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Bridgewater S, Ndosi M, Dawson J, Richards P, Silverthorne C, Dures E, Goodman SM, Hill C, Mackie SL, Robson JC. Validation of a new glucocorticoid-specific Patient-Reported Outcome Questionnaire (the Steroid PRO). Ann Rheum Dis 2024; 83:394-400. [PMID: 37949468 PMCID: PMC10894813 DOI: 10.1136/ard-2023-224946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 10/24/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVES Glucocorticoids used in the treatment of inflammatory rheumatic conditions can impact on health-related quality of life. An underpinning qualitative study developed a long-list of candidate items for a treatment-specific patient-reported outcome (PRO) measure. The objective of this paper is to determine scale structure and psychometric properties of the Steroid PRO. METHODS A cross-sectional survey of adults from the UK, USA, Australia and New Zealand, taking glucocorticoids for a rheumatic disease. Initial survey collected demographics, clinical information, 40 Steroid PRO candidate items and EuroQol-5 Dimensions- 5 levels (EQ-5D-5L). Follow-up, 3-5 days later, collected Steroid PRO candidate items and a condition-change ('transition') question. Analysis included Rasch measurement model, exploratory factor analysis (EFA), and hypothesis testing for discriminative validity, convergence validity and test-retest reliability. RESULTS Total responses 946: UK n=743 (79%); USA n=139 (15%); Australia/New Zealand n=64 (7%); mean age 57.6 (SD=13.6); 833 (88%) women. Participants with inflammatory arthritis n=197 (21%), connective tissue disease and/or vasculitis n=402 (42%), giant cell arteritis and/or polymyalgia rheumatica n=347 (37%). Twenty-five items were removed due to lack of fit to Rasch model. Of the remaining items, EFA suggested four subscales: Social impact (4 items); Impact on appearance (3 items); Psychological impact (5 items); Treatment concerns (3 items). Rasch modelling supported a four-subscale structure and total score, confirming construct validity and reliability. Hypothesis testing confirmed discriminant and convergence validity. Intraclass correlation coefficient (total score) was 0.809 demonstrating excellent (test-retest) reliability. CONCLUSIONS The Steroid PRO is a 15-item, valid and reliable scale for measuring the impact of glucocorticoid therapy in people with rheumatic diseases.
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Affiliation(s)
- Susan Bridgewater
- School of Health and Social Wellbeing, University of the West of England, Bristol, UK
- Rheumatology Department, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Mwidimi Ndosi
- School of Health and Social Wellbeing, University of the West of England, Bristol, UK
- Rheumatology Department, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Jill Dawson
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Pamela Richards
- School of Health and Social Wellbeing, University of the West of England, Bristol, UK
- Rheumatology Department, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Christine Silverthorne
- School of Health and Social Wellbeing, University of the West of England, Bristol, UK
- Rheumatology Department, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Emma Dures
- School of Health and Social Wellbeing, University of the West of England, Bristol, UK
- Rheumatology Department, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Susan M Goodman
- Rheumatology Department, Hospital for Special Surgery, New York, New York, USA
| | - Catherine Hill
- Rheumatology Department, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Sarah L Mackie
- Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Joanna C Robson
- School of Health and Social Wellbeing, University of the West of England, Bristol, UK
- Rheumatology Department, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
