More pages

Issue 1

Content PageEditorial TeamJoanne Strain Pg. 2Person-centred Cultures:Valuing All PersonsProfessor Brendan McCormack Pg. 3-4 Communica- Clinical tion Toolkits Focus: in Dementia Dysphagia Care Gary Mitchell, Gary Colin Sheeran Cousins & Joanne Strain Pg. 5-7 Pg. 8-11CPD Care Home Ambitions for Journal ScanReflective Palliative CareExercise:Dysphagia Dr Sarah Russell Pg. 13-17Pg. 12 Pg. 18

EditorialI am very proud to introduce you to the first Thank you to our contributors for our firstedition of Four Seasons Health Care’s new issue. I hope you find these original articlesnursing journal – Care Home Nursing. As useful to your nursing practice. If you areHead of Nursing at Four Seasons Health Care interested in writing or being supported toI am delighted that we are able to showcase write a piece for our journal please feel freethe wonderful and innovative work that our to get in contact with our editor-in-chiefcare homes across the UK deliver so that we Gary Mitchell via email: [email protected] may learn best practice from one another. co.uk. As an editorial team we would beOur ethos at Care Home Nursing is quite delighted to share knowledge and examplessimply to improve the quality and experience of good practice so that others can learn andof residents in our care homes. ultimately we can enhance our resident’s quality of life. Also, if there is a topic or articleIn this inaugural issue we are delighted to that you would like to see covered please alsoshare original articles from internationally let us know!renowned Professor Brendan McCormack,Head of Nursing at Queen Margaret Special additional content, that complimentsUniversity Edinburgh & Sarah Russell, Head of the contents of this issue, is available viaResearch and Clinical Innovation at Hospice SOAR in the Nursing Community section.UK. Professor McCormack explores the Please login to SOAR, join our Nursingimportance of person-centred cultures while Community and share your thoughts &Sarah examines the importance of palliative feelings what on you liked, what you foundcare for older people. I am also delighted to helpful and what you would like to see moreshare an original article from Colin Sheeran, of in future issues. Last, but most importantly,Dementia Project Facilitator at Four Seasons thank you all for the wonderful work you doHealth Care, on the importance of using in our care homes each and every day!communication toolkits for people living withdementia. Our editorial team have also put Joanne Strain, Head of Nursingtogether a useful guide to dysphagia whichcan be used for continuing professionaldevelopment (CPD) as directed in the maintext. Consultant Editor: Editor in Chief: Clinical Editor: Gary Cousins,Joanne Strain, Head of Gary Mitchell, Resident Resident Experience Care Experience Care Specialist Specialist Nursing

Person-centred Cultures:Valuing All PersonsProfessor Brendan McCormackThe concept of ‘person-centredness’has become established in approachesto the delivery of health and social careand particularly within nursing and carework. Evidence from research suggeststhat adopting a person-centred approachprovides more holistic care. In addition, itmay improve the overall care experience forresidents and families, increase satisfactionwith the level of care provided amongstaff, and promote team working. Existingevidence is consistent in the view that beingperson-centred requires the formation ofpurposeful relationships between care staff,residents, families and others significant tothem in their lives and that these relationshipsare built on mutual trust, understanding anda sharing of collective knowledge. In recentyears, there has been a lot of research intoperson-centred care and perhaps moreimportantly, into the broader idea of ‘person-centred cultures’.Person-centred care focuses on the care management and leadership values continueprovided to residents in the context of their to exist in nursing and care work.wider social network (including families,friends and other significant relationships). The key goal in the development of a positivePerson-centred cultures on the other hand learning culture is to recognise and overcomeare focused on creating a community in care individual, group and organisational barrierssettings that places significance on how the in order to move towards an effective culturesame person-centred care values are applied and overcome the features of workplacesin the context of staff. Research into person- that nurture hierarchical management andcentred cultures shows that if we don’t have horizontal violence, which we know preventcare settings that operationalise the same a person-centred culture being made real forvalues of resect, compassion, kindness and everyone.dignity for staff then we can’t expect themto deliver person-centred care. However we Developing person-centred cultures requiresalso know that these values that are espoused a sustained commitment to the facilitationin mission statements and organisational of multiple aspects of culture change inframeworks are often not easily realised by care settings and organisations as a whole.staff in practice. Despite a large literature However, despite many examples of well-on teams, team-effectiveness and team- intentioned projects, it continues to be theculture, dysfunctional team relationships case that embedding person-centrednessand dissonance between espoused and lived in team, unit and organisational cultures is a

