Family INvolvement in inTensive care: A qualitative exploration of critically ill patients, their families and critical care nurses (INpuT study)

Aims and objectivesTo understand the different factors that impact on the involvement of adult family members in the care of critically ill patients from the perspective of patients, families and nurses, with the aim to inform the enactment of a patient‐ and family‐centred care intervention to support the patient–family–nurse partnership in care involvement.BackgroundExisting evidence lacks theoretical underpinning and clarity to support enactment of patient‐ and family‐centred care and involvement of families in the care of the critically ill patient.DesignQualitative exploratory design using thematic analysis.MethodsThis study was conducted at two adult intensive care units in two tertiary university hospitals in the central belt of Scotland. Between 2013–2014, we conducted semi‐structured interviews with critically ill survivors (n = 19) and adult family members (n = 21), and five focus groups with nurses (n = 15) across both settings. Data were digitally recorded, transcribed verbatim, and uploaded in NVivo 10. Data were analysed thematically using a constructivist epistemology. Ethical approval was obtained prior to data collection. Data are reported according to the Consolidated Criteria for Reporting Qualitative Research checklist.ResultsFamily's situational awareness; the perceived self in care partnership; rapport and trust; and personal and family attributes were the main factors that affected family involvement in care. Two key themes were identified as principles to enact patient‐ and family‐centred care in adult intensive care units: “Need for ‘Doing family’” and “Negotiations in care involvement.”ConclusionsNegotiating involvement in care requires consideration of patients' and family members' values of doing family and the development of a constructive patient–family–nurses' partnership.Relevance to clinical practiceFuture policy and research should consider patients' and family's needs to demonstrate family bonds within a negotiated process in care participation, when developing tools and frameworks to promote patient‐ and family‐centred care in adult intensive care units

Access to and use of clinical services and disease-modifying therapies by people with progressive multiple sclerosis in the United Kingdom

Background: According to current UK guidelines everyone with progressive MS should have access to an MS Specialist but levels of access and use of clinical services is unknown. Our objective was to investigate access to MS Specialists, use of clinical services and disease-modifying therapies (DMTs) by people with progressive MS in the United Kingdom. Methods: A UK wide, online survey was conducted via the UK MS Register. Inclusion criteria: age over 18 years, primary or secondary progressive MS and a member of the UK MS Register. Participants were asked about access to MS Specialists; recent clinical service use; receipt of regular review and current and previous DMT use. Participant demographics; quality of life and disease impact measures were supplied from the UK MS Register. Results: In total 1298 participants responded: 5% were currently taking DMT; 23% had previously taken DMT; and 95% reported access to an MS Specialist. Most utilised services were: MS Doctor/Nurse (50%), General Practitioner (45%), and Physiotherapist (40%). Seventy-four percent received a regular review although 37% received theirs less than annually. Current DMT use was associated with better quality of life but past DMT use was associated with poorer quality of life and higher impact of disease. Conclusions: Access to, and use of, MS Specialists was high. However a gap in service provision was highlighted in both receiving and frequency of regular reviews

Exploring scale-up, spread, and sustainability: an instrumental case study tracing an innovation to enhance dysphagia care

Background Adoption, adaptation, scale-up, spread, and sustainability are ill-defined, undertheorised, and little-researched implementation science concepts. An instrumental case study will track the adoption and adaptation, or not, of a locally developed innovation about dysphagia as a patient safety issue. The case study will examine a conceptual framework with a continuum of spread comprising hierarchical control or ‘making it happen’, participatory adaptation or ‘help it happen’, and facilitated evolution or ‘let it happen’. Methods This case study is a prospective, longitudinal design using mixed methods. The fifteen-month (October 2012 to December 2013) instrumental case study is set in large, healthcare organisation in England. The innovation refers to introducing a nationally recognised, inter-disciplinary dysphagia competency framework to guide workforce development about fundamental aspects of care. Adoption and adaptation will be examined at an organisational level and along two, contrasting care pathways: stroke and fractured neck of femur. A number of educational interventions will be deployed, including training a cadre of trainers to cascade the essentials of dysphagia management and developing a Dysphagia Toolkit as a learning resource. Mixed methods will be used to investigate scale-up, spread, and sustainability in acute and community settings. A purposive sample of senior managers and clinical leaders will be interviewed to identify path dependency or the context specific particularities of implementation. A pre- and post-evaluation, using mealtime observations and a survey, will investigate the learning effect on staff adherence to patient specific dysphagia recommendations and attitudes towards dysphagia, respectively. Official documents and an ethnographic field journal allow critical junctures, temporal aspects and confounding factors to be explored. Discussion Researching spread and sustainability presents methodological and practical challenges. These include fidelity, adaptation latitude, time, and organisational changes. An instrumental case study will allow these confounding factors to be tracked over time and in place. The case study is underpinned by, and will test a conceptual framework about spread, to explore theoretical generalizability