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Lyne SA, Yip K, Vasiliou VS, Katz DA, Richards P, Tieu J, Black RJ, Bridgewater S, Palmowski A, Beaton D, Maxwell LJ, Robson JC, Mackie SL, Goodman SM, Hill CL. Consensus of the definitions of the OMERACT glucocorticoid impact core domain set for people with rheumatic and musculoskeletal diseases. Semin Arthritis Rheum 2024; 64:152338. [PMID: 38134623 DOI: 10.1016/j.semarthrit.2023.152338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/21/2023] [Accepted: 11/28/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND The Outcome Measures in Rheumatology (OMERACT) Glucocorticoid (GC) Impact Working Group has been working to develop a core domain set to measure the impact of GCs on patients living with rheumatic and musculoskeletal diseases. The mandatory domains previously identified for inclusion in all clinical trials measuring the GC effects include infection, bone fragility, mood disturbance, hypertension, diabetes, weight, fatigue, and mortality. Before progressing to instrument selection, the Working Group sought to establish precise definitions of all mandatory domains within the core domain set. METHODS OMERACT methodology was applied with the use of evidence and consensus-based decision making of all stakeholder groups (patient research partners, health care professionals, clinician researchers, industry members and methodologists) to develop detailed definitions for the broad domain, target domain and domain components, taking into consideration sources of variability that could affect measurement of the domain. The working group synthesized prior qualitative studies, quantitative work, and results from Delphi rounds, to develop a rich definition of 'what' is to be measured. RESULTS Between 2021 and 2023, the OMERACT Working Group on GC Impact conducted virtual meetings to establish domain definitions. First, we mapped each domain onto an OMERACT Core Area. All domains were primarily represented within the Pathophysiological Manifestations Core Area, except from Fatigue which was primarily Life Impact and Weight which spanned both Core Areas. Sources of variability included cultural factors, age, gender, education level, socioeconomic status, personal experiences, emotional state, and language barriers. The domain definitions will form the foundation for instrument selection and the initial step of domain / concept match and content validity in the OMERACT pillar of 'truth' before moving on to feasibility and discrimination. CONCLUSION The OMERACT GC Impact Working Group has developed and agreed upon detailed domain definitions for core domains. Future steps of the working group are to select instruments and develop the core outcome measurement set for clinical trials measuring the impact of GC on patients with rheumatic and musculoskeletal diseases.
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Affiliation(s)
- Suellen A Lyne
- Rheumatology Unit, The Queen Elizabeth Hospital, Adelaide, Australia; Adelaide Medical School, The University of Adelaide, Adelaide, Australia
| | - Kevin Yip
- Division of Rheumatology, Hospital for Special Surgery, New York, NY, USA
| | | | | | | | - Joanna Tieu
- Rheumatology Unit, The Queen Elizabeth Hospital, Adelaide, Australia; Adelaide Medical School, The University of Adelaide, Adelaide, Australia
| | - Rachel J Black
- Rheumatology Unit, The Queen Elizabeth Hospital, Adelaide, Australia; Adelaide Medical School, The University of Adelaide, Adelaide, Australia
| | - Susan Bridgewater
- Rheumatology Research, Centre for Health and Clinical Research, University of the West of England, Bristol, UK
| | - Andriko Palmowski
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Germany; Section for Biostatistics and Evidence-based Research, the Parker Institute, Frederiksberg and Bispebjerg Hospital, University of Copenhagen, Frederiksberg, Denmark
| | - Dorcas Beaton
- Institute for Work & Health, University of Toronto, Canada
| | - Lara J Maxwell
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Joanna C Robson
- Rheumatology Research, Centre for Health and Clinical Research, University of the West of England, Bristol, UK; Rheumatology Department, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Sarah L Mackie
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Susan M Goodman
- Division of Rheumatology, Hospital for Special Surgery, New York, NY, USA
| | - Catherine L Hill
- Rheumatology Unit, The Queen Elizabeth Hospital, Adelaide, Australia; Adelaide Medical School, The University of Adelaide, Adelaide, Australia.
