This paper discusses a development of Flanagan's critical incident technique (CIT) to elicit indicators of high and low quality nursing from patients and their nurses on medical, surgical and elderly care wards. Stages in undertaking the CIT are identified and presuppositions held by most researchers about the nature of the technique are identified. The paper describes how the authors moved to a different set of presuppositions during the course of the study. Preliminary analysis of interview transcripts revealed that critical incidents need not always be demarcated scenes with a clear beginning and end, but may arise from respondents summarizing their overall experience within their description of one incident. Characteristically respondents were unable to give a detailed account of such incidents but validity may be established by the fact that respondents appear to recount what actually happened as they saw it, and what they said was clearly important to them. The researchers found that the most appropriate basic unit of analysis was not the incident itself but 'happenings' revealed by incidents that are 'critical' by virtue of being important to respondents with respect to the quality of nursing care. The importance of CIT researchers achieving an understanding of the 'meaning' of critical happenings to respondents is emphasized. Analysis of the interview transcripts is facilitated by the use of INGRES, a relational database computer program which should enable a 'personal theory' of quality nursing for each respondent, both patients and nurses, to be described. The study suggests that the CIT is a flexible technique which may be adapted to meet the demands of nursing research. If carefully applied, the CIT seems capable of capitalizing on respondents' own stories and avoids the loss of information which occurs when complex narratives are reduced to simple descriptive categories. Patients and nurses have unique perspectives on nursing and their views are of primary importance in understanding what quality means with respect to the interpersonal processes that are integral to nursing care. This paper discusses the identification of indicators of quality nursing from interviews with patients and nurses using the authors' development of Flanagan's critical incident technique.
Mental Health Link - a facilitated programme - aimed to develop systems within primary care and links with specialists to improve care for patients with long-term mental illness. A process evaluation based on Pawson and Tilley’s Realistic Evaluation complemented a randomized controlled trial. This article describes the method developed for this ‘realistic evaluation’, the mechanisms behind the integration of linked specialist workers and discusses practical and theoretical issues arising from the use of the realistic evaluation framework as a way of explaining the results of trials and service development. Retrospective interviews identified the important outcomes and were used to construct ‘Context-Mechanism-Outcome’ configurations. The 12 case studies represented what had happened. A second-level analysis using analytic induction developed ‘middle range theories’ designed to be of value to those developing care elsewhere. The intervention was successful in stimulating productive joint working, through case discussions, but often failed to ensure a review of progress.
Recent research into the development of a child's theory of mind has investigated individual differences in children's acquisition of the concept. Most of the research that has attempted to delineate this acquisition process has approached the question from a social‐cognitive developmental perspective, measuring differences such as family size, mother‐child interaction and pretend play. Until now there has been little attempt to test empirically the claims which have been made within the psychoanalytic developmental literature—that measures of affective development, such as attachment, are also likely to be related to the development of a theory of mind and emotional understanding. The main finding of the present study was that attachment security (as measured by the SAT) was a significant correlate of theory of mind competence (as measured by a belief‐desire reasoning task), even when the contribution of chronological age, verbal mental age and social maturity were controlled for, in preschoolers and young school‐aged children.
BackgroundComplex interventions have components which can vary in different contexts. Using the Realistic Evaluation framework, this study investigates how a complex health services intervention led to developments in shared care for people with long-term mental illness.MethodsA retrospective qualitative interview study was carried out alongside a randomised controlled trial. The multi-faceted intervention supported by facilitators aimed to develop systems for shared care. The study was set in London. Participants included 46 practitioners and managers from 12 participating primary health care teams and their associated community mental health teams. Interviews focussed on how and why out comes were achieved, and were analysed using a framework incorporating context and intervening mechanisms.ResultsThirty-one interviews were completed to create 12 case studies. The enquiry highlighted the importance of the catalysing, doing and reviewing functions of the facilitation process. Other facets of the intervention were less dominant.The intervention catalysed the allocation of link workers and liaison arrangements in nearly all practices. Case discussions between link workers and GPs improved individual care as well as helping link workers become part of the primary care team; but sustained integration into the team depended both on flexibility and experience of the link worker, and upon selection of relevant patients for the case discussions. The doing function of facilitators included advice and, at times, manpower, to help introduce successful systems for reviewing care, however time spent developing IT systems was rarely productive. The reviewing function of the intervention was weak and sometimes failed to solve problems in the development of liaison or recall.ConclusionCase discussions and improved liaison at times of crisis, rather than for proactive recall, were the key functions of shared care contributing to the success of Mental Health Link. This multifaceted intervention had most impact through catalysing and doing, whereas the reviewing function of the facilitation was weak, and other components were seen as less important.Realistic Evaluation provided a useful theoretical framework for this process evaluation, by allowing a specific focus on context. Although complex interventions might appear 'out of control', due to their varied manifestation in different situations, context sensitive process evaluations can help identify the intervention's key functions.
The aim in the present study, which was carried out in one nursing home for older people, was to determine the feasibility of working with care workers and very frail service users to investigate links between the levels of work satisfaction and stress of the staff, and the quality of care and morale of the residents. Most of the 44 care staff (70%) and 22 cognitively intact residents (82%) participated willingly in completing rating scales through self-completion questionnaire or by interview. Well-validated scales were used to measure job satisfaction, work stress, organisational commitment, perceived quality of care, and morale and mental health. The findings revealed a staff group with a fairly high level of job dissatisfaction and stress, who were, nevertheless, very committed to the nursing home. The morale of the residents was good although the residents rated the home atmosphere lower than the staff did. Significant correlations emerged, in the expected direction, between satisfaction, commitment, stress and quality of care perceived by staff. The correlations between home atmosphere perceived by residents, and their morale and mental health were low; further investigation is needed with a larger sample. This feasibility study supports the need for further research using a case-study approach in a small number of homes because of the labour-intensive nature of the data collection and the importance of triangulating data from many sources.
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