challenge, and indeed often seems ‘elusive’ Further Readingin the everyday (chaotic) world of practice.In addition, for some, the whole agenda of McCormack B and McCance T (2016) Per-person-centred care is merely a buzz term son-centred Nursing and Health Care – The-or a process of ‘naming that which already ory and Practice, Wiley Publishing, Oxfordexists’, i.e. “we are doing it anyway aren’twe?” Others however may have identified McCormack B and McCance T (2010) Per-issues and ideas that stimulate new ways of son-centred Nursing: Theory, models andthinking about practice and are wondering methods. Blackwell Publishing, Oxford.“how do I move towards this way of workingwith colleagues and residents?” Both these McCormack B and McCance T (2006) Devel-positions pose challenges to the facilitation opment of a framework for person-centredof person-centred cultures. What is clear is nursing. Journal of Advanced Nursing, 56(5):that for person-centredness to be realised, 1-8.a sustained commitment to its developmentand maintenance in practice is required fromorganisations.The real challenge for all organisations is themovement from individual ‘person-centredmoments’ to ‘person-centred cultures’. Itis clearly evident from the internationalliterature that this cannot happen by relyingon the individual motivation of practitioners,but instead requires a sustained commitmentto facilitated culture change with teams andacross organisations.

Communication Toolkits inDementia CareColin SheeranMany people will know about memory boxes stimulate conversation and interaction withand how these can be used in dementia care. residents and relatives. While there areThey are useful tool for reminiscence and striking similarities between a ‘memory box’meaningful activity for people living with and this ‘communication toolkit’, one keydementia. difference is that memory boxes are often related to the past, while communicationAs part of the Four Seasons Dementia Care toolkits can also be more about the presentFramework this theory has been taken a stage day.further. Just like a memory box, acommunication toolkit it is a collection ofobjects and personal memorabilia to “I really look forward to coming here. It’s like being at home but with more company and lots to do. They always have my favourite music.”

What could a communication tool kit include?A communication toolkit is personalised to While this paper focuses on dementia care,that individual and as a consequence each it should be highlighted that all care homeone will, and should be, different. Some nurses should seek to help all their residentsitems that form communication toolkits are develop communication toolkits – even iflisted below: they do not live with dementia. In order to illuminate the many benefits of utilising• Photos communication toolkits in practice the• Clothes- hats / ties / scarves following two case studies are presented.• Favourite snacks / sweets• Medals• Certificates• Cards• Music / playlist• Games- cards / dominoes• Letters and postcards• Jewellery / makeup• Favourite drinks• Mobile phone / keys / wallet / mirror /hairbrush• Virtual message- voice or video recording• Anything else that is meaningful to theindividual.

Case Study 1The ‘virtual message’ is growing in popularity over and over, becoming more distressed andand can be a useful tool to use when anxious as the afternoon progressed. Insteadresidents ask difficult questions like: where of continually phoning his wife care staffis my wife? Or when can I go home? While suggested that she record a video messagethere is a raging debate on the topic of telling that the staff could play back to him when hewhite lies to people living with dementia became anxious. The following short videofor therapeutic benefit, care staff often feel message was recorded onto an IPad:uncomfortable about how to approach thesedifficult questions. This is because there ‘Hi Granddad, Nana Kate has justare occasions that no matter how these picked us up from school. See youquestions are answered they may cause the soon’resident distress and diminish their quality oflife. As a result of this short video message, William often became less anxious andNow consider the case of William. William his episodes of distress diminished overwould regularly ask where his wife was just time. The simple recording of a short videoafter she had visited. She always left just after message was an important component of3pm to pick to up their grandchildren from William’s communication toolkit.school and he would repeat the questionCase Study 2Now consider the case of Elsie. Elsie, like Elsie was a resident who didn’t oftenmany people living in the advanced stages initiate conversation, but would join intoof dementia, did not eat well. She had been conversations when staff sat with herlosing weight for some time and ate very and shared a cup of coffee and a piece oflittle of her meals. Elsie’s case was managed chocolate. Elsie’s communication toolkitin the traditional way with many visits from also included 2 china cups and saucers frommultidisciplinary professionals asserting home. Through the sharing of her coffeethe importance of maintaining adequate and chocolate Elsie appeared to feel morenutritional intake. However these visits did purposeful in her interactions and morenot make any difference as Elsie continued to connected within the culture of the home.lose weight.Elsie’s nutritional status did improve as aresult of some person-centred additions toher own communication toolkit. Her toolkitincluded a bar of dark chocolate and a jarof her favourite coffee. On one hand, byproviding Elsie with food and drinks that sheliked, there was a positive increase in Elsie’snutritional status. In addition to meeting thisphysical need, Elsie also saw an increase inher social quality of life; this is because ofmore opportunities for social engagementwith others.

