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© Crown copyright 2013. Contains public sector information licensed under the Open Government Licence v3.0© Queen’s Printer and Controller of HMSO 2019. This work was produced by Harriset al.under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.20132019Crown copyrightQueen’s Printer and Controller of HMSOBackgroundThe government response to the care failures at the Mid Staffordshire NHS Foundation Trust led to the policy imperative of ‘regular interaction and engagement between nurses and patients’ (Francis R.Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office; 2013. © Crown copyright 2013. Contains public sector information licensed under the Open Government Licence v3.0) in the NHS. The pressure on nursing to act resulted in the introduction of the US model, known as ‘intentional rounding’, into nursing practice. This is a timed, planned intervention that sets out to address fundamental elements of nursing care by means of a regular bedside ward round.ObjectivesThe study aims were to examine what it is about intentional rounding in hospital wards that works, for whom and in what circumstances.DesignA multimethod study design was undertaken using realist evaluation methodology. The study was conducted in four phases: (1) theory development; (2) a national survey of all NHS acute trusts in England; (3) in-depth case studies of six wards, involving individual interviews, observations, retrieval of routinely collected ward outcome data and analysis of costs; and (4) synthesis of the study findings.SettingThe study was conducted in acute NHS trusts in England.ParticipantsA total of 108 acute NHS trusts participated in the survey. Seventeen senior managers, 33 front-line nurses, 28 non-nursing professionals, 34 patients and 28 carers participated in individual interviews. Thirty-nine members of nursing staff were shadowed during their delivery of intentional rounding and the direct care received by 28 patients was observed.Review methodsA realist synthesis was undertaken to identify eight context–mechanism–outcome configurations, which were tested and refined using evidence collected in subsequent research phases.ResultsThe national survey showed that 97% of NHS trusts had implemented intentional rounding in some way. Data synthesis from survey, observation and interview findings showed that only two of the original eight mechanisms were partially activated (consistency and comprehensiveness, and accountability). The evidence for two mechanisms was inconclusive (visibility of nurses and anticipation); there was minimal evidence for one mechanism (multidisciplinary teamwork and communication) and no evidence for the remaining three (allocated time to care, nurse–patient relationships and communication, and patient empowerment). A total of 240 intentional rounds were observed within 188 hours of care delivery observation. Although 86% of all intentional rounding interactions were observed to be documented, fidelity to the original intervention [i.e. the Studer Group protocol (Studer Group.Best Practices: Sacred Heart Hospital, Pensacola, Florida. Hourly Rounding Supplement. Gulf Breeze, FL: Studer Group; 2007)] was generally low.LimitationsIntentional rounding was often difficult for researchers to observe, as it was rarely delivered as a discrete activity but instead undertaken alongside other nursing activities. Furthermore, a lack of findings about the influence of intentional rounding on patient outcomes in the safety thermometer data limits inferences on how mechanisms link to clinical outcomes for patients.ConclusionsThe evidence from this study demonstrates that the effectiveness of intentional rounding, as currently implemented and adapted in England, is very weak and falls short of the theoretically informed mechanisms. There was ambivalence and concern expressed that intentional rounding oversimplifies nursing, privileges a transactional and prescriptive approach over relational nursing care, and prioritises accountability and risk management above individual responsive care.Future workIt is suggested that the insights and messages from this study inform a national conversation about whether or not intentional rounding is the optimum intervention to support the delivery of fundamental nursing care to patients, or if the time is right to shape alternative solutions.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

This paper describes an Experience-based Co-design (EBCD) project that aimed to increase patient activity within an acute stroke unit. We apply the concept of liminality to explore ways in which the EBCD process, a form of Participatory Action Research, may dilute or even dissolve social hierarchies and challenge assumptions about practices and constraints in this care setting, thereby opening up possibilities for transformation that enhances the therapeutic value of the space for patients and care providers alike. By occasioning a liminal phase of possibility for change, the work of one co-design group explored in detail here suggests that, in this process, the sociomaterial interactions involving patients, family members, staff, and the physical space are refashioned and re-inscribed in transformed ‘emplaced’ relationships of care., Highlights • EBCD improved an acute stroke unit environment to provide greater opportunity for social and therapeutic activity. • The structured EBCD approach provided a ‘liminal’ space within which collaborative change could be enabled. • Liminality facilitated trust and built a sense of community between participating patients, families and staff. • The different roles adopted by participants during the process challenged norms and effected change.

Introduction: Health and social care services in England are moving towards greater integration, yet little is known about how leadership of integrated care teams and systems can be supported and improved. This realist review explores what works about the leadership of integrated care teams and systems, for whom, in what circumstances and why.\ud \ud Methods: A realist synthesis approach was undertaken in 2020 to explore English language literature on the leadership of integrated care teams and systems, complemented by ongoing stakeholder consultation.\ud \ud Results: Evidence was identified for seven potentially important components of leadership in integrated care teams and systems: ‘inspiring intent to work together’; ‘creating the conditions’; ‘balancing multiple perspectives’; ‘working with power’; ‘taking a wider view’; ‘a commitment to learning and development’ and ‘clarifying complexity’.\ud \ud Discussion: Research into the leadership of integrated care teams and systems is limited, with ideas often reverting to existing framings of leadership, where teams and organisations are less complex. Research also often focuses on the importance of who the leader is rather than what they do.\ud \ud Conclusion: This review has generated new perspectives on the leadership of integrated care teams and systems that can be built upon, developed, and tested further.

Background Stroke patients are often inactive outside of structured therapy sessions – an enduring international challenge despite large scale organizational changes, national guidelines and performance targets. We examined whether experienced-based co-design (EBCD) – an improvement methodology – could address inactivity in stroke units. Aims To evaluate the feasibility and impact of patients, carers, and staff co-designing and implementing improvements to increase supervised and independent therapeutic patient activity in stroke units and to compare use of full and accelerated EBCD cycles. Methods Mixed-methods case comparison in four stroke units in England. Results Interviews were held with 156 patients, staff, and carers in total; ethnographic observations for 364 hours, behavioral mapping of 68 patients, and self-report surveys from 179 patients, pre- and post-implementation of EBCD improvement cycles. Three priority areas emerged: (1) ‘Space’ (environment); (2) ‘Activity opportunities’ and (3) ‘Communication’. More than 40 improvements were co-designed and implemented to address these priorities across participating units. Post-implementation interview and ethnographic observational data confirmed use of new social spaces and increased activity opportunities. However, staff interactions remained largely task-driven with limited focus on enabling patient activity. Behavioral mapping indicated some increases in social, cognitive, and physical activity post-implementation, but was variable across sites. Survey responses rates were low at 12–38% and inconclusive. Conclusion It was feasible to implement EBCD in stroke units. This resulted in multiple improvements in stroke unit environments and increased activity opportunities but minimal change in recorded activity levels. There was no discernible difference in experience or outcome between full and accelerated EBCD; this methodology could be used across hospital stroke units to assist staff and other stakeholders to co-design and implement improvement plans.

