Screaming silences: lessons from the application of a new research framework

This paper presents the lessons learned from the application of a new research framework, The Silences Framework (Serrant-Green, 2011) in the context of a qualitative study exploring the fragility hip fracture recovery experiences of people under 60. Originating from research exploring ethnicity, gender and sexual health decisionmaking, this new framework provides a useful research tool for researching underrepresented groups and topics. It is likely to be attractive to nurses as it is underpinned by core nursing values such as advocacy based action, places participant and public voices at the centre of the research and resembles the familiar nursing process. The structure and flexibility it offers also make it relevant for new and experienced researchers in a variety of contexts. Current conceptions of marginalisation in healthcare are explored with reference to nursing research and practical tips are provided for others interested in applying and further testing this new research framework

Fragility hip fracture in the under 60s: a qualitative study of recovery experiences and the implications for nursing

Background: Hip fracture is a common, serious, complex injury and an important cause of morbidity, mortality and rising healthcare costs. Incidence and impact in the under 60s has been under researched. The aim of this study was therefore to explore the recovery experiences of young adults with an isolated hip fracture following a minor fall to inform future care delivery. Methods and Findings The Silences Framework was used to guide a critical interpretivist study. Thirty in-depth, minimally structured, story-telling interviews were conducted with participants between one and 10 years post injury. One cross-cutting theme, ‘Communication’ and four main themes: ‘Experience of care’, ’Impact on self’, ‘Impact on others’ and ‘Moving forward’ were identified. The findings indicated multi-faceted, often long term, physical, social and psychological impact on participants, their family and wider social networks. This included Post Traumatic Stress Disorder type symptoms and impact on work, finances and relationships. Inadequacies in the current care pathway and limited relevance of the commonly used patient reported hip fracture outcome measures used for young adults were also identified. Conclusion: The dominant discourse on fragility hip fracture almost exclusively focuses on the elderly and short-term outcomes. This was the first study investigating the long-term impact of fragility hip fracture in young adults from their perspective and the first application of a new research framework in an acute care setting. It found the needs of younger hip fracture patients are not adequately recognised or addressed. Increased awareness and improvements in healthcare provision are needed to minimise the long-term personal and societal impact of fragility fracture in the under 60s

Silent slips trips and broken hips: the recovery experiences of young adults following an isolated fracture of the proximal femur

A thesis submitted in partial fulfilment of the requirements of the University of Wolverhampton for the degree of Doctor of PhilosophyIsolated hip fracture following a minor fall is a serious injury, normally requiring urgent surgical treatment and a complex recovery journey. Although commonly associated with the elderly, incidence and impact in adults under 60 years of age may be underestimated. The extensive literature almost exclusively focuses on the elderly, surgical interventions and relatively short-term outcomes. Young adults are also missing from the dominant societal discourse and healthcare policy on fragility hip fracture. They therefore represent a silent sub-subset of the fragility hip fracture population, whose recovery experiences and needs, particularly in the longer term, remain largely unknown. A critical interpretivist approach and The Silences Framework (Serrant-Green, 2011), were used to ‘give voice’ to young adults with isolated hip fracture. Thirty participants, between one and ten years post injury, completed an in-depth, minimally structured interview in which they told their story of recovery. An inductive, thematic analysis was undertaken integrating Braun and Clarke (2006) and the four phase cyclical analysis of The Silences Framework (Serrant-Green, 2011). One cross-cutting theme: Communication emerged, together with four other main themes: Experience of care, Impact on self, Impact on others and Moving forward. 11 The findings indicated wide variation in the quality of care, often influenced by social and professional norms regarding hip fracture patient characteristics such as age and mode of injury. Multi-faceted, often long term, physical, social and psychological impact on participants, their family and wider social networks was also found. This included Post Traumatic Stress Disorder type symptoms and impact on work, finances and relationships. The study highlighted some limitations of the current hip fracture care pathway for supporting the specific recovery needs of young adults. It also identified some limited effectiveness of commonly used patient reported outcome measures for hip fracture in this young client group. Exploring the recovery experiences of this under-represented group confirmed, but also altered the silences initially identified. Furthermore, it uncovered new silences which informed recommendations for future research; healthcare practice and policy. This study offers the first long term exploration of the impact of isolated hip fracture following a minor fall in young adults from their perspective. In doing so, it has also demonstrated the appropriateness of The Silences Framework (Serrant-Green, 2011) for guiding a person-centred, experience-based, acute orthopaedic/rehabilitation study undertaken by a student researcher

Identity, positionality and reflexivity: relevance and application to research paramedics

This article introduces the reader to the concepts of identity, positionality and reflexivity and outlines their relevance to research paramedics. We outline how a researcher’s identity and positionality can influence all aspects of research, including the research question, study design, data collection and data analysis. We discuss that the ‘insider’ position of paramedics conducting research with other paramedics or within their specific clinical setting has considerable benefits to participant access, understanding of data and dissemination, while highlighting the difficulties of role duality and power dynamics. While positionality is concerned with the researcher clearly stating their assumptions relating to the research topic, the research design, context and process, as well as the research participants; reflexivity involves the researcher questioning their assumptions and finding strategies to address these. The researcher must reflect upon the way the research is carried out and explain to the reader how they moved through the research processes to reach certain conclusions, with the aim of producing a trustworthy and honest account of the research. Throughout this article, we provide examples of how these concepts have been considered and applied by a research paramedic while conducting their PhD research studies within a pre-hospital setting, to illustrate how they can be applied practically

