "abuse" or "poor practice", focussing more on individual acts or omissions than on institutional practices. When faced with vignettes, staff demonstrated a lack of agreement regarding what constitutes either abuse or poor practice., Conclusions: The implications for practice in residential care settings and for safeguarding training are discussed., (© 2019 John Wiley & Sons Ltd.)

Background: The demand for hospice-at-home (HH) nurses is increasing due to an ageing global population and many people preferring to die at home. Therefore, the retention of existing HH nurses is vital., Aims: This paper explores HH nurses' experiences of caring for dying patients to discover the factors that enable them to maintain their enthusiasm for their work, and cope with the challenges of working in a patient's home., Methods: This qualitative study consisted of multiple unstructured interviews with 16 HH nurses conducted in England., Findings: The interviews show that HH nurses: use a broad range of coping mechanisms; encounter intense, complex, unpredictable and ethically unclear challenges; identify a need for more support; and love their job., Conclusion: In order for nurses to continue to enjoy their job, extra support to incorporate protected time for debriefing at the end of an HH nurse's shift is needed. Nurses also need training to develop positive coping skills, external supervision on a one-to-one basis as needed, and have their value demonstrated, by their employers and managers recognising and acknowledging them. These factors are likely to facilitate in the retention of employment of HH nurses.

Background: Rising numbers of older people with obesity living in care homes is an international phenomenon. Addressing dietary management of residents with obesity is a cause of debate and controversy. On one hand, the 'obesity paradox' suggests obesity protects against morbidity in frail older people. On the other hand, obesity reduces functional status and restricts activity for this group. This paper considers care home staff's experience and views of supporting dietary management and choice for residents with obesity within the context of this controversy., Design: In this qualitative study, 33 staff from seven care homes in the North East England participated in focus groups, and data were analysed using Braun and Clarkes's (2006) six-phase thematic analysis approach., Findings: Findings indicate that participants' support of dietary management and choice for residents with obesity may be strongly influenced by the care home environment. Care priorities, dietary management approaches, care home life and family involvement in residents' dietary intake facilitate and encourage weight gain, and as such, pose challenges for staff attempting to support weight management of residents with obesity., Conclusion: Findings suggest that in the care home setting, nutrition policy, guidelines and service commissioning processes and staff nutrition education should include management of obesity. Furthermore, families should be supported to understand the implications of their own caring behaviours on residents' nutritional status., (© 2020 The Authors. International Journal of Older People Nursing published by John Wiley & Sons Ltd.)

Introduction: Mental health is a growing global concern with a significant rise in patients calling emergency services to respond to their needs. Paramedics in the UK are increasingly being asked to respond to this increase in demand., Aim: This study explores how paramedics perform in practice when managing patients experiencing mental health issues., Methods: Qualitative observation over 240 h and interviews involving 21 paramedics and 20 patients with mental illness., Results: Using Goffman's seminal text Presentation of Self to frame the analysis the findings of this study reveal that paramedics '"perform" on two stages: front stage and back stage. Their coping mechanisms, in the metaphorical sense, include props such as uniform and scripts filled with humour, stereotyping and nostalgia to aid in their management of this specialist patient group., Conclusions: Paramedics feel frustrated and unsupported when dealing with patients experiencing mental health issues. This study identifies the coping mechanisms paramedics use to manage this patient group but questions the longevity of these mechanisms and therefore recommends additional support for paramedics with further supportive education around mental health., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2019. Published by Elsevier Ltd.)

Background: Children and young people with learning disabilities experience poor health outcomes and lengthier hospital admissions than those without learning disabilities. No consistently applied, systematic approach exists across the NHS to identify and record this population. This paper describes practices in English hospitals to identify children and young people with learning disabilities., Method: Interviews: 65 NHS staff. Questionnaire: 2,261 NHS staff. Conducted across 24 NHS hospitals in England., Results: No standardized approach exists to identify children or young people with a learning disability or for this information to be consistently recorded, communicated to relevant parties within a hospital, Trust or across NHS services. Staff reported a reliance on parents to inform them about their child's needs but concerns about "flagging" patients might be a significant barrier., Discussion: Without an integrated systematic way across the NHS to identify children with learning disabilities, their individual needs will not be identified., (© 2019 The Authors. Journal of Applied Research in Intellectual Disabilities Published by John Wiley & Sons Ltd.)

WHAT IS KNOWN ABOUT THIS SUBJECT?: Burnout is a prominent issue in psychiatric nursing and associated with significant adverse consequences for staff, service users and at an organizational level. Exploration of the extent and predictors of burnout in secure settings has received little research attention. It is not fully understood why prevalence rates of burnout in forensic settings are not elevated in comparison to other settings, despite the presence of known risk-related correlates. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: In contrast to previous research, findings suggest that clinical supervision may not be an effective, stand-alone intervention to support staff experiencing burnout. Thus, the current focus on clinical supervision to mitigate burnout may be insufficient in forensic services. The ward environment (specifically how safe staff feel, how therapeutic the ward feels and how well service users relate to one another) was found to be more important than clinical supervision in terms of burnout for forensic psychiatric nursing staff. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Policies regarding staff health and well-being should be developed with due consideration given to the association between burnout and the working environment. It should not be assumed that clinical supervision is sufficient to mitigate burnout in practice. Further research assessing all types of support and the ward environment is needed to gain a better understanding of its relationship to burnout. ABSTRACT: Introduction Despite extensive research examining burnout in psychiatric nursing staff, literature exploring key predictors of burnout in secure psychiatric settings has been relatively neglected. Research has yet to explore burnout in these settings by adopting previously identified predictors such as support or the ward environment. Aim The current study aimed to reduce this gap by exploring burnout, the perceived effectiveness of clinical supervision and ward environment. Method In 2014, nursing staff working in a medium secure forensic psychiatric unit in the United Kingdom (N = 137) provided demographic information and completed the measures assessing: Burnout, clinical supervision and the ward environment. Results Approximately 10% of nursing staff could be classed as "burnt-out". The main predictors of burnout were age and ward environment. Clinical supervision had minimal association with burnout. Discussion The current study sheds doubt on clinical supervision as a potential intervention for burnout and results appear comparable to research within other settings. The implications of the ward environment, supervision and burnout are discussed herein. Implication for Practice Interventions may need to focus on a positive ward environment (including patient cohesion, experienced safety and enhancing the therapeutic atmosphere). Organizations should support younger nursing staff as they appear particularly vulnerable to burnout., (© 2019 John Wiley & Sons Ltd.)