IntroductionOlder people living in residential and nursing care homes often have complex needs and are at high risk of poor health outcomes and mortality, especially if they contract COVID-19. Care homes use infection prevention and control measures such as social distancing and isolating residents to protect them from COVID-19. The care home sector has stated that implementing social distancing and isolation when caring for residents is a significant challenge. This paper presents the protocol of a mixed-methods study to explore and understand the real-life experiences of implementing social distancing and isolation of residents in care homes for older people from the perspective of residents, families/friends and staff working in and with care homes. The study aims to develop a toolkit of resources for health and care delivery now and for future outbreaks of infectious diseases.Methods and analysisThe study will be conducted in three phases. Phase 1 is a rapid review of evidence to collate knowledge on the mechanisms and measures used by care homes and long-term facilities to socially distance and isolate older people or control the spread of other infectious and contagious diseases. The review results will contribute to participant interviews in phase 2 and toolkit development in phase 3. Phase 2 will involve case studies with six care homes in England, involving the conduct of individual interviews with residents, families and friends, and staff, collection of care home policies and protocols related to social distancing and isolation for residents, and routinely collected care home data. A focus group with a purposive sample of external key informants will also be conducted. Phase 3, synthesising findings from phases 1 and 2, will inform the codesign of a toolkit of resources for residents, families/friends and care homes.Ethics and disseminationThe study has been approved by Coventry and Warwick Research Ethics Committee (20/WM/0318). To maximise impact, we will work closely with the Study Committees and the Patient and Public Involvement group to ensure the findings reach key stakeholders, including residents, families/friends, care homes, commissioners and organisations representing care home providers. We will disseminate the study outputs in peer-reviewed and professional journals, at professional conferences and via other knowledge transfer activities with the care home sector, and resident and carer organisations. The toolkit comprising evidence-informed guidance and resources and a mosaic film will be hosted on a project webpage.Registration detailsThis project is funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research Programme (Project reference NIHR132541). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.PROSPERO registration numberCRD42021226734.

ObjectiveTo explore facilitators and barriers to using experience-based co-design (EBCD) and accelerated EBCD (AEBCD) in the development and implementation of interventions to increase activity opportunities for inpatient stroke survivors.DesignMixed-methods process evaluation underpinned by normalisation process theory (NPT).SettingFour post-acute rehabilitation stroke units in England.ParticipantsStroke survivors, family members, stroke unit staff, hospital managers, support staff and volunteers. Data informing our NPT analysis comprised: ethnographic observations, n=366 hours; semistructured interviews with 76 staff, 53 stroke survivors and 27 family members pre-EBCD/AEBCD implementation or post-EBCD/AEBCD implementation; and observation of 43 co-design meetings involving 23 stroke survivors, 21 family carers and 54 staff.ResultsFormer patients and families valued participation in EBCD/AEBCD perceiving they were equal partners in co-design. Staff engaged with EBCD/AEBCD, reporting it as a valuable improvement approach leading to increased activity opportunities. The structured EBCD/AEBCD approach was influential in enabling coherence and cognitive participation and legitimated staff involvement in the change process. Researcher facilitation of EBCD/AEBCD supported cognitive participation, collective action and reflexive monitoring; these were important in implementing and sustaining co-design activities. Observations and interviews post-EBCD/AEBCD cycles confirmed creation and use of new social spaces and increased activity opportunities in all units. EBCD/AEBCD facilitated engagement with wider hospital resources and local communities, further enhancing activity opportunities. However, outside of structured group activity, many individual staff–patient interactions remained task focused.ConclusionsEBCD/AEBCD facilitated the development and implementation of environmental changes and revisions to work routines which supported increased activity opportunities in stroke units providing post-acute and rehabilitation care. Former stroke patients and carers contributed to improvements. NPT’s generative mechanisms were instrumental in analysis and interpretation of facilitators and barriers at the individual, group and organisational level, and can help inform future implementations of similar approaches.

IntroductionAs systems of health and social care in England move towards more integrated and collaborative models, leaders will need different skills than their predecessors to enable system leadership, building partnerships and working across organisations and sectors. There is little understanding of what the mechanisms for effective leadership across integrated health and social care systems might be, the contexts that influence good leadership, or the nature of the resulting outcomes. This review aims to identify, refine and test programme theories of leadership of integrated team-based services in health and social care, exploring what works, for whom and in what circumstances.Methods and analysisThis study uses a realist synthesis approach, following RAMESES guidelines, supported by stakeholder consultation. Stage 1 will develop initial programme theories about leadership of integrated health and social care based on a review of the scientific and grey literature and a stakeholder consultation workshop. Stage 2 will involve focused searching of empirical literature, data extraction and synthesis to refine the initial programme theories and identify relationships between identified contexts, mechanisms and outcomes. A second stakeholder event will guide the focus of the review. Stage 3 will further refine and interrogate the theories testing them against substantive theory on leadership of complex systems and through the experiences and expertise of the stakeholder group.Ethics and disseminationOur study does not require ethics committee approval. This research will contribute to building an in-depth understanding of what aspects of leadership of integrated team-based services work, for whom and in what circumstances. It will identify the professional development needs of leaders and provide recommendations about optimal organisational and interorganisational structures and processes that support effective leadership in integrated health and social care systems. Findings will be disseminated through peer-reviewed journal publications, conference presentations and formal and informal reports.PROSPERO registration numberCRD42018119291

As a member of NATO, Norway supports efforts to enhance deterrence, crisis management and regional security in the North Atlantic and High North — including Scandinavia and northern Russia, as well as the waters of the Arctic Ocean, Barents Sea and North Sea. To inform ongoing strategy and policy development, Norway commissioned RAND to gather insights into other NATO Allies' perspectives on strategic opportunities and challenges in the region.

While the affordances of the digital age certainly enable more diverse students to access higher education, higher education assessment is often underpinned by notions of equality rather than equity. Drawing together key literature and data from interviews with 53 first year undergraduate students from low socio-economic status backgrounds, this chapter identifies three potential causes of assessment inequity which appear to persist into the digital age: student assessment self-efficacy, prior preparation, and external pressures. It then identifies how the affordances of modern technology can be used to help combat these challenges.

Regulation 2017/821 requires EU importers to ensure that minerals with which they work originate from responsible sources and that businesses comply with and report on supply chain due diligence obligations with special focus on so-called conflict-affected and high-risk areas (CAHRAs). This report presents the methodology proposed by RAND Europe to produce an indicative, non-exhaustive, regularly updated list of CAHRAs under Regulation 2017/821.

Most ex-Service personnel transition effectively into civilian life, but some face challenges that hinder a successful transition. This can lead to some individuals committing crimes and finding themselves within the criminal justice system. RAND Europe was commissioned to evaluate the Ex-Service Personnel in the CJS Programme, to understand how projects have helped reduce reoffending and provide support to ex-Service personnel in the CJS.