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Bridgewater S, Shepherd MA, Dawson J, Richards P, Silverthorne C, Ndosi M, Almeida C, Black RJ, Cheah JTL, Dures E, Ghosh N, Hoon EA, Lyne S, Navarro-Millan I, Pearce-Fisher D, Ruediger C, Tieu J, Yip K, Mackie SL, Goodman S, Hill C, Robson JC. Measuring the impact of steroid therapy on health-related quality of life in patients with rheumatic diseases: international development of a glucocorticoid treatment-specific patient-reported outcome measure. Rheumatology (Oxford) 2023; 62:3565-3575. [PMID: 36840642 PMCID: PMC10629780 DOI: 10.1093/rheumatology/kead081] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 02/01/2023] [Accepted: 02/07/2023] [Indexed: 02/26/2023] Open
Abstract
OBJECTIVES Glucocorticoids (GCs) ('steroids') are used to treat rheumatic diseases but adverse effects are common. We aimed to explore the impact of GC therapy on health-related quality of life (HRQoL), to inform the development of a treatment-specific patient-reported outcome measure (PROM) for use in clinical trials and practice. METHODS Semi-structured qualitative interviews were conducted with patients from the UK, USA and Australia, treated for a rheumatic condition with GCs in the last 2 years. Purposive sampling was used to select participants with a range of demographic and disease features. An initial conceptual framework informed interview prompts and cues. Interviews elicited GC-related physical and psychological symptoms and salient aspects of HRQoL in relation to GC therapy. Interview data were analysed inductively to develop initial individual themes and domains. Candidate questionnaire items were developed and refined. RESULTS Sixty semi-structured qualitative interviews were conducted (UK n = 34, USA n = 10, Australia n = 16). The mean age was 58 years; 39/60 were female; and 18 rheumatic diseases were represented. Some 126 individual themes were identified and organized into six domains: physical symptoms; psychological symptoms; psychological impact of steroids; impact of steroids on participation; impact of steroids on relationships; and benefits of steroids. Candidate questionnaire items were tested and refined by piloting with patient research partners, iterative rounds of cognitive interviews and linguistic translatability assessment, informing a draft questionnaire. CONCLUSION We describe an international qualitative study to develop candidate items for a treatment-specific PROM for patients with rheumatic diseases. A future survey will enable the validation of a final version of the PROM.
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Affiliation(s)
- Susan Bridgewater
- Faculty of Health and Applied Sciences, School of Health and Social Wellbeing, University of the West of England—UWE Bristol, Bristol, UK
- Academic Rheumatology Department, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Michael A Shepherd
- Faculty of Health and Applied Sciences, School of Health and Social Wellbeing, University of the West of England—UWE Bristol, Bristol, UK
- Academic Rheumatology Department, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Jill Dawson
- Department of Population Health (HSRU), University of Oxford, Oxford, UK
| | - Pamela Richards
- Academic Rheumatology Department, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Christine Silverthorne
- Faculty of Health and Applied Sciences, School of Health and Social Wellbeing, University of the West of England—UWE Bristol, Bristol, UK
- Academic Rheumatology Department, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Mwidimi Ndosi
- Faculty of Health and Applied Sciences, School of Health and Social Wellbeing, University of the West of England—UWE Bristol, Bristol, UK
- Academic Rheumatology Department, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Celia Almeida
- Faculty of Health and Applied Sciences, School of Health and Social Wellbeing, University of the West of England—UWE Bristol, Bristol, UK
- Academic Rheumatology Department, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Rachel J Black
- Discipline of Medicine, The University of Adelaide, Adelaide, Australia
- Rheumatology Department, Royal Adelaide Hospital, Adelaide, Australia
- Department of Rheumatology, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Jonathan T L Cheah