The PREVENT policy introduced a duty for British health professionals to identify and report patients they suspect may be vulnerable towards radicalisation. Research on PREVENT's impact in healthcare is scant, especially on the lived experiences of staff. This study examined individual interviews with 16 critical National Health Service (NHS) professionals who participated in mandatory PREVENT counter-radicalisation training, half of whom are Muslims. Results reveal two themes underlying the self-censorship healthcare staff. The first theme is fear, which critical NHS staff experienced as a result of the political and moral subscript underlying PREVENT training: the 'good' position is to accept the PREVENT duty, and the 'bad' position is to reject it. This fear is experienced more acutely by British Muslim healthcare staff. The second theme relates to the structures which extend beyond PREVENT but nonetheless contribute to self-censorship: distrustful settings in which the gaze of unknown colleagues stifles personal expression; reluctant trainers who admit PREVENT may be unethical but nonetheless relinquish responsibility from the act of training; and socio-political conditions affecting the NHS which overwhelm staff with other concerns. This paper argues that counter-terrorism within healthcare settings may reveal racist structures which disproportionality impact British Muslims, and raises questions regarding freedom of conscience.

This paper explores prisoner and staff views of the current smoking policy in English and Welsh prisons (a partial ban permitting smoking in prison cells) and gauges perceptions of the implications of the forthcoming policy change which will see a total smoking ban within all parts of the institution. Five focus group discussions in one medium security male prison in England were undertaken. Three focus groups were undertaken with prisoners (both smokers and non-smokers) and two focus groups with staff. The findings suggest that smoking is embedded in the fabric of prison life and serves several functions, including alleviating anxiety in prisoners. The current smoking policy was perceived as being a fair policy that both supported smoking and non-smoking prisoners. There were concerns, however, that a total smoking ban would have adverse outcomes for prisoners and staff, including deleterious effects on mental health and the potential for violence. The paper concludes by suggesting that the incoming policy, which sees a total smoking ban in prisons, is laudable, but this research suggests that without careful implementation there may be adverse health and organisational outcomes.

Objective: To explore the transition from midwifery one-to-one support in labour within a midwife-led birth environment to an obstetric-led unit from the perspectives of midwives and women., Design: Ethnographic study. Data was collected from eleven transfers to an obstetric-led unit. The transfer process was observed for four women. Semi-structured interviews were completed following the births with eleven women and eleven midwives. Nine maternity records were also analysed., Setting: An alongside midwife-led unit, freestanding midwife-led unit, women's homes in England., Findings: Territorial behaviour was the main theme experienced by midwives when transferring women to obstetric-led units. Territorial behaviour manifested itself as a feeling of 'us versus them' behaviours, 'feeling under scrutiny' and being aware of 'conflicting ideologies'. For women there were four themes that had an impact on their experiences of transfer obstetric-led units including: (1) their midwife continuing the care on the labour ward, (2) having time to adjust to their new situation, (3) all staff introducing themselves and (4) not being separated from their baby for long periods of time., Conclusion and Implications for Practice: Transfer from a midwife-led birth environment to an obstetric-led unit is a stressful situation for midwives and women. This paper highlights how territorial behaviours impacted negatively for midwives during transfer to an obstetric-led unit. More research is required to understand territorial behaviours within the maternity services and how more respectful compassionate working relationships can be created. Additionally, from the perspective of women this paper highlights four aspects of care that positively impacted on the experiences of women and even helped them to build resilience to cope with the change of location, situation, medical interventions and new carers when transferring to an obstetric-led unit., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Considerable international governmental support is focused on the timely diagnosis of dementia and post-diagnostic care of people with dementia. Identifying those at high risk of dementia is one approach to timely diagnosis. General practitioners (GPs) are well-placed clinicians in the community to provide both pre- and post-diagnostic dementia care. However, GPs have in the past consistently demonstrated low confidence in both diagnosing dementia and providing care for these complex patients particularly for patients in the post-diagnostic phase. It is currently unclear how future GPs view dementia care. We aimed to evaluate the current attitudes and experiences of future GPs in dementia care and their views on targeting high risk groups. All (n = 513) GP trainees were approached by email to participate in a cross-sectional web and paper-based survey in the North of England. A further reminder was sent out two months after the initial invitation. We received 153 responses (29.8% response rate, 66.7% female, average age 31 (range 25-55 years old). The main difficulties encountered included coordinating supporting services for carers and the person with dementia and responding to co-existing behavioral and psychiatric symptoms. Further education in dementia management was considered to be important by respondents. GP trainees were generally very positive about their future role in caring for people with dementia, particularly in the area of earlier diagnosis via identification of high-risk individuals. Future GPs in one area of England are very positive about their key role in dementia care. In order to facilitate the delivery of high quality, community-based care, work is required to establish core post-diagnostic dementia support services. Further research is needed to identify effective systems to enable accurate assessment and to ensure earlier diagnosis in high-risk groups.

In this paper, we test path models that study the interrelations between primary health care provider attitudes towards working with drinkers, their screening and brief advice activity, and their receipt of training and support and financial reimbursement. Study participants were 756 primary health care providers from 120 primary health care units (PHCUs) in different locations throughout Catalonia, England, The Netherlands, Poland, and Sweden. Our interventions were training and support and financial reimbursement to providers. Our design was a randomized factorial trial with baseline measurement period, 12-week implementation period, and 9-month follow-up measurement period. Our outcome measures were: attitudes of individual providers in working with drinkers as measured by the Short Alcohol and Alcohol Problems Perception Questionnaire; and the proportion of consulting adult patients (age 18+ years) who screened positive and were given advice to reduce their alcohol consumption (intervention activity). We found that more positive attitudes were associated with higher intervention activity, and higher intervention activity was then associated with more positive attitudes. Training and support was associated with both positive changes in attitudes and higher intervention activity. Financial reimbursement was associated with more positive attitudes through its impact on higher intervention activity. We conclude that improving primary health care providers' screening and brief advice activity for heavy drinking requires a combination of training and support and on-the-job experience of actually delivering screening and brief advice activity.

Background: Sub-optimal adoption of evidence based practice by primary health care professionals (PHCPs) is affecting the health of people with chronic obstructive pulmonary disease (COPD). This paper shows how 'patient stories' were used to engineer professional and organisational change., Methods: 'Stories' were transmitted via a pre-planned question and answer session involving patients and carers. The impact on PHCPs' attitudes and behaviour was explored through observing the session, open-text questionnaires completed by the PHCPs at the end of the session and clinician interviews., Findings: The stories about living with COPD, told by patients and their carers, were found to be an innovative and powerful way to impact PHCPs' attitude and behaviour. Strong motivational context was created, in which clinicians were able to see the relevance of learning through active engagement with real people., Conclusion: Long term conditions such as COPD have long term implications for the daily lives of patients and their carers. Hearing about these consequences in 'the first person' is an influential training tool with a powerful impact on PHCPs' attitudes and behaviour.

