The DINARC© Toolkit - Clinical Academic Research Capacity-Building and Post-Doctoral Development for Nurses, Midwives and Allied Health Professionals (NMAHP)

The challenges of developing nurses, midwives and AHPs (NMAHPs) as clinical academics (CA) have received international attention. Balancing clinical practice and academic pursuit, often where managers are unfamiliar with academic career requirements, is one such challenge; however, the current literature provides limited developmental guidance. The aim of this article is to describe the DINARC© (Dissemination, Implementation, Networking, Active Research and Clinical practice) Toolkit, a continuous practice development aide for NMAHPs who are in the early post-doctoral phase of a clinical academic career (CAC). We identified five DINARC© elements, through evidence review and synthesis, as requisites for supporting the progression of a CAC. An ‘expert reference group’ (CAs, academic supervisors and nurse leaders) advised and assisted in development of the DINARC© concept. A Practitioner Research Plan and Mentor–Mentee Discussion Guide was developed and applied within a large metropolitan UK university teaching hospital; this was designed to identify the essential elements required to successfully navigate a CAC pathway. Early feedback from practitioners and managers suggests that DINARC© aids CAs in navigating an early CAC and offers guidance for managers. Further application and evaluation of DINARC© is now required by those developing a CAC. Implications for practice: DINARC© is a resource to guide practitioners’ CAC development with the goal of integrating and strengthening clinically-based NMAHP research activities, with related improvements in patient care. We believe that DINARC© has wider relevance as a useful tool, worthy of testing internationally

Asset rich cash poor in the economic downturn: the financial challenges facing retired older people

