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Undergraduate nursing students face challenges that can result in stress leading to impaired performance, physical illness, high turnover and sickness absence (Kinman and Jones 2001). Students therefore require skills and knowledge to help them cope with the challenges of learning professional practice. This paper explores the concept of resilience, with an emphasis on how educational programmes can foster resilient practices among student nurses. Educators can facilitate resilience by incorporating resilience teaching and training that includes, the core concepts of resilience: self-efficacy, reflective ability and self-confidence. Critical appraisal and synthesis of the literature resulted in the identification of three themes: attributes, programmes and transition. The following five key learning and teaching methods were identified as supporting the development of resilience: peer activities; reflective practice; directed study; problem based learning/enquiry based learning and experiential learning Having resilience and resilient qualities is an integral part of nursing, having a positive impact upon the health and well-being of the nurse as practitioner. Resilient qualities and behaviours can be developed through the facilitation of appropriate learning and teaching interventions.

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BACKGROUND: Sub-optimal adoption of evidence based practice by primary health care professionals (PHCPs) is affecting the health of people with chronic obstructive pulmonary disease (COPD). This paper shows how 'patient stories' were used to engineer professional and organisational change. METHODS: 'Stories' were transmitted via a pre-planned question and answer session involving patients and carers. The impact on PHCPs' attitudes and behaviour was explored through observing the session, open-text questionnaires completed by the PHCPs at the end of the session and clinician interviews. FINDINGS: The stories about living with COPD, told by patients and their carers, were found to be an innovative and powerful way to impact PHCPs' attitude and behaviour. Strong motivational context was created, in which clinicians were able to see the relevance of learning through active engagement with real people. CONCLUSION: Long term conditions such as COPD have long term implications for the daily lives of patients and their carers. Hearing about these consequences in 'the first person' is an influential training tool with a powerful impact on PHCPs' attitudes and behaviour.

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BACKGROUND: The international literature on patient and public involvement (PPI) in research covers a wide range of issues, including active lay involvement throughout the research cycle; roles that patients/public can play; assessing impact of PPI and recommendations for good PPI practice. One area of investigation that is less developed is the sustainability and impact of PPI beyond involvement in time-limited research projects. METHODS: This paper focuses on the issues of sustainability, the importance of institutional leadership and the creation of a robust infrastructure in order to achieve long-term and wide-ranging PPI in research strategy and programmes. RESULTS: We use the case of a Primary Care Research Centre to provide a historical account of the evolution of PPI in the Centre and identified a number of key conceptual issues regarding infrastructure, resource allocation, working methods, roles and relationships. CONCLUSIONS: The paper concludes about the more general applicability of the Centre's model for the long-term sustainability of PPI in research.

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BACKGROUND: Pulmonary rehabilitation (PR), a programme of exercise, education and psycho-social support, is recommended for patients with chronic obstructive pulmonary disease but referral rates are relatively low compared with need. AIM: Working with primary care clinicians (GPs and practice nurses) from eight practices, this project developed strategies for influencing clinician and patient behaviours as a means of increasing referral rates for PR. METHODS: A participatory action research design was employed. Semi-structured questionnaires captured clinicians' baseline knowledge of PR and their ideas for increasing referrals. Actionable changes were then recommended. Audits (at baseline, mid-point and end of project) were used to assess and initiate improvements in the quality of practice data about PR referrals. The impacts of these changes were explored via further clinician surveys (free text questionnaire). Semi-structured questionnaires, posted to patients eligible for PR, assessed their characteristics, and, where applicable, their views on PR referral processes and reasons for not wanting PR. FINDINGS: The baseline survey of clinicians (n=22) revealed inadequate knowledge about PR, particularly among GPs. Actionable changes recommended included in-house education sessions, changes to practice protocols, and 'pop-ups' and memory aids (mugs and coasters) to prompt clinician/patient discussions about PR. Audit findings resulted in changes to improve the quality and availability of coded information about patients eligible for PR. These changes, supported by clinicians (n=9) in the follow-up survey, aimed to facilitate and increase the quality of patient/clinician discussions about PR. Findings from the patient survey (n=126, response rate 25.7%) indicate that such changes will increase the uptake of PR as patients who accepted a referral for PR provided more positive feedback about their discussions with clinicians. CONCLUSIONS: The strategies introduced were relatively easy to implement and the anticipated advantage is more patients accessing the health and quality of life benefits that PR offers.