Why use a communication toolkit?The benefits of a communication toolkit include:• Getting to know the person and their life story• Understand choices and preferences• Identify likes and dislikes• Recognise interests and plan activity• Reminisce• Respond to distress• Answer difficult questions• Build relationships and trust• Enhance care planningHow can I develop a toolkit?The greatest success is achieved when you put your own personal toolkit together anduse this to demonstrate the idea to relatives. Telling relatives a bit about you helps to buildrapport and encourages them to think about what is important to the resident. You will getmore enriched life stories and will have the resources to prevent and alleviate distress throughmeaningful communication and activity.

Clinical Focus: DysphagiaGary Mitchell, Gary Cousins & Joanne StrainIntroductionDysphagia is a condition in which residents have difficulty with swallowing.According to recent research, the average person swallows approximately 600 times per day.Broadly speaking there are 4 phases of swallowing and these include:1. Oral Preparatory Phase – when food is chewed in the mouth.2. Oral Phase – when the tongue pushes food toward the back of the throat to trigger the swallow reflex.3. Pharyngeal Phase – which occurs after the swallow is triggered and the food (also known as a bolus) moves down the upper part of the throat known as the pharynx.4. Oesophageal phase – When the food moves past the pharynx and enters the oesophagus where it moves further down into the stomach.Figure one: The Swallowing Reflex A person with dysphagia will have a problem at one or more of these phases.

Causes of DysphagiaThere are many possible causes of dysphagia disease progressing. Obstructive dysphagiabut these can be divided into three main is less common and may be caused bycategories: neurological, obstructive or cancers of the mouth or throat, late effectsmuscular. of radiotherapy or infections like thrush or Tuberculosis. Muscular dysphagia is rarerNeurological dysphagia is caused by still and is caused when the muscles neededconditions or diseases that affect the central to swallow are affected by neuromuscularnervous system, for example stroke, multiple conditions such as scleroderma or achalasia.sclerosis, Parkinson’s disease and dementia.Importantly, people who live with progressive The prevalence of dysphagia varies but itneurological conditions like those listed may is estimated to affect between 50-75% ofnot have dysphagia at diagnosis or admission nursing home residents at some time duringto a care home. This is because dysphagia their stay.is likely to be as a consequence of theirSigns of DysphagiaThe main signs of dysphagia include:• Difficulty or painful chewing or swallowing.• Excessive salivation.• Hoarse voice.• Unintended weight loss.• Coughing and choking before, during and after swallow.• Change in respiratory patterns.• Recurrent chest infections.• Change in eating habits.• Unexplained high temperatures.Effects of DysphagiaDysphagia impacts the person with the can lead to more serious complications likecondition as well as their family members pneumonia, malnutrition and dehydration.and care partners. Swallowing difficulties can From a holistic point of view, dysphagia canlead to aspiration and reduced oral intake. cause residents to feel socially excluded,Aspiration refers to the process when food, particularly at mealtimes when they may seedrink or medications pass into the trachea other residents eating normal meals. This(instead of the oesophagus). It is important to is because many residents who live withhighlight that aspiration can be silent and, in dysphagia may have to eat altered-texturedsome cases, it is not obvious when observing meals to avoid risks of dysphagia.a resident during the process of eating ordrinking that the material is going into thetrachea rather than the oesophagus. This

Effects of DysphagiaDysphagia impacts the person with the trachea rather than the oesophagus. Thiscondition as well as their family members can lead to more serious complications likeand care partners. Swallowing difficulties can pneumonia, malnutrition and dehydration.lead to aspiration and reduced oral intake. From a holistic point of view, dysphagia canAspiration refers to the process when food, cause residents to feel socially excluded,drink or medications pass into the trachea particularly at mealtimes when they may see(instead of the oesophagus). It is important to other residents eating normal meals. Thishighlight that aspiration can be silent and, in is because many residents who live withsome cases, it is not obvious when observing dysphagia may have to eat altered-textureda resident during the process of eating or meals to avoid risks of dysphagia.drinking that the material is going into theNursing Management ofDysphagiaOnce dysphagia has been suspected, nursing for example helping the resident to sit in anstaff should complete a screening tool to flag upright position or assisting the resident toup if that patient requires further assessment cut their food up into smaller pieces to makeby a speech and language therapist. All res- swallowing easier. Figure two provide anidents should already have monthly choking overview of some techniques which have canassessments in place and these should be also be adopted.evaluated a minimum of once per month andas soon as a resident’s condition changes. Inthe interim period, simple measures shouldbe adopted to help the person eat and drink,Figure Two: Nursing Management of Dysphagia Techniques Intervention Rationale1. Screening To identify residents who are at risk of dysphagia.2. Referral3. Resident Positioning To ensure formal assessment is carried out by specialists.4. Altered Textured Diet To ensure resident is in position conducive to eating & drinking.5. Red-Tray System To ensure correct consistency of food so as swallowing is safer. To highlight that resident has dysphagia and is a higher risk of choking.