Background Compassion is integral to professional nursing practice worldwide and a fundamental value in healthcare. Following serious care failures at a healthcare provider in the United Kingdom, a government commissioned report (the Francis Report) made several recommendations for strengthening compassion in nursing care and consequently ‘intentional rounding’ was incorporated into nursing practice in the United Kingdom. Intentional rounding is a structured process implemented primarily in the United Kingdom, North America and Australia, whereby nurses conduct 1–2 hourly checks on every patient using a standardised protocol and documentation. Objectives To examine the role of intentional rounding in the delivery of compassionate nursing care in England from multiple perspectives. Methods This paper reports qualitative findings from one phase of a realist evaluation of intentional rounding which used a mixed-methods approach. Individual, semi-structured interviews were undertaken with 33 nursing staff, 17 senior nurse managers, 34 patients and 28 family carers from three geographically spread case study hospital sites in England. Interviews elicited detailed reflections on the contexts, mechanisms and outcomes of intentional rounding and how it impacted the interviewee and those around them. Results This study found little evidence that intentional rounding ensures the comfort, safety or dignity of patients or increases the delivery of compassionate care. The systematised approach of intentional rounding emphasises transactional care delivery in the utilisation of prescribed methods of recording or tick boxes rather than relational, individualised patient care. It has the potential to reduce the scope of nursing care to a minimum standard, leading to a focus on the fundamentals as well as the prevention of adverse events. Its documentation is primarily valued by nursing staff as a means of protecting themselves through written proof or ‘evidence’ of care delivered, rather than as a means of increasing compassionate care. Conclusions This large-scale, theoretically-driven study of intentional rounding – the first of its kind – demonstrates that intentional rounding prioritises data collection through tick boxes or a prescriptive and structured recording of care. Thus, intentional rounding neither improves the delivery of compassionate nursing care nor addresses the policy imperative it was intended to target. This study raises questions about the role, contribution and outcomes from intentional rounding and suggests a need for a wider, international debate within the nursing profession about its future use. If an intervention to increase compassionate nursing care is required, it may be better to start afresh, rather than attempting to adapt the system currently implemented.

Background: There is growing attention in the UK and internationally to the representation of black and minority ethnic groups in healthcare education and the workplace. Although the NHS workforce is very diverse, ethnic minorities are unevenly spread across occupations, and considerably underrepresented in senior positions. Previous research has highlighted that this inequality also exists at junior levels with newly qualified nurses from non-White/British ethnic groups being less likely to get a job at graduation than their White/British colleagues. Although there is better national data on the scale of inequalities in the healthcare workforce, there is a gap in our understanding about the experience of job seeking, and the factors that influence disadvantage in nursing and other professions such as physiotherapy. Aim: This qualitative study seeks to fill that gap and explores the experience of student nurses (n=12) and physiotherapists (n=6) throughout their education and during the first 6-months post qualification to identify key experiences and milestones relating to successful employment particularly focusing on the perspectives from different ethnic groups. Participants: Participants were purposively sampled from one university to ensure diversity in ethnic group, age and gender. Methods: Using a phenomenological approach, in-depth semi-structured interviews were conducted at course completion and 6 months later. Results: Two main themes were identified. The ‘proactive self’ (‘It’s up to me’) theme included perceptions of employment success being due to student proactivity and resilience; qualities valued by employers. The second theme described the need to ‘fit in’ with organisational culture. Graduates described accommodating strategies where they modified aspects of their identity (clothing, cultural markers) to fit in. At one extreme, rather than fitting in, participants from minority ethnic backgrounds avoided applying to certain hospitals due to perceptions of discriminatory cultures, ‘I wouldn’t apply there ‘cos you know, it’s not really an ethnic hospital’. In contrast, some participants recognised that other graduates (usually white) did not need to change and aspects of their identity brought unsolicited rewards 'if your face fits then the barriers are reduced'. Conclusions: The findings indicate that success in getting work is perceived as determined by individual factors, and fitting in is enabled by strategies adopted by the individual rather than the workplace. Demands for change are more acute for graduates from black and minority ethnic backgrounds. This is an issue for healthcare organisations seeking to be inclusive and challenges employers and educators to acknowledge inequalities and take action to address them. Keywords: ethnicity; employability; nurses; physiotherapists; job seeking activities; equality of employment

Objective Older people resident in care homes often rely on staff for support relating to their activities of daily living, including intimate care such as continence care. Managing fecal incontinence can be challenging for both residents and care staff. We conducted this review to describe the prevalence, incidence, and correlates of fecal incontinence among care home residents. Design Systematic literature review. Setting and participants Older care home residents (both nursing and residential care) aged 60 years and older. Measures We defined double incontinence as the presence of fecal plus urinary incontinence, isolated fecal incontinence as fecal incontinence with no urinary incontinence, and all fecal incontinence as anyone with fecal incontinence (whether isolated or double). The CINAHL and MEDLINE databases were searched up to December 31, 2017, to retrieve all studies reporting the prevalence and/or incidence and correlates of fecal incontinence. Results We identified 278 citations after removing duplicates, and 23 articles met the inclusion criteria. There were 12 high-quality studies, 5 medium-quality studies, and 6 low-quality studies. The medians for prevalence (as reported by the studies) of isolated fecal incontinence, double incontinence, and all fecal incontinence were 3.5% [interquartile range (IQR) = 2.8%], 47.1% (IQR = 32.1%), and 42.8% (IQR = 21.1%), respectively. The most frequently reported correlates of fecal incontinence were cognitive impairment, limited functional capacity, urinary incontinence, reduced mobility, advanced age, and diarrhea. Conclusions/Implications Fecal incontinence is prevalent among older people living in care homes. Correlates included impaired ability to undertake activities of daily living, reduced mobility, laxative use, and altered stool consistency (eg, constipation or diarrhea) which are potentially amenable to interventions to improve fecal incontinence. (C) 2019 AMDAeThe Society for Post-Acute and Long-Term Care Medicine. This is an open access articleunder the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the effects of interventions for treating or managing faecal incontinence (FI) in older people living in care homes; and to critically appraise and summarise current evidence on the associated resource use, costs and cost‐effectiveness. Note: we are covering treatment (interventions aiming to cure or improve symptoms) and management (interventions aiming to contain symptoms, such as pads or anal plugs, or reduce effects of symptoms, such as skin protection) of FI. Prevention of FI in those who do not currently have the symptom is beyond the scope of this review.