Primary care challenges in diagnosing and referring patients with suspected rheumatoid arthritis: a national cross-sectional GP survey

Objective: National guidelines advocate referring patients with persistent synovitis to rheumatology within 3 working days of presentation to primary care. This occurs infrequently. We aimed to identify modifiable barriers to early referral of suspected RA patients among English general practitioners (GPs). Methods: We carried out a national cross-sectional survey of 1388 English GPs (RA Questionnaire for GPs [RA-QUEST] study). Questions addressed GPs’ confidence in diagnosing RA, clinical factors influencing RA diagnosis/referral, timeliness of referrals and secondary care access. Data were captured using 10-point visual analog scales, five-point Likert scales, yes/no questions or free text, and were analysed descriptively. Results: Small joint swelling and pain were most influential in diagnosing RA (91 and 84% rated the importance of these as 4 or 5 on a five-point Likert scale, respectively); investigations including RF (61% rating 4 or 5) and anti-CCP antibody (72% rating 4 or 5) were less influential. Patient history had the greatest impact on the decision to refer (92% rating this 4 or 5 on a 5-point Likert scale), with acute phase markers (74% rating 4 or 5) and serology (76% rating 4 or 5) less impactful. Despite the importance placed on history and examination, only 26% referred suspected RA immediately without investigations; 95% of GPs organizing further tests opted to test for RF. Conclusion: For suspected RA patients to be referred within 3 days of presentation to primary care there needs to be a paradigm shift in GPs’ approaches to making referral decisions, with a focus on clinical history and examination findings, and not the use of investigations such as RF

Mental health care and resistance to fascism

Mental health nurses have a critical stake in resisting the right-wing ideology of British fascism. Particularly concerning is the contemporary effort of the British National Party (BNP) to gain credibility and electoral support by the strategic re-packaging of a racist and divisive political manifesto. Evidence that some public sector workers are affiliated with the BNP has relevance for nursing at a series of levels, not least the incompatibility of party membership with a requirement of the Professional Code to avoid discrimination. Progressive advances, though, need to account for deep rooted institutionalized racism in the discourse and practice of healthcare services. The anomalous treatment of black people within mental health services, alongside racial abuse experienced by ethnic minority staff, is discussed in relation to the concept of race as a powerful social category and construction. The murder of the mentally ill and learning disabled in Nazi Germany, as an adjunct of racial genocide, is presented as an extreme example where professional ethics was undermined by dominant political ideology. Finally, the complicity of medical and nursing staff in the state sanctioned, bureaucratic, killing that characterized the Holocaust is revisited in the context of ethical repositioning for contemporary practice and praxis

Do surgical care bundles reduce the risk of surgical site infections in patients undergoing colorectal surgery? A systematic review and cohort meta-analysis of 8,515 patients

Background. Care bundles are a strategy that can be used to reduce the risk of surgical site infection (SSI), but individual studies of care bundles report conflicting outcomes. This study assesses the effectiveness of care bundles to reduce SSI among patients undergoing colorectal surgery. Methods. We performed a systematic review and meta-analysis of randomized controlled trials, quasiexperimental studies, and cohort studies of care bundles to reduce SSI. The search strategy included database and clinical trials register searches from 2012 until June 2014, searching reference lists of retrieved studies and contacting study authors to obtain missing data. The Downs and Black checklist was used to assess the quality of all studies. Raw data were used to calculate pooled relative risk (RR) estimates using Cochrane Review Manager. The I2 statistic and funnel plots were performed to identify publication bias. Sensitivity analysis was carried out to examine the influence of individual data sets on pooled RRs. Results. Sixteen studies were included in the analysis, with 13 providing sufficient data for a metaanalysis. Most study bundles included core interventions such as antibiotic administration, appropriate hair removal, glycemic control, and normothermia. The SSI rate in the bundle group was 7.0% (328/ 4,649) compared with 15.1% (585/3,866) in a standard care group. The pooled effect of 13 studies with a total sample of 8,515 patients shows that surgical care bundles have a clinically important impact on reducing the risk of SSI compared to standard care with a CI of 0.55 (0.39–0.77; P = .0005). Conclusion. The systematic review and meta-analysis documents that use of an evidence-based, surgical care bundle in patients undergoing colorectal surgery significantly reduced the risk of SSI

Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science

Abstract Background Many interventions found to be effective in health services research studies fail to translate into meaningful patient care outcomes across multiple contexts. Health services researchers recognize the need to evaluate not only summative outcomes but also formative outcomes to assess the extent to which implementation is effective in a specific setting, prolongs sustainability, and promotes dissemination into other settings. Many implementation theories have been published to help promote effective implementation. However, they overlap considerably in the constructs included in individual theories, and a comparison of theories reveals that each is missing important constructs included in other theories. In addition, terminology and definitions are not consistent across theories. We describe the Consolidated Framework For Implementation Research (CFIR) that offers an overarching typology to promote implementation theory development and verification about what works where and why across multiple contexts. Methods We used a snowball sampling approach to identify published theories that were evaluated to identify constructs based on strength of conceptual or empirical support for influence on implementation, consistency in definitions, alignment with our own findings, and potential for measurement. We combined constructs across published theories that had different labels but were redundant or overlapping in definition, and we parsed apart constructs that conflated underlying concepts. Results The CFIR is composed of five major domains: intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation. Eight constructs were identified related to the intervention (e.g., evidence strength and quality), four constructs were identified related to outer setting (e.g., patient needs and resources), 12 constructs were identified related to inner setting (e.g., culture, leadership engagement), five constructs were identified related to individual characteristics, and eight constructs were identified related to process (e.g., plan, evaluate, and reflect). We present explicit definitions for each construct. Conclusion The CFIR provides a pragmatic structure for approaching complex, interacting, multi-level, and transient states of constructs in the real world by embracing, consolidating, and unifying key constructs from published implementation theories. It can be used to guide formative evaluations and build the implementation knowledge base across multiple studies and settings.http://deepblue.lib.umich.edu/bitstream/2027.42/78272/1/1748-5908-4-50.xmlhttp://deepblue.lib.umich.edu/bitstream/2027.42/78272/2/1748-5908-4-50-S1.PDFhttp://deepblue.lib.umich.edu/bitstream/2027.42/78272/3/1748-5908-4-50-S3.PDFhttp://deepblue.lib.umich.edu/bitstream/2027.42/78272/4/1748-5908-4-50-S4.PDFhttp://deepblue.lib.umich.edu/bitstream/2027.42/78272/5/1748-5908-4-50.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/78272/6/1748-5908-4-50-S2.PDFPeer Reviewe

End of the spectacular decrease in fall-related mortality rate: Men are catching up

Objectives: We determined time trends in numbers and rates of fall-related mortality in an aging population, for men and women. Methods. We performed secular trend analysis of fall-related deaths in the older Dutch population (persons aged 65 years or older) from 1969 to 2008, using the national Official-Cause-of-Death-Statistics. Results. Between 1969 and 2008, the age-adjusted fall-related mortality rate decreased from 202.1 to 66.7 per 100 000 older persons (decrease of 67%). However, the annual percentage change (change per year) in mortality rates was not constant, and could be divided into 3 phases: (1) a rapid decrease until the mid-1980s (men -4.1%; 95% confidence interval [CI] = -4.9, -3.2; women -6.5%; 95% CI, -7.1, -5.9), (2) flattening of the decrease until the mid-1990s (men -1.4%; 95% CI = -2.4, -0.4; women -2.0%; 95% CI = -3.4, -0.6), and (3) stable mortality rates for women (0.0%; 95% CI = -1.2, 1.3) and rising rates for men (1.9%; 95% CI = 0.6, 3.2) over the last decade. Conclusions. The spectacular decrease in fall-related mortality ended in the mid-1990s and is currently increasing in older men at