Search

Aims and objectives: To identify barriers and facilitators to implementing community nurses being trained as psychological wellbeing practitioners and integrating this practice into home‐based primary care nursing, through key stakeholders' perceptions. Background: Current drivers in UK primary care aim to increase access to mental health services and treatment, to achieve parity of esteem between physical and mental health care for patients who are housebound. However, there remains limited evidence on how to successfully implement this. Training community nurses as psychological wellbeing practitioners to offer mental health care alongside their current home‐based services is one option. Design: A pluralistic qualitative study. This study followed the COREQ checklist for reporting qualitative research. Methods: Twenty key stakeholders were purposively recruited and interviewed including twelve health professionals and eight patients. Semi‐structured interviews were analysed using a theoretical thematic analysis informed by normalisation process theory concepts of coherence, cognitive participation, collective action and reflexive monitoring, to explore the barriers and facilitators to implementation. Results: Staff and patients reported high coherence and cognitive participation, valuing the integrated roles. Facilitators included the development of clearer referral pathways and increased mental health knowledge in the wider team. However, sustainability and current siloed healthcare systems were identified as barriers to implementation. Conclusions: A key obstacle to long‐term implementation was the practical structures and financial boundaries of siloed healthcare systems, making long‐term sustainability unviable. Relevance to clinical practice: Community nurses with additional mental health training can integrate these skills in practice and are valued by their team and patients offering holistic care to patients within their home and informal knowledge transfer to the wider team. However, long‐term sustainability is required if this is to be adopted routinely. Further evidence is needed to better understand the positive outcomes to patients and potential cost savings. [ABSTRACT FROM AUTHOR]

Abstract Background The physiotherapy profession has undergone a paradigmatic shift in recent years, where a ‘biopsychosocial’ model of care has acquired popularity in response to mounting research evidence indicating better patient outcomes when used alongside traditional physiotherapy. However, research has not examined how this new dimension to traditional physical therapy is implemented within the therapeutic consultation. Methods The study aimed to investigate physiotherapists’ reported approaches to back pain care in the context of increasing pressure to address patients’ psychosocial concerns. A secondary analysis of semi-structured qualitative interviews with 12 UK physiotherapists was conducted. Respondents were sampled from a national survey, to include a broad mix of physiotherapists. Data were analysed thematically, adopting the constant comparative methodology. Results The combination of traditional physical therapy with a broader biopsychosocial approach presented significant challenges. Physiotherapists responded by attempting to navigate patients’ biopsychosocial problems through use of various strategies, such as setting boundaries around their clinical role and addressing lay health beliefs of patients through the provision of reassurance and lifestyle advice. Conclusions As psychosocial issues, alongside biomechanical factors, command a prominent place within the back pain consultation, physiotherapists may benefit from further specific training and mentoring support in identifying specific strategies for combining the best of traditional physiotherapy approaches with greater focus on patients’ beliefs, fears and social context.

Abstract Background Low-back related leg pain with or without nerve root involvement is associated with a poor prognosis compared to low back pain (LBP) alone. Compared to the literature investigating prognostic indicators of outcome for LBP, there is limited evidence on prognostic factors for low back-related leg pain including the group with nerve root pain. This 1 year prospective consultation-based observational cohort study will describe the clinical, imaging, demographic characteristics and health economic outcomes for the whole cohort, will investigate differences and identify prognostic indicators of outcome (i.e. change in disability at 12 months), for the whole cohort and, separately, for those classified with and without nerve root pain. In addition, nested qualitative studies will provide insights on the clinical consultation and the impact of diagnosis and treatment on patients' symptom management and illness trajectory. Methods Adults aged 18 years and over consulting their General Practitioner (GP) with LBP and radiating leg pain of any duration at (n = 500) GP practices in North Staffordshire and Stoke-on-Trent, UK will be invited to participate. All participants will receive a standardised assessment at the clinic by a study physiotherapist and will be classified according to the clinically determined presence or absence of nerve root pain/involvement. All will undergo a lumbar spine MRI scan. All participants will be managed according to their clinical need. The study outcomes will be measured at 4 and 12 months using postal self-complete questionnaires. Data will also be collected each month using brief postal questionnaires to enable detailed description of the course of low back and leg pain over time. Clinical observations and patient interviews will be used for the qualitative aspects of the study. Discussion This prospective clinical observational cohort will combine self-reported data, comprehensive clinical and MRI assessment, together with qualitative enquiries, to describe the course, health care usage, patients' experiences and prognostic indicators in an adult population presenting in primary care with LBP and leg pain with or without nerve root involvement.

