How can pain management in the emergency department be improved? Findings from multiple case study analysis of pain management in three UK emergency departments

Introduction: Inadequate pain management in EDs is a worldwide problem, yet there has been little progress in understanding how pain management can be improved. There is only weak evidence and limited rationale to support interventions to improve pain management. We used naturalistic, qualitative methods to understand the factors that influence how pain is managed within the adult ED. Methods: We used a multiple case study design incorporating 143-hour non-participant observation, documentary analysis and semistructured interviews with 37 staff and 19 patients at three EDs in the North of England between 2014 and 2016. We analysed data using thematic analysis. Results: Our analysis demonstrated that pain management was not well aligned with the core priorities of the ED and was overlooked when other works took priority. We identified that (1) pain management was not perceived to be a key organisational priority for which staff were held accountable and staff had limited awareness of their performance, (2) pain management was not a core component of ED education and training, (3) ED processes and structures were not aligned with pain management and pain reassessment was overlooked unless staff escalated pain management outside of normal processes and (4) staff held embedded beliefs that conceptualised pain management as distinct from core priorities and limited their capacity to improve. However, EDs were able to improve pain management by aligning processes of pain management with other core works, particularly patient flow (eg, nurse-initiated analgesia at triage). Implications: EDs may be able to improve pain management by ensuring pain management processes align with key ED priorities. Undertaking multifaceted changes to structures and processes may enable staff to improve pain management and develop a culture in which pain management can be prioritised more easily. Future interventions need to be compatible with the wider work of the ED and enable patient flow in order to be adopted and maintained

On the solution of multi-body wave energy converter motions using pseudo-spectral methods

Multi-body wave energy converters are composed of several bodies interconnected by joints. Two different formulations are adopted to describe the dynamics of multi-body systems: the Differential and Algebraic Equations (DAEs) formulation and the Ordinary Differential Equations (ODEs) formulation. While the number of variables required for the description of the dynamics of a multi-body system is greater in the DAE formulation than in the ODE formulation, the ODE formulation involves an extra computational effort in order to describe the dynamics of the system with a smaller number of variables. In this paper, pseudo-spectral methods are applied in order to solve the dynamics of multi-body wave energy converters using both DAE and ODE formulations. Apart from providing a solution to the dynamics of multi-body systems, pseudo-spectral methods provide an accurate and efficient formulation for the control of multi-body wave energy converters. As an application example, this paper focuses on the dynamic modeling of a twobody hinge-barge device. Wave-tank tests were carried out on the device in order to validate the DAE and ODE formulation against experimental data. The comparison between pseudospectral methods and a method based on the integration of the equations of motion, e.g. the Runge-Kutta method, showed that pseudo-spectral methods are computationally more stable and they require a less computational effort for short time steps

On the solution of multi-body wave energy converter motions using pseudo-spectral methods

Multi-body wave energy converters are composed of several bodies interconnected by joints. Two different formulations are adopted to describe the dynamics of multi-body systems: the Differential and Algebraic Equations (DAEs) formulation and the Ordinary Differential Equations (ODEs) formulation. While the number of variables required for the description of the dynamics of a multi-body system is greater in the DAE formulation than in the ODE formulation, the ODE formulation involves an extra computational effort in order to describe the dynamics of the system with a smaller number of variables. In this paper, pseudo-spectral methods are applied in order to solve the dynamics of multi-body wave energy converters using both DAE and ODE formulations. Apart from providing a solution to the dynamics of multi-body systems, pseudo-spectral methods provide an accurate and efficient formulation for the control of multi-body wave energy converters. As an application example, this paper focuses on the dynamic modeling of a twobody hinge-barge device. Wave-tank tests were carried out on the device in order to validate the DAE and ODE formulation against experimental data. The comparison between pseudospectral methods and a method based on the integration of the equations of motion, e.g. the Runge-Kutta method, showed that pseudo-spectral methods are computationally more stable and they require a less computational effort for short time steps

The Mixed Methods Appraisal Tool (MMAT) version 2018 for information professionals and researchers

INTRODUCTION: Appraising the quality of studies included in systematic reviews combining qualitative and quantitative evidence is challenging. To address this challenge, a critical appraisal tool was developed: the Mixed Methods Appraisal Tool (MMAT). The aim of this paper is to present the enhancements made to the MMAT. DEVELOPMENT: The MMAT was initially developed in 2006 based on a literature review on systematic reviews combining qualitative and quantitative evidence. It was subject to pilot and interrater reliability testing. A revised version of the MMAT was developed in 2018 based on the results from usefulness testing, a literature review on critical appraisal tools and a modified e-Delphi study with methodological experts to identify core criteria. TOOL DESCRIPTION: The MMAT assesses the quality of qualitative, quantitative, and mixed methods studies. It focuses on methodological criteria and includes five core quality criteria for each of the following five categories of study designs: (a) qualitative, (b) randomized controlled, (c) nonrandomized, (d) quantitative descriptive, and (e) mixed methods. CONCLUSION: The MMAT is a unique tool that can be used to appraise the quality of different study designs. Also, by limiting to core criteria, the MMAT can provide a more efficient appraisal