ConclusionDysphagia can have huge implications for residents in care homes. These residents can beaffected both physically and psychologically. Given the prevalence of dysphagia in residentswithin care homes, it is important that nurses continually assess their residents so as todetermine if dysphagia is occurring. It is important that dysphagia is recognised and treatedearly so as to ensure measures are put in place to reduce the effects of dysphagia.Figure Three: 3 Key Points on Dysphagia 3 Key points1. Dysphagia can be a short or long-term condition which causes a resident to have difficulty in swallowing food, drink or medications. 2. It is important for nurses to refer residents with suspected dysphagia to speech and language therapists in a timely manner. 3. Many residents can be given altered-textured diets to help residents with dysphagia.

(CPD) Continuing ProfessionalDevelopment Exercise –DysphagiaOnce you have read the article on dysphagia multidisciplinary team involvement,you can complete this CPD exercise. Self- communication with Norman and hiscompletion of this exercise will count family and immediate steps to maintaintowards one hour of your CPD time which safety. When answering this question youis required for NMC revalidation. You may should refer to both Norman’s clinical andcomplete these exercises independently or psychological needs.with colleagues. Please retain a record ofyour answers as evidence for inclusion in your 4. The National Patient Safety AgencyCPD file. (NPSA) has produced guidelines on textured food called “Dysphagia diet food texture1. SIGN has a national clinical guideline descriptors”. Please login to your SOAR(119) called “management of patients with account and download this guidance. Oncestroke: Identification and management you have read this think about some of yourof dysphagia”. Please login to your SOAR residents who are currently on textured,account, download this guidance, review or modified, meals and summarise thethe document and consider the holistic following descriptors.impact of dysphagia on residents in yourcare home with specific reference to the B = Thin Purée Dysphagia Dietthree headings of: evaluation of swallowing C = Thick Purée Dysphagia Dietafter stroke, nutritional interventions and D = Pre-mashed Dysphagia Dietthe effects of therapy on patients. E = Fork Mashable Dysphagia Diet2. Speech and language therapists arethe specialists in relation to managementof dysphagia. Please login to your SOARaccount and review the document “RCSLTResource Manual for Commissioning andPlanning Services for SLCN: Dysphagia”.Reflect on these standards and discusshow you might work alongside speech andlanguage therapists to deliver better care toresidents living with dysphagia.3. Please consider the following short case-study: Norman is a 92 year old man livingwith dementia in a care home. Norman hasrecently lost weight and is now at risk ofmalnutrition. In addition he does not seemto be finishing his meals like he used to andis coughing during his meals. Please makea list of the steps you would take in orderto support Norman with his nutritionalneeds, including any assessments,

Care Home Ambitions forPalliative CareSarah RussellWhat are your ambitions for palliative care? As we live longer, in changing socio economiccircumstances with multiple comorbidities; care homes have a significant part to play.What’s the need? Why bother?There is a big need. In the UK, approximately Good palliative care in care homes hashalf a million people live in (Lang and Buisson been shown to reduce emergency hospital2010) and around 20% of the population die admissions, reduce levels of distress in(Seymour et al. 2011) in care homes. residents, families and care home staff, improve staff-resident communication andWhat is palliative care and adherence to residents’ wishes, and promotewho should deliver it? greater openness about death and dying among staff (Farrington, 2014; Goodman, 2014, Anstey 2016).The terms palliative and end of life care are feel out of our competence or confidenceoften used interchangeably (Mitchel et al zone.2016) and the inconsistency in definitionscontributes to confusion in describing Palliative care focuses on physical, emotional,the service, population, provision, access psychological, spiritual and social support.points, evaluation, user understanding It takes part in any setting and with anyand challenges in research. (Russell 2015). diagnoses. Whilst there remain differentIt is important to have clarity about your models of hospice and palliative care (charityindividual and organisation understanding and/or NHS funded) service provision aroundof palliative care so that you can plan, fund, the country; as an approach, service anddeliver, monitor, measure and evaluate your intervention it has been shown to benefitcare. people at the end of life.In essence, palliative care is multi- Care homes as providers of a significantprofessional approach, attitude and amount of peoples care therefore have aintervention to care for those who have an major role to play. Recently the Nationalincurable illness. Historically it used to be Palliative and End of Life Care Partnershipassociated only with the last days or hours of national framework (2015:11) www.life, but now it is recognised to be applicable endoflifecareambitions.org.uk published sixearly in the course of illness (WHO 2016). ambitions for care.In other words, it could be appropriate years,months, or weeks before the very last daysof life. We all should be part of it and takeresponsibility as individuals and organisationsto seek help, support or more learning if we