This international comparative paper examines how child protection workers in four countries, England, Finland, Norway, USA (CA), involve children in decision making regarding involuntary child removal. The analysis is based on 772 workers' responses to a vignette describing preparations for care order proceedings. We examine children's involvement along three dimensions including information given to the child, information gathered from the child, and opportunities for their perspectives and interests to be considered. Results show that child protection workers weigh children's involvement differently based upon age. Staff in the four countries were more likely to talk with an older child, to provide information, to gather information, and to include in relevant decision making if the child were 11 compared to five in our vignette. Although the Nordic countries and England provide policy guidance regarding children's role in child protection decision making, we did not see consistently higher indicators of children's involvement from the respondents in these countries. Using child protection system frames to analyze the findings did not produce consistent differences between the family service systems and child protection systems included in this study. Findings highlight the wide range in practices concerning children's involvement in decision making, and the wide space for professional discretion in implementing practice with children at the local level., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: Globally, smoking remains a significant issue for mental health populations. Many mental health trusts in England are facing challenges of implementing the National Institute for Health and Care Excellence guidance according to which all mental health settings, no matter the type, should be entirely smoke-free and provide comprehensive smoking cessation support., Aim: The aim of this paper was to determine if unit type and unit manager smoking status influence mental health smoke-free policy implementation., Method: This paper reports on the secondary analysis of data from a cross-sectional survey of 147 mental health inpatient settings in England, in 2010. The original study's main aim was to understand unit managers' perceived reasons for success or failure of smoke-free policy., Results: Unit managers (n = 131) held a positive stance towards supporting smoke-free policy and most perceived that the policy was successful. Non-smoker unit managers were more likely to adopt complete bans than smoker unit managers, whereas smoker unit managers were more likely than non-smoker unit managers to think that stopping smoking aggravated patients' mental illness. Smoking rates for staff and patients remain high, as perceived by unit managers, regardless of unit type. Proportion of units offering nicotine replacement therapy and peer support to patients was significantly higher in locked units compared to semi-locked or residential rehabilitation. Applied strategies significantly vary by type of unit, whereas unit managers' knowledge, attitude and practices vary by their smoking status., Discussion: There are nuanced differences in how smoke-free policy is enacted which vary by unit type. These variations recognise the differing contexts of care provision in different types of units serving different patient groups. Addressing staff smoking rates, promoting consistency of staff response to patients' smoking and providing staff education and support continue to be key strategies to successful smoke-free policy., Conclusions: Our results demonstrate the importance of taking into account the type of unit and acuity of patients when enacting smoke-free policy and addressing staff smoking., (© The Author(s) 2015.)

The difficulties faced in the recruitment and retention of nursing staff in nursing homes for older people are an international challenge. It is therefore essential that the causes of nurses' reluctance to work in these settings are determined. This paper considers the influence that multiple-source care funding issues have on nursing home nurses' experiences and views regarding the practice and appeal of the role. The methodology for this study was hermeneutic phenomenology. Thirteen nurses from seven nursing homes in the North East of England were interviewed in a sequence of up to five interviews and data were analysed using a literary analysis method. Findings indicate that participants are uncomfortable with the business aspects that funding issues bring to their role. The primary difficulties faced are: tensions between care issues and funding issues; challenges associated with 'selling beds'; and coping with self-funding residents' changing expectations of care. The findings of the study suggest that multiple-source care funding systems that operate in nursing homes for older people pose challenges to nursing home nurses. Some of these challenges may impact on their recruitment and retention., (© 2014 John Wiley & Sons Ltd.)

Background: This paper presents the findings of a study exploring the impact of a values-based training initiative on the practice of mental health workers. This work is set within the context of increasing attention on the values of nurses and other health care workers as a response to national reports on care failure and negative media attention., Objective: To examine written response feedback from participants on a national training programme for values-based practice (VBP) in order to examine any intention to change practice., Design: A national evaluation using quantitative and qualitative methodologies was conducted to gather data on reflections and self-report impact of the Ten Essential Shared Capabilities' training programme., Setting: The training was delivered in a range of hospital, community and third sector training programmes across eight regions in England., Participants: The participants were predominantly nurses but all sectors in the mental health community including service users as co-facilitators and participants were represented., Methods: This study presents the qualitative findings from a cross-sectional survey. Using NVIVO 10 software, data were analysed using the framework method of qualitative analysis., Results: Four principal themes emerged from the data'Thinking differently''Changes to practice''Creating an effective learning environment and skills for practice development' and 'Increasing self-awareness'., Conclusions: The quality and safety drive in the NHS has an emphasis on delivery of evidence based practice. It was concluded that an active focus on values based practice merits equal attention and status., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: The perspectives and experiences of trial staff are increasingly being investigated as these can be used to improve recruitment, adherence to trial protocols and support given to future staff. We interviewed staff working on a type 1 diabetes trial in order to aid interpretation of trial findings, inform recommendations for the rollout of the treatments investigated and provide recommendations for the conduct of future trials. However, our interviews uncovered aspects of trial work erstwhile unrecognised or underreported in the trials literature, and it is these which form the focus of this paper., Methods: In-depth interviews were conducted with (n = 18) staff, recruited from seven centres, who were involved in recruitment and trial delivery. Data were analysed thematically., Results: Alongside logistical and practical issues which made trial work challenging, staff often talked spontaneously and at length about how trial work had affected them emotionally. Staff not only described the emotional stresses arising from having to meet recruitment targets and from balancing research roles with clinical responsibilities, they also discussed having to emotionally manage patients and their colleagues. The emotional aspects of trial work particularly came to the fore when staff notified patients about their treatment allocation. On such occasions, staff described having to employ emotional strategies to pre-empt and manage potential patient disappointment and anger. Staff also described having to manage their own emotions when patients withdrew from the trial or were not randomised to the treatment arm which, in their clinical judgment, would have been in their best interests. To help address the emotional challenges they encountered, staff highlighted a need for more practical, emotional and specialist psychological support., Conclusions: More attention should be paid to the emotional aspects of trial work to help ensure trial staff are adequately supported. Such support could comprise: increased training for staff to improve their own and patients' understandings of randomization, role-play to develop techniques to manage patient anger and disappointment, sharing of good practice, formalised team support with psychological input and access to specialist psychological support to troubleshoot complex emotional and ethical issues.

Background: Case management has been suggested as a way of improving the quality and cost-effectiveness of support for people with dementia. In this study we adapted and implemented a successful United States' model of case management in primary care in England. The results are reported elsewhere, but a key finding was that little case management took place. This paper reports the findings of the process evaluation which used Normalization Process Theory to understand the barriers to implementation., Methods: Ethnographic methods were used to explore the views and experiences of case management. Interviews with 49 stakeholders (patients, carers, case managers, health and social care professionals) were supplemented with observation of case managers during meetings and initial assessments with patients. Transcripts and field notes were analysed initially using the constant comparative approach and emerging themes were then mapped onto the framework of Normalization Process Theory., Results: The primary focus during implementation was on the case managers as isolated individuals, with little attention being paid to the social or organizational context within which they worked. Barriers relating to each of the four main constructs of Normalization Process Theory were identified, with a lack of clarity over the scope and boundaries of the intervention (coherence); variable investment in the intervention (cognitive participation); a lack of resources, skills and training to deliver case management (collective action); and limited reflection and feedback on the case manager role (reflexive monitoring)., Conclusions: Despite the intuitive appeal of case management to all stakeholders, there were multiple barriers to implementation in primary care in England including: difficulties in embedding case managers within existing well-established community networks; the challenges of protecting time for case management; and case managers' inability to identify, and act on, emerging patient and carer needs (an essential, but previously unrecognised, training need). In the light of these barriers it is unclear whether primary care is the most appropriate setting for case management in England. The process evaluation highlights key aspects of implementation and training to be addressed in future studies of case management for dementia.

