Caroline Watkins

Caroline Watkins
Professor of Stroke & Older People’s Care
Director of Research and Innovation, College of Health and Wellbeing
University of Central Lancashire
Preston, UK
&
Australian Catholic University, Sydney
clwatkins@uclan.ac.uk
Participation in Health Research:
Edge walking?

Research priorities those of clinicians?
“Practitioners will continue to ignore research
publications until they are seen as helpful and
relevant”
Sobell (1996)

Key Message
Today’s research is tomorrow’s care……

Trainees Coordinating CentreTrainees Coordinating Centre
National Institute for Health Research
Established 2006:
A vehicle for implementing
Government’s strategy for
applied health research
£1bn annual spend
Vision:
Improving health and wealth
of nation through research

NIHR Remit
• People and patient based applied health research
• Research capacity to improve health/healthcare
• Patients, samples or data from patients, people who are
not patients, populations, health technology assessment
and health services research
• The potential to have an impact on the needs of patients
and the public within 5 years of completion
• Prepared to support research into medical education
• No basic research involving animals and/or animal tissue

Trainees Coordinating Centre
Research Training
Opportunities from
NIHR
David Richards, PenCLAHRC,
University of Exeter Medical School
(additional material from Peter Thompson, NIHR TCC)

NIHR Fellowships Programme
• Salary
• Full tuition fees (for PhD)
• Research costs
• Full training and development
• Awards 3 years full time (part-time options of 75% or
60%) or up to 5 years for SRF
• Can be based at HEI or NHS Trust
• Annual competition for all levels
• Next launch – October 2016

Post Doctoral Research
Fellowship (NIHR PDF)
Early post doctoral Fellowship
(≤ 3 years WTE Post Doctorate)
3 years FT (4 or 5 years PT)
Applicant:
PhD/MD or have submitted
Output from research
Evidence of commitment to
research career
Doctoral training award
Applicant:
Some previous research experience
Some outputs from research
Evidence of commitment to research
career
Doctoral Research Fellowship
(NIHR DRF)
NIHR Fellowships

Senior Research Fellowship
(NIHR SRF)
Most senior NIHR Fellowship
5 years ( Chair)
Applicant:
Significant postdoctoral experience
Outstanding publication record
Independence
Leadership potential
Record of research capacity
development
Later postdoctoral award (≤ 7 yrs
WTE Post Doctorate)
Applicant:
PhD/MD and postdoctoral
experience
Significant output from research
Evidence of increasing
independence
Experience of developing research
skills of others
Career Development Fellowship
(NIHR CDF)
NIHR Fellowships

NIHR Fellowships
Postdoctoral award (≤ 5 yrs WTE Post Doctorate)
18 months to 2 years FT or PT
Applicant:
PhD/MD and maybe postdoctoral experience
• Individuals from any scientific discipline wanting to
contribute to improving health or healthcare e.g. basic
scientists moving to applied health research
• Individuals who have had their research careers
interrupted e.g. career break, who can identify clear
training needs
• Proposed research must be within the NIHR remit
Transitional Research Fellowship
(NIHR TRF) new from 2013

HEE/NIHR Integrated Clinical
Academic Programme
Health Education England Review recommended expansion to all
registered non medical/dental registered healthcare professionals
committed to developing a career which combines research and
continued clinical practice.

HEE/NIHR Integrated Clinical
Academic Programme
• Funded HEIs advertise places
(institutional award)
• 100 places per annum
available over next 3 years
• The University of Manchester
• University of Nottingham
• University of Leeds
• The City University London
• University of Southampton
• University of Brighton
• Kingston University London
• University of Plymouth
• University of East Anglia
• Coventry University
• PhD research whilst developing clinical skills
• Based at English NHS trust, other health care
organisation or HEI
• Min 1 yr clinical experience and current statutory
registration
• Need for both a good academic and clinical
supervisor
• Salary, PhD tuition fees, research, training &
development costs (100% NHS, 80% HEI except
training & development @100%)
• 3 years FT (4 or 5 years PT)
• Next call March 2017
HEE/NIHR Masters in
Clinical Research
HEE/NIHR Clinical Doctoral Research
Fellowship