The types and effects of feedback for emergency ambulance staff: a systematic mixed studies review and meta-analysis

Background: Extensive research has been conducted into the effects of feedback interventions within many areas of healthcare, but prehospital emergency care has been relatively neglected. Exploratory work suggests that enhancing feedback and follow-up to Emergency Medical Service (EMS) staff might provide staff with closure and improve clinical performance. Our aim was to summarise the literature on the types of feedback received by EMS professionals and its effects on the quality and safety of patient care, staff well-being and professional development. Methods: A systematic review and meta-analysis, including primary research studies of any method published in peer-reviewed journals. Studies were included if they contained information on systematic feedback to emergency ambulance staff regarding their performance. Databases searched from inception were MEDLINE, EMBASE, AMED, PsycInfo, HMIC, CINAHL and Web of Science, with searches last updated on 2nd August 2022. Study quality was appraised using the Mixed Methods Appraisal Tool. Data analysis followed a convergent integrated design involving simultaneous narrative synthesis and random-effects multilevel meta-analyses. Results: The search strategy yielded 3183 articles, with 48 studies meeting inclusion criteria after title/abstract screening and full-text review. Interventions were categorised as audit and feedback (n=31), peer-to-peer feedback (n=3), post-event debriefing (n=2), incident-prompted feedback (n=1), patient outcome feedback (n=1) or a combination thereof (n=4). Feedback was found to have a moderate positive effect on quality of care and professional development with a pooled effect of d=0.50 [95% CI 0.34, 0.67]. Feedback to EMS professionals had large effects in improving documentation (d=0.73 [0.00, 1.45]) and protocol adherence (d=0.68 [0.12, 1.24], as well as small effects in enhancing cardiac arrest performance (d=0.46 [0.06, 0.86]), clinical decision-making (d=0.47 [0.23, 0.72]), ambulance times (d=0.43 [0.12, 0.74]) and survival rates (d=0.22 [0.11, 0.33]). The between-study heterogeneity variance was estimated at σ2=0.32 (95% CI 0.22, 0.50), with an I2 value of 99% (95% CI 98%, 99%), indicating substantial statistical heterogeneity. Conclusion: This review demonstrated that the evidence base currently does not support a clear single point estimate of the pooled effect of feedback to EMS staff as a single intervention type due to study heterogeneity. Further research is needed to provide guidance and frameworks supporting better design and evaluation of feedback interventions within EMS

The role of feedback and follow up in ambulance services: a qualitative interview study

Background: International studies have shown that the feedback that ambulance staff receive lacks structure, relevance, credibility and routine implementation (Cash, 2017; Morrison, 2017). Research from psychology and implementation science suggests that feedback can change professional behaviour, improve clinical outcomes and positively influence staff mental health (Ivers, 2012; Michie and Williams, 2003). The aim of this study was to explore the experience of ambulance staff regarding current feedback provision and their views on how feedback impacts on patient safety, staff wellbeing and professional development. Methods: A qualitative study conducted as part of a wider study of work-related wellbeing in ambulance staff. 25 semi-structured interviews with prehospital staff in a clinical role from a UK ambulance service sampled using theoretical sampling. Theoretically-informed thematic analysis using psychological theory linked to the self-motives framework for feedback-seeking behaviour. Results: Study participants viewed current feedback provision as inadequate and consistently expressed a desire for increased feedback. Participants raised concerns that inadequate feedback could negatively impact on patient safety by preventing learning from mistakes. Enhancing feedback provision was suggested to improve patient safety by supporting professional development and clinical decision-making, through facilitating reflection, knowledge acquisition and professional behaviour change. Similarly, participants thought that enhanced feedback could improve staff wellbeing by enabling closure and encouraging intra-professional dialogue and peer-support. The self-motives framework was useful in interpreting personal and professional motivators for feedback-seeking behaviour within the data. Conclusions: In accordance with previous research in this area, this study highlights prehospital clinicians’ strong desire for feedback. Furthermore, it suggests that enhancing prehospital feedback could improve patient safety by enriching clinical decision-making and supporting professional development, as well as promote staff wellbeing. Findings from this initial study will be used to guide a PhD programme to address this evidence gap

The evolution of non-small cell lung cancer metastases in TRACERx

Metastatic disease is responsible for the majority of cancer-related deaths1. We report the longitudinal evolutionary analysis of 126 non-small cell lung cancer (NSCLC) tumours from 421 prospectively recruited patients in TRACERx who developed metastatic disease, compared with a control cohort of 144 non-metastatic tumours. In 25% of cases, metastases diverged early, before the last clonal sweep in the primary tumour, and early divergence was enriched for patients who were smokers at the time of initial diagnosis. Simulations suggested that early metastatic divergence more frequently occurred at smaller tumour diameters (less than 8 mm). Single-region primary tumour sampling resulted in 83% of late divergence cases being misclassified as early, highlighting the importance of extensive primary tumour sampling. Polyclonal dissemination, which was associated with extrathoracic disease recurrence, was found in 32% of cases. Primary lymph node disease contributed to metastatic relapse in less than 20% of cases, representing a hallmark of metastatic potential rather than a route to subsequent recurrences/disease progression. Metastasis-seeding subclones exhibited subclonal expansions within primary tumours, probably reflecting positive selection. Our findings highlight the importance of selection in metastatic clone evolution within untreated primary tumours, the distinction between monoclonal versus polyclonal seeding in dictating site of recurrence, the limitations of current radiological screening approaches for early diverging tumours and the need to develop strategies to target metastasis-seeding subclones before relaps