Partners At Care Transitions (PACT). Exploring older peoples’ experiences of transitioning from hospital to home in the UK: protocol for an observation and interview study of older people and their families to understand patient experience and involvement in care at transitions

Introduction: Lengths of hospital inpatient stays have reduced. This benefits patients, who prefer to be at home, and hospitals, which can treat more people when stays are shorter. Patients may, however, leave hospital sicker, with ongoing care needs. The transition period from hospital to home, can be risky, particularly for older patients with complex health and social needs. Improving patient experience, especially through greater patient involvement, may improve outcomes for patients and is a key indicator of care quality and safety. In this research we aim to: capture the experiences of older patients and their families during the transition from hospital to home; and identify opportunities for greater patient involvement in care, particularly where this contributes to greater individual- and organisational-level resilience. Methods and Analysis: A ‘focused ethnography’ comprising observations, ‘Go-Along’ and semi-structured interviews will be used to capture patient and carer experiences during different points in the care transition from admission to 90 days after discharge. We will recruit 30 patients and their carers from six hospital departments across two NHS Trusts. Analysis of observations and interviews will use a Framework approach to identify themes to understand the experience of transitions and generate ideas about how patients could be more actively involved in their care. This will include exploring what ‘good’ care at transitions look like and seeking out examples of success, as well as recommendations for improvement. Ethics and dissemination: Ethical approval was received from the NHS Research Ethics Committee in Wales. The research findings will add to a growing body of knowledge about patient experience of transitions, in particular providing insight into the experiences of patients and carers throughout the transitions process, in ‘real time’. Importantly, the data will be used to inform the development of a patient-centred intervention to improve the quality and safety of transitions

How older people enact care involvement during transition from hospital to home: A systematic review and model

Background Current models of patient‐enacted involvement do not capture the nuanced dynamic and interactional nature of involvement in care. This is important for the development of flexible interventions that can support patients to ‘reach‐in’ to complex health‐care systems. Objective To develop a dynamic and interactional model of patient‐enacted involvement in care. Search strategy Electronic search strategy run in five databases and adapted to run in an Internet search engine supplemented with searching of reference lists and forward citations. Inclusion criteria Qualitative empirical published reports of older people's experiences of care transitions from hospital to home. Data extraction and synthesis Reported findings meeting our definition of involvement in care initially coded into an existing framework. Progression from deductive to inductive coding leads to the development of a new framework and thereafter a model representing changing states of involvement. Main results Patients and caregivers occupy and move through multiple states of involvement in response to perceived interactions with health‐care professionals as they attempt to resolve health‐ and well‐being‐related goals. ‘Non‐involvement’, ‘information‐acting’, ‘challenging and chasing’ and ‘autonomous‐acting’ were the main states of involvement. Feeling uninvolved as a consequence of perceived exclusion leads patients to act autonomously, creating the potential to cause harm. Discussion and conclusion The model suggests that involvement is highly challenging for older people during care transitions. Going forward, interventions which seek to support patient involvement should attempt to address the dynamic states of involvement and their mediating factors

An intervention to support stroke survivors and their carers in the longer term (LoTS2Care): study protocol for the process evaluation of a cluster randomised controlled feasibility trial

Background: Whilst pathways relating to the early stages of stroke care have become well established, strategies for longer-term care are less developed and longer-term outcomes remain poor for many stroke survivors. New Start, a complex intervention that includes needs identification, exploration of social networks and components of problem-solving and self-management, was designed to improve stroke survivors’ quality of life by addressing unmet needs and increasing participation. It is delivered approximately 6 months post-stroke by trained staff (facilitators). We are currently undertaking a cluster randomised feasibility trial of the New Start intervention with an embedded process evaluation, which is an important component of the design and testing of complex interventions as it provides an understanding of how interventions are delivered and function in different settings. Methods/design: This mixed methods process evaluation will explore the degree to which New Start is implemented as intended, the impact of context on intervention delivery and the acceptability of the intervention for stroke survivors, their families and practitioners. It will include non-participant observation of facilitator training and intervention delivery. Interviews with stroke survivors, facilitators and other relevant staff (including administrators and managerial staff) will be undertaken. Qualitative data from interview transcripts, facilitator reflections and observational field notes will be analysed thematically alongside numerical data documenting intervention delivery collected as part of the trial. Discussion: This process evaluation will identify factors that aid and impede implementation of the New Start intervention and improve understanding of this novel approach to longer-term stroke care. Trial registration: ISRCTN Registry, ISRCTN38920246. Registered on 22 June 2016

Adapting a communication coaching intervention for obstetric sonographers delivering unexpected news: A qualitative study