Good Applications
1. Applicant
• (trajectory, career outputs)
2. Research Project
• (scientific quality, appropriate scale and scope)
3. Training and Development
• (meet the needs of the candidate and the project)
4. Environment
• (research Excellence Framework rating, facilities)
5. Supervision/mentorship
• (track record in relevant field, time and commitment)

Project
• Doable
• Applied
• Relevant
• Five year impact rule
• Quality high
• PPI
– VETO ALERT!
– Do not confuse PPI with focus groups and qualitative data –
that’s different (so don’t include that piece in the PPI section).
PPI is actual involvement in the research process itself.
– PPI is NOT people as research participants/subjects giving data

• Enable health and social care
practitioners to develop skills
to design and lead high quality
clinical research
• Research relevant to
patients/clients & NHS priorities
• Facilitate practitioner careers
combining clinical research and
research leadership with
developing clinical practice
For more information:
Visit:
http://www.uclan.ac.uk/study_here
/
postgraduate_study.php
Email: Dr Lois Thomas
lhthomas@uclan.ac.uk

INTERNSHIPS
 LINCS - 2010
Lancashire Initiative for Nursing and Caring research in Stroke: Oral Flora (4
LTHTR staff)
 HENW – 2013-2016
Range of projects (10 staff) annually
 CLAHRCS - 2014
Range of projects (10 staff) & now 15 annually
 Senior Investigator/RCF - 2016
Range of projects – Grass Roots Care (4 LTHTR staff)

Changes in Oral Flora in Acute Stroke:
An observational study
Professor Caroline Watkins
University of Central Lancashire
United Kingdom Swallow Research Group
February 2016

Stroke
• UK: 150,000 people/annum
• Top 3 cause of death
• Leading cause of adult disability
• 1/5 acute hospital beds
• Increased risk of respiratory infection-first few weeks
• Risk of infection mostly more dependent patients
• 10% of stroke patients develop pneumonia
• Pneumonia associated with death (OR 3.62)
• Pneumonia potentially linked to poor oral hygiene

Current oral care practices
• Poor oral health within supported care (Hally, 2003)
• Low priority in the hierarchy of care (Adams, 1996)
• Nursing staff dislike oral care (Boyle, 1992)
• Often delegated to care assistants (Wårdh, 1997)
• Lack of knowledge and equipment (Wårdh et al 2000)
• Lack of evidence relating to oral care interventions (Brady, 2006)

Why is oral care important to stroke patients?
Unable to attend to oral hygiene due
to Physical and cognitive problems
Contributing factors following stroke
• Dysphagia with increased risk of
aspiration of bacteria laden saliva
• Facial weakness
• Food Debris in mouth
• Medication
• Oxygen therapy
• Dehydration/Taste
• Mouth Breathing
• Inability to recognise need for oral care
• Inability for express need for oral care
• Hemiplegia
• Decreased oral sensation

Oral Flora
• Complex
bionetwork
• High diversity of
oral flora
• Disruption to oral
cleanliness may
lead to overgrowth
of pathogenic
bacteria

Thick plaque forms
Gums are very red and swollen.
This person has gum disease
If plaque is not removed it will
harden to become tartar
(calculus)
Tooth decay

Aims
1. Identify patient characteristics and clinical
factors e.g.infection, that may affect oral flora
2. Describe bacterial profile of oral flora during
the first two weeks post-stroke
3. Examine changes in condition of oral cavity

Procedure
• Time Point 1: <48 hs post-admission
Patient characteristics i.e. demographic data
Clinical data (documentation of infection)
Oral DNA samples
Oral assessment using THROAT
• Time Point 2: 48-72 hs after time point one
Oral DNA samples
• Time Point 3: 7 days post-admission
Oral DNA samples

International Stroke Research Collaboration (ISReC)

1. Patient characteristics & Clinical factors
0
2
4
6
8
10
12
Time point one Time point Two Time point Three
Respiratory
Oral
UTI
Cellulitus
Septacaemia