AIM: To investigate the views of senior nurse and human resource managers of strategies to retain hospital nurses in a metropolitan area.BACKGROUND: Against a global shortage, retaining nurses is a management imperative for the quality of hospital services.METHOD: Semi-structured interviews, thematically analysed.RESULTS: Metropolitan areas have many health organisations in geographical proximity, offering nurses choices in employer and employment. Senior nurse and human resource managers recognised the complexity of factors influencing nurse turnover, including those that 'pulled' nurses out of their jobs to other posts and factors that 'pushed' nurses to leave. Four themes emerged in retaining nurses: strategy and leadership, including analysis of workforce and leavers' data, remuneration, the type of nursing work and career development and the immediate work environment.CONCLUSIONS: In contexts where multiple organisations compete for nurses, addressing retention through strategic leadership is likely to be important in paying due attention and apportioning resources to effective strategies.IMPLICATIONS FOR NURSING MANAGEMENT: Aside from good human resource management practices for all, strategies tailored to different segments of the nursing workforce are likely to be important. This metropolitan study suggests attention should be paid to strategies that address remuneration, progressing nursing careers and the immediate work environment.

In order for nurses and other health care professionals to make important contributions to the literature, there must be an awareness of the many areas where unintentional ethical conflicts can arise. Leading ethical concerns include plagiarism, duplicate submission, authorship standards, bias, and conflicts of interest. Although many sources are available on the variety of ethical concerns, this article takes the position to identify the area of concern and describe why it is an ethical violation. Solutions are posed for resolving the conflict, including why medical librarians can help in the publishing process.

The value and importance of UK nursing research was given a resounding endorsement in a recent assessment of research quality, the Research Excellence Framework 2014 (REF2014). The overview report by the main panel A (MPA) of the REF2014 considered that diversity and quality of research submitted to the sub-panel unit of assessment (UOA) 3 (Allied Health Professions, Dentistry, Nursing and Pharmacy) to be strong. They concluded

OBJECTIVES: to evaluate accuracy, sensitivity, specificity and inter-rater agreement of AVPU (Alert, Voice, Pain, Unresponsive) when used by non-specialist nursing staff assessing consciousness, and to investigate users' views. METHODS: Video-recorded simulations of assessments of consciousness were developed and verified by an expert panel. Participants scored simulations using AVPU and completed questionnaires eliciting views on the scale. AVPU scores were compared with functional levels agreed by the panel. SETTING: A large urban teaching hospital. RESULTS: Fifty-one participants scored 255 simulations. Overall accuracy was 82.4% (95% CI=77.7-87.1%), sensitivity 0.94 (95% CI=0.90-0.98), specificity 0.74 (95% CI=0.66-0.82) and inter-rater agreement (un-weighted kappa) 0.782. Accuracy was low for simulations depicting an orientated patient whose eyes open to speech (49% correct) and a confused patient with spontaneous eye opening (61.5% correct). Sensitivity and agreement for levels corresponding to "Alert" and "Voice" were 0.81 (95% CI=0.69-0.93) and kappa=0.506. Participants expressed uncertainty about aspects of AVPU's use. CONCLUSIONS: AVPU had low rates of accuracy, sensitivity and agreement in distinguishing between "Alert" and "Voice", and low specificity overall, suggesting it may be unsuitable for early warning scoring. Participants expressed doubts about the use of AVPU.

Background Co-production is defined as the voluntary or involuntary involvement of users in the design, management, delivery and/or evaluation of services. Interest in co-production as an intervention for improving healthcare quality is increasing. In the acute healthcare context, co-production is promoted as harnessing the knowledge of patients, carers and staff to make changes about which they care most. However, little is known regarding the impact of co-production on patient, staff or organisational outcomes in these settings.\ud \ud \ud Aims To identify and appraise reported outcomes of co-production as an intervention to improve quality of services in acute healthcare settings.\ud \ud \ud Design Rapid evidence synthesis.\ud \ud \ud Data sources Medline, Cinahl, Web of Science, Embase, HMIC, Cochrane Database of Systematic Reviews, SCIE, Proquest Dissertation and Theses, EThOS, OpenGrey; CoDesign; The Design Journal; Design Issues.\ud \ud \ud Study selection Studies reporting patient, staff or organisational outcomes associated with using co-production in an acute healthcare setting.\ud \ud \ud Findings 712 titles and abstracts were screened; 24 papers underwent full-text review, and 11 papers were included in the evidence synthesis. One study was a feasibility randomised controlled trial, three were process evaluations and seven used descriptive qualitative approaches. Reported outcomes related to (a) the value of patient and staff involvement in co-production processes; (b) the generation of ideas for changes to processes, practices and clinical environments; and (c) tangible service changes and impacts on patient experiences. Only one study included cost analysis; none reported an economic evaluation. No studies assessed the sustainability of any changes made.\ud \ud \ud Conclusions Despite increasing interest in and advocacy for co-production, there is a lack of rigorous evaluation in acute healthcare settings. Future studies should evaluate clinical and service outcomes as well as the cost-effectiveness of co-production relative to other forms of quality improvement. Potentially broader impacts on the values and behaviours of participants should also be considered.

Background: Nurse turnover is an issue of concern in health care systems internationally. Understanding which interventions are effective to reduce turnover rates is important to managers and health care organisations. Despite a plethora of reviews of such interventions, strength of evidence is hard to determine. Objective: We aimed to review literature on interventions to reduce turnover in nurses working in the adult health care services in developed economies. Method: We conducted an overview (systematic review of systematic reviews) using the Cochrane Database of Systematic Reviews, MEDLINE, EMBASE, Applied Social Sciences Index and Abstracts, CINAHL plus and SCOPUS and forward searching. We included reviews published between 1990 and January 2015 in English. We carried out parallel blinded selection, extraction of data and assessment of bias, using the Assessment of Multiple Systematic Reviews. We carried out a narrative synthesis. Results: Despite the large body of published reviews, only seven reviews met the inclusion criteria. These provide moderate quality review evidence, albeit from poorly controlled primary studies. They provide evidence of effect of a small number of interventions which decrease turnover or increase retention of nurses, these being preceptorship of new graduates and leadership for group cohesion. Conclusion: We highlight that a large body of reviews does not equate with a large body of high quality evidence. Agreement as to the measures and terminology to be used together with well-designed, funded primary research to provide robust evidence for nurse and human resource managers to base their nurse retention strategies on is urgently required.

INTRODUCTION: \ud \ud Intentional rounding (IR) is a structured process whereby nurses in hospitals carry out regular checks, usually hourly, with individual patients using a standardised protocol to address issues of positioning, pain, personal needs and placement of items. The widespread implementation of IR across the UK has been driven by the recommendations of the Francis Inquiry although empirical evidence of its effectiveness is poor. This paper presents a protocol of a multimethod study using a realist evaluation approach to investigate the impact and effectiveness of IR in hospital wards on the organisation, delivery and experience of care from the perspective of patients, their family members and staff.\ud \ud METHODS AND ANALYSIS: \ud \ud The study will be conducted in four phases. Phase 1: theory development using realist synthesis to generate hypotheses about what the mechanisms of IR may be, what particular groups may benefit most or least and what contextual factors might be important to its success or failure which will be tested in subsequent phases of the study. Phase 2: a national survey of all NHS acute trusts to explore how IR is implemented and supported across England. Phase 3: case studies to explore how IR is implemented 'on the ground', including individual interviews with patients, family members and staff, non-participant observation, retrieval of routinely collected patient outcomes and cost analysis. Phase 4: accumulative data analysis across the phases to scrutinise data for patterns of congruence and discordance and develop an overall evaluation of what aspects of IR work, for whom and in what circumstances.\ud \ud ETHICS AND DISSEMINATION: \ud \ud The study has been approved by NHS South East Coast-Surrey Research Ethics Committee. Findings will be published in a wide range of outputs targeted at key audiences, including patient and carer organisations, nursing staff and healthcare managers.