- Department of Medicine, Division of Rheumatology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Emma Dures
- Faculty of Health and Applied Sciences, School of Health and Social Wellbeing, University of the West of England—UWE Bristol, Bristol, UK
- Academic Rheumatology Department, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Nilasha Ghosh
- Division of Rheumatology, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Elizabeth A Hoon
- Discipline of General Practice, The University of Adelaide, Adelaide, Australia
- School of Public Health, The University of Adelaide, Adelaide, Australia
| | - Suellen Lyne
- Discipline of Medicine, The University of Adelaide, Adelaide, Australia
- Department of Rheumatology, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Iris Navarro-Millan
- Department of Medicine, Division of Rheumatology, University of Massachusetts Medical School, Worcester, MA, USA
- Division of General Internal Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Diyu Pearce-Fisher
- Division of Rheumatology, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Carlee Ruediger
- Department of Rheumatology, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Joanna Tieu
- Department of Rheumatology, The Queen Elizabeth Hospital, Adelaide, Australia
- Rheumatology Unit, Lyell McEwin Hospital, Adelaide, Australia
| | - Kevin Yip
- Division of Rheumatology, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Sarah L Mackie
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Susan Goodman
- Division of Rheumatology, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Catherine Hill
- Discipline of Medicine, The University of Adelaide, Adelaide, Australia
- Rheumatology Department, Royal Adelaide Hospital, Adelaide, Australia
- Department of Rheumatology, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Joanna C Robson
- Faculty of Health and Applied Sciences, School of Health and Social Wellbeing, University of the West of England—UWE Bristol, Bristol, UK
- Academic Rheumatology Department, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
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Dures E, Bridgewater S, Abbott B, Adams J, Berry A, McCracken LM, Creanor S, Hewlett S, Lomax J, Ndosi M, Thorn J, Urban M, Ewings P. Brief intervention to reduce fatigue impact in patients with inflammatory arthritis: design and outcomes of a single-arm feasibility study. BMJ Open 2022; 12:e054627. [PMID: 35851019 PMCID: PMC9297231 DOI: 10.1136/bmjopen-2021-054627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES Patients with inflammatory arthritis report that fatigue is challenging to manage. We developed a manualised, one-to-one, cognitive-behavioural intervention, delivered by rheumatology health professionals (RHPs). The Fatigue - Reducing its Effects through individualised support Episodes in Inflammatory Arthritis (FREE-IA) study tested the feasibility of RHP training, intervention delivery and outcome collection ahead of a potential trial of clinical and cost-effectiveness. METHODS In this single-arm feasibility study, eligible patients were ≥18 years, had a clinician-confirmed diagnosis of an inflammatory arthritis and scored ≥6/10 on the Bristol Rheumatoid Arthritis Fatigue (BRAF) Numerical Rating Scale (NRS) Fatigue Effect. Following training, RHPs delivered two to four sessions to participants. Baseline data were collected before the first session (T0) and outcomes at 6 weeks (T1) and 6 months (T2). The proposed primary outcome was fatigue impact (BRAF NRS Fatigue Effect). Secondary outcomes included fatigue severity and coping, disease impact and disability, and measures of therapeutic mechanism (self-efficacy and confidence to manage health). RESULTS Eight RHPs at five hospitals delivered 113 sessions to 46 participants. Of a potential 138 primary and secondary outcome responses at T0, T1 and T2, there were 13 (9.4%) and 27 (19.6%) missing primary and secondary outcome responses, respectively. Results indicated improvements in all measures except disability, at either T1 or T2, or both. CONCLUSIONS This study showed it was feasible to deliver the intervention, including training RHPs, and recruit and follow-up participants with high retention. While there was no control group, observed within-group improvements suggest potential promise of the intervention and support for a definitive trial to test effectiveness.
