Reducing uncertainty: an exploratory study of people's treatment decisions after transient ischaemic attack or minor stroke

Little is known about people's responses to the impact of a transient ischaemic attack or minor stroke on their health status and future risk of stroke. In this thesis my aims are: to explore how the experience of TIA or minor stroke affects people's perception of their health and their uptake of health maintenance measures; to examine people's assessment, interpretation and perceptions of evidence in relation to their stroke risk; to explore the ways in which people reach decisions about treatment options in the light of their personal experience and in the context of evidence-based healthcare; and to explore the effect of anticipated regret in these processes. I conducted 28 audiotaped one-to one interviews with a purposive sample of 20 participants, each of whom had previously experienced a TIA or minor stroke. Ten of them had carotid endarterectomy in addition to best medical treatment (BMT). The data collection and analysis used a reflexive approach, based on my clinical nursing practice in this field, and was informed by the constant comparative method of grounded theory. My findings show that the experience of TIA diminishes people's quality of life and leads to a process of acknowledgement versus denial of its potential threat to health. People access evidence from formal and informal sources in the process of reaching decisions about their treatment. Their decisions tend to be deterministic in nature, even when they are aware of the scientific evidence. I present a theoretical framework, in which the central theme is the person's use of strategies to reduce uncertainty relating to their risk of stroke. I propose that people's primary aim in seeking health care, accessing information, and making treatment choices after TIA or minor stroke, is to reduce their perception of uncertainty about the threat of a future stroke, rather than to reduce stroke risk itself. I discuss the implications of these findings in relation to directions for future research, health care policy and nursing practice

Men’s health – the impact of stroke

Stroke is a leading cause of adult death and the most common cause of complex disability in the UK. This article discusses the incidence and impact of stroke, focusing on a range of issues from a male perspective, including stroke prevention, psychological needs, sexuality and return to work. There are some gender differences in modifiable risk factors for stroke, and women have better knowledge of stroke symptomatology. For men, the development of post-stroke depression is associated with greater physical disability. (c) Sherborne Gibbs Limite

Great expectations? A qualitative study of health professionals' perspectives on breaking bad news about rehabilitation potential after traumatic brain injury or spinal injury

Background: Neurorehabilitation units play an important role in facilitating recovery for those with complex needs following a neurological event. National guidance highlights the importance of providing patients and their families with information and fostering realistic expectations. This may involve the breaking of bad news. The aim of this study is to explore health professionals’ perspectives on breaking bad news in the neurorehabilitation setting. Method: 15 health professionals (physiotherapists, occupational therapists, nurses, speech therapists, psychologists and doctors) working at a 24 bedded neurorehabilitation unit in a National Health Service acute trust in England were recruited. A qualitative study was conducted using patient vignettes to facilitate discussions during semi-structured interviews and a focus group. The results were analysed using thematic analysis. Results: Four major themes emerged: influencing factors, current approaches used, staff experiences, and strategies to improve breaking bad news. There was a need for better management of patients' and families' expectations. Breaking bad news was seen as emotionally demanding yet often unrecognised work. Conclusions: Breaking bad news in the neurorehabilitation setting is complex and under-recognised work, involving multiple health professionals. There is a need for both experience and training to improve skills and confidence in breaking bad news

Clinical academic research internships for nurses, midwives and allied health professionals: a qualitative evaluation

Background: Nurses, midwives and allied health professionals are integral to research, yet rarely engage simultaneously in research and clinical practice. Clinical academic internships offer a route to access academic research training. This study aimed to elucidate facilitators and barriers to participation and engagement, and suggest improvements for future programmes. Method: The experiences of 10 health professional research interns were explored, using a method based on a synthesis between grounded theory and content analysis. Findings: Four categories emerged: 1) integrating clinical and research aspirations; 2) Support – or lack of it; 3) The hidden curriculum; 4) The legacy effect. Within these categories, respondents identified a variety of facilitators and barriers to engagement, including unforeseen challenges. Conclusion: Formal support is necessary but not sufficient to foster engagement and maximise benefits. Participation must be supported by colleagues and enabled by institutional structures. The potential impact of internships on engagement with research is considerable but requires collaboration between all stakeholders. Implications for Practice: Deeper institutional engagement is needed so that internship opportunities are fully supported by all colleagues and practically enabled by institutional structures. Future schemes should attempt to promote opportunities to collaborate via group projects to reduce researcher isolation

Non-medical prescribing in primary care in the United Kingdom: an overview of the current literature

Background: Non-medical prescribers (NMPs) are perceived as a complement to busy general practice in primary care. Aim: To conduct an overview of the literature available on the role and impact of non-medical prescribing (NMP) on primary care patients. Method: The search was conducted using multiple databases to find articles published between January 2015-January 2021. Inclusion criteria: NMPs in primary care in the United Kingdom, written in English language. Exclusion criteria: research conducted in secondary care or outside the UK. Findings: 285 studies were identified; 15 were eligible for critical appraisal. Key themes were: NMP’s positive perceptions were autonomy, job satisfaction and colleague support; negative perceptions included risk, lack of continuous professional development (CPD), organisational support. Conclusion: By reviewing the perceptions of NMPs in primary care, organisations can ensure when employing new NMPs that the adequate CPD and support is in place. Thereby reducing NMPs concerns about the ligation risk of prescribin

Medication adherence early after stroke: using the Perceptions and Practicalities framework to explore stroke survivors’, informal carers’ and nurses’ experiences of barriers and solutions

