A systematic review of barriers to early presentation and diagnosis with cancer among Black women

Objective: To explore barriers to early presentation and diagnosis with breast cancer among black women. Design: Systematic review. Methods: We searched multiple bibliographic databases (January 1991–February 2013) for primary research, published in English, conducted in developed countries and investigating barriers to early presentation and diagnosis with symptomatic breast cancer among black women (?18 years). Studies were excluded if they did not report separate findings by ethnic group or gender, only reported differences in time to presentation/diagnosis, or reported on interventions and barriers to cancer screening. We followed Cochrane and PRISMA guidance to identify relevant research. Findings were integrated through thematic synthesis. Designs of quantitative studies made meta-analysis impossible. Results: We identified 18 studies (6183 participants). Delay was multifactorial, individual and complex. Factors contributing to delay included: poor symptom and risk factor knowledge; fear of detecting breast abnormality; fear of cancer treatments; fear of partner abandonment; embarrassment disclosing symptoms to healthcare professionals; taboo and stigmatism. Presentation appears quicker following disclosure. Influence of fatalism and religiosity on delay is unclear from evidence in these studies. We compared older studies (?10 years) with newer ones (<10 years) to determine changes over time. In older studies, delaying factors included: inaccessibility of healthcare services; competing priorities and concerns about partner abandonment. Partner abandonment was studied in older studies but not in newer ones. Comparisons of healthy women and cancer populations revealed differences between how people perceive they would behave, and actually behave, on finding breast abnormality. Conclusions: Strategies to improve early presentation and diagnosis with breast cancer among black women need to address symptom recognition and interpretation of risk, as well as fears of the consequences of cancer. The review is limited by the paucity of studies conducted outside the USA and limited detail reported by published studies preventing comparison between ethnic groups

Implementing large-scale quality improvement – lessons from the productive ward: Releasing time to care

Purpose: This paper is concerned with facilitating large-scale quality improvement in health care, and specifically understanding more about the known challenges associated with implementation of Lean innovations: receptivity, the complexity of adoption processes, evidence of the innovation, and embedding change. Lessons are drawn from the implementation of The Productive Ward: Releasing Time to CareTM programme in English hospitals.Design/participants: The study which the paper draws upon was a mixed-method evaluation which aimed to capture the perceptions of three main stakeholder groups: national-level policymakers (15 semi-structured interviews), senior hospital managers (a national web-based survey of 150 staff), and healthcare practitioners (case studies within five hospitals involving 58 members of staff). The views of these stakeholder groups were analysed using a diffusion of innovations theoretical framework to examine aspects of the innovation, the organisation, the wider context and linkages. Findings: Although The Productive Ward was widely supported, stakeholders at different levels identified varying facilitators and challenges to implementation. Key issues for all stakeholders were staff time to work on the programme and showing evidence of the impact on staff, patients and ward environments. Implications: To support implementation policymakers should focus on expressing what can be gained locally using success stories and guidance from ‘early adopters’. Service managers, clinical educators and professional bodies can help to spread good practice and encourage professional leadership and support. Further research could help to secure support for the programme by generating evidence about the innovation, and specifically its clinical effectiveness and broader links to public expectations and experiences of healthcare.Originality/value: This paper draws lessons from the implementation of The Productive Ward programme in England which can inform the implementation of other large-scale programmes of quality improvement in health care

Exploring the nature and impact of leadership on the local implementation of The Productive Ward Releasing Time to Care™