Realist synthesis offers a novel and innovative way to interrogate the large literature on interprofessional teamwork in health and social care teams. This article introduces realist synthesis and its approach to identifying and testing the underpinning processes (or "mechanisms") that make an intervention work, the contexts that trigger those mechanisms and their subsequent outcomes. A realist synthesis of the evidence on interprofessional teamwork is described. Thirteen mechanisms were identified in the synthesis and findings for one mechanism, called "Support and value" are presented in this paper. The evidence for the other twelve mechanisms ("collaboration and coordination", "pooling of resources", "individual learning", "role blurring", "efficient, open and equitable communication", "tactical communication", "shared responsibility and influence", "team behavioural norms", "shared responsibility and influence", "critically reviewing performance and decisions", "generating and implementing new ideas" and "leadership") are reported in a further three papers in this series. The "support and value" mechanism referred to the ways in which team members supported one another, respected other's skills and abilities and valued each other's contributions. "Support and value" was present in some, but far from all, teams and a number of contexts that explained this variation were identified. The article concludes with a discussion of the challenges and benefits of undertaking this realist synthesis.

This article is the third in a series reporting the process and findings of a realist synthesis of interprofessional teamwork in health and social care. The synthesis articulated and tested four "mechanisms" (processes) of teamwork related to communication and found variable evidence to support them. Evidence was strongest for "efficient, open and equitable communication" and "tactical communication", but lacking for the shared responsibility element of the "shared responsibility and influence" mechanism. Little evidence was found to support or oppose the mechanism, "team behavioural norms", so its status as a mechanism of interprofessional teamwork is unclear. A striking finding for all the mechanisms was the dearth of information on how they affected patient clinical outcomes and experiences.

Realist synthesis is a theory-driven approach for evaluating complex interventions using empirical evidence, which seeks an explanatory analysis of who a complex intervention works for, how, why, and in what circumstances. Interprofessional teamworking in healthcare is one such complex intervention, as teams are influenced by social and organizational factors, which makes them highly variable and context dependent. This article concludes a series of four articles that report on a realist synthesis of interprofessional teamworking. The synthesis identified 13 mechanisms that are reported in the literature to be the underlying processes through which interprofessional teamworking produces its effects. This article explores four of these mechanisms: a shared purpose; critical reflection; innovation; and leadership. These mechanisms together explain how a team sets and maintains its focus and direction. This article highlights that whilst many assumptions are made within the healthcare literature about how these mechanisms operate within teams, these assumptions are not always founded upon strong empirical evidence.

Aim: The aim of this paper is to inform and advise researchers on the practical issues associated with involving stroke patients and their carers in research. Background: The involvement of patients and carers in research is increasingly recognised as important, yet researchers are often unclear on how to do this in practice. This is particularly evident in the field of stroke care, where there is limited information available about how to involve stroke patients and their carers in research effectively, or about the difficulties associated with this. Data source: Experience of developing a patient and carer advisory group. Review methods: This paper reflects on the process the authors undertook when developing a stroke patient and carer advisory group as part of a research study exploring the effect of interprofessional team working on the experiences and outcomes after stroke of patients and carers. Discussion: This paper discusses the challenges and the benefits of developing a stroke patient and carer and advisory group, and offers advice to other researchers undertaking a similar process. It aims to provide some practical suggestions that may aid researchers wishing to involve stroke patients and carers in their research. Conclusion: Stroke patients are likely to be older and have long-term physical disabilities or communication problems that may make their involvement in research more challenging to implement. However, with planning and consideration and the allocation of sufficient time and resources, stroke patients and their carers can be effectively involved, resulting in benefits to the research process and output, and to researchers, patients and carers. Implications for practice/research: Pay attention to planning and the practical details of involving stroke patients and their carers in research, ensuring that meetings are arranged in an accessible venue. Use straightforward language in all forms of communication. Listen carefully to their views and perspectives and be prepared to make changes to the study and revise methods if appropriate.

Dietary carotene intake during the year before diagnosis was estimated for 96 men with lung cancer, 75 men with other epithelial cancers, and 97 hospital controls. Relative to those of men in the lowest third of carotene intake (less than 1,683 micrograms/day), the smoking-adjusted odds ratios for men in the middle (1,683-2,698 micrograms/day) and upper (greater than 2,698 micrograms/day) thirds of carotene intake were 0.67 and 0.45, respectively, for lung cancer (one-sided test for trend, p = 0.048) and 0.63 and 0.65, respectively, for other epithelial cancers (one-sided test for trend p = 0.074). The protective effect of estimated dietary carotene intake was considerably stronger than was the effect of total intake of carotene-rich vegetables and fruits (grams per day), providing some evidence that the protective factor is carotene itself rather than another component of vegetables and fruits.

The recent finding that many permanent and semipermanent hair dyes are strongly mutagenic in a laboratory test, together with the fact that single female hair-dressers had higher than expected death rates from breast-cancer in 1959-63, prompted a study into the use of hair dyes by patients with breast cancer and by matched controls. There was no difference between the patients and their controls in their use of hair dyes. There were also no significant differences between the two groups when the analysis was confinedto women who had used dyes over four years and over nine years before diagnosis. The only significant findings were a higher proportion of past or present smokers among women aged over 50 who used hair dyes and an association between hair dyes use and age at first pregnancy. Further epidemiological studies are clearly needed in view of the mutagenicity found in the Ames test, and the fact th and several human carcinogens are also mutagenic according to this test.

Researchers have always recognised the importance of disseminating the findings of their work, however, recently the need to proactively plan and drive the impact of those findings on the wider society has become a necessity. Firstly, this is because funders require evidence of return from investment and secondly and crucially because national research assessments are becoming powerful determinants of future funding. In research studies associated with nursing, impact needs to be demonstrated by showing the effect on a range of stakeholders including service users, patients, carers, the nursing workforce and commissioners. Engaging these groups is a well-known challenge influenced by lack of access to academic journals, lack of time to read long complex research papers and lack of opportunities to interact directly with the researchers. This needs to be addressed urgently to enable nursing research to increase the impact that it has on health delivery and the work of clinical practitioners. Social media is potentially a novel way of enabling research teams to both communicate about research as studies progress and to disseminate findings and research funders are increasingly using it to publicise information about research programmes and studies they fund. A search of the healthcare literature reveals that advice and guidance on the use of social media for research studies is not well understood or exploited by the research community. This paper, therefore, explores how using social networking platforms, notably Twitter™ offers potential new ways for communicating research findings, accessing diverse and traditionally hard-to-reach audiences, knowledge exchange at an exponential rate, and enabling new means of capturing and demonstrating research impact. The paper discusses approaches to initiate the setup of social networking platforms in research projects and considers the practical challenges of using Twitter™ in nursing and healthcare research. The discussion is illuminated with examples from our current research. In summary, we suggest that the use of social media micro-blogging platforms is a contemporary, fast, easy and cost effective way to augment existing ways of disseminating research which helps drive impact.

