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Aims/Questions\ud To explore the barriers and facilitators to nurses accessing clinical supervision; explore the barriers and facilitators to organizations implementing clinical supervision and capture what skills nurses require to facilitate clinical supervision.\ud \ud Design\ud Scoping review of peer-reviewed research and grey literature.\ud \ud Data sources\ud CINAHL, Medline, PsychINFO and Scopus were searched for relevant papers published between 1990 and 2020. Google, Google Scholar, OpenGrey & EThOS were used to search for grey literature.\ud \ud Review Methods\ud PRISMA-ScR guidelines were used during the literature review process. Eighty-seven papers were included, and data were extracted from each paper using a standardized form. Data synthesis was undertaken using Seidel's analytical framework.\ud \ud Results\ud Five themes were identified: Definitions and Models, (Mis) Trust and the Language of Supervision, Alternative Parallel Forums and Support Mechanisms, Time and Cost and Skills required.\ud \ud Conclusion\ud Since its inception in the 1990s, clinical supervision has long been regarded as a supportive platform for nurses to reflect on and develop their practice. However, this review highlights that despite an awareness of the skills required for nurses to undertake clinical supervision, and the facilitators for nurses to access and organizations to implement clinical supervision, there have been persistent barriers to implementation. This review identifies these persistent factors as ‘barriers to overcoming the barriers' in the clinical supervision landscape. These require critical consideration to contribute towards moving clinical supervision forward in the spirit of its original intentions.\ud \ud Impact\ud This review progresses the debate on clinical supervision through critically analysing the barriers to overcoming the barriers. To this end, the review is designed to stimulate critical discussions amongst nurses in different clinical spaces and key stakeholders such as policy makers and regulatory bodies for the nursing profession.

© 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.

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.

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 Clinically assisted hydration (CAH) at end of life is a contentious issue (Cabanero-Martinez et al, 2016) There is disagreement as to its benefits and this can lead to a lack of concordance between medical and nursing opinions, with nurses feeling unable to challenge doctors (Churchman, 2010; Van Der Riet, 2008; Mayashita, 2007). Prior to introducing a feasibility study on CAH (Davies, 2018) on one hospice site, an unpublished survey of nursing staff revealed widespread dissatisfaction with the standard practice of not routinely offering CAH. Following completion of the study a staff survey was undertaken to see if attitudes had changed. Aims To determine if nurses feel coerced into accepting the current hospice policy on CAH. To examine how nurses interacted with families when asked about CAH. To explore staff engagement with research on CAH. Method A semi-structured questionnaire sent to all nursing staff including HCA’s, with closed and open-ended questions. The responses were analysed using descriptive statistics and thematic analysis. Results The responses indicated that; The majority accept standard care without feeling coerced (68%). Nurses felt they could challenge accepted practice (62%). An overwhelming majority felt the hospice should be engaged in research on CAH (80%). Nursing staff expressed the following; Nurses wanted to be more involved in decision making around CAH. Many felt that a standard practice should be replaced with individual patient decisions. Staff were frequently asked about CAH and felt able to discuss the risks and benefits with families. Conclusions Overall, nurses accepted hospice standard practice on CAH and did not feel coerced. A few opposed further research, most welcomed it to establish an evidence base.

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

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.

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.

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.

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.

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.