Background: Assessing the cultural competence of medical students that have completed the curriculum provides indications on the effectiveness of cultural competence training in that curriculum. However, existing measures for cultural competence mostly rely on self-perceived cultural competence. This paper describes the outcomes of an assessment of knowledge, reflection ability and self-reported culturally competent consultation behaviour, the relation between these assessments and self-perceived cultural competence, and the applicability of the results in the light of developing a cultural competence educational programme., Methods: 392 medical students, Youth Health Care (YHC) Physician Residents and their Physician Supervisors were invited to complete a web-based questionnaire that assessed three domains of cultural competence: 1) general knowledge of ethnic minority care provision and interpretation services; 2) reflection ability; and 3) culturally competent consultation behaviour. Additionally, respondents graded their overall self-perceived cultural competence on a 1-10 scale., Results: 86 medical students, 56 YHC Residents and 35 YHC Supervisors completed the questionnaire (overall response rate 41%; n= 177). On average, respondents scored low on general knowledge (mean 46% of maximum score) and knowledge of interpretation services (mean 55%) and much higher on reflection ability (80%). The respondents' reports of their consultation behaviour reflected moderately adequate behaviour in exploring patients' perspectives (mean 64%) and in interaction with low health literate patients (mean 60%) while the score on exploring patients' social contexts was on average low (46%). YHC respondents scored higher than medical students on knowledge of interpretation services, exploring patients' perspectives and exploring social contexts. The associations between self-perceived cultural competence and assessed knowledge, reflection ability and consultation behaviour were weak., Conclusion: Assessing the cultural competence of medical students and physicians identified gaps in knowledge and culturally competent behaviour. Such data can be used to guide improvement efforts to the diversity content of educational curricula. Based on this study, improvements should focus on increasing knowledge and improving diversity-sensitive consultation behaviour and less on reflection skills. The weak association between overall self-perceived cultural competence and assessed knowledge, reflection ability and consultation behaviour supports the hypothesis that measures of sell-perceived competence are insufficient to assess actual cultural competence.

This article aims to reflect on handovers that take place in respite settings-a healthcare setting with little mention in the literature. The author presents a reflective account of the practice of handover in one respite unit in south-east England. As these are the author's own observations and experience, no reflective model has been used as a guide. The article also reports on the findings of a small web-based survey conducted by Facebook and email contacts that aimed to understand the attitudes of health professionals, mainly from the respite-care setting, towards the practice of clinical handover. The findings showed that handover is an important part of safer care practice and is highly valued by the respondents as being a planning and organising mechanism for better management of shifts. This paper concludes by raising awareness of the lack of information available about the practice of clinical handover in respite settings. It also suggests the need for an in-depth study on handover practice in respite care.

Background: The study aimed to explore the views of general practitioners (GPs), nurses and physiotherapists towards extending the role of sickness certification beyond the medical profession in primary care., Methods: Fifteen GPs, seven nurses and six physiotherapists were selected to achieve varied respondent characteristics including sex, geographical location, service duration and post-graduate specialist training. Constant-comparative qualitative analysis of data from 28 semi-structured telephone interviews was undertaken., Results: The majority of respondents supported the extended role concept; however members of each professional group also rejected the notion. Respondents employed four different legitimacy claims to justify their views and define their occupational boundaries in relation to sickness certification practice. Condition-specific legitimacy, the ability to adopt a holistic approach to sickness certification, system efficiency and control-related arguments were used to different degrees by each occupation. Practical suggestions for the extension of the sickness certification role beyond the medical profession are underpinned by the sociological theory of professional identity., Conclusions: Extending the authority to certify sickness absence beyond the medical profession is not simply a matter of addressing practical and organisational obstacles. There is also a need to consider the impact on, and preferences of, the specific occupations and their respective boundary claims. This paper explores the implications of extending the sick certification role beyond general practice. We conclude that the main policy challenge of such a move is to a) persuade GPs to relinquish this role (or to share it with other professions), and b) to understand the 'boundary work' involved.

Purpose: The purpose of this paper is to engage stakeholders in the development of a community based chronic pain-management service and identify their different agendas for service design and delivery., Design/methodology/approach: Data were collected using the Nominal Group Technique (NGT), a ten-step process that generates qualitative and quantitative data. Seven NGT groups were conducted in the south-west region of the UK, three with General Practitioners and nurses, three with chronic pain patients, and one with Healthcare Commissioners., Findings: The patient agenda for service development focused on process of care issues particularly the need for deep- empathy and emotional support from providers, while professionals prioritised cost-effectiveness. While there was some overlap between agendas they were largely discrete and often contradictory., Research Limitations/implications: - The findings imply service planners will need to make trade-offs between cost-containment and patient satisfaction. The methodology did not allow trade-offs to be put to participants in a structured form. However, such techniques are available, for example, Conjoint Analysis. There may also be value in bringing together patients and professionals in joint focus groups, to see if the gap between their different agendas can be bridged through discussion., Originality/value: The findings provide a novel insight into the competing agendas of patients and professionals regarding service development and design which will be of value to service planners and managers as they strive to reconcile these differences.

Objective: The objective of this paper was to explore some of the specific strategies used by midwife mentors to mediate practice learning from the perspective of a sample of student midwives., Design: Audio-diaries were completed by student midwives over ten days in practice and were transcribed using discourse analysis. A sub-sample from 19 students' learning diaries from a national midwifery education study conducted by Pope et al. (2003) has been selected as the diaries informed a separate study., Participants: The sample of student midwives were studying on degree and diploma programmes at five case study sites in England., Main Findings: Students described how their mentors apparently successfully tailored their teaching to the students' needs. However, there was perceived disparity in techniques used by individual mentors to pass on their practice know-how. The findings demonstrate the pivotal role of the mentor for 'scaffolding' learning and also using 'fading' techniques within a cognitive apprenticeship model., Key Conclusions and Implications for Practice: Mentors need assistance to adapt their mentoring styles and to use a wider range of instruction strategies for student midwives. This has practical implications for mentor preparation programmes and mentorship models., (Crown Copyright © 2012. Published by Elsevier Ltd. All rights reserved.)