Abstract Background Changing clinicians' behaviour is recognised as a major challenge. It is clear that behaviour change not only depends on demonstrating the proven effectiveness of clinical interventions; contextual and occupational factors, such as 'change readiness', may be central to their implementation. This paper highlights the context of behaviour change in relation to a healthcare innovation introduced within primary care, highlighting the importance of organisational and interpersonal factors that may help explain the dynamics of implementation. Methods Qualitative interviews were conducted with general practitioners (GPs) before (n = 32) and after (n = 9) the introduction of a subgrouping for targeted treatment system. GPs were offered an electronic six-item subgrouping tool, to identify patients according to their risk of poor outcome ('high', 'low') in order to help inform their decision making about treatment approaches. Recruitment was based on a 'maximum diversification sample', to obtain a wide representation of views across all five practices. A coding scheme was developed based on the emergent findings, and the data were analysed using 'constant comparison', drawing upon insights and developing connections between themes. We adopted the normalisation process theory (NPT) to explain the uptake of the new system and to examine the relevance of coherence for the implementation of innovations in organisations. Results GPs perceived back pain as a low clinical priority, and highlighted the importance of 'practical' and 'relational' coherence in decisions to adopt and engage with the new subgrouping for targeted treatment system. Health professionals often engage in 'sense making' about new innovations to 'road test' their applicability or relevance to daily clinical routines. Low back pain was generally perceived as an 'uninteresting' and clinically unchallenging health problem by GPs, which may partly explain their lack of engagement with the new subgrouping for targeted treatment system. The adoption of this new way of working by GPs was determined by the meaning that they ascribed to it in the context of their daily clinical routines. Conclusions We conclude that the key obstacle to implementation of the new subgrouping for targeted treatment system for low back pain in primary care was an initial failure to achieve 'coherence' of the desired practice change with GPs. Despite this, GPs used the tool to different degrees, though this signified a general commitment to participating in the study rather than a deeper attitude change towards the new system.

Asset-based approaches to health promotion have become increasingly popular as a way to tackle health inequalities by empowering people in more disadvantaged communities to use local resources and increase control over health and its determinants. However, questions remain about how they work in practice. This article presents the findings from a systematic scoping review of the empirical literature on asset-based approaches in communities. The aim was to identify the key elements of asset-based approaches, and how they are operationalised in interventions aimed at promoting health and reducing inequalities in local communities. Four databases were searched (Medline, PsycINFO, CINAHL, ASSIA) and papers were included if they described interventions explicitly adopting an asset-based approach but excluded if limited to asset identification. Thirty articles were included in the review. Data were extracted on the type of assets that the intervention built upon, how assets were mobilised, the expected outcomes and evaluation methods. A framework is presented that synthesises the key characteristics of asset-based interventions to promote health in communities. Three main approaches to mobilising assets were identified in the literature: (A) connecting assets, (B) raising awareness of assets and (C) enabling assets to thrive. It is argued that asset-based approaches to health promotion take a wide variety of forms, making it difficult to anticipate outcomes and to evaluate interventions. The framework presented here can be used to better understand the processes through which asset-based approaches work in practice to promote health and reduce inequalities. [ABSTRACT FROM AUTHOR]

Background Liver disease is common, but not part of routine chronic disease management in primary care. Aim The aim of this study was to explore the challenges of implementing pathways of care for liver disease within existing highly protocolised structures in primary care. Method Semi-structured interviews with 20 health professionals working in primary care. Interviews were informed by normalisation process theory (NPT) and boundary theory. Data were subject to thematic analysis. Results Three themes were identified relating to chronic disease work; definitions; need and worth, and roles. Participants identified that understanding and value of roles within chronic disease management were pre-defined by targets imposed on them as part of national incentives schemes. Structural boundaries constrained professional autonomy and the potential to influence this area of primary care management, including taking on new work. Conclusion The inability to influence care decisions blurs occupational boundaries and goes to the core of what it means to be a professional. Unless liver disease sits within this target-based system, it is unlikely to become part of routine work in primary care. [ABSTRACT FROM AUTHOR]

We show that if G is a discrete Abelian group and A ⊂ G has ∥1A∥B(G) ¤ M then A is O(exp(pM))-stable in the sense of Terry and Wolf. [ABSTRACT FROM AUTHOR]