This discursive paper is a structured analysis of four completed national and regional studies carried out in the UK. It sets out retrospectively to explore the impact of key contextual, professional and personal features and mechanisms on innovation and outcomes in nursing and the extent to which these are common or diverge across the studies (cases). As successive governments across the world turn their attention to developing nursing as a means of increasing productivity and effectiveness in health care, there is a need for evidence to inform workforce policy and planning about the circumstances that enable positive levers and mechanisms, which influence outcomes to operate. This analysis takes advantage of recent conceptual work on organisational governance and incentives by asking new questions of established data to illuminate our understanding of the pathway to innovation in nursing. Data from the four evaluations (cases) were aggregated and explored thematically within Davies et al.’s framework (Studying health care organisations — links between governance, incentives and outcomes: a review of the literature. Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R&D (NCCSDO). http://www.sdo.nihr.ac.uk/files/project/66-final-report.pdf, 2005) of governance, incentives and outcomes. The themes were grouped into three categories: contextual, professional and personal, and interrogated by inter-researcher scrutiny. Taking account of the limitations of comparing studies carried out for different purposes and in different policy circumstances, there are compelling messages emerging about the organisational support, professional leadership and factors that motivate change and innovation in nursing. The analysis suggests that separating governance from incentives oversimplifies what is a complex interplay between organisational governance and the professional and personal enabling factors supporting innovation. The nature of these relationships deserves further study.

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.

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.

OBJECTIVES: to evaluate the outcome and cost of transfer to a nursing-led inpatient unit for ‘intermediate care’. The unit was designed to replace a period of care in acute hospital wards and promote recovery before discharge to the community. DESIGN: randomized controlled trial comparing outcomes of care on a nursing-led inpatient unit with the system of consultant-managed care on a range of acute hospital wards. SETTING: hospital wards in an acute inner-London National Health Service trust. SUBJECTS: 175 patients assessed to be medically stable but requiring further inpatient care, referred to the unit from acute wards. INTERVENTION: 89 patients were randomly allocated to care on the unit (nursing-led care with no routine medical intervention) and 86 to usual hospital care. MAIN OUTCOME MEASURES: length of hospital stay, discharge destination, functional dependence (Barthel index) and direct healthcare costs. RESULTS: care in the unit had no significant impact on discharge destination or dependence. Length of inpatient stay was significantly increased for the treatment group (P=0.036; 95% confidence interval 1.1–20.7 days). The daily cost of care was lower on the unit, but the mean total cost was £1044 higher—although the difference from the control was not significant (P=0.150; 95% confidence interval -£382 to £2471). CONCLUSIONS: the nursing-led inpatient unit led to longer hospital stays. Since length of stay is the main driver of costs, this model of care—at least as implemented here—may be more costly. However, since the unit may substitute for both secondary and primary care, longer-term follow-up is needed to determine whether patients are better prepared for discharge under this model of care, resulting in reduced primary-care costs.

AIM: To explore nurses' archived accounts of Matron Muriel Powell's management and leadership style and the impact of this on the implementation and sustainability of innovation in the workplace. BACKGROUND: In popular discourse, the matron has become an emblem of leadership. Although the title disappeared in the UK in the late 1960s as part of the re-organization recommended by the Salmon Report, it re-appeared in 2002 in an attempt to improve care standards by reasserting a strong nursing presence and clinical leadership role. DESIGN: Secondary data analysis using qualitative thematic analysis. METHODS: This paper draws on interview data held in the 'Nurses Voices' archive. The interview transcripts of 132 nurses who trained or worked at St George's hospital in 1920-1980 were analysed in depth between March 2011-January 2012 and themes were generated inductively by grouping together emergent codes in the data with similar meaning. RESULTS: Looking back, the nurses recalled strong memories of the leadership of Matron Powell. Her presence emerged as a significant influence throughout the interviews. Two resonant themes were identified: innovation and open communication. CONCLUSIONS: Through her visibility and direct access with patients and staff, Dame Muriel Powell showed what we would now call transformative leadership qualities. Her leadership created a culture of open communication and innovation that initiated change in the organization and the nursing workforce. Looking back and learning from historical figures can deepen understanding and provide pointers for the nurse leaders of today.