This paper reports on a study that explored the perceptions of students and lecturers regarding support within a pre-registration midwifery programme in one Higher Education Institution in England. A mixed method design was used: questionnaires were completed by first year and third year students and lecturers, complemented by focus groups with each of the three sets of participants. The findings showed that there are multi-focal challenges for student midwives in undertaking their programme of study. The main theme that emerged was of the difficulties involved in maintaining an appropriate work-life balance, especially within what was seen as a relatively inflexible programme structure. The value of peer support was also highlighted as a key factor in helping the students succeed in their studies. There were a number of implications for midwifery educators to consider in optimising support for students. These include ensuring that students have realistic expectations at the outset of their studies, formalising peer support mechanisms and reviewing programmes to provide more flexibility to better underpin the maintenance of an appropriate work-life balance. Further study is warranted to explore perceptions of support in practice and to identify the factors that help students to persevere in their studies., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: Research on staffed housing for people with intellectual disability has identified the challenges in achieving postitive quality of life outcomes. However, a less well considered dimension of such services is that they are places of living and dying. This paper looks at the experiences of staff in dealing with issues of death and dying., Method: In depth qualitative interviews were held with 22 staff in 5 different providers and who had experienced, in total, 27 deaths of people with intellectual disability., Results: The data highlight that staff felt providing a good quality of care at the end of life was an important but unrecognised dimension of their work. This work could be broken down into several different phases, dying, death and beyond death. Bad deaths were felt to be those deaths which prevented staff from 'being there' with individuals over those phases., (© 2013 Blackwell Publishing Ltd.)

Aim: To undertake a service evaluation of the NHS East of England Supporting Self-Care in General Practice programme., Background: The number of people purported to live with long-term conditions continues to rise generating increasing policy emphasis on the importance of self-care. Previous work has highlighted barriers to implementing self-care interventions in general practice, including a lack of organisational approaches to providing self-care and limited engagement and training of healthcare professionals. In response to these barriers and policy drivers, NHS East of England Strategic Health Authority developed and commenced the Supporting Self-care in General Practice (SSCiGP) programme, which seeks to transform the relationships between people with long-term conditions and primary care practitioners., Methods: This was a mixed methods study, carried out over two phases, which included interviews, survey work and practice-based case studies., Results: This paper focuses on findings related to clinician and practice level change. Clinicians reported changes in their perceptions and in consultation practices following attendance on the SSCiGP programme. These changes were linked to empathy and patient-centredness that mirrored what patients valued in interactions with clinicians. There were qualitative and descriptive differences, but no statistically significant differences between clinicians who had and had not attended the SSCiGP programme. Time was recognised as a significant barrier to implementing, and sustaining skills learnt from the SSCiGP programme. Greater impact at practice level could be achieved when there was whole practice commitment to values that underpinned the SSCiGP programme. There was evidence that such approaches are being incorporated to change practice systems and structures to better facilitate self-care, particularly in practices who were early programme adopters., Conclusion: This evaluation demonstrates that training around clinician change can be effective in shifting service delivery when sat within a cultural framework that genuinely situates patients at the centre of consultations and practice activity.

Purpose: The language used by National Health Service (NHS) "commissioning" managers when discussing their roles and responsibilities can be seen as a manifestation of "identity work", defined as a process of identifying. This paper aims to offer a novel approach to analysing "identity work" by triangulation of multiple analytical methods, combining analysis of the content of text with analysis of its form., Design/methodology/approach: Fairclough's discourse analytic methodology is used as a framework. Following Fairclough, the authors use analytical methods associated with Halliday's systemic functional linguistics., Findings: While analysis of the content of interviews provides some information about NHS Commissioners' perceptions of their roles and responsibilities, analysis of the form of discourse that they use provides a more detailed and nuanced view. Overall, the authors found that commissioning managers have a higher level of certainty about what commissioning is not rather than what commissioning is; GP managers have a high level of certainty of their identity as a GP rather than as a manager; and both GP managers and non-GP managers oscillate between multiple identities depending on the different situations they are in., Originality/value: This paper offers a novel approach to triangulation, based not on the usual comparison of multiple data sources, but rather based on the application of multiple analytical methods to a single source of data. This paper also shows the latent uncertainty about the nature of commissioning enterprise in the English NHS.

Purpose: The purpose of this paper is to report the findings from an evaluation project conducted to investigate the impact of two staff engagement programmes introduced to four National Health Service (NHS) hospital Trusts in England. It seeks to examine this development in the context of current policy initiatives aimed at increasing the level of staff involvement in decision-making, and the related literature., Design/methodology/approach: A mixed-methods approach incorporating document analysis, interviews, a survey and appreciative inquiry, informed by the principles of impact evaluation design, was used., Findings: The main finding to emerge was that leadership was crucial if widespread staff engagement was to be achieved. Indeed, in some of the trusts the staff engagement programmes were seen as mechanisms for developing leadership capability. The programmes had greater impact when they were "championed" by the Chief Executive. Effective communication throughout the organisations was reported to be a prerequisite for staff engagement. Problems were identified at the level of middle management where the lack of confidence in engaging with staff was a barrier to implementation., Practical Implications: The nature of the particular organisational context is crucial to the success of efforts to increase levels of staff engagement. The measures that were found to work in the trusts would need to be adapted and applied to best meet the needs of other organisations., Originality/value: Many health care organisations in England will need to harness the efforts of their workforce if they are to meet the significant challenges of dealing with financial restraint and increasing patient demand. This paper provides some insights on how this can be done.

Since 1974 the National Health Service (NHS) has been subject to successive reorganisations which have shaped and reshaped patterns of administration, clinical care and services. This paper uses two sources of oral evidence: a Witness Seminar with a group of administrators who attended the NHS National Administrators' Training Scheme in the late 1950s and a collection of interviews with doctors and managers who have played key roles in the health services of Manchester and Salford between 1974 and 2007. It surveys the day-to-day interactions between doctors and administrators/managers in hospital settings and analyses what these reveal about relationships within the broader context of shifting organisational structures and management styles. It suggests that the evidence challenges the historical stereotyping of the two groups and that strong working relationships have been determined as much by the values of respect and association as by changes to structures or management styles.

