Nurses' views of using computerized decision support software in NHS Direct

Background. Nurses working in NHS Direct, the 24-hour telephone advice line in England, use computerized decision support software to recommend to callers the most appropriate service to contact, or to advise on self-care. Aims. To explore nurses' views of their roles and the computerized decision support software in NHS Direct. Methods. Qualitative analysis of semi-structured interviews with 24 NHS Direct nurses in 12 sites. Findings. Nurses described both the software and themselves as essential to the clinical decision-making process. The software acted as safety net, provider of consistency, and provider of script, and was relied upon more when nurses did not have clinical knowledge relevant to the call. The nurse handled problems not covered by the software, probed patients for the appropriate information to enter into the software, and interpreted software recommendations in the light of contextual information which the software was unable to use. Nurses described a dual process of decision-making, with the nurse as active decision maker looking for consensus with the software recommendation and ready to override recommendations made by the software if necessary. However, nurses' accounts of the software as a guide, prompt or support did not fully acknowledge the power of the software, which they are required to use, and the recommendation of which they are required to follow under some management policies. Over time, the influence of nurse and software merges as nurses internalize the software script as their own knowledge, and navigate the software to produce recommendations that they feel are most appropriate. Conclusions. The nurse and the software have distinct roles in NHS Direct, although the effect of each on the clinical decision-making process may be difficult to determine in practice

How can pain management in the emergency department be improved? Findings from multiple case study analysis of pain management in three UK emergency departments

Introduction: Inadequate pain management in EDs is a worldwide problem, yet there has been little progress in understanding how pain management can be improved. There is only weak evidence and limited rationale to support interventions to improve pain management. We used naturalistic, qualitative methods to understand the factors that influence how pain is managed within the adult ED. Methods: We used a multiple case study design incorporating 143-hour non-participant observation, documentary analysis and semistructured interviews with 37 staff and 19 patients at three EDs in the North of England between 2014 and 2016. We analysed data using thematic analysis. Results: Our analysis demonstrated that pain management was not well aligned with the core priorities of the ED and was overlooked when other works took priority. We identified that (1) pain management was not perceived to be a key organisational priority for which staff were held accountable and staff had limited awareness of their performance, (2) pain management was not a core component of ED education and training, (3) ED processes and structures were not aligned with pain management and pain reassessment was overlooked unless staff escalated pain management outside of normal processes and (4) staff held embedded beliefs that conceptualised pain management as distinct from core priorities and limited their capacity to improve. However, EDs were able to improve pain management by aligning processes of pain management with other core works, particularly patient flow (eg, nurse-initiated analgesia at triage). Implications: EDs may be able to improve pain management by ensuring pain management processes align with key ED priorities. Undertaking multifaceted changes to structures and processes may enable staff to improve pain management and develop a culture in which pain management can be prioritised more easily. Future interventions need to be compatible with the wider work of the ED and enable patient flow in order to be adopted and maintained

What does the ideal urgent and emergency care system look like? A qualitative study of service user perspectives

Background: Policies aimed at diverting care from EDs to alternative services have not been successful in reducing ED attendances and have contributed to confusion for service users when making care-seeking decisions. It is important that service users are at the heart of decision making to ensure new services meet the needs of those who will be accessing them. In this study, service users were encouraged to think freely about the desirable qualities of an ideal urgent and emergency care (UEC) system. Methods: From September to February 2019, an open inductive methodology was used to conduct focus groups with service users who had used UK UEC services within the previous year. Service users that had contact with NHS111, ambulance service, General Practice out-of-hours, minor injuries unit, walk-in centre or ED were purposively sampled and stratified into the following groups: (1) 18–45 years; (2)≥75 years; (3) adults with young children; (4) adults with long-term conditions. Focus groups were structured around experiences of accessing UEC services and perspectives of an ‘ideal’ UEC system. Results: 30 service users took part in the study, across four focus groups. The ideal UEC system centred around three themes: a simplified UEC system (easier to understand and a single-point of access); more ‘joined-up’ UEC services and better communication between health staff and patients. Conclusion: Desirable qualities of an ideal UEC system from a service user perspective related to simplifying access for example, through a single point of access system where health professionals decide the appropriate service required and improving continuity of care through better integration of UEC services. Service users value reassurance and communication from health professionals about care pathways and care choices, and this helps service users feel more in control of their healthcare journey

Why is pain management so difficult in the Emergency Department? A systematic mixed studies review and thematic synthesis of staff perceptions of enablers and barriers to pain management within the Emergency Department

Introduction: Pain is the most common presenting feature within the ED, yet undertreatment of pain in the ED is a well-documented problem worldwide. Despite the development of interventions to address this problem, there is still limited understanding of how pain management can be improved within the ED. This systematic mixed studies review aims to identify and critically synthesise research exploring staff views of barriers and enablers to pain management to understand why pain continues to be undertreated in the ED. Methods: We systematically searched five databases for qualitative, quantitative and mixed methods studies reporting ED staff views of barriers and enablers to pain management in the ED. Studies were quality assessed using the Mixed Methods Appraisal Tool. Data were extracted and qualitative themes were generated by deconstructing data then developing interpretative themes. Data were analysed using convergent qualitative synthesis design. Results: We identified 15 297 articles for title/abstract review, reviewed 138 and included 24 in the results. Studies were not excluded due to low quality, although lower scoring studies contributed less data to the analysis. Quantitative surveys focused more on environmental factors (eg, high workload and bureaucratic restrictions), while qualitative studies revealed more insight about attitudes. We developed five interpretative themes from the thematic synthesis: (1) pain management is seen as important but not a clinical priority; (2) staff do not recognise the need to improve pain management; (3) the ED environment makes it difficult to improve pain management; (4) pain management is based on experience, not knowledge; and (5) staff lack trust in the patient’s ability to judge pain or manage it appropriately. Conclusions: Overly focusing on environmental barriers as principal barriers to pain management may mask underlying beliefs that hinder improvements. Improving feedback on performance and addressing these beliefs may enable staff to understand how to prioritise pain management