Introduction: Despite widespread recognition that communicating unexpected news during obstetric ultrasound examinations is challenging, there is a dearth of research investigating how to teach evidence-based communication to sonographers. Communication Coaching is a supportive, positive method that has previously been associated with improvements in communication, patient satisfaction, and reduced burnout in clinicians. However, to date, no study has coached sonographers. This study explored stakeholders’ views on a proposed Communication Coaching intervention and used these data to adapt the intervention for use with qualified obstetric sonographers. Methods: Semi-structured interviews were conducted with people who have a vested interest in unexpected news delivery and thematic analysis was conducted on the data. Eight sonographers, six people with lived experience of receiving unexpected news and six representatives from third-sector organisations who support expectant parents were recruited (18 women; 2 men, aged between 21 and 75 years). Results: Participants viewed the planned Communication Coaching intervention favourably and suggested adaptations. The two main themes were (1) the practicalities of coaching, and (2) content. The first theme had four subthemes: (a) brief and flexible structure, (b) online modality, (c) sensitive and positive coach and (d) organisational awareness. The second theme had three subthemes: (a) specific language and behaviour recommendations, (b) adaptable to different service-users and situations and (c) confer relevant emotional skills and techniques. Conclusions: Communication Coaching could be a feasible and acceptable intervention for qualified sonographers if specific, limited adaptations are made as recommended by the stakeholders. Further evaluation of the intervention in practice is necessary

Improving patient experience and safety at transitions of care through the Your Care Needs You (YCNY) intervention: a study protocol for a cluster randomised controlled feasibility trial

Background Patients, particularly older people, often experience safety issues when transitioning from hospital to home. Although the evidence is currently equivocal as to how we can improve this transition of care, interventions that support patient involvement may be more effective. The ‘Your Care Needs You’ (YCNY) intervention supports patients to ‘know more’ and ‘do more’ whilst in hospital in order that they better understand their health condition and medications, maintain their daily activities, and can seek help at home if required. The intervention aims to reduce emergency hospital readmissions and improve safety and experience during the transition to home. Methods As part of the Partners At Care Transitions (PACT) programme of research, a multi-centred cluster randomised controlled trial (cRCT) will be conducted to explore the feasibility of the YCNY intervention and trial methodology. Data will be used to refine the intervention and develop a protocol for a definitive cRCT. Ten acute hospital wards (the clusters) from varying medical specialties including older peoples’ medicine, trauma and orthopaedics, cardiology, intermediate care, and stroke will be randomised to deliver YCNY or usual care on a 3:2 basis. Up to 200 patients aged 75 years and over and discharged to their own homes will be recruited to the study. Patients will complete follow-up questionnaires at 5-, 30-, and 90-days post-discharge and readmission data up to 90-days post-discharge will be extracted from their medical records. Study outcomes will include measures of feasibility (e.g. screening, recruitment, and retention data) and processes required to collect routine data at a patient and ward level. In addition, interviews and observations involving up to 24 patients/carers and 28 staff will be conducted to qualitatively assess the acceptability, usefulness, and feasibility of the intervention and implementation package to patients and staff. A separate sub-study will be conducted to explore how accurately primary outcome data (30-day emergency hospital readmissions) can be gathered for the definitive cRCT. Discussion This study will establish the feasibility of the YCNY intervention which aims to improve safety and experience during transitions of care. It will identify key methodological and implementation issues that need to be addressed prior to assessing the effectiveness of the YCNY intervention in a definitive cluster randomised controlled trial. Trial registration UK Clinical Research Network Portfolio: 42191; ISTCRN: ISRCTN51154948. Registered 16/07/2019

Managing the unmanageable: A qualitative study exploring sonographer experiences of and training in unexpected and difficult news delivery

Introduction Ultrasound is used to diagnose pregnancy complications such as miscarriage and fetal health conditions. Within the UK, findings identified during ultrasound examination are delivered by sonographers as standard. However, little is known about the experiences of sonographers when delivering unexpected news (DUN), the impact this has on them, or their preferences for training on news delivery. Methods Qualitative interviews were completed with fourteen sonographers and were analysed using an inductive thematic approach. Key themes were identified. Results Participants said that obstetric ultrasound often involves ‘managing’ the patient encounter, including: navigating (unrealistic) patient expectations; handling their own responses to unexpected findings; and managing interaction by moderating emotional expression and communication practices to deliver patient-centred and empathic care. Persistent uncertainty of outcomes, prognosis and patient reactions, alongside high workloads, and frequent siloed working, makes DUN challenging for sonographers. DUN was experienced as emotionally burdensome, and sonographers employed personal coping strategies to reduce stress/burnout. However, the greatest mitigation for stress/burnout was support from peers, though accessing this was challenging. Peers were also described as key sources of learning, especially through observation. Conclusion Challenges associated with DUN are an enduring experience for sonographers. Facilitating regular ongoing support and training would enable sonographers to cope with negative aspect of the role, including the emotional burden of DUN. Implications for practice Long patient lists are prioritised to deal with high demand for services. However, sonographer wellbeing needs to be a key priority to avoid stress and burnout. This means facilitating protected time to access support from colleagues, multidisciplinary working where possible, and regular access to training to support DUN. Training focusing on communication practices, alongside dealing with emotional burdens of the role would be beneficial