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Affiliation(s)
- Emma Dures
- Academic Rheumatology, Bristol Royal Infirmary, Bristol, UK
- School of Health and Social Wellbeing, University of the West of England, Bristol, UK
| | - Susan Bridgewater
- Academic Rheumatology, Bristol Royal Infirmary, Bristol, UK
- School of Health and Social Wellbeing, University of the West of England, Bristol, UK
| | - Bryan Abbott
- Academic Rheumatology, Bristol Royal Infirmary, Bristol, UK
| | - Jo Adams
- Health Sciences, University of Southampton, Southampton, UK
| | - Alice Berry
- Academic Rheumatology, Bristol Royal Infirmary, Bristol, UK
- School of Health and Social Wellbeing, University of the West of England, Bristol, UK
| | - Lance M McCracken
- Division of Clinical Psychology, Uppsala University, Uppsala, Sweden
| | - Siobhan Creanor
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Sarah Hewlett
- School of Health and Social Wellbeing, University of the West of England, Bristol, UK
| | - Joe Lomax
- Peninsula Medical School, Plymouth University, Plymouth, UK
| | - Mwidimi Ndosi
- Academic Rheumatology, Bristol Royal Infirmary, Bristol, UK
- School of Health and Social Wellbeing, University of the West of England, Bristol, UK
| | - Joanna Thorn
- Bristol Population Health Science Institute, University of Bristol, Bristol, UK
| | - Marie Urban
- Academic Rheumatology, Bristol Royal Infirmary, Bristol, UK
| | - Paul Ewings
- Taunton and Somerset NHS Foundation Trust, Taunton, UK
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Bridgewater S, Shepherd MA, Dawson J, Richards P, Silverthorne C, Ndosi M, Almeida C, Black RJ, Cheah JTL, Dures E, Ghosh N, Hoon EA, Lyne S, Navarro-Millan I, Pearce-Fisher D, Ruediger C, Tieu J, Yip K, Mackie S, Goodman S, Hill C, Robson J. POS0040-HPR PATIENT PERCEPTIONS OF IMPACT OF GLUCOCORTICOID THERAPY IN THE RHEUMATIC DISEASES: INTERNATIONAL DEVELOPMENT OF A TREATMENT-SPECIFIC PATIENT REPORTED OUTCOME MEASURE. Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.1479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BackgroundGlucocorticoids (GCs) are a key treatment for inflammatory rheumatic diseases, but they cause a wide range of adverse side-effects which are of concern both to patients and clinicians.ObjectivesThe objective of this study was to explore the impact of GC therapy on health-related quality of life (HRQoL) during treatment for rheumatic diseases, as a basis for development of a Patient-Reported Outcome Measure (PROM) to be used in clinical trials and practice.MethodsPatients from the UK, USA and Australia who were treated with GCs in the last two years for a rheumatic condition were invited to take part in semi-structured qualitative interviews. Purposive sampling was used to include participants with a range of demographic and disease features. A steering committee of patient research partners, clinicians and methodologists devised an initial conceptual framework, which informed interview prompts and cues. Interviews were carried out by experienced qualitative researchers who encouraged participants to tell their stories and talk about the effects, both adverse and beneficial, of their experiences and perceptions of treatment with GCs, to identify salient physical and psychological symptoms and aspects of HRQoL. The interview data were organised using NVivo, and inductive analysis identified initial themes and domains. Candidate questionnaire items were developed and refined using cognitive interviewing, linguistic assessment, and input from patient research partners.ResultsSixty semi-structured qualitative interviews were conducted (UK n=34, USA n=10, Australia n=16). Mean participant age was 58 years; 39 (66.1%) were female. Purposive sampling of participants provided a broad range of demographic features, GC dosages and inflammatory rheumatic conditions, with 27% having connective tissue disease, 25% inflammatory arthritis, 30% systemic vasculitis and 16% other rheumatic conditions.Initial domains were developed to identify key themes relating to treatment using GCs and their impact on HRQoL; see Figure 1.Figure 1.Steroid PRO Initial ThemesA long-list of 134 initial candidate questionnaire items was developed from the individual themes. These items were reviewed by a qualitative working group of patient research partners, researchers and clinicians to reduce duplication and ambiguity of items. The resulting 62 items were tested and refined by piloting with patient research partners, iterative