2. Oral bacterial profile
• 103 bacterial phylotypes were isolated (98-100% sequence
similarity cut-off for defining a phylotype)
• 29 of which are considered to be non-oral flora
• Of 367 samples, 211 (57.5%) Streptococcus genus
• Abnormal Streptococcus phylotypes occurred in 23 (11%)
samples.
• Average number of different bacterial phylotypes/person
2.72, 2.76 and 2.32 at time points 1, 2 and 3 respectively
(range 0 – 11)
• No significant difference in the average number of different
phylotypes found across all three time points

3. Condition of the oral cavity over three time points

Thank you
Acknowledgements:
• Dr Louise Connell
• Dr Liz Boaden
• Wendy Loughlin
• Annette Munro
• Dr Hazel Dickinson
• Karen Shevlin
• Dr Craig Smith
• Dr Liz Lightbody
• Dr Michael Leathley
• Alison McLoughlin
• Mary Lyons
• Simarjit Singhrao
• Zarine Khan
• Prof StJohn Crean

British Journal of
Healthcare Assistants
November 2013 Vol
07 No 11

Stroke Care
• High quality stroke care is care that is right for that
patient at that point on their care pathway
• To deliver the right care staff must have the right
– Knowledge
– Skills
– Abilities
– Time

Knowledge?
• It ain’t what you know that gets you into trouble
• It’s what you know for sure that just ain’t so
Mark Twain

Funding from the National Health and Medical Research Council
(NHMRC) of Australia
An international collaborative project

Sitting up is the typical nursing position for
patients in the UK

Lying flat is common in some
countries
China
Switzerland

Lying flat is standard care for acute ischaemic
stroke in hospitals in Switzerland
Day Mobilisation schedule Importance
1 Bedrest/lying flat strict
2 Bedrest head 30 degrees strict
3 Bedrest head 60 degrees strict
4 Sitting on edge of bed
(accompanied during care)
5 Sitting in a chair
(accompanied during care)
6 Walking around in the
room (with care assistant)
7 Walking around freely

Balance of potential benefits and risks
of sitting up vs lying flat
Sat up
• Reduce cerebral oedema,
especially in ICH or
malignant MCA infarction
• Improve cardiac function
• Improve oxygenation
• Increase alertness
Lying down
• Improve collateral cerebral
blood flow
 arterial
 venous
• Rest the brain

Overview
An international, multicentre, cluster
randomised, crossover, blinded outcome
assessment trial to compare the lying flat with
sitting up in acute stroke

Trial Schema
Lying Flat Head Positioning
0° for first 24 hours
Sitting Up Head Positioning
≥30° for first 24 hours
Randomisation
Sitting Up Head Positioning
≥30° for first 24 hours
Lying Flat Head Positioning
0° for first 24 hours
STUDY SITES
Standard
Nursing and
Medical
Care
(Local
Guidelines)
Crossover Crossover
Blinded assessment of outcome at 90 days
Blinded assessment of
outcome at 90 days

Why a cluster cross-over design?
Cluster
• To avoid contamination, patients will not see differences in
practice
• Better compliance from both staff and patients
Cross-over
• Internally adjusts for background variation across hospitals
• All hospitals will change practice from usual policy, thus
internally adjusting for ‘change’
• Fewer centres needed
• Reduce sample size by ≥30%

Consent
• Cluster guardian
– No consent to the intervention, the intervention will be the “usual
care” at that time point
– Necessary to prevent contamination of the intervention
– Insufficient evidence for a specific ideal head position
– Head position in both groups within the range of routine practice
• Individual patient consent
– Consent for data collection (in-hospital data)
– As soon as possible
– Centralised 90 days follow-up assessments

Results
• >100 sites worldwide
• 41 UK sites
• >10,000 patients worldwide
• ~4000 UK patients
• 3rd European Stroke Organisation
Conference 2017, Prague, 16-18th May

Implementing Research:
Everybody’s
business?
Patient
Research
Nurse/Coordinator
Clinician
Manager
Researcher

Key Message
Research is for patients
and not clinicians or researchers……..

Key to success is working together!
Research Support Team rsenquiries@uclan.ac.uk

Caroline Watkins

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Caroline Watkins