Socioeconomic disparities in access to intensive insulin regimens for adults with type 1 diabetes : a qualitative study of patient and healthcare professional perspectives

Background Type 1 diabetes is a complex chronic condition which requires lifelong treatment with insulin. Health outcomes are dependent on ability to self-manage the condition. Socioeconomic inequalities have been demonstrated in access to treatment and health outcomes for adults with type 1 diabetes; however, there is a paucity of research exploring how these disparities occur. This study explores the influence of socioeconomic factors in gaining access to intensive insulin regimens for adults with type 1 diabetes. Methods We undertook a qualitative descriptive study informed by a phenomenological perspective. In-depth face-to-face interviews were conducted with 28 patients and 6 healthcare professionals involved in their care. The interviews were analysed using a thematic approach. The Candidacy theory for access to healthcare for vulnerable groups framed the analysis. Results Access to intensive insulin regimens was through hospital-based specialist services in this sample. Patients from lower socioeconomic groups had difficulty accessing hospital-based services if they were in low paid work and because they lacked the ability to navigate the healthcare system. Once these patients were in the specialist system, access to intensive insulin regimens was limited by non-alignment with healthcare professional goals, poor health literacy, psychosocial problems and poor quality communication. These factors could also affect access to structured diabetes education which itself improved access to intensive insulin regimens. Contact with diabetes specialist nurses and attendance at structured diabetes education courses could ameliorate these barriers. Conclusions Access to intensive insulin regimens was hindered for people in lower socioeconomic groups by a complex mix of factors relating to the permeability of specialist services, ability to navigate the healthcare system and patient interactions with healthcare providers. Improving access to diabetes specialist nurses and structured diabetes education for vulnerable patients could lessen socioeconomic disparities in both access to services and health outcomes

Health literacy levels of British adults: a cross-sectional survey using two domains of the Health Literacy Questionnaire (HLQ)

Background A person’s health literacy determines whether they are able to make appropriate health decisions and are able to follow treatment instructions. This is important because low health literacy is associated with mortality and extra costs to the healthcare system. Our aim was to describe the health literacy levels of British adults using a nationally representative population survey, and show how health literacy levels vary by population characteristics. Methods A population based cross-sectional survey including questions from two domains from the Health Literacy Questionnaire™: 1) Understanding health information well enough to know what to do, and 2) Ability to actively engage with health care providers. Both domains are made up of 5 Likert style questions with 5 levels ranging from ‘cannot do or always difficult’ (1) to ‘always easy’ (5). The survey was conducted by NatCen in Britain (2018) as part of the annual British Social Attitudes survey. We used weighted descriptive analyses and regression to explore the relationship between population characteristics and health literacy. Weighted analyses were used to ensure the sample was representative of the British population. Results A total of 2309 responded to the questionnaire. The mean score for ‘understanding information’ was 3.98 (95% CI: 3.94, 4.02) and for ‘ability to engage’ was 3.83 (95% CI: 3.80, 3.87), where 5 is the highest score. 19.4% had some level of difficulty reading and understanding written health information, and 23.2% discussing health concerns with health care providers. The adjusted logistic regression for ‘understanding information’ showed that those with lower health literacy were more likely to be in the most socially deprived quintile (OR 2.500 95% CI: 1.180, 5.296), have a limiting health condition or disability (OR 4.326 95% CI: 2.494, 7.704), and have no educational qualifications (OR 7.588 95% CI: 3.305, 17.422). This was similar for the ‘ability to engage’ domain. Conclusions This study described the distribution of health literacy levels for the British population in 2018. Interventions to improve health literacy will best be targeted at those with lower levels of education, those living in the most deprived areas, and those with a limiting health condition or disability

The role of qualitative research in adding value to a randomised controlled trial: lessons from a pilot study of a guided e-learning intervention for managers to improve employee wellbeing and reduce sickness absence

The GEM study was funded by the National Institute for Health Research Public Health Research Programme (project number 10/3007/06)

Maximising the impact of qualitative research in feasibility studies for randomised controlled trials: guidance for researchers

Feasibility studies are increasingly undertaken in preparation for randomised controlled trials in order to explore uncertainties and enable trialists to optimise the intervention or the conduct of the trial. Qualitative research can be used to examine and address key uncertainties prior to a full trial. We present guidance that researchers, research funders and reviewers may wish to consider when assessing or undertaking qualitative research within feasibility studies for randomised controlled trials. The guidance consists of 16 items within five domains: research questions, data collection, analysis, teamwork and reporting. Appropriate and well conducted qualitative research can make an important contribution to feasibility studies for randomised controlled trials. This guidance may help researchers to consider the full range of contributions that qualitative research can make in relation to their particular trial. The guidance may also help researchers and others to reflect on the utility of such qualitative research in practice, so that trial teams can decide when and how best to use these approaches in future studies