So what do these Ambitionsmean to care homes?1. Policies and procedures are person 5. There are robust, accessible systems in centred, equitable and responsive to place to document and communicate diversity. For example, Chaudhury et al peoples wishes and decisions as well (2016) report the importance of a home a day to day care. For example, The like environment as well as consistent Parliamentary and Health Service staff practices. The Choice in End of Life Ombudsman (2015) report the lack of Care Programme Board (2015) report how coordination between professionals and important it is to people to have their organisations causes significant distress. choices and wishes heard. 6. Care homes are communities in2. There are ongoing education and themselves as well as local and continuous professional development geographical spaces. For example, My opportunities for all staff. For example, Home Life vision of where all care homes Pyper et al (2014), Badger et al (2012), for older people are great places to live, Goodman et al (2014), Anstey et al (2016) die, visit and work http://myhomelife. report the importance and influence of org.uk/ . Other examples include the staff education on end of life practice and Northern Ireland Hospice Project Echo experience. knowledge network which supported nursing homes in Northern Ireland. http://3. Staff are competent and confident in echonorthernireland.co.uk/wordpress/ the assessment and management of wp-content/uploads/2016/05/ECHO- palliative care including the last days of NI-Evaluation-Report-2015-2016.pdf . life. Recent reports such as Jones et al Hospice UK has developed a dementia (2016) look promising for evidence-based community of practice https://www. interventions to improve end of life care. hospiceuk.org/what-we-offer/clinical- and-care-support/hospice-enabled-4. Communication is embedded as ongoing dementia-care conversations as people contemplate, discuss, decide and document their future wishes and choices (advance care planning). For example, The Choice in End of Life Care Programme Board (2015) report people want opportunities to talk about their dying.

So what are our ambitions for palliative care?For those we care for our ambitions should be this:“I can make the last stage of my life as good as possible because everyone works togetherconfidently, honesty and consistently to help me and the people who are important to me,including my carer(s)” (National Voices and The National Council for Palliative Care and NHSEngland 2015).As I see more and more care home and hospice and palliative care partnerships and initiatives,I am ambitious that together we can make a difference.Sarah RussellHead of Research and Clinical Innovation Hospice UKHospice UK is the national charity for hospice care, supporting over 200 hospices in the UK.We believe that everyone matters throughout their life right up until they die, and that no oneshould die in avoidable pain or suffering.Our aim is to make sure that everyone with a life limiting or terminal condition gets the verybest care, and we believe hospices are critical to achieving this.https://www.hospiceuk.org/