BACKGROUND: Securing employment after qualification is of utmost importance to newly qualified nurses to consolidate knowledge and skills. The factors that influence success in gaining this first post are not known. OBJECTIVES: The study aimed to describe the first post gained after qualification in terms of setting, nature of employment contract and geographical distribution and explore the relationship between a range of factors (including ethnicity) and employment at the point of qualification. DESIGN: An exploratory study using structured questionnaires and secondary analysis of data routinely collected by the universities about students and their progress during their course. SETTINGS: The study was conducted in eight universities within a large, multicultural city in the UK as part of the 'Readiness for Work' research programme. PARTICIPANTS: Eight hundred and four newly qualified nurses who had successfully completed a diploma or degree from one of the universities; a response rate of 77% representing 49% of all graduating students in the study population. METHODS: Data were collected by self-completed semi-structured questionnaires administered to students at the time of qualification and at three months post-qualification. Routinely collected data from the universities were also collected. RESULTS: Fifty two percent of participants had been offered a job at the point of qualification (85% of those who had applied and been interviewed). Of these, 99% had been offered a nursing post, 88% in the city studied, 67% in the healthcare setting where they had completed a course placement. 44% felt "confident" and 32% "very confident" about their employment prospects. Predictors of employment success included ethnicity, specialty of nursing and university attended. Predictors of confidence and preparedness for job seeking included ethnicity, nursing specialty, gender and grade of degree. Newly qualified nurses from non-White/British ethnic groups were less likely to get a job and feel confident about and prepared for job seeking. CONCLUSIONS: This study has demonstrated that ethnicity does lead to employment disadvantage for newly qualified nurses. This is an important contribution towards recognizing and describing the evidence so that appropriate responses and interventions can be developed. It is important that universities and healthcare institutions work closely together to support students at this important time in their nursing career.

Background Safe and timely access to effective and appropriate medication through primary care settings is a major concern for all countries addressing both acute and chronic disease burdens. Legislation for nurses and other professionals allied to medicine to prescribe exists in a minority of countries, with more considering introducing legislation. Although there is variation in the range of medicines permitted to be prescribed, questions remain as to the contribution prescribing by nurses and professionals allied to medicine makes to the care of patients in primary care and what is the evidence on which clinicians, commissioners of services and policy makers can consider this innovation. Methods A integrative review of literature on non-medical prescribing in primary care was undertaken guided by dimensions of health care quality: effectiveness, acceptability, efficiency and access. Results 19 papers of 17 empirical studies were identified which provided evidence of patient outcome of non medical prescribing in primary care settings. The majority were undertaken in the UK with only one each from the USA, Canada, Botswana and Zimbabwe. Only two studies investigated clinical outcomes of non-medical prescribing. Seven papers reported on qualitative designs and four of these had fewer than ten participants. Most studies reported that non medical prescribing was widely accepted and viewed positively by patients and professionals. Conclusions Primary health care is the setting where timely access to safe and appropriate medicines is most critical for the well-being of any population. The gradual growth over time of legislative authority and in the numbers of non-medical prescribers, particularly nurses, in some countries suggests that the acceptability of non-medical prescribing is based on the perceived value to the health care system as a whole. Our review suggests that there are substantial gaps in the knowledge base to help evidence based policy making in this arena. We suggest that future studies of non-medical prescribing in primary care focus on the broad range of patient and health service outcomes and include economic dimensions.