Purpose: The purpose of this paper is to explore the nature and impact of leadership in relation to the local implementation of quality improvement interventions in health care organisations. Design/Methodology/Approach: Using empirical data from two studies of the implementation of The Productive Ward: Releasing Time to Care in English hospitals, the paper explores leadership in relation to local implementation. Data were attained from in-depth interviews with senior managers, middle managers and frontline staff (n = 79) in 13 NHS hospital case study sites. Framework Approach was used to explore staff views and to identify themes about leadership. Findings: Four overall themes were identified: different leadership roles at multiple levels of the organisation, experiences of "good and bad" leadership styles, frontline staff having a sense of permission to lead change, leader's actions to spread learning and sustain improvements. Originality/Value: This paper offers useful perspectives in understanding informal, emergent, developmental or shared "new" leadership because it emphasises that health care structures, systems and processes influence and shape interactions between the people who work within them. The framework of leadership processes developed could guide implementing organisations to achieve leadership at multiple levels, use appropriate leadership roles, styles and behaviours at different levels and stages of implementation, value and provide support for meaningful staff empowerment, and enable leader's boundary spanning activities to spread learning and sustain improvements.</p

12‐hour shifts:Prevalence, views and impact

The provision of 24-hour nursing care inevitably involves shift work and flexible working, including “long days” or 12-hour shifts (Newey and Hood 2004, Lorenz 2008). However, these shift patterns have become increasingly controversial, with concerns raised over performance, fatigue, stress and patient safety. Historically, traditional shift work patterns were based on three eight-hour shifts per day (Ferguson and Dawson 2011, Estabrooks et al. 2009), but over the past 20 years there has been a tendency to move away from this pattern of working in preference for the 12-hour shift (Todd et al. 1989, McGettrick and O’Neill 2006).In the UK, many hospitals utilise 12-hour shifts primarily because managers believe it is a more cost effective way of providing 24-hour care, with lower costs and greater continuity of staffing (Estabrooks et al. 2009). Some nurses also prefer to work longer daily hours with fewer shifts, which gives them greater flexibility and more days away from work (Josten et al. 2003). As the majority of the nursing workforce is female, this may also make it easier to balance work and personal responsibilities (Messing 1997, Josten et al. 2003). However, there are increasing concerns over potential threats to patient safety and quality of care (Stimpfel and Aiken 2013), and some employers now question the benefits of such extended hours and are choosing to revert to eight-hour shifts (Geiger-Brown and Trinkoff 2010). Although the handover period has been criticised for being unproductive, with no formal ‘overlap’ 12-hour shifts can have a negative impact on opportunities for ward meetings, teaching, mentorship, teambuilding and research (Sprinks 2012). A study in the US by Stimpfel and colleagues published in 2013 found that nurses who worked shifts of 12-hours or longer were significantly more likely to report poor quality care and poor patient safety when compared to those working eight-hour shifts. Patients also reported lowersatisfaction with care in hospitals where staff worked longer shifts (Stimpfel et al. 2012).Shift work is a common feature across many industries. Fatigue associated with long shifts has been linked with disasters such as the Chernobyl nuclear accident, Three Mile Island incident and the grounding of the Exxon Valdez (Miller 2011). However, research to date is equivocal and some studies have found little differences in terms of cost or productivity (Williamson et al. 1994) or levels of fatigue (Duchon et al. 1994) by shift length. A systematic review by Smith et al. (1998) compared eight and 12-hour shifts across a broad range of industries and concluded that longer shifts increased fatigue but also led to an increase in job performance. Tucker et al. (1998) examined the effect of shift length on alertness. Their findings showed that more rest days between shifts were associated with slightly higher levels of alertness and lower levels of fatigue.In nursing, Geiger-Brown and Trinkoff (2010) reviewed studies up until 2008. In five of the seven studies reviewed, those working 12-hour shifts were significantly more fatigued. Estabrooks et al. (2009) reviewed 12 studies comparing the effect of eight and 12-hour shifts on quality of care and health care provider outcomes. They found insufficient evidence to conclude that shift length had an effect on patient or healthcare outcomes. A common question asked by health care employers and employees around shift work is “is it OK to work 12-hour shifts?” (Ferguson and Dawson 2011, p. 519). Our current study brings together findings from previously published studies and from new analysis of previously collected data, to address this question.AimThe aim of this study is to review existing data sources to identify what we know about the prevalence of 12-hour shifts in nursing and the impact on both staff and patients. Specifically, this study aims to address the following questions:What is the prevalence of 12-hour shifts in nursing?How much internal variation in shift length is there in NHS hospitals?What impact does shift length have on quality of patient care and staff experience?<br/