Background: A respiratory distress symptom cluster has recently been identified in lung cancer associated with breathlessness, cough and fatigue, and the study reported here is part of a wider body of work being undertaken to develop a novel non-pharmacological intervention (NPI) for the management of this symptom cluster. The current paper reports the views of health care professionals (HCPs) involved with cancer care regarding the most appropriate ways of developing and delivering such a novel intervention., Methods: Five focus groups, supplemented with additional telephone interviews, were conducted with a range of both community- and acute-based HCPs involved in symptom management for lung cancer patients. Participants included oncologists, palliative care consultants, specialist nurses, occupational therapists and physiotherapists. The focus groups were transcribed verbatim and analysed using NVIVO to support a framework analysis approach., Results: The current delivery of NPIs was found to be ad hoc and varied between sites both in terms of what was delivered and by which health care professionals. The provision of NPIs within acute medical settings faced common problems concerning staffing time and space, and there was a recognition that the preference of most patients to make as few hospital visits as possible also complicated NPI teaching. Moreover, there may only be a small window of opportunity in which to effectively teach lung cancer patients a novel NPI as the period between diagnosis and the onset of severe symptoms is often short., Discussion: The participants agreed that the novel symptom management NPI should be individually personalised to the needs of each patient and be available for patients when they become receptive to it. Moreover, they agreed that the intervention would be most effective if delivered to patients individually rather than in groups, outside acute medical settings where possible and closer to patient's homes, should be delivered by an HCP rather than a trained volunteer or lay person and should involve informal carers wherever practicable.

It is widely assumed that interprofessional learning (IPL) impacts positively on interprofessional working (IPW) in health and social care. However, there is no clear evidence that pre-qualifying IPL improves service delivery. The direct effect of pre-qualifying IPL on IPW and service delivery is difficult to demonstrate; researchers must rely on professionals' self-report in this regard. This paper presents findings from a qualitative study in which semi-structured interviews were used to collect individuals' views and perceptions about pre-qualifying IPL as preparation for practice. Two groups of participants came from four health and social care professions: adult nursing, midwifery, physiotherapy and social work. One group had experienced a substantial pre-qualifying IPL initiative, while the other group had not. Useful insights were gained from comparing the views and perceptions of individuals from these two groups. The total sample comprised 29 practitioners: 19 were educated on interprofessional curricula and 10 on traditional uniprofessional curricula. Thematic data analysis produced findings about pre-qualifying education as preparation for IPW. These findings suggest that pre-qualifying IPL can prepare individuals to work effectively as qualified professionals with colleagues from other disciplines and that effective IPW impacts positively on service delivery.

This paper outlines the history of workforce strategies for providing mental health care to "black and ethnic minorities" in England. Universal mental health policies failed to deliver equity in care, and thus specific policies were launched to address ethnic inequalities in care experiences and outcomes. The emphasis on race equality rather than cultural complexity led to widespread acceptance of the need for change. The policy implementation was delivered in accord with multiple regional and national narratives of how to reduce inequalities. As changes in clinical practice and services were encouraged, resistance emerged in various forms from clinicians and policy leaders. In the absence of commitment and then dispute about forms of evidence, divergent policy and clinical narratives fuelled a shift of attention away from services to silence issues of race equality. The process itself represents a defence against the pain of acknowledging systemic inequities whilst rebutting perceived criticism. We draw on historical, psychoanalytic, and learning theory in order to understand these processes and the multiple narratives that compete for dominance. The place of race, ethnicity, and culture in history and their representation in unconscious and conscious thought are investigated to reveal why cultural competence training is not simply an educational intervention. Tackling inequities requires personal development and the emergence and containment of primitive anxieties, hostilities, and fears. In this paper we describe the experience in England of moving from narratives of cultural sensitivity and cultural competence, to race equality and cultural capability, and ultimately to cultural consultation as a process. Given the need to apprehend narratives in care practice, especially at times of disputed evidence, cultural consultation processes may be an appropriate paradigm to address intersectional inequalities.

Objectives: This paper examines how the interaction between financial and clinical risk at two critical phases of health care reform in England has been experienced by frontline staff caring for vulnerable patients with long term conditions., Methods: The paper draws on contracting theory and two interdisciplinary and in-depth qualitative research studies undertaken in 1995 and 2007. Methods common to both studies included documentary analysis and interviews with managers and front line professionals. The 1995 study employed action-based research and included observation of community care; the 2007 study used realistic evaluation and included engagement with service user groups., Results: In both reform processes, financial risk was increasingly devolved to frontline practitioners and smaller organizational units such as GP commissioning groups, with payment by unit of activity, aimed at changing professionals' behaviour. This financing increased perceived clinical risk and fragmented the delivery of health and social care services requiring staff efforts to improve collaboration and integration, and created some perverse incentives and staff demoralisation., Conclusions: Health services reform should only shift financial risk to frontline professionals to the extent that it can be efficiently borne. Where team work is required, contracts should reward collaborative multi-professional activity.

Aim: finding appropriate ways of obtaining contemporaneous data in acute settings is an ethical and practical dilemma for researchers. Our aim was to evaluate the use of diaries by midwives in a research study informed by a phenomenological approach., Setting and Sample: a purposive sample of 12 midwives working across three Trusts in the North West of England., Method: a phenomenological approach was used to guide a study exploring midwives views of confidence when providing intrapartum care. Two methods of data collection were used; diaries and semi-structured interviews. This is a methodological paper reporting on the usefulness of diaries used with participants who were health professionals in a health-care setting., Results: participants completing qualitative diaries provided rich data, recording not only a description of events but also their emotional response to such events. A high degree of self-reflection and analysis was also evident. The participants provided contextual and time situated data although remaining focused on the phenomena being explored. Furthermore, the diaries highlighted the data that may not have been uncovered by interview alone., Conclusion: use of diaries for qualitative data collection is feasible and well received by health professionals. Individuals completing diaries were engaged in a reflective process enabling them to address significant events. Hence, diaries may provide benefits to both the researcher and the participant. They proved appropriate to a study requiring an exploration of the lived experience of the participants. Researchers conducting research informed by a phenomenological perspective should consider diaries as a valuable data collection tool., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

With the publication of the new NMC standards for pre-registration nursing education, undergraduate curricula are being written in universities across England. There are many drivers for the curricula but one that has until recently received scant attention is the service user's and carer's voice. This paper discusses the findings of a qualitative study that asked 52 service users and carers about the qualities they sought in nurses and their views on nurse education. Eight focus groups were conducted with a broad range of service users and carers from primary and secondary care, and voluntary organisations. Data were analysed using the framework approach facilitated by a qualitative analysis software programme. The sample was diverse, but there were similarities in the qualities they valued in nurses. They sought technical competence, knowledge and willingness to seek information, but overwhelmingly prioritised 'a caring professional attitude'. This was articulated as empathy, communication skills and non-judgmental patient centred care: major themes in the new NMC standards. Our participants also expressed concern about whether the educational preparation of nurses can develop these caring qualities. We discuss this concern, the challenges for nurse educators it presents and how we can engage service users and carers in shaping and delivering our new curricula., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

This opinion paper considers obesity and its relationship to dental practice. Twenty-three per cent of people in England are estimated to be obese, a figure that is predicted to continue rising. It follows that obese patients are frequently encountered in general dental practice. The authors review the links between obesity and dental health, the possible barriers and challenges to providing dental care for obese people, and how these may be overcome. They also report the findings of a London survey investigating the current provision of specialist dental services for obese patients who cannot be treated in a standard dental chair. Services across London were highly variable and in some areas no provision was identified. The implications of the rising prevalence of obesity for service planners and practitioners are also discussed.