Older people are thought to be particularly vulnerable during times of economic downturn. Little is currently understood of the impact of the current economic downturn on the financial circumstances and wellbeing of retired people and the nature of the services and support needed to enable them to cope financially and maintain their wellbeing and quality of life. Retired people are not a homogenous group. Therefore, this study explores the impact of the downturn on a specific group: house owners over the age of 65, not in receipt of means tested state benefits and living on modest incomes. This group may be described as “asset rich cash poor” (ARCPs). It is thought that this group is particularly vulnerable as they are not eligible for state support but are insufficiently well off to be living comfortably. Findings from this research, although focused on retired people with specific circumstances, may have wider relevance in relation to retired people with different financial circumstances. The purpose of this study is to investigate the experiences of asset rich cash poor older people in the economic downturn, in order to establish: • how they manage their financial circumstances in these times; • the impact of the downturn on their wellbeing and quality of life; and • whether services and support available to this group and other older people could be improved. The study comprised two phases. In phase one, the perspectives of older people were explored by carrying out 28 semi-structured interviews with older people in the asset rich cash poor category, permanently resident in Dorset, some of whom lived in a conurbation and others in rural areas. In phase two, the study explored perspectives of key financial advice/information/service providers through four focus groups comprising: health and social care professionals; financial advisors from the private sector; and professionals from the third (not for profit) sector. 6 ASSET RICH CASH POOR IN THE ECONOMIC DOWNTURN The study has shown that the economic downturn is having a marked impact on the financial, social, mental and physical wellbeing of this sample of asset rich cash poor older people in Dorset. For many, the level of income that they had expected when planning for retirement had not come to fruition and they feel poor in relation to their previous lifestyle and retirement expectations. The key findings and policy implications of the study are: Key finding 1: Many ARCP older people particularly women, had done little retirement planning. Many ARCP older people had insufficiently planned for their retirement. In particular some women had relied on their husbands to manage all finances and had not provided for their own pensions. This reflects the findings of earlier studies on the older generation. Policy implications The independent Money Advice Service (formerly the FSA Consumer Financial Education Board) should commit greater financial resource to the awareness raising and skill development of future generations to help people plan more carefully for their retirement. Although the findings of this study show a widespread need among older people for information and advice, resources should be targeted particularly at women, especially those who have had extended periods out of workplace. Private, public and voluntary sector services should respond to this increased investment through developing and testing out models of financial capability training, with an emphasis on financial planning, as well as its mode of delivery. There may be potential in raising awareness of the need for retirement planning and associated training to non-working women through health visiting or child care services. For older people who have planned ahead, pensions and savings have been traditionally seen as a key way to plan responsibly for one’s retirement future. But these are not risk free as has been played out in the recent years of economic downturn, with the associated low interest rates and return on investment. People planning ahead for retirement need to be reminded of the impact of any future recession and the risks of this if it coincides with their planned retirement date. ASSET RICH CASH POOR IN THE ECONOMIC DOWNTURN 7 Key finding 2: Older people, in the ARCP category, tended to manage the money they had very carefully, despite the economic downturn, and had an aversion to debt. This finding mirrors the quantitative study of Atkinson et al. (2006) who found older people to be better at managing money than the younger generations. In discussion of the financial pressures placed upon them in term of escalating essential and non-essential expenditure, no interviewees referred to having resorted to unsecured debt. Policy implications Managing money is identified in this study and earlier studies as a strength within older people. Therefore, financial capability training for this age group should focus on the other dimensions of financial capability where older people are less skilled, for example choosing financial products and staying informed. Older people should be considered an asset in society and their strong skills in managing money should be utilised. Those organisations wishing to develop and deliver financial capability curricula for younger people could consider intergenerational programmes in which older people participate as guest speakers, sharing their experiences in managing money with younger generations. These educators could be encouraged to work together with the Money Advice Service and the Department of Health and financial advice and information providers to bring various age groups together. Key finding 3: The combination of reduced income from investments, increases in pensions which do not keep pace with inflation, combined with increases in costs for essential and non-essential expenditure, is having an impact on social, physical and mental wellbeing and is causing noticeable life style changes. The effects of the economic downturn on ARCP older people’s wellbeing was highlighted by both older people themselves and service providers. In both phases of the research, reference is made to feelings of anxiety, worry, fear, depression and concern. 8 ASSET RICH CASH POOR IN THE ECONOMIC DOWNTURN Policy implications Reduced wellbeing during the economic downturn in this age group is likely to put an increased demand on health and social care services. Policy makers in the Department of Health have a vested interest therefore in developing strategies to counter this negative impact. One recommendation to enhance social wellbeing is that the Money Advice Service, the Department of Health and local councils fund national and local initiatives to further support and develop social clubs or other groups for older people, with an emphasis on financial planning and management. This would help sustain wellbeing and provide a network of peers with whom older people might exchange financial experiences and information. Third and private sector organisations such as care homes and age related charities are well-placed to contribute to the development of these programmes. Key finding 4: The economic downturn is impacting on older people indirectly though cuts to public and third sector services. The economic downturn has been associated with cuts in funding to many services previously relied on by older people for their physical, social and mental wellbeing. Library closures were a cause of concern and a particular worry was the risk of withdrawal of bus passes. Policy implications Private sector service providers will need to fill the gap in services that currently support the health and wellbeing of older people, a gap left by the increased withdrawal of public and third sector services. A reduction of these services in particular will have a strong impact on the social, mental and physical wellbeing of older people. Key finding 5: Older people, in the ARCP category, do not always access enough or appropriate financial information. Many choose to seek financial information from trusted health and social care providers, their family and/or friends rather than from financial professionals. Older people, and professionals that support them, reported that older people are not always accessing the sound financial information which they may need, whether it be on financial products, forward financial planning or how to obtain the benefits they are entitled to. Lack of trust in financial advisors was widespread. Independent financial advisors indicated that older people on lower incomes were using their services less frequently. Some were either self-reliant by researching ASSET RICH CASH POOR IN THE ECONOMIC DOWNTURN 9 on the internet or using the media, or tapped into sources of social capital found within their social networks. Policy implications More effort and resource needs to be put in place to address these very serious concerns about access to advice and support by older people. Older people are approaching health professionals for financial advice, despite the fact that these professionals may not be best placed to provide this. Health professionals need to be able to direct these queries to trained financial service providers. Financial services within the private sector should therefore form interagency partnerships with more trusted public and third sector services in order to improve access to the services they provide. There is a very significant concern about lack of trust in advisors and banks. The need to rebuild reputation must be addressed by regulators, the advisors and banks themselves, with an increased emphasis being placed on the value systems of financial services and the role they can play in promoting community and individual wellbeing. The strength of the social networks of older people should also be harnessed, suggesting again that there is potential in targeting or developing social clubs for older people as locations to enhance financial capability. Key finding 6: In order to make ends meet, some older people in the ARCP category may take greater financial risks or be more vulnerable to abuse in an economic downturn. The professionals that support older people expressed concerns that the economic downturn may push older people towards riskier behaviours without them fully understanding the implications of the risks. There is also a risk of older people becoming more vulnerable to financial abuse. Policy implications Policy makers need to ensure that older people are made aware of the risks of financial abuse. As older people are often turning to more trusted health and social care providers for advice on financial matters, health/social care providers as well as financial service providers should both develop means to keep their older clients regularly informed of potential financial risk within the current economic climate. As financial support is not the remit of many of the health care providers and financial services is a regulated activity, it is advisable they form partnerships with the finance sector, in order to better inform their patients/clients of current financial risks or to be able to refer them on to qualified support. Service providers may also 10 ASSET RICH CASH POOR IN THE ECONOMIC DOWNTURN offer a helpline in which older people feel safe to disclose, anonymously if need be, any concerns of financial abuse they may be exposed to. Charities already offering these services (e.g. Age UK and Action on Elder Abuse-AEA) should be supported in these endeavours through encouraging partnerships between financial service providers on the one hand and health/social care providers on the other in order that the latter can provide accurate and up to date information on financial risk to its partners. A recent partnership between local financial advisors and the charity Age UK is an excellent example of this (Age UK, 2012). It is also essential that the Money Advice Service raises awareness of this risk. As the provision of financial services is a regulated activity, it is important to ensure that any activities undertaken by health/social care providers are not in breach of financial services regulations. Key finding 7: Older people made no reference to the Money Advice Service or the Financial Services Authority (FSA) as a source of help or advice. At the time of this study none of the interviewees of the focus groups made any reference to the role of the Financial Service Authority (FSA) or the Money Advice Service in providing information or advice about financial matters to older people. Policy implications Although the Money Advice Service is now independent of the FSA, and is endeavoring to target a wider population, it is not clear why our interviewees never referred to it. It may either be due to a lack of awareness of the service, a serious indictment of the outreach of the FSA, or alternatively a lack of IT expertise in older people, demonstrated also by their very limited use of online banking. In either event, older people may be denied access to key forms of help and advice on financial matters. Resources need to be devoted to either increasing IT literacy among older people, or alternatively providing help and support using traditional forms of communication and/or increasing the reach of the Money Advice Service by targeting this age group specifically. In conclusion, therefore, older people in this study reported being affected markedly by the current economic downturn. Members of the financial sector, including accountants, and the Money Advice Service have a responsibility to support older people during this and future downturns. They must reflect on ways in which they might tailor their support towards this group. One way of doing so is by actively seeking collaborative interagency partnerships with third and public sector health and social care professionals to improve their access and understanding of older ASSET RICH CASH POOR IN THE ECONOMIC DOWNTURN 11 clients. These more trusted professionals will be able to direct financial enquiries to accountants and financial advisors who older people may otherwise not have had the confidence, knowledge or trust to approach directly. Accountants and other financial services should also be aware of the particular challenges facing asset rich but cash older people and adapt their advice accordingly when dealing with this group. They should reflect in their consultations that many older people are fully capable of managing their money but are in greater need of advice on how to invest their money and plan ahead for their future. They should also think outside of the box in providing support, considering ways, for example, in which the power of existing social networks might be harnessed. 12 ASSET RICH CASH POOR IN THE ECONOMIC DOWNTUR