Uneven development: comparing the indigenous healthcare workforce in Saudi Arabia, Bahrain and Oman

INTRODUCTION A global shortage of health care workers has led to an increase in international migration, often from low-income ‘sending’ countries in Africa, India and the Phillipines (Lorenzo et al., 2007; Seboni, 2009; Hamada et al., in press) to high income ‘receiving’ countries including the UK and the US (Bach, 2007; Brush and Sochalski, 2007; Smith et al., 2006). In the Middle East, many countries have come to rely on international recruitment to staff their burgeoning health care facilities but they are now forced to compete with other countries in an increasingly global market. Here we explore workforce issues in three Gulf states: Saudi Arabia, Bahrain and Oman, which have had different degrees of success in recruiting indigenous health care workers.We suggest that historical, social and religious forces create challenges to women’s participation in the labour market in the Gulf states and impede local health workforce recruitment

Measuring relational aspects of hospital care in England with the 'Patient Evaluation of Emotional Care during Hospitalisation' (PEECH) survey questionnaire

OBJECTIVES: To first, validate in English hospitals the internal structure of the ‘Patient Evaluation of Emotional Care during Hospitalisation’ (PEECH) survey tool which was developed in Australia and, second, to examine how it may deepen the understanding of patient experience through comparison with results from the Picker Patient Experience Questionnaire (PPE-15). DESIGN: A 48-item survey questionnaire comprising both PEECH and PPE-15 was fielded. We performed exploratory factor analysis and then confirmatory factor analysis using a number of established fit indices. The external validity of the PEECH factor scores was compared across four participating services and at the patient level, factor scores were correlated with the PPE-15. SETTING: Four hospital services (an Emergency Admissions Unit; a maternity service; a Medicine for the Elderly department and a Haemato-oncology service) that contrasted in terms of the reported patient experience performance. PARTICIPANTS: Selection of these acute service settings was based on achieving variation of the following factors: teaching hospital/district general hospital, urban/rural locality and high-performing/low-performing organisations (using results of annual national staff and patient surveys). A total of 423 surveys were completed by patients (26% response rate). RESULTS: A different internal structure to the PEECH instrument emerged in English hospitals. However, both the existing and new factor models were similar in terms of fit. The correlations between the new PEECH factors and the PPE-15 were all in the expected direction, but two of the new factors (personal interactions and feeling valued) were more strongly associated with the PPE-15 than the remaining two factors (feeling informed and treated as an individual). CONCLUSIONS: PEECH can help to build an understanding of complex interpersonal aspects of quality of care, alongside the more transactional and functional aspects typically captured by PPE-15. Further testing of the combined instrument should be undertaken in a wider range of healthcare settings

Exploring the nature and impact of leadership on the local implementation of The Productive Ward Releasing Time to Care™

Purpose: The purpose of this paper is to explore the nature and impact of leadership in relation to the local implementation of quality improvement interventions in health care organisations. Design/Methodology/Approach: Using empirical data from two studies of the implementation of The Productive Ward: Releasing Time to Care in English hospitals, the paper explores leadership in relation to local implementation. Data were attained from in-depth interviews with senior managers, middle managers and frontline staff (n = 79) in 13 NHS hospital case study sites. Framework Approach was used to explore staff views and to identify themes about leadership. Findings: Four overall themes were identified: different leadership roles at multiple levels of the organisation, experiences of "good and bad" leadership styles, frontline staff having a sense of permission to lead change, leader's actions to spread learning and sustain improvements. Originality/Value: This paper offers useful perspectives in understanding informal, emergent, developmental or shared "new" leadership because it emphasises that health care structures, systems and processes influence and shape interactions between the people who work within them. The framework of leadership processes developed could guide implementing organisations to achieve leadership at multiple levels, use appropriate leadership roles, styles and behaviours at different levels and stages of implementation, value and provide support for meaningful staff empowerment, and enable leader's boundary spanning activities to spread learning and sustain improvements.</p