References:Anstey S, Powell T, Coles B, Hale R, Gould National Palliative and End of Life Care Part-D (2016) Education and training to enhance nership, 2015. Ambitions for Palliative andend-of-life care for nursing home staff: a sys- End of Life Care: A national framework fortematic literature review. BMJ Support Palliat local action 2015-2020,Care. 2016 Jun 21. National Voices and The National CouncilBadger F, Plumridge G, Hewison A, Shaw KL, for Palliative Care (NCPC) and NHS EnglandThomas K, Clifford C. (2012) An evaluation of (2015). Every Moment Counts: A narrative forthe impact of the Gold Standards Framework person centred coordinated care for peopleon collaboration in end-of-life care in nursing near the end of life. London: National Voices.homes. A qualitative and quantitative evalua-tion. Int J Nurs Stud. 2012 May;49(5):586-95. Parliamentary and Health Service Ombuds- man (PHSO) (2015). Dying without dignity. In-Chaudhury H, Hung L, Rust T, Wu S. (2016) Do vestigations by the Parliamentary and Healthphysical environmental changes make a dif- Service Ombudsman into complaints aboutference? Supporting person-centered care at end of life care. PHSO: London: 2015.mealtimes in nursing homes. Dementia (Lon-don). 2016 Jan 12. Pyper T,Sawyer J, Pyper C Mayhew L., 2013 PHAST Evaluation of Three End of Life CareFarrington, C. J. (2014). Blended e-learn- Training Pilots in East of England v58 Publicing and end of life care in nursing homes: Health Action Support Team (PHAST)a small-scale mixed-methods case study.BMC Palliative Care, 13(1), 31. http://doi. Russell, S., 2015. Do definitions matter in pal-org/10.1186/1472-684X-13-31 liative care? International journal of palliative nursing, 21(4), pp.160–161.Goodman, C., 2014. Evaluation of the End ofLife Care Train the Trainer ( TTT ) Education Seymour, J. E., Kumar, A., & Froggatt, K.Model, University of Hertfordshire, Hatfield. (2011). Do nursing homes for older people have the support they need to provide end-Jones L, Candy B, Davis S, Elliott M, Gola A, of-life care? A mixed methods enquiry inHarrington J, Kupeli N, Lord K, Moore K, Scott England. Palliative Medicine, 25(2), 125–138.S, Vickerstaff V, Omar RZ, King M, Leavey G, http://doi.org/10.1177/0269216310387964Nazareth I, Sampson EL. (2016) Developmentof a model for integrated care at the end The Choice in End of Life Care Programmeof life in advanced dementia: A whole sys- Board (2015). What’s important to me. Atems UK-wide approach. Palliat Med. 2016 Review of Choice in End of Life Care. TheMar;30(3):279-95. Choice in End of Life Care Programme Board: London.Lang and Buisson (2010) Care of Elderly Peo-ple: UK Market Survey 2010-11. London: Laing WHO Definition of Palliative Care (2016)and Buisson. http://www.who.int/cancer/palliative/defini- tion/en/Mitchell G, Agnelli J, McGreevy J, DiamondM, Roble H, McShane E, Strain J. (2016) Pallia-tive and end of life care for people living withdementia in care homes: part 1. Nurs Stand.2016 Jun 22;30(43):54-63.

Journal ScanThe editorial team have identified 15 recently of Community Nursing, 21, (6), pp. 284-291.published articles that you may be interestedin reading and sharing amongst your team. 11. Barber, C. (2016) Moving into a care home:These articles can be accessed through the the mental health implications, Nursing andnursing community on your SOAR system: Residential Care, 18, (5), pp. 264-266.1. Mitchell, G., Agnelli, J., McGreevy, J., 12. Brown, A. (2016) Venous leg ulcers:Diamond, M., Roble, H., McShane, E. & Strain, treating a chronic condition, Nursing andJ. (2016) Palliative and end of life care for Residential Care, 18, (5), pp. 255-259.people living with dementia in care homes:part 1, Nursing Standard, 30, (43), pp. 54-63. 13. Blaikley, C. (2016) Treating malnutrition in older people, Nursing and Residential Care,2. Middleton, C. & Llewellyn, D. (2016) How 18, (6), pp. 308-310.to record and evidence practice hours forrevalidation, Nursing Standard, 30, (43), pp. 14. Lee, A. (2016) Identifying and managing42-46. constipation in older people, Nursing and Residential Care, 16, (8), pp. 366-369.3. Middleton, C. & Llewellyn, D. (2016) Howto prepare for revalidation, Nursing Standard, 15. Booles, K. (2016) Personalised care30, (42), pp. 42-44.4. Warren, G. (2016) Moving and handling:reducing risk through assessment, NursingStandard, 30, (40), pp. 49-57.5. Shaw, M. (2016) How to administer eyedrops and eye ointment, Nursing Standard,30, (39), pp. 34-36.6. Burns, J. (2016) Patient safety andhydration in the care of older people, NursingOlder People, 28, (4), pp. 21-24.7. Griffith, R. (2016) Handwriting and a nurse’sduty of care, British Journal of Nursing, 25,(11), pp. 622-623.8. Waterhouse, C. (2016) A basicunderstanding of dysphagia in neurosciencenursing, British Journal of NeuroscienceNursing, 12, (2), pp. S10-S14.9. McGuinness, H & Folan, H. (2016) Severemental illness and physical health care, BritishJournal of Mental Health Nursing, 5, (2), pp.81-86.10. Means, T. (2016) Improving quality ofcare and reducing unnecessary hospitaladmissions: a literature review, British Journal