Emollient product design: objective measurements of formulation structure, texture and performance, and subjective assessments of user acceptability

Background: The choice of prescribed emollients is usually based on cost and patient preference. Differences in formulations can affect user acceptability. Aim: To compare the physical performance, user acceptability and various product design features of two emollient gels that are prescribed in the UK and alleged to be therapeutically interchangeable because their formulations are described as having the same contents of oily ingredients. Results: We found that here are in fact significant measurable differences between the structure and performance of the two formulations, which materially affect their user acceptability. These differences are attributed to the use of different types of gelling agents and other ingredients of differing grades/quality and concentrations, and probably due to the formulations being made by different manufacturing processes. We also identified other product design features that are important to user appeal, including the type of container in which the formulations are presented, the type of dispensing devices provided, and the nature and form of the supplied user instructions. Conclusion: Patients and prescribers should be aware that there can be important differences in performance and user appeal between emollients, even between products that, superficially, may appear to be very similar. These important performance aspects should be characterized for new emollient introductions to encourage better informed product selection

The person-centered dermatology self-care index: a tool to measure education and support needs of patients with long-term skin conditions

Objective To validate the Person-Centered Dermatology Self-Care Index (PeDeSI) as a tool for clinical assessment and for potential use in research evaluation. Design To date, no validated assessment measures exist to identify the education and support needs of patients living with long-term dermatological conditions and to enable them to self-manage as effectively as possible. The PeDeSI assessment tool was developed to meet this need using the self-efficacy construct and a model of concordance within prescribing practice. In total, 200 copies of the PeDeSI were distributed for validation, and 145 (72.5%) were returned completed. Data were analyzed using statistical software. Frequency distributions of all items were examined, and internal consistency was summarized using Cronbach α. Exploratory factor analysis was used to disclose any underlying structure among the data items. Setting Three specialist dermatology centers in acute care hospitals. Participants Dermatology specialist nurses treating patients with chronic dermatoses. Intervention A PeDeSI was completed with each patient during his or her usual outpatient consultation. Main Outcome Measure Cronbach α. Results Cronbach α was 0.90, indicating good internal consistency. Eliminating individual items in turn made little difference in Cronbach α (range, 0.89-0.90). Item total correlations ranged from 0.44 to 0.76 (median, 0.68). Exploratory factor analysis extracted just one factor (eigenvalue, 5.37), with no other factors having eigenvalues exceeding 1.00. Factor loadings on individual items ranged from 0.47 to 0.80. Conclusion The PeDeSI is a valid, reliable, and clinically practical tool to systematically assess the education and support needs of patients with long-term dermatological conditions and to promote treatment concordance

A service evaluation of the Eczema Education Programme: an analysis of child, parent and service impact outcomes.

