Grace Lindsay

BACKGROUND: Emergency Nurse Practitioners (ENP) are increasingly managing minor injuries in Accident and Emergency departments across the United Kingdom. This study aimed to develop methods and tools that could be used to measure the quality of ENP-led care. These tools were then tested in a randomized controlled trial. METHODS: A convenience sample of 199 eligible patients, over 16 years old, and with specific minor injuries was randomized either to ENP-led care (n = 99) or Senior House Officer (SHO)-led care (n = 100) and were diagnosed, treated, referred or discharged by this lead clinician. Following treatment, patients were asked to complete a patient satisfaction questionnaire related to the consultation. Clinical documentation was assessed using a 'Documentation Audit Tool'. A follow-up questionnaire was sent to all patients at 1 month. Return visits to the department and missed injuries were monitored. RESULTS: Patients were satisfied with the level of care from both ENPs and SHOs. However, they reported that ENPs were easier to talk to (P = 0.009); gave them information on accident and illness prevention (P = 0.001); and gave them enough information on their injury (P = 0.007). Overall they were more satisfied with the treatment provided by ENPs than with that from SHOs (P < 0.001). ENPs' clinical documentation was of higher quality than SHOs (P < 0.001). No differences were found in recovery times, level of symptoms, time off work or unplanned follow-up between groups. Missed injuries were the same for both groups (n = 1 in each group). CONCLUSION: The study was sufficiently large to demonstrate higher levels of patient satisfaction and clinical documentation quality with ENP-led than SHO-led care. A larger study involving 769 patients in each arm would be required to detect a 2% difference in missed injury rates. The methods and tools used in this trial could be used in Accident and Emergency departments to measure the quality of ENP-led care.

We sought to understand the barriers and facilitators to participation in research from the perspectives of South Asian people with asthma. Eight focus groups were conducted in the preferred language of participants. Sampling was purposeful to ensure inclusion of males and females from differing ethnic, linguistic and religious backgrounds. The forming of trusting relationships was described as pivotal to the successful recruitment of minority ethnic groups into research; personalized approaches were likely to be better received than more impersonal written approaches. Notable barriers to participation included: the stigma of being labelled with asthma; concerns surrounding participation in pharmaceutical trials; major time or travel commitments and a failure to show respect by not making information available in minority ethnic languages. Flexibility, in terms of timing, location and respecting of cultural and religious sensitivities around gender segregation, together with the offer of incentives, were highlighted as key factors to promote participation. The barriers to recruitment are largely surmountable, but these will necessitate the use of resource intensive and more personalized approaches than are commonly employed for the White European origin population. Our proposed model to enhance recruitment is likely to have transferability beyond the field of asthma.

Coronary artery disease patients’ perception of their health and expectations of benefit following coronary artery bypass grafting This prospective descriptive study has analysed 214 patient interviews before and 1 year after coronary artery bypass grafting (CABG). The preoperative interview explored issues related to the impact of coronary artery disease upon health and expectations of benefit from the patients’ perspective. The postoperative interview examined patients’ accounts of the experience of operation and its impact on their health. A thematic analysis of the interview data was undertaken. The main factors relating to health status preoperatively were described in terms of ‘dependency’ on others and medication, and ‘impending doom’ of some major life threatening event. Benefits to health postoperatively were viewed in terms of ‘removal of a death sentence’ and ‘freedom of choice’. Expectations of benefit from operation were varied and included ‘freedom and independence’, ‘hope, chance and uncertainty’ and ‘addition of years to life and life to years’. Undergoing the operation was described by themes of the ‘enormity of the experience’ and ‘the importance of lay support’. These findings provide a greater understanding of the ‘lived experience’ of both coronary artery disease and undergoing coronary artery bypass grafting. Unrealistic expectations of the benefits of CABG highlights the need for improvement in the way patients are informed about risks and benefits of interventions. In addition, the views and insights suggest that CABG operation is regarded as a significant major life event; thus more information, advice and counselling might help support patients before, during and after surgery.

BACKGROUND: over the next 20 years it is anticipated that there will be a significant increase in those aged 75 and over, and a consequent increase in cardiovascular disease, cancer and chronic illness. As this shift takes effect, there will be an increased need for treatment strategies that are of known benefit to this age group and a consequent rise in demand for clinical trials that are conducted specifically with the older population. Because factors that motivate older individuals to participate in clinical trials may differ from those that influence younger adults, it is important to evaluate the strategies used to encourage recruitment and retention and to determine how appropriate these are. AIM: evaluation of the reasons why subjects agree to participate in a controlled clinical trial of vascular disease prevention and the strategies used to improve compliance and protocol adherence. SETTING: Scotland. SUBJECTS: 2,520 Prospective Study of Pravastatin in the Elderly at Risk participants, aged 70-82 with either pre-existing vascular disease or at least one major vascular risk factor (hypertension, cigarette smoking, or diabetes mellitus). DESIGN OF STUDY: two-stage iterative survey. Stage I was exploratory. RESULTS: curiosity, or an interest in finding out more about the study, 'a desire to support research', and anticipated personal benefits, such as health screening, were the most important motivators for generating initial interest in the trial. Ongoing health monitoring was the most important recruitment and retention motivator (P = 0.001). CONCLUSIONS: curiosity, self interest and altruism may act as motivators at different points in the study time-line. However, fostering positive relationships between staff and recruits, and keeping recruits informed about the progress of the study are likely to maximise the retention of older subjects to long-term trials.

BACKGROUND: Emerging evidence suggests that heart failure (HF) patients who have mild cognitive impairment (MCI) may experience greater difficulty with self-care. OBJECTIVE: This article reports a systematic review that addressed the objective "What is the evidence for an association between MCI and self-care, measured in 1 or more of the self-care domains related to HF, in adults who have a diagnosis of chronic HF?" METHOD: We adopted Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for the review and synthesis of quantitative research studies that formally measured both cognitive function and self-care in HF patients and sought to describe the relationship between these factors. RESULTS: Ninety-one potentially relevant studies were located; 10 studies (2006-2014) were included. Because of heterogeneity in the retrieved studies, meta-analysis was not possible. Narrative synthesis found growing evidence regarding the association between MCI and adverse effects on self-care in HF. Nine studies reported significant positive associations between MCI and self-care in HF, either specifically in relation to medication adherence or more generic measures of self-care activity. One study reported a significant, negative correlation between cognitive function and self-care, suggesting that worse cognitive function was associated with better self-care; however, this is partially explained by a small sample size and mixed methodology. CONCLUSIONS: These findings have implications for clinical practice. It is known that HF patients have difficulty with self-care, and the influence of cognitive function needs to be considered when providing professional support. Further research to determine the feasibility and acceptability of cognitive assessment in routine clinical care is recommended.