Background Informal carers frequently suffer adverse consequences from caring. General practice teams are well positioned to support them. However, what carers of stroke survivors want and expect from general practice, and the practical support measures they might like, remain largely unexplored. The aims of this study are twofold. Firstly it explores both the support stroke carers would like from general practice and their reactions to the community based support proposed in the New Deal. Secondly, perceptions of a general practice team are investigated covering similar topics to carer interviews but from their perspective. Methods Semi-structured interviews were conducted with 13 stroke carers and 10 members of a general practice team. Carers' experiences and expectations of general practice and opinions of support measures from recent government policy were explored. General practice professionals were asked about their perceived role and their perceptions of carers' support needs. Interviews were content analysed. Results Carers' expectations of support from general practice were low and they neither received nor expected much support for themselves. General practice was seen as reactive primarily because of time constraints. Some carers would appreciate emotional support but others did not want additional services. Responses to recent policy initiatives were mixed with carers saying these might benefit other carers but not themselves. General practice professionals' opinions were broadly similar. They recognise carers' support needs but see their role as reactive, focussed on stroke survivors, rather than carers. Caring was recognised as challenging. Providing emotional support and referral were seen as important but identification of carers was considered difficult. Time constraints limit their support. Responses to recent policy initiatives were positive. Conclusions Carers' expectations of support from general practice for themselves are low and teams are seen as reactive and time constrained. Both the carers and the general practice team participants emphasised the valuable role of general practice team in supporting stroke survivors. Research is needed to determine general practice teams' awareness and identification of carers and of the difficulties they encounter supporting stroke carers. Carer policy initiatives need greater specificity with greater attention to diversity in carer needs.

This article highlights findings from three studies into nurse-led inpatient units. The results are not the same in each case, particularly with regard to length of stay, and the authors discuss the possible reasons for this. Further work is needed to develop NLIUs and identify cost savings.

Title. Work sampling: a quantitative analysis of nursing activity in a neuro-rehabilitation setting. Aim. The aim of this investigation was to establish the distribution and proportion of nursing activity represented by patient-related care activities (direct and indirect), and other nursing activities (unit-related and personal) within one inpatient neurological rehabilitation unit. Background. A set of tools has been developed for estimating the care/nursing hours required for direct hands-on patient care in hospital rehabilitation settings. However, to apply this information to estimate the actual staffing requirements in relation to a given caseload, it is necessary to know the proportion of nursing workload assigned to other activities and how this may vary throughout the day. Method. A work sampling study was conducted during 2004. A snapshot of nursing activity was recorded at 5-minute intervals from 06·00 to 23·55 spread over 2 weeks, with one session from 06·00 to 15·25 and the second from 15·30 to 23·55. Results. A total of 8883 nursing activities were observed and recorded over 126 hours and categorized as follows: 4060 (46%) direct patient care, 2218 (25%) indirect patient care, 874 (10%) unit-related and 1731 (19%) personal time. The proportions of direct care fluctuated throughout the day, with direct care activities mainly concentrated in early mornings and to a lesser extent evenings. Conclusion. Direct patient care accounted for less than half of the nursing activity in a rehabilitation setting. Estimates of staffing requirement must also take account of the time required for indirect care and non-patient related activity.

BACKGROUND: With the changing demographic profile of the nursing workforce, retaining the skill and experience of nurses in mid-life is very important. Work-life balance is a concept that is gaining increasing prominence in today's society. However, little is known about older nurses' experience of family friendly policies and flexible working. OBJECTIVES: This study explored the organisational, professional and personal factors that influence perceptions of commitment and participation in the workforce for nurses working in mid-life (aged 45 and over). DESIGN: A qualitative study using a range of methods including biographical methods, semi-structured face-to-face interviews, focus groups and telephone interviews. Data were analysed using constant comparative method. SETTINGS: A large inner city acute teaching hospital and an inner city mental health and social care trust providing both community and inpatient health and social care. PARTICIPANTS: 34 nurses and 3 health care assistants participated in individual interviews, 10 nurses participated in two focus groups and 17 managers participated in individual telephone interviews. RESULTS: Four themes emerged: the nature of nursing poses a challenge to the implementation of flexible working, differences in perceptions of the availability of flexible working, ward managers have a crucial role in the implementation of flexible working policies and the implementation of flexible working may be creating an inflexible workforce. CONCLUSIONS: The findings suggest that there are limits to the implementation of flexible working for nurses. In some areas there is evidence that the implementation of flexible working may be producing an inflexible workforce as older nurses are required to compensate for the flexible working patterns of their colleagues. Ward managers have a key role in the implementation of family friendly policies and require support to fulfil this role. There is a need for creative solutions to address implementation of flexible working for all nurses to ensure that workforce policy addresses the need to retain nurses in the workforce in a fair and equitable way.