Tests and assessments are valued in society, especially when the cost of getting it right matters, for example, when they are used to certify people we need to trust in order to assure public safety and well-being (e.g., engineers, doctors, pilots, train drivers, electricians, teachers, etc.). Without such formal assessments, we would need to rely solely on the attestation of some individual who may well be subject to the influences of collusion, corruption, and cheating (which is why tests were devised in the first place). Alternatively, we might have to rely on free market processes which would take time to weed out incompetents; we know that deficient practitioners (e.g., peddlers of quackery, pseudo-medicine, or health fraud) may well harm unsuspecting and naive citizens (e.g., Gerald Shirtcliff ’s engineering work, produced under false engineering credentials, may have contributed to a building collapse in the 2011 Christchurch earthquake with significant loss of life; Howe, 2014). Hence, society needs confidence that learners and professionals can perform satisfactorily the responsibilities we assign them and we rely on validated evidence of those competencies before opportunities are given.

Background Nurses leaving their jobs and the profession are an issue of international concern, with supply-demand gaps for nurses reported to be widening. There is a large body of existing literature, much of which is already in review form. In order to advance the usefulness of the literature for nurse and human resource managers, we undertook an overview (review of systematic reviews). The aim of the overview was to identify high quality evidence of the determinants and consequences of turnover in adult nursing. Methods Reviews were identified which were published between 1990 and January 2015 in English using electronic databases (the Cochrane Database of Systematic Reviews, MEDLINE, EMBASE, Applied Social Sciences Index and Abstracts, CINAHL plus and SCOPUS) and forward searching. All stages of the review were conducted in parallel by two reviewers. Reviews were quality appraised using the Assessment of Multiple Systematic Reviews and their findings narratively synthesised. Results Nine reviews were included. We found that the current evidence is incomplete and has a number of important limitations. However, a body of moderate quality review evidence does exist giving a picture of multiple determinants of turnover in adult nursing, with - at the individual level - nurse stress and dissatisfaction being important factors and -at the organisational level - managerial style and supervisory support factors holding most weight. The consequences of turnover are only described in economic terms, but are considered significant. Conclusions In making a quality assessment of the review as well as considering the quality of the included primary studies and specificity in the outcomes they measure, the overview found that the evidence is not as definitive as previously presented from individual reviews. Further research is required, of rigorous research design, whether quantitative or qualitative, particularly against the outcome of actual turnover as opposed to intention to leave. Trial registration PROSPERO Registration 17 March 2015: CRD42015017613. Electronic supplementary material The online version of this article (10.1186/s12913-017-2707-0) contains supplementary material, which is available to authorized users.

Results 158 potentially relevant papers were published between 1973 and 2014; 85 primary research studies and 10 reviews were included. These addressed 5 themes: risks to patients, patient experience, risks to staff, staff experience and impact on the organisation of work. Evidence of the effects of 12-hour shift patterns is inconclusive in all 5 themes, with some studies demonstrating positive impacts and others negative or no impacts.

State funded systems of health care in advanced economies are under severe pressure as a result of ageing populations, rising public expectations and increasing demands for health care. In the UK, ...

SUMMARY A woman aged 40 who had given birth to seven mentally retarded children was diagnosed as having phenylketonuria. Her blood phenylalanine was 18mg/100ml. All the children were microcephalic and retarded in growth, and characteristic facies, skeletal and ear abnormalities were found. Two of the children had Fallot's tetralogy, and one of these two had infantile spasms. Mild diffuse abnormalities were present in the electroencephalograms of four of the children. The findings reinforce the need for careful dietary treatment of pregnant women with phenylketonuria. RESUME Chez une femme de 40 ans ayant donne naissance a sept enfants arrieres mentaux, on a pu porter le diagnostic de phenylcetonurie. Son taux sanguin de phenylalanine etait de 18mg/100ml. Tous les enfants etaient microcephaliques, retardes dans leur croissance, et presentaient un facies caracteristique, des anomalies du squelette et de l'oreille. Deux des enfants avaient une tetralogie de Fallot et chez l'un de ces deux derniers, on notait des spasmes infantiles. Des anomalies diffuses moderees etaient presentes sur les eeg de quatre des enfants. Ces fails renforcent la necessite d'un traitement dietetique soigneux chez les femmes enceintes presentant une phenylcetonurie. ZUSAMMENFASSUNG Eine Frau im Alter von 40 Jahren, die sieben geistig retardierte Kinder geboren hatte, wurde als Phenylketonurikerin diagnostiziert. Ihr Blutphenylalaninspiegel betrug 18mg/100ml. Alle Kinder waren mikrocephal, mindenvuchsig und hatten eine charakteristische Facies und Skelett-und Ohrmisbildungen. Zwei der Kinder hatten eine Fallot'sche Tetralogie und eines davon hatte Neugeborenenkrampfe. Leichte diffuse Veranderungen im eeg fanden sich bei vier Kindern. Die Befunde machen erneut sehr deutlich, das eine sorgfaltige diatetische Uberwachung einer schwangeren Frau mit einer Phenylketonurie erforderlich ist. RESUMEN Una mujer de 40 anos que habia dado a luz siete ninos mentalmente retardados fue diagnosticada de fenilcetonuria. La fenilalanina de su sangre era de 18mg/100ml. Todos los ninos eran microcefalicos y con crecimiento retardado, con facies caracteristica y anomalias esqueleticas y de oreja. Dos de los ninos tenian tetralogia de Fallot y uno de estos dos tenia espasmos infantiles. Habian anomalias difusas ligeras en los eeg de cuatro de los ninos. Los hallazgos refuerzan la necesidad de un cuidadoso tratamiento dietetico de las gestantes con fenilcentonuria.

Elite groups are interesting as they frequently are powerful (in terms of position, knowledge and influence) and enjoy considerable authority. It is important, therefore, to involve them in research concerned with understanding social contexts and processes. This is particularly pertinent in healthcare, where considerable strategic development and change are features of everyday practice that may be guided or perceived as being guided, by elites. This paper evolved from a study investigating the availability and role of nurses whose remit involved leading nursing research and development within acute NHS Trusts in two health regions in Southern England. The study design included telephone interviews with Directors of Nursing Services during which time the researchers engaged in a reflective analysis of their experiences of conducting research with an `elite' group. Important issues identified were the role of gatekeepers, engagement with elites and the use of the telephone interview method in this context. The paper examines these issues and makes a case for involving executive nurses in further research. The paper also offers strategies to help researchers design and implement telephone interview studies successfully to maximise access to the views and experiences of `hard to reach groups', such as elites, while minimising the associated disruption.