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OBJECTIVES: Exacerbations of chronic obstructive pulmonary disease (COPD) are the third largest cause of emergency hospital admissions in the UK. This systematic literature review explored the relationship between the hospitalization rates and the COPD comorbidities, anxiety, and depression. METHODS: The Centre for Research Dissemination's framework for systematic reviews was followed using search terms relating to COPD, anxiety, depression, and hospital admission. Papers identified were assessed for relevance and quality, using a suitable Critical Appraisal Skills Programme tool and Mixed Methods Assessment Tool. RESULTS: Twenty quantitative studies indicated that anxiety and depression led to a statistically significant increase in the likelihood of COPD patients being hospitalized. These comorbidities also led to an increased length of stay and a greater risk of mortality postdischarge. Other significant factors included lower Body-Mass Index, Airflow Obstruction, Dyspnea, and Exercise scores, female gender, lower socioeconomic status, poorer patient perceived quality of life, increased severity of lung function, and less improvement in dyspnea from admission to discharge. It was also highlighted that only 27%-33% of those with depression were being treated for it. Four qualitative studies revealed that patients saw anxiety and depression as a major factor that affected their ability to cope with and self-manage their condition. IMPLICATIONS: Findings from the systematic review have highlighted a need for better recognition and treatment of anxiety and depression amongst individuals with COPD. Ongoing research will develop and test strategies for promoting better management and self-management as a means of reducing hospital admissions.

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In 2007, the UK government set performance targets and public service agreements to control the escalation of emergency bed-days. Some years earlier, nine English local authorities had each created local networks with their health and third sector partners to tackle this increase. These networks formed the 'Improving the Future for Older People' initiative (IFOP), one strand of the national 'Innovation Forum' programme, set up in 2003. The nine sites set themselves one headline target to be achieved jointly over three years; a 20 per cent reduction in the number of emergency bed-days used by people aged 75 and over. Three ancillary targets were also monitored: emergency admissions, delayed discharges and project sustainability. Collectively the sites exceeded their headline target. Using a realistic evaluation approach, we explored which aspects of network governance appeared to have contributed to these emergency bed-day reductions. We found no simple link between network governance type and outcomes. The governance features associated with an effective IFOP network appeared to suggest that the selection and implementation of a small number of evidence-based services was central to networks' effectiveness. Each service needed to be coordinated by a network-based strategic group and hierarchically implemented at operational level by the responsible network member. Having a network-based implementation group with a 'joined-at-the-top' governance structure also appeared to promote network effectiveness. External factors, including NHS incentives, health reorganisations and financial targets similarly contributed to differences in performance. Targets and financial incentives could focus action but undermine horizontal networking. Local networks should specify which interventions network structures are intended to deliver. Effective projects are those likely to be evidence based, unique to the network and difficult to implement through vertical structures alone.

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Good integration of services that aim to reduce avoidable acute hospital bed use by older people requires frontline staff to be aware of service options and access them in a timely manner. In three localities where closer inter-organisational integration was taking place, this research sought patients' perceptions of the care received across and within organisational boundaries. Between February and July 2008, qualitative methods were used to map the care journeys of 18 patients (six from each site). Patient interviews (46) covered care received before, at the time of and following a health crisis. Additional interviews (66) were undertaken with carers and frontline staff. Grounded theory-based approaches showed examples of well-integrated care against a background of underuse of services for preventing health crises and a reliance on 'traditional' referral patterns and services at the time of a health crisis. There was scope to raise both practitioner and patient awareness of alternative care options and to expand the availability and visibility of care 'closer to home' services such as rapid response teams. Concerns voiced by patients centred on the adequacy of arrangements for organising ongoing care, while family members reported being excluded from discussions about care arrangements and the roles they were expected to play. The coordination of care was also affected by communication difficulties between practitioners (particularly across organisational boundaries) and a lack of compatible technologies to facilitate information sharing. Finally, closer organisational integration seemed to have limited impact on care at the patient/practitioner interface. To improve care experienced by patients, organisational integration needs to be coupled with vertical integration within organisations to ensure that strategic goals influence the actions of frontline staff. As they experience the complete care journey, feedback from patients can play an important role in the service redesign agenda.

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The literature on patient and public involvement (PPI) in research covers a wide range of topics. However, one area of investigation that appears under developed is the sustainability and impact of PPI beyond involvement in time-limited research projects. This paper presents a case study of PPI development in one primary care research centre in England, and its approach to making this sustainable using documentary sources and material from a formal evaluation. We provide narrative accounts of the set-up, operation and main processes of PPI, and its perceived impact. PPI requires a long-term perspective with participation and trust growing over time, and both users and researchers learning what approaches work best. PPI is a complex interplay of clarity of purpose, defined roles and relationships, organised support (paid PPI staff) and a well-funded infrastructure. 'Soft systems' are equally important such as flexible and informal approaches to meetings, adapting timetables and environments to meet the needs of lay members and to create spaces for relationships to develop between researchers and lay members that are based on mutual trust and respect. This case study highlights that the right combination of ethos, flexible working practices, leadership, and secure funding goes a long way to embedding PPI beyond ad hoc involvement. This allows PPI in research to be integrated in the infrastructure and sustainable.