Title. Northwick Park Care Needs Assessment: adaptation for inpatient neurological rehabilitation settings Aim. This paper is a report of a study to establish which timings and assumptions of the Northwick Park Dependency Scale and Care Needs Assessment are appropriate to the inpatient rehabilitation setting and which, if any, require adjustment. Background. Cost-effective provision of nursing care relies on being able to adjust staffing levels in accordance with patient dependency. The Northwick Park Dependency Scale and Care Needs Assessment enables direct assessment of nursing care needs in community settings. Method. An observational study was conducted in 2004 to record the time taken to complete direct nursing care interventions in a rehabilitation ward and to compare these times with simultaneously recorded time-estimates provided by the Care Needs Assessment. A total of 1168 nursing interactions were timed for 50 care episodes. Results. There was considerable variation in the time taken for each nursing intervention, depending on overall patient dependency and the number of nurses required. Although there was good correlation between observed care times and those estimated by the Care Needs Assessment, observation confirmed that most interventions took substantially less time than the estimates. There was also a very different pattern of care in hospital compared with the community, with shorter, more frequent interactions as nurses distribute their time between different patients, and activities other than direct patient care. Conclusion. The Northwick Park Care Needs Assessment tool already has widespread application in other countries and its continued use for estimating community care needs remains relevant. The tool, once fully developed, will have the potential to contribute to international rehabilitation nursing workforce planning and research.

BACKGROUND: The Nursing led inpatient Unit (NLU) is one of a range of services that have been considered in order to manage more successfully the transition between hospital and home for patients with extended recovery times. This is an update of an earlier review published in The Cochrane Library in Issue 3, 2004. OBJECTIVES: To determine whether nursing‐led inpatient units are effective in preparing patients for discharge from hospital compared to usual inpatient care. SEARCH METHODS: We searched The Cochrane Library, the Specialized Register of the Cochrane Effective Practice and Organisation of Care (EPOC) group, MEDLINE, CINAHL, EMBASE, BNI and HMIC databases. Citation searches were undertaken on the science and social science citation indices. Authors were contacted to identify additional data. The initial search was done in January 2001. The register search was updated in October 2006, the other database searches were updated in November 2006 and the citation search was run in January 2007. SELECTION CRITERIA: Controlled trials and interrupted time series designs that compared the NLU to usual inpatient care managed by doctors. Patients over 18 years of age following an acute hospital admission for a physical health condition. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed study quality. MAIN RESULTS: Ten random or quasi‐random controlled trials reported on a total of 1896 patients. There was no statistically significant effect on inpatient mortality (OR 1.10, 95% CI 0.56 to 2.16) or mortality to longest follow up (OR 0.92, 95% CI 0.65 to 1.29) but higher quality studies showed a larger non‐significant increase in inpatient mortality (OR 1.52, 95% CI 0.86 to 2.68). Discharge to institutional care was reduced for the NLU (OR 0.44 95% CI 0.22 to 0.89) and functional status at discharge increased (SMD 0.37, 95% CI 0.20 to 0.54) but there was a near significant increase in inpatient stay (WMD 5.13 days 95% CI ‐0.5 days to 10.76 days). Early readmissions were reduced (OR 0.52 95% CI 0.34 to 0.80). One study compared a NLU for the chronically critically ill with ICU care. Mortality (OR 0.62 95% CI 0.35 to 1.10) and length of inpatient stay differ did not differ (WMD 2 days, 95% CI 10.96 to ‐6.96 days). Early readmissions were reduced (OR 0.33 95% CI 0.12 to 0.94). Costs of care on the NLU were higher for UK studies but lower for US based studies. AUTHORS' CONCLUSIONS: There is some evidence that patients discharged from a NLU are better prepared for discharge but it is unclear if this is simply a product of an increased length of inpatient stay. No statistically significant adverse effects were noted but the possibility of increased early mortality cannot be discounted. More research is needed.