Background: Secondary prevention medication after stroke reduces risk of recurrence, but adherence is often poor. Stroke survivors’, carers’ and nurses’ perspectives of early post-stroke medication adherence are unexplored. Aim: to explore stroke survivors’, carers’ and nurses’ views and experiences about adhering to medication early after post-stroke hospital discharge. Methods: Qualitative individual and group interviews, utilizing the Perceptions and Practicalities framework. Nine people <2 months post-stroke, three carers, and fifteen nurses from one UK stroke unit participated. Interviews were digitally recorded, transcribed and thematically analysed. Results: There were four main themes with two subthemes. 1) Perceptions of medication taking after stroke. Factors affecting adherence included depression, imperceptible benefits, and concerns about adverse effects. 2) Perceptions about those at higher risk of poor medication adherence. Nurses suggested that poor adherence might be more likely in those living alone or with previous nonadherence. 3) Practicalities of taking medication early after stroke; these included post-stroke disabilities, cognition, polypharmacy, and lack of information. 4a) Practicalities of addressing poor medication adherence during the hospital stay. Solutions included multidisciplinary co-ordination, but nurses and stroke survivors described suboptimal use of opportunities to promote adherence. 4b) Practicalities of addressing poor medication adherence post-discharge. Solutions included modifications and support from carers, but stroke survivors reported difficulties in evolving systems for taking medications. Conclusions: Stroke survivors and informal carers lack knowledge and support needed to manage medication early after discharge. Nurses’ opportunities to promote medication adherence are under-exploited. Medication adherence strategies to support stroke survivors early after discharge are needed

Pilot study evaluating the feasibility of comparing computer game play with close work during occlusion in children aged 2-7 years with amblyopia

Background/Aims: Computer games have been used to stimulate vision in amblyopia with varying degrees of success. The aim of this pilot study was to evaluate the feasibility of conducting a randomised controlled trial to test the effectiveness of computer game play compared to close work during occlusion treatment in children. Method: Children aged 2–7 years with amblyopia and no prior amblyopia treatment were invited to participate. Participants were randomised to a computer game group or close work group and asked to complete two hours occlusion per day, incorporating one hour of their allocated activity. LogMAR visual acuity (VA) was assessed before treatment commenced and after 7(±1) weeks. The same examiner, who was unaware of the allocated treatment, assessed the participant using the same VA test. Results: Eighteen participants (mean age of 4.2 ± 1.3 years) completed the study. After seven weeks the mean VA of the amblyopic eye in the computer game group improved by 0.147 ± 0.182 logMAR, and in the close work group improved by 0.181 ± 0.124 logMAR. The difference in VA improvement between the computer game and the close work groups was not statistically significant (F(1,32) = 3.71; p = 0.06). Conclusion: No significant difference was found in visual outcomes between the two groups, but a larger sample size would be needed to draw conclusions regarding the amblyopic population. Evaluation of the study design suggests it would be feasible to conduct a randomised controlled trial comparing computer games and close work during occlusion to determine if a significant difference in visual outcome exists

Medication-taking after stroke: a qualitative meta-synthesis of the perspectives of stroke survivors, informal carers and health professionals

Background Lifelong secondary prevention medication is recommended after stroke or transient ischaemic attack. However, poor medication adherence and persistence, which lead to suboptimal health outcomes, are common, but the reasons for this are not well understood, mainly because there have been few studies reporting adherence barriers in stroke survivors. Objective The aim of this review was to undertake a meta-synthesis of qualitative studies of medication-taking after stroke. Outcomes of interest were: lived experiences, views and beliefs, and strategies and solutions used by community-dwelling stroke and TIA survivors, informal carers and healthcare professionals in relation to medication taking. Method The review protocol was registered on PROSPERO (CRD42018086792). A search of online bibliographic databases was performed using key search terms of stroke, persistence, adherence and medication for years 1980-2018. Citation tracking was also carried out. Studies using qualitative or mixed methods were included. Systematic data extraction and synthesis were conducted using a meta-ethnographic approach. Results Twelve studies were eligible for inclusion, with a total of 412 participants, two-thirds of whom were stroke survivors, ranging from 1 month to over 20 years post-stroke. Third-order themes identified were ‘Medicines Work’ – Information Work; Health Care Work; Carer Work; Emotional Work; Practical Work; and an underpinning theme of Trust. However, many studies had significant methodological weaknesses. Conclusions This synthesis suggests that the burden of ‘medicines work’ after stroke is substantial and multifaceted. Its successful undertaking depends on mutual trust between stroke survivors, carers and health care professionals, and trust in the benefits of medicines themselves

Perceptions and experiences of emergency department staff during the implementation of the four-hour rule/national emergency access target policy in Australia: A qualitative social dynamic perspective

Background: The Four-Hour Rule or National Emergency Access Target policy (4HR/NEAT) was implemented by Australian State and Federal Governments between 2009 and 2014 to address increased demand, overcrowding and access block (boarding) in Emergency Departments (EDs). This qualitative study aimed to assess the impact of 4HR/NEAT on ED staff attitudes and perceptions. This article is part of a series of manuscripts reporting the results of this project. Methods: The methodology has been published in this journal. As discussed in the methods paper, we interviewed 119 participants from 16 EDs across New South Wales (NSW), Queensland (QLD), Western Australia (WA) and the Australian Capital Territory (ACT), in 2015-2016. Interviews were recorded, transcribed, imported to NVivo 11 and analysed using content and thematic analysis. Results: Three key themes emerged: Stress and morale, Intergroup dynamics, and Interaction with patients. These provided insight into the psycho-social dimensions and organisational structure of EDs at the individual, peer-to-peer, inter-departmental, and staff-patient levels. Conclusion: Findings provide information on the social interactions associated with the introduction of the 4HR/NEAT policy and the intended and unintended consequences of its implementation across Australia. These themes allowed us to develop several hypotheses about the driving forces behind the social impact of this policy on ED staff and will allow for development of interventions that are rooted in the rich context of the staff\u27s experiences. © 2019 The Author(s)