The systematic support of parents of children with eczema is essential in effective disease management. The few existing support models have a limited evidence base. This paper reports the outcome-orientated service evaluation of an original, extensive, social learning-theory based, nurse-led Eczema Education Programme (EEP)

A randomized controlled trial to evaluate the effect of a new skincare regimen on skin barrier function in those with podoconiosis in Ethiopia.

BACKGROUND: Podoconiosis affects an estimated 3 million people in Ethiopia with a further 19 million at risk. Volcanic soil and pathogens enter skin breaches in the feet causing inflammation, lymphoedema and hyperkeratosis. There is no robust evidence on optimal podoconiosis skincare regimens to improve skin barrier function (SBF). OBJECTIVES: To evaluate the effectiveness of a new, low-cost, evidence-based intervention to improve SBF in the lower limbs of those with podoconiosis. METHODS: A randomized controlled trial (NCT02839772) was conducted over 3 months in two podoconiosis clinics (n = 193). The intervention comprised 2% (v/v) glycerine added to a reduced volume of soaking water. The control group received the current skincare regimen. Primary outcome measures were transepidermal water loss (TEWL) and stratum corneum hydration (SCH) at four specific sites on the lower limbs. RESULTS: Improvement in SBF was observed in both groups across all measurement sites and time points, although this was significantly greater in the experimental group. TEWL reduced in both groups at all sites. For example, on top of the foot the estimated group difference in TEWL at visit 4 was 1·751 [standard error (SE) = 0·0390] in favour of the experimental group [t = 3·15, degrees of freedom (df) = 189·58, P = 0·002, 95% confidence interval (CI) 0·066-2·85], indicating a greater reduction in TEWL in the experimental group. Similarly, at the same site the estimated group difference in SCH at visit 4 was -2·041 (SE = 0·572) in favour of the experimental group (t = -3·56, df = 186·74, P < 0·001, 95% CI -3·16 to -0·91), indicating a greater increase in SCH in the experimental group. There were also significantly greater reductions in odour, number of wounds and largest foot circumference in the experimental vs. the control group. CONCLUSIONS: The addition of 2% (v/v) glycerol to a reduced volume (83% reduction) of soaking water significantly improved SBF

Parental self-efficacy and the management of childhood atopic eczema: development and testing of a new clinical outcome measure

Background: Effective parental management of childhood eczema requires education and support to reduce disease severity and improve child quality of life. Self-efficacy is a key factor influencing effective chronic disease management. There are no published scales to measure parental self-efficacy in managing childhood eczema. The Parental Self-Efficacy with Eczema Care Index (PASECI) was designed to measure parental self-efficacy in managing childhood eczema as a pre- and post-intervention tool in the evaluation of a structured Eczema Education Programme (EEP). Objective: To develop and test the validity, reliability and sensitivity of a new outcome measure (PASECI) designed to assess parental self-efficacy in managing their child’s eczema to determine pre and post changes in educational intervention evaluation studies. Methods: PASECI was developed from literature, expert consultation and piloting of a 40-item prototype. The final 29-item scale is arranged on 4 subscales. Parents of children with eczema aged 0-16 years (n=242) attending the EEP were assessed at 1 week pre-EEP and 4 weeks post-intervention. Cronbach α and factor analyses were undertaken. Results: PASECI has face, content and construct validity. It is reliable, with high item internal consistency (Cronbach α > 0.87 in all domains). Factor analysis revealed 4 viable domains. It was sensitive to change for post intervention measures using Sign tests (p<0.001). Conclusions: PASECI is a useful, valid, reliable and sensitive evaluative outcome measure of self-efficacy in parents managing childhood eczema

Anarchism and Health

This article looks at what anarchism has to offer in debates concerning health and healthcare. I present the case that anarchism’s interest in supporting the poor, sick, and marginalized, and rejection of state and corporate power, places it in a good position to offer creative ways to address health problems. I maintain that anarchistic values of autonomy, responsibility, solidarity, and community are central to this endeavor. Rather than presenting a case that follows one particular anarchist theory, my main goal is to raise issues and initiate debate in this underresearched field in mainstream bioethics