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BACKGROUND: Partnerships for Older People Projects (POPP) was a national initiative in England aimed at improving health, well-being and quality of life (QoL) for older people by developing local services. This development paper reports the key findings of a local evaluation in relation to quality of life, well-being and health-related QoL to provide practical understanding at the local level about what this means in relation to the schemes delivered. OBJECTIVES: To identify the impact of POPP schemes received by older people in Wigan on their QoL and well-being; and establish their feedback on services using local indicators. METHODS: Convenience samples of older people receiving services from three selected 'community facing low level' schemes were recruited over a two-month period. They completed a semi-structured questionnaire at baseline (T1) and at follow-up 6 weeks later (T2). Information was collected on health status and health-related QoL using the EQ-5D, biographical information, overall QoL and well-being as part of the national evaluation and a local indicator, feedback on services. RESULTS: Response rates were 70% (T1 45/64, mean age 72 years) and 43% at T2 (25/58, mean age 55 years). Following receipt of these schemes improvements were found for self care, anxiety and depression, health status and QoL although these differences were not statistically significant due to the small sample size and loss to follow-up. Feedback on local service use related to schemes 'being fit for purpose' and 'aspects of service delivery'. CONCLUSION: This local evaluation illustrates a pragmatic approach to service development and delivery of preventative services, with potential to benefit health and well-being of older people and support their continued living independently in the community. It provides detail and better understanding of what this means locally to people in context of national findings.

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AIM AND OBJECTIVE: This study has investigated older people's experiences of a recent fall, its impact on their health, lifestyle, quality of life, care networks, prevention and their views on service use. BACKGROUND: Falls are common in older people and prevalence increases with age. Falls prevention is a major policy and service initiative. DESIGN: An exploratory, qualitative design involving two time points. METHOD: A convenience sample of 27 older people from two primary care trusts who had a recent fall. Taped semi structured qualitative interviews were conducted and repeated at follow up to detect change over time and repeat falls. Data were collected on their experience of falls, health, activities of living, lifestyle, quality of life, use of services, prevention of falls, informal care and social networks. Content analysis of transcribed interviews identified key themes. RESULTS: The majority of people fell indoors (n = 23), were repeat fallers (n = 22) with more than half alone when they fell (n = 15). For five people it was their first ever fall. Participants in primary care trust 1 had a higher mean age than those in primary care trust 2 and had more injurious falls (n = 12, mean age 87 years vs. n = 15, mean age 81 years). The majority of non-injurious falls went unreported to formal services. Falls can result in a decline in health status, ability to undertake activities of living, lifestyle and quality of life. CONCLUSIONS: Local informal care and support networks are as important as formal care for older people at risk of falls or who have fallen. Access to falls prevention programmes and services is limited for people living in more rural communities. RELEVANCE TO PRACTICE: Falls prevention initiatives and services should work with local communities, agencies and informal carers to ensure equitable access and provision of information, resources and care to meet the needs of older people at risk or who have fallen.

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INTRODUCTION: This research has considered current developments in the provision of services for people with long-term conditions within the NHS of England. Community Matrons are being employed and by adopting a case management approach they are aiming to improve patient care and reduce their demands for acute hospital care. DESCRIPTION: Qualitative research was undertaken to explore experiences of community matrons and service leads on the development, implementation and provision of services for people with long-term conditions. CONCLUSIONS: This research provides evidence of what is being done to meet the challenge of long-term conditions and provides lessons for similar challenges and service development for different areas of care and in other countries. Continual system and role change has had effects on service delivery and on the whole care. These effects relate to; defining the role of community matron and structure of service, training staff, identifying patients, providing infrastructure, demonstrating benefits, identifying gaps in services, ability to reduce avoidable admissions and identifying the advantages and difficulties of the role. DISCUSSION: All of these aspects should be used to inform future development.

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AIM: This paper is a report of a study to explore the experiences of older people who suffered a recent fall and identify possible factors that could contribute to service development. BACKGROUND: Falls in older people are prevalent and are associated with morbidity, hospitalization and mortality, personal costs to individuals and financial costs to health services. METHOD: A convenience sample of 27 older people (mean age 84 years; range 65-98) participated in semi-structured taped interviews. Follow-up interviews during 2003-2004 were undertaken to detect changes over time. Data were collected about experience of the fall, use of services, health and well-being, activities of daily living, informal care, support networks and prevention. Thematic content analysis was undertaken. FINDINGS: Twenty-seven initial interviews and 18 follow-up interviews were conducted. The majority of people fell indoors (n = 23) and were alone (n = 15). The majority of falls were repeat falls (n = 22) and five were a first-ever fall. People who reflected on their fall and sought to understand why and how it occurred developed strategies to prevent future falls, face their fear, maintain control and choice and continue with activities of daily living. Those who did not reflect on their fall and did not know why it occurred restricted their activities and environments and remained in fear of falling. CONCLUSION: Assisting people to reflect on their falls and to understand why they happened could help with preventing future falls, allay fear, boost confidence and aid rehabilitation relating to their activities of daily living.