Background: For the first 5 years of the UK primary care pay for performance scheme, the Quality and Outcomes Framework (QOF), quality indicators were introduced without piloting. However, in 2009, potential new indicators were piloted in a nationally representative sample of practices. This paper describes an in-depth exploration of family physician, nurse and other primary-care practice staff views of the value of piloting with a particular focus on unintended consequences of 13 potential new QOF indicators., Method: Fifty-seven family-practice professionals were interviewed in 24 representative practices across England., Results: Almost all interviewees emphasised the value of piloting in terms of an opportunity to identify unintended consequences of potential QOF indicators in 'real world' settings with staff who deliver day-to-day care to patients. Four particular types of unintended consequences were identified: measure fixation, tunnel vision, misinterpretation and potential gaming. 'Measure fixation,' an inappropriate attention on isolated aspects of care, appeared to be the key unintended consequence. In particular, if the palliative care indicator had been introduced without piloting, this might have incentivised poorer care in a minority of practices with potential harm to vulnerable patients., Conclusions: It is important to identify concerns and experiences about unintended consequences of indicators at an early stage when there is time to remove or adapt problem indicators. Since the UK government currently spends over £1 billion each year on QOF, the £150,000 spent on each piloting cohort (0.0005% of the total QOF budget) appears to be good value for money.

Child health promotion services in England have been revolutionised in the last decade, with a shift from a low-threshold universal service to a more highly targeted programme. This has affected health visitors' preventive healthcare work with families. This paper draws on findings from the qualitative arm of a mixed-methods study that aimed to explore how child health promotion reform has been implemented. The particular focus of this paper is on health visitors' experiences of the process of policy reform. In-depth semi-structured telephone interviews were conducted with 25 health visitors working in urban areas in England, and data were analysed thematically. Health visitors described policy change as being enforced, but views on the new programme were coloured by the extent to which practitioners retained the autonomy to offer a service according to their professional judgment. Where practitioners retained professional autonomy, services were adequately staffed and there was a functional working environment, then interviewees were positive about child health promotion reform. Where health visitors felt they could not offer an appropriate level of health promotion services, they had grave concerns about the impact on child public health.

Background: Conflict (aggression, substance use, absconding, etc.) and containment (coerced medication, manual restraint, etc.) threaten the safety of patients and staff on psychiatric wards. Previous work has suggested that staff variables may be significant in explaining differences between wards in their rates of these behaviours, and that structure (ward organisation, rules and daily routines) might be the most critical of these. This paper describes the exploration of a large dataset to assess the relationship between structure and other staff variables., Methods: A multivariate cross-sectional design was utilised. Data were collected from staff on 136 acute psychiatric wards in 26 NHS Trusts in England, measuring leadership, teamwork, structure, burnout and attitudes towards difficult patients. Relationships between these variables were explored through principal components analysis (PCA), structural equation modelling and cluster analysis., Results: Principal components analysis resulted in the identification of each questionnaire as a separate factor, indicating that the selected instruments assessed a number of non-overlapping items relevant for ward functioning. Structural equation modelling suggested a linear model in which leadership influenced teamwork, teamwork structure; structure burnout; and burnout feelings about difficult patients. Finally, cluster analysis identified two significantly distinct groups of wards: the larger of which had particularly good leadership, teamwork, structure, attitudes towards patients and low burnout; and the second smaller proportion which was poor on all variables and high on burnout. The better functioning cluster of wards had significantly lower rates of containment events., Conclusion: The overall performance of staff teams is associated with differing rates of containment on wards. Interventions to reduce rates of containment on wards may need to address staff issues at every level, from leadership through to staff attitudes.

Aim: This paper is a report of an evaluation of the implementation of nurse prescribing in an acute care hospital in England., Background: At the time of the study, evaluation of nurse prescribing had taken place in community settings, but little was known about its impact and effectiveness in acute care. Although nurse prescribing has permitted doctor-nurse substitution in acute episodic care, some doctors have expressed concerns about patient safety in relation to nurse prescribing., Methods: A mixed methods single-case study was conducted in 2005-06, using purposive sampling. Semi-structured interviews were carried out with 18 hospital staff, non-participant observation of two nurses and two doctors undertaking 52 patient-prescriber consultations with 47 patients, and a questionnaire survey with 122 patients (response rate 61%: n=74)., Results: Nurse prescribing was found to benefit patients through service delivery improvement and using staff skills differently. Nurse prescribers and their colleagues were positive about role and service changes and their impact on patient care. No differences were found between the ways in which nurses and doctors performed prescribing roles, but there was a statistically significant difference between the medication-related information satisfaction ratings of patients who had seen a nurse prescriber, compared to those seen by a doctor., Conclusion: Nurses and doctors were found to provide equivalent care. Shared vision, local champions, action learning and peer support were the enabling factors that helped to embed the new prescribing roles within the study site., (© 2010 The Authors. Journal of Advanced Nursing © 2010 Blackwell Publishing Ltd.)

Community nursery nurses (CNNs) are an important part of the multidisciplinary team. This paper discusses how two students undertaking a foundation degree in early years experienced changes to their personal and professional identities. A 'life history' approach was used to understand and interpret their experiences in depth. Both students would not have entered higher education had it not been for the widening participation drive. The higher education experience had a positive influence on personal and professional identity for the learners. They underlined that the widening participation drive can enable those students from 'non-traditional backgrounds' to enter and benefit from higher education. However, changes to higher education funding and public sector cutbacks have raised grave concerns about the continued ability of CNNs and other early years practitioners to access such courses. This could have a negative effect on the continuing professional development and subsequent changing identities within this particular group.

Accessible Summary: This paper reports on a piece of research which is summarized below. • This research explored how mental health inpatient staff, (including nurses, doctors and other professional disciplines) experience caring for patients who both have mental health problems and who use illicit drugs. (Illicit drugs are illegal drugs which incur a criminal prosecution for possession and/or use). The results of the study were gathered from questionnaires and interviews which asked staff about their viewpoints and experiences. • The questionnaire results included a section which measured staff attitude towards patients who use illicit drugs and who have mental health problems. Staff who had received training in how to work with people with these problems were found to have a less negative attitude towards these patients. The length of time staff members had worked in their posts or had worked in a particular setting did not have any effect on their attitude. For example, their attitude was not more or less negative towards patients with these problems. • Ten members of staff were interviewed to find out more in-depth information about their viewpoints and experiences. Overall, these staff members reported a lack of training, difficulty in accessing support and problematic issues within the teams they worked. • This paper highlights the importance of training to support staff in working with mental health patients who use illicit drugs; and how this affects staff attitude positively towards patients with these problems., Abstract: The extent of illicit substance use within inpatient mental health settings is becoming a major cause of concern. This poses growing challenges not only for the management of inpatient units, but also for providing continuity of care. Service users with co-occurring substance use are more likely to disengage from services. The process of engagement can be hindered by negative attitudes of staff. This study aimed to identify and explore multidisciplinary staff attitudes and experiences in caring for inpatients with co-occurring ill-mental health problems and illicit substance use. A questionnaire incorporating the Drug and Drugs Problems Perceptions Questionnaire (DDPPQ) was used with a non-probability sample of 84 multidisciplinary staff working on nine mental health units. Semi-structured interviews were then carried out with 10 members of staff. Overall, respondents reported: lack of training; difficulty in accessing support structures; and problematic issues with multidisciplinary decision making and processes. The DDPPQ results showed that staff who had received training held less negative attitudes towards illicit substance users regardless of their length of clinical work experience or type of work setting. Recommendations are made about the importance of training and staff support for the development of less negative attitudes towards this client group., (© 2010 Blackwell Publishing.)