Aim : To determine whether the Northwick Park Care Needs Assessment (NPCNA) could be used to estimate nursing staff requirements in an inpatient rehabilitation setting. Design : Retrospective analysis of NPCNA data in comparison with nursing staff provision over a six-month period from 1 April 2003 to 30 September 2003. Setting : A specialist neurorehabilitation unit. Methods : Daily care requirements for the ward were calculated at two-week intervals by summing the NPCNA care-hour estimates for all inpatients. Nursing staff hours provided were identified from the unit's duty rota and agency records for each corresponding period. Results : In total, 271 care-hour recordings were extracted from 59 patients. There was a poor relationship between the calculated total ward care-hour requirements and nursing staff hours provided (Pearson's r = 0.31, P = 0.29); but staff hours provided fell significantly short of estimated daily care requirements (mean shortfall 6.2 hours/day, SD 8.6 (95% confidence interval (CI) 0.73, 11.1), P = 0.03)). The shortfall was most obvious during peak care periods in the morning and at bedtime, which resonates with experience reported by nursing staff that they are overstretched at these times. A marked discrepancy between qualified nursing staff hours provided and NPCNA-estimated `special nursing' care requirements highlights a failure to address important facets of the rehabilitation nursing role. Conclusions : The NPCNA, which was designed to assess only direct care needs in a community setting, requires the further development of a new algorithm before it could be used to estimate nursing staff requirements in a rehabilitation ward setting.

OBJECTIVES: To determine whether transfer to a nursing-led inpatient unit (NLIU) prior to discharge from hospital can improve clinical outcome and reduce length of stay and readmission rate for medically stable post-acute patients assessed as requiring inpatient care. METHOD: Retrospective secondary data analysis of individual patient data (n=471) from a programme of three, purposefully replicated, pragmatic randomized controlled trials. Patients were referred to the NLIU by their consultant (attending doctor/surgeon) for nursing-led subacute/post-acute care and randomly allocated to a treatment group for planned transfer to the NLIU for the remainder of their hospital stay or to a control group for traditional consultant-led care in acute wards. Outcome measures were physical function (Barthel Index), length of stay, discharge destination, mortality, psychological well-being (General Health Questionnaire-12), health-related distress (Nottingham Health Profile Distress Index), incidence of complications and readmission within 7, 28, 90 and 180 days. RESULTS: Patients allocated to the NLIU showed greater improvement in physical function (P

Objectives:To evaluate the effectiveness of interventions used to support self-management, and to explore patients’ experiences after acute coronary syndrome in relation to self-management. Design:Scoping review. Data sources Keyword search of CINAHL Plus, Medline, the Cochrane Library, and PsycINFO databases for studies conducted with adult population and published in English between 1993 and 2014. Review methods: From title and abstract review, duplicated articles and obviously irrelevant studies were removed. The full texts of the remaining articles were assessed against the selection criteria. Studies were included if they were original research on 1) effectiveness of self-management interventions among individuals following acute coronary syndrome; or 2) patients’ experience of self-managing recovery from acute coronary syndrome. Results 44 articles (19 quantitative and 25 qualitative) were included. Most studies were conducted in western countries and quantitative studies were UK centric. Self-management interventions tended to be complex and include several components, including education and counselling, goal setting and problem solving skills which were mainly professional-led rather than patient-led. The review demonstrated variation in the effectiveness of self-management interventions in main outcomes assessed - anxiety and depression, quality of life and health behavioural outcomes. For most participants in the qualitative studies, acute coronary syndrome was unexpected and the recovery trajectory was a complex process. Experiences of making adjustment and adopting lifestyle changes following acute coronary syndrome were influenced by subjective life experiences and individual, sociocultural and environmental contexts. Participants’ misunderstandings, misconceptions and confusion about disease processes and management were another influential factor. They emphasised a need for ongoing input and continued support from health professionals in their self-management of rehabilitation and recovery, particularly during the initial recovery period following hospital discharge. Conclusions:Evidence of the effectiveness of self-management interventions among people with acute coronary syndrome remains inconclusive. Findings from the patients’ experiences in relation to self-management following acute coronary syndrome provided important insights into what problems patients might have encountered during self-managing recovery and what support they might need, which can be used to inform the development of self-management interventions. Theoretical or conceptual frameworks have been minimally employed in these studies and should be incorporated in future development and evaluation of self-management interventions as a way of ensuring clarity and consistency related to how interventions are conceptualised, operationalised and empirically studied. Further research is needed to evaluate self-management interventions among people following acute coronary syndrome for sustained effect and within different health care contexts.

Increasing numbers of HIV-positive young people are transitioning from paediatric to adult services. According to the latest Collaborative HIV Paediatric Study (CHIPS) report1 there are 1873 children with vertically acquired HIV (HIV acquired by mother-to-child transmission) in UK and Ireland, with 595 young people transitioning to adult services. There have been 50–100 young people transferring each year between 2007 and 2013, with a median age of 17.5 (interquartile range 16.6–18.3) years.1 Those aged >15 years have increased from

Objective : In order to determine whether post-acute intermediate care in nursing-led inpatient units (NLUs) is effective in preparing patients for discharge from hospital we conducted a systematic review of the evidence. Review methods : The Cochrane Library, Effective Practice and Organisation of Care specialist register, Medline, Cinahl, Embase, British Nursing Index and the HMIC databases were searched for all available dates up to mid-2003. The science and social science citation indices were searched for papers that cited key works. Authors of papers were asked to identify additional research. Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time-series designs that compared the NLU to usual post-acute inpatient care for adults were included in the review. Studies were assessed for quality. Statistical meta-analysis on the results of controlled trials was performed. Sensitivity analyses were conducted to determine the impact of methodological quality on conclusions. Outcomes : Outcomes considered were mortality, institutionalisation after discharge, functional status early readmission, length of inpatient stay and cost. Results : Nine random or quasi-random controlled trials involving 1669 patients were reviewed. Quality was variable. The mean age of patients in all studies was over 70 years. There was no statistically significant difference in inpatient mortality between NLU and usual inpatient care (OR 1.10, 95% CI 0.56–2.16). The NLU was associated with reduced odds of discharge to institutional care (OR 0.44 95% CI 0.22–0.89), better functional status at discharge (SMD 0.37, 95% CI 0.20–0.54) and reduced odds of early readmission (OR 0.52 95% CI 0.34–0.80). Length of stay until discharge home was increased by 5.13 days (WMD) (95% CI–0.5–10.76 days). At longest follow up (3–6 months) there was no statistically significant difference in the proportion of patients in institutional care (OR 0.97, 95% CI 0.60–1.58). The results were not generally sensitive to study quality. Conclusions : The NLU successfully functions as a form of intermediate care, so far there is no evidence of adverse outcome from the lower level of routine medical care. However, more research is required to confirm safety. Patients discharged from NLUs have higher levels of function although it is unclear if the benefit is simply a product of an increased stay. There is no evidence of benefit over the longer term.