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OBJECTIVES: We assessed the economic and clinical implications of systematic long-term nutrition team follow-up of patients after percutaneous endoscopic gastrostomy. METHODS: We designed a prospective, randomized, controlled, single-blind trial in a large district hospital and its catchment area. All adult patients referred for a gastrostomy were eligible and randomized into two groups. The intervention group had regular follow-up by the nutrition team (weekly in hospital, monthly after discharge) with appropriate support and advice for patient, carer, and primary care professionals. The control group had no specific nutrition team input (as is often current practice). Endpoints to the study were 12 mo, elective removal of tube, or death. The primary outcome was total health care costs. Secondary outcomes were complications, length of stay, readmissions, nutritional status, and quality of life. RESULTS: One hundred twelve patients were recruited. Eleven died before the start of the trial, leaving 47 in the intervention group and 54 in the control group. They were well matched for age, sex, and underlying diagnosis. Overall, the health care costs were 13,330 sterlings per patient in the intervention group compared with 16,858 pound sterlings in the control group (two-tailed, P = 0.27), a saving of 21% per patient. The intervention group had shorter lengths of stay, fewer and briefer readmissions, earlier removal of gastrostomy (where appropriate), shorter duration of feeding, and less demand for general practitioners and district nurse inputs. Nutritional status and quality of life were similar. CONCLUSIONS: Regular systematic nutrition team follow-up for gastrostomy-fed patients does not increase costs and may improve quality of care.

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BACKGROUND: The implementation of the National Health Service Plan for the UK will see an expansion of services for intermediate care. Such services are usually targeted at older people and aim to: prevent 'avoidable' admissions to acute inpatient care; facilitate the timely discharge of patients from acute inpatient care; promote patient rehabilitation. A range of services might fall under the banner of intermediate care. They are usually delivered in patients' homes or in non-acute institutions. This paper describes an evaluation of a multidisciplinary Rapid Response Team (RRT). This service aimed to provide a home based alternative to care previously provided in an acute hospital bed which was acceptable to patients and carers and which maintained clinical care standards. The service was provided for the population of Hereford, a rural town in the middle of England. METHODS: A mixed-method descriptive design using quantitative and qualitative techniques was used to monitor: the characteristics of service users, the types and amounts of care received, any 'adverse' events arising from that care, and the acceptability of the service to patients and carers. A collaborative approach involving key stakeholders allowed appropriate data to be gathered from patient case notes, RRT staff, local health and social care providers, and patients and their carers. A suite of self-completed questionnaires was, therefore, designed to capture study data on patients and activities of care, and workshops and semi-structured interview schedules used to obtain feedback from users and stakeholders. RESULTS: Service users (231) were elderly (mean age 75.9), from three main diagnostic categories (respiratory conditions 19.0%, heart/stroke 16.2%, falls 13.4%), with the majority (57.0%) having both medical and social care needs. All patients received care at home (mean duration 5.6 days) with only 5.7% of patients having to be re-admitted to acute care. Overall, patients and carers had positive attitudes to the new service but some expressed concerns about their ability to influence the choice of care option (24.1% and 25.0% of patients and carers, respectively), whilst 22.7% of carers were concerned about the quality of information about care. CONCLUSIONS: Both the nature of schemes for intermediate care, and the policy context in which they are introduced, mean that pragmatic methodologies are often required to evaluate their impacts. Unfortunately, this need for pragmatism can then mean that it is difficult to reach definitive conclusions about the merits of schemes. However, the findings of this evaluation suggest that the Rapid Response Team provided an 'acceptable' alternative to an extended period of care in an acute setting. Such schemes may have relevance beyond the NHS of the UK as a means of providing a more appropriate and cost efficient match between patients' needs for care, the types of care provided, and the place in which care is provided.

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Facilitating access is concerned with helping people to command appropriate health care resources in order to preserve or improve their health. Access is a complex concept and at least four aspects require evaluation. If services are available and there is an adequate supply of services, then the opportunity to obtain health care exists, and a population may 'have access' to services. The extent to which a population 'gains access' also depends on financial, organisational and social or cultural barriers that limit the utilisation of services. Thus access measured in terms of utilisation is dependent on the affordability, physical accessibility and acceptability of services and not merely adequacy of supply. Services available must be relevant and effective if the population is to 'gain access to satisfactory health outcomes'. The availability of services, and barriers to access, have to be considered in the context of the differing perspectives, health needs and material and cultural settings of diverse groups in society. Equity of access may be measured in terms of the availability, utilisation or outcomes of services. Both horizontal and vertical dimensions of equity require consideration.

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