The health professions are engaged in an ongoing and dynamic process involving reflection and adaptation, with factors such as socio-economic and cultural developments and technological innovations compelling professions to respond to changed circumstances. This paper concerns English community pharmacy, where recent reforms provide financial incentives to deliver interventions, which have the potential for pharmacists to promote their knowledge and skills, as part of a professionalising strategy. The paper, drawing on interviews with 49 pharmacists, describes how responses to reforms are not necessarily in accordance with either national policy goals or enhancement of professional status. Debates about professional status and role extension have often focused on health professions' subordination to medicine. This paper highlights the importance and interplay of other factors which help explain the inability to capitalise fully on the potential contribution to professional status, which reforms to extend professional roles afford., (Copyright 2010 Elsevier Ltd. All rights reserved.)

Aim: This paper is a report of a study of the views and experiences of nurses and other prison healthcare staff about their roles and the nursing care they provide to prisoners., Background: Nurses have become the key providers of healthcare in prison settings in England, replacing the previous prison service-run system. However, there is very little evidence about the health services they provide to meet the health needs of prisoners., Method: A ethnographic study was conducted. Participants were 80 healthcare staff working in 12 prisons of all security categories in England. Twelve individual interviews with general healthcare managers and 12 key informant focus group discussions with healthcare staff were undertaken in 2005 using a semi-structured interview schedule. Issues investigated included participants' thoughts and experiences of nursing roles and delivery of primary healthcare. The group discussions and interviews were analysed to identify emerging themes., Findings: Participants gave accounts of day-to-day processes and the healthcare routine. They saw their work as identifying and meeting the health needs of prisoners and maintaining their health, and identified major influences that shaped their daily work, including new ways of working in primary care. They identified how policy and organizational changes were affecting their roles, and acknowledged the conflict between the custody regime and healthcare delivery., Conclusion: The move towards a NHS-led primary healthcare service within prisons, predominantly delivered by nurses, has made positive changes to healthcare. Healthcare managers have benefited from the involvement of the local NHS in improving the health of prisoners.

Aim: This paper is a report of a study of the perceptions of nurses who work in abortion services., Background: International debate surrounds abortion. In England and Wales the Abortion Act which was introduced in 1967 recently came under public review in relation to its legal limit of 24 weeks gestation. The review did not extend to those working within abortion services, and these nurses' views remained unknown. Investigating the perceptions of nurses who work in abortion services adds a dimension to the debate from a professional perspective which has hitherto been absent., Methods: Qualitative semi-structured interviews were conducted in 2007 with nine nurses working in three different abortion clinics in the United Kingdom. NVivo was used to manage the interview data and thematic analysis identified patterns of nursing concepts and attitudes., Findings: Two global themes of 'Attitudes Towards' and 'Coping With' abortion were identified. Six organizational themes detailed these: 'society', 'nurses' and 'reasoning' in 'Attitudes Towards' and 'role', 'clients' and 'late gestation abortion' in 'Coping With'. Eleven basic themes further described the organizational themes. Kim's theory of Human Living was used to clarify and provide a rationale for the nursing approach to care in this setting., Conclusion: The ability of participants to care for their clients as individuals illustrates the nature of empowerment of the nurses to attain the goals of the client. Making this support explicit through defined roles for nurses would potentially enable nurses in abortion services to perform their role more effectively at all gestation times.

Aim: This paper is a report of a study exploring the views of nurses and team members on the implementation of nurse prescribing in diabetes services., Background: Nurse prescribing is adopted as a means of improving service efficiency, particularly where demand outstretches resources. Although factors that support nurse prescribing have been identified, it is not known how these function within specific contexts. This is important as its uptake and use varies according to mode of prescribing and area of practice., Method: A case study was undertaken in nine practice settings across England where nurses prescribed medicines for patients with diabetes. Thematic analysis was conducted on qualitative data from 31 semi-structured interviews undertaken between 2007 and 2008. Participants were qualified nurse prescribers, administrative staff, physicians and non-nurse prescribers., Findings: Nurses prescribed more often following the expansion of nurse independent prescribing rights in 2006. Initial implementation problems had been resolved and few current problems were reported. As nurses' roles were well-established, no major alterations to service provision were required to implement nurse prescribing. Access to formal and informal resources for support and training were available. Participants were accepting and supportive of this initiative to improve the efficiency of diabetes services., Conclusion: The main factors that promoted implementation of nurse prescribing in this setting were the ability to prescribe independently, acceptance of the prescribing role, good working relationships between doctors and nurses, and sound organizational and interpersonal support. The history of established nursing roles in diabetes care, and increasing service demand, meant that these diabetes services were primed to assimilate nurse prescribing.

In recent years, there has been a great deal of collective rumination about social scientists' role in society. In the post-1997 UK context, public policy commitments to 'evidence-based policy' and 'knowledge transfer' have further stimulated such reflections. More recently, Michael Burawoy's 2004 address to the American Sociological Association, which called for greater engagement with 'public sociology' has reverberated throughout the discipline, motivating a series of debates about the purpose of sociological research. To date, most such contributions have been based on personal experience and anecdotal evidence. In contrast, this paper responds directly to Burawoy's suggestion that we should 'apply sociology to ourselves,' in order that we 'become more conscious of the global forces' driving our research (Burawoy 2005: 285). Drawing on an empirical research project designed to explore of the relationship between health inequalities research and policy in Scotland and England, in the period from 1997 until 2007, this paper discusses data from interviews with academic researchers. The findings suggest that the growing pressure to produce 'policy relevant' research is diminishing the capacity of academia to provide a space in which innovative and transformative ideas can be developed, and is instead promoting the construction of institutionalized and vehicular (chameleon-like) ideas. Such a claim supports Edward Said's (1994) insistence that creative, intellectual spaces within the social sciences are increasingly being squeezed. More specifically, the paper argues we ought to pay far greater attention to how the process of seeking research funding shapes academic research and mediates the interplay between research and policy.