For over a decade, the need to develop a robust evidence base for nursing, midwifery and health visiting through research has been part of the UK government's R&D strategy. Progress has been slow and little is known about the organisational reality of the most recent strategies. This study aimed to investigate the nature of posts with named responsibilities to lead and develop nursing and midwifery research activity, based in acute NHS hospital trusts. Data were obtained through telephone interviews with directors of nursing services, and a postal survey of relevant staff. Fifty two people responsible for nursing and midwifery R&D were invited to complete the questionnaire, of whom 34 responded. The majority of trusts were able to name an individual responsible for leading nursing R&D, although the remit of the role varied considerably. The effectiveness of implementing any national research strategy is likely to be constrained by the lack of consistency regarding nursing research roles, a factor that may also be implicated in the lack of progress in securing a meaningful contribution to NHS research from nursing R&D.

Interprofessional teamwork is seen in healthcare policy and practice as a key strategy for providing safe, efficient and holistic healthcare and is an accepted part of evidence-based stroke care. The impact of interprofessional teamwork on patient and carer experience(s) of care is unknown, although some research suggests a relationship might exist. This study aimed to explore patient and carer perceptions of good and poor teamwork and its impact on experiences of care. Critical incident interviews were conducted with 50 patients and 33 carers in acute, inpatient rehabilitation and community phases of care within two UK stroke care pathways. An analytical framework, derived from a realist synthesis of 13 'mechanisms' (processes) of interprofessional teamwork, was used to identify positive and negative 'indicators' of teamwork. Participants identified several mechanisms of teamwork, but it was not a subject most talked about readily. This suggests that interprofessional teamwork is not a concept that is particularly important to stroke patients and carers; they do not readily perceive any impacts of teamwork on their experiences. These findings are a salient reminder that what might be expected by healthcare professionals to be important influences on experience may not be perceived to be so by patients and carers.

Interprofessional teamwork has become an integral feature of healthcare delivery in a wide range of conditions and services in many countries. Many assumptions are made in healthcare literature and policy about how interprofessional teams function and about the outcomes of interprofessional teamwork. Realist synthesis is an approach to reviewing research evidence on complex interventions which seeks to explore these assumptions. It does this by unpacking the mechanisms of an intervention, exploring the contexts which trigger or deactivate them and connecting these contexts and mechanisms to their subsequent outcomes. This is the second in a series of four papers reporting a realist synthesis of interprofessional teamworking. The paper discusses four of the 13 mechanisms identified in the synthesis: collaboration and coordination; pooling of resources; individual learning; and role blurring. These mechanisms together capture the day-to-day functioning of teams and the dependence of that on members' understanding each others' skills and knowledge and learning from them. This synthesis found empirical evidence to support all four mechanisms, which tentatively suggests that collaboration, pooling, learning, and role blurring are all underlying processes of interprofessional teamwork. However, the supporting evidence for individual learning was relatively weak, therefore there may be assumptions made about learning within healthcare literature and policy that are not founded upon strong empirical evidence. There is a need for more robust research on individual learning to further understand its relationship with interprofessional teamworking in healthcare.

OBJECTIVES: To provide a comprehensive scoping review of evidence of the impact and effectiveness of 12h shifts in the international nursing literature, supplemented by a review of evidence in other, non-nursing related industries. DATA SOURCES: A search of the academic literature was undertaken in electronic databases (AMED, MEDLINE, CINAHL, PsychInfo, Scopus, HMIC, the Cochrane Library, Business Source Premier, Econ Lit, ASSIA and Social Policy and Practice). REVIEW METHODS: A total of 158 potentially relevant nursing research papers and reviews were published between 1973 and 2014. Two reviewers independently reviewed the articles, leaving 85 primary research studies and 10 review papers in the nursing field to be included in the scoping review. Thirty-one relevant primary research papers and reviews were also identified in the non-nursing related industries literature. RESULTS: Research into 12h nursing shifts fell within five broad themes: 'risks to patients', 'patient experience', 'risks to staff', 'staff experience' and 'impact on the organisation of work'. There was inconclusive evidence of the effects of 12h shift patterns in all five themes, with some studies demonstrating positive impacts and others negative or no impacts. This also mirrors the evidence in other, non-nursing related industries. The quality of research reviewed is generally weak and most studies focus on the risks, experience and work/life balance for staff, with few addressing the impact on patient outcomes and experience of care or work productivity. CONCLUSIONS: There is insufficient evidence to justify the widespread implementation or withdrawal of 12h shifts in nursing. It is not clearly understood where there are real benefits and where there are real and unacceptable risks to patients and staff. More research focusing on the impact of 12h nursing shifts on patient safety and experience of care and on the long term impact on staff and work organisation is required.

BACKGROUND: A growing number of countries legislate for nurses to have medication prescribing authority although it is a contested issue. The UK is one of these countries, giving authority to nurses with additional qualifications since 1992 and incrementally widened the scope of nurse prescribing, most recently in 2006. The policy intention for primary care was to improve efficiency in service delivery through flexibility between medical and nursing roles. The extent to which this has occurred is uncertain. This study investigated nurses prescribing activities, over time, in English primary care settings.\ud \ud METHODS: A secondary data analysis of a national primary care prescription database 2006-2010 and National Health Service workforce database 2010 was undertaken.\ud \ud RESULTS: The numbers of nurses issuing more than one prescription annually in primary care rose from 13,391 in 2006 to 15,841 in 2010. This represented forty three percent of those with prescribing qualifications and authorisation from their employers. The number of items prescribed by nurses rose from 1.1% to 1.5% of total items prescribed in primary care. The greatest volume of items prescribed by independent nurse prescribers was in the category of penicillins, followed by dressings. However, the category where independent nurse prescribers contributed the largest proportion of all primary care prescriptions was emergency contraception (9.1%). In contrast, community practitioner nurse prescribers' greatest volume and contribution was in the category of gel and colloid dressings (27%), medicated stockings (14.5%) and incontinence appliances (4.2%). There were slightly higher rates of nurse prescribing in areas with higher levels of socio-economic deprivation and fewer physicians per capita, but the correlations were weak and warrant further investigation.\ud \ud CONCLUSIONS: The percentage of prescriptions written by nurses in primary care in England is very small in comparison to physicians. Our findings suggest that nurse prescribing is used where it is seen to have relative advantage by all stakeholders, in particular when it supports efficiency in nursing practice and also health promotion activities by nurses in general practice. It is in these areas that there appears to be flexibility in the prescribing role between nurses and general practitioners.