In recent years, there has been an increasing policy focus on the role of interprofessional education in healthcare. However, the literature emphasizes process rather than outcomes, with little that specifically relates interprofessional educational interventions to the care of people with long-term conditions. This article questions what we know about interprofessional interventions in the care of people with chronic disease, examines the evidence for and potential of interprofessional education in changing practice, and makes suggestions for further research.

Aims The nursing-led inpatient unit is designed to substitute for a period of care in acute hospital wards and to improve patient outcome prior to discharge to the community. This paper aims to evaluate the cost, from the UK National Health Service perspective, of transfer to a nursing-led inpatient unit for intermediate care and to discuss the impact of these findings to the future development and sustainability of the nursing-led inpatient unit. Background Recent economic analyses have showed that nursing-led inpatient units are associated with increased costs of care with length of stay as the main driver of inpatient costs. Method The cost-effectiveness analysis was part of a randomized-controlled trial with a sample size of 175, of which 89 were in the nursing-led inpatient unit arm and 86 in the control arm. Resource use data included length of stay, investigations performed, multiprofessional input and nursing input. Clinical outcome was measured using Barthel Index, a functional status measure. Results Cost per day was lower on the nursing-led inpatient unit although cost per hospital stay was higher due to significantly increased length of stay. Postdischarge community care costs were lower. The incremental cost-effectiveness ratio of the treatment was £1044 per point improvement of the Barthel Index. Conclusions The nursing-led inpatient unit was associated with higher costs however, the question of whether the nursing-led inpatient unit is cost-effective has not been clearly answered because of the limited follow-up period of the study. The increased cost of care on the nursing-led inpatient unit was not a major factor in local management decisions about the future of the unit. The changes in the context of service provision within which the nursing-led inpatient unit operated as a result of substantial investment in intermediate care did have a major impact.

BACKGROUND Little is known about the frequency with which information from the Internet is presented by patients within primary care consultations or the subsequent impact that it may have on those consultations. OBJECTIVES The aims of this study were to describe the frequency with which Internet information was presented within primary care consultations in one inner-city health authority and to describe the characteristics of the subsequent consultation from the perspective of the health professionals involved. METHODS A postal survey was used to estimate the frequency of Internet information presentation and eight in-depth interviews were used to obtain health professionals' perceptions of the consultations that followed. RESULTS Presentation of information from the Internet was relatively infrequent within primary care at the time of the survey (November 2000 to March 2001), but frequencies of presentation were higher for GPs than for any other health professional group. Health professionals have stereotypical views of Internet users and fear for their own professional status in relation to the Internet-informed patient or client. CONCLUSIONS Although presentation of information from the Internet to date remains relatively infrequent, health professionals appear to feel threatened by it and adopt strategies that minimize its impact on the subsequent consultation.

Recruitment of frail older people to research: lessons learnt through experience Background. With the emphasis on the need for clinical governance and evidence-based practice in the healthcare industry there is increasing pressure on researchers to provide tangible research evidence of the effectiveness of new treatments, interventions and services. Recruiting an adequate size of sample is an important factor in the success or otherwise of a study to answer the research question. Difficulty in the recruitment of older people to research is widely acknowledged. However, much can be achieved to maximize the success of this process. Aims of the paper. This paper describes and explores our experience of recruiting frail, older people to research, with particular emphasis on ensuring quality in the process of research related to ethical practice. Conclusions. Recruitment of frail older people to research can be a complex process in which the awareness and integrity of the researcher is key in upholding the principle of nonexploitation. It is important not to underestimate this difficulty and to ensure that the data collection period is sufficient to recruit adequate numbers. There is a need to continue to develop and refine recruitment skills and strategies to maximize the involvement of frail older people to research while protecting their right to refuse.