rounds of cognitive interviews with patients with a range of rheumatic conditions from the UK, USA and Australia, and a linguistic translatability assessment, to define a draft questionnaire of 40 items.ConclusionThis international qualitative study underpins the development of candidate items for a treatment-specific PROM for patients with rheumatic diseases. The draft questionnaire is currently being tested in an online large-scale survey to determine the final scale structure and measurement properties using Rasch analysis, factor analysis, test-retest, comparison with EQ5D, and known groups analysis.Disclosure of InterestsSusan Bridgewater Grant/research support from: Vifor Pharma, Michael A Shepherd Grant/research support from: Vifor Pharma, Jill Dawson: None declared, Pamela Richards: None declared, Christine Silverthorne: None declared, Mwidimi Ndosi: None declared, Celia Almeida: None declared, Rachel J Black: None declared, Jonathan T.L. Cheah: None declared, Emma Dures: None declared, Nilasha Ghosh: None declared, Elizabeth A Hoon: None declared, Suellen Lyne: None declared, Iris Navarro-Millan Consultant of: Honorarium on Swedish Orpham Biovitrum (SOBI) advisory board 2021, Diyu Pearce-Fisher: None declared, Carlee Ruediger: None declared, Joanna Tieu: None declared, Kevin Yip: None declared, Sarah Mackie: None declared, Susan Goodman: None declared, Catherine Hill: None declared, Joanna Robson Speakers bureau: EULAR Symposium 2021 for Vifor Pharma, Consultant of: Honorarium for Vifor Pharma advisory board 2021, Grant/research support from: Vifor Pharma 2020-2022
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Berry A, Bridgewater S, Abbott B, Adams J, Dures E. Acceptability of a brief fatigue intervention for inflammatory arthritis: a qualitative process evaluation. Rheumatol Adv Pract 2022; 6:rkac064. [PMID: 36042875 PMCID: PMC9415192 DOI: 10.1093/rap/rkac064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 07/15/2022] [Indexed: 11/29/2022] Open
Abstract
Objectives We developed a brief cognitive behavioural, one-to-one intervention to reduce fatigue impact for patients with inflammatory arthritis. This qualitative process evaluation explored intervention acceptability and potential refinements from the perspective of patients who attended sessions and rheumatology health professionals (RHPs) who delivered the intervention. Methods Interviews were conducted with patients and RHPs from five National Health Service (NHS) sites. Data were analysed using inductive thematic analysis. Results Twenty-two patients and 11 RHPs participated. Patient themes Collaborative, non-judgemental consultations: patients valued having space to reflect, where their fatigue was validated. Relevant content, but not ground-breaking: patients appreciated the opportunity to tailor content to individual priorities. Daily diaries were useful to visualize fatigue. Self-awareness: patients reported increased acceptance, sense of control, and confidence to manage fatigue. Degrees of openness to change: sessions prompted patients to engage in behaviour change. For some, complicated lives made it difficult to plan for change. RHP themes Engagement with intervention: RHPs liked training face to face, and sessions were more enjoyable with experience of delivery. Research vs clinical practice: RHPs expressed concern about fitting sessions into NHS clinic appointments. It was difficult to offer follow-up sessions within 2 weeks. Collaborating with patients: RHPs reported that patients engaged with the tools and strategies. Some RHPs followed the manual in a linear way, whereas others used it flexibly. Conclusion There is potential for this brief fatigue intervention to benefit patients. Future research will focus on flexibility to fit with local services and creating educational resources to use in a range of contexts.
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Affiliation(s)
- Alice Berry
- School of Health and Social Wellbeing, Faculty of Health and Applied Sciences, University of the West of England
- Academic Rheumatology, University Hospitals Bristol and Weston NHS Foundation Trust , Bristol
| | - Susan Bridgewater
- School of Health and Social Wellbeing, Faculty of Health and Applied Sciences, University of the West of England
- Academic Rheumatology, University Hospitals Bristol and Weston NHS Foundation Trust , Bristol
| | - Bryan Abbott
- Academic Rheumatology, University Hospitals Bristol and Weston NHS Foundation Trust , Bristol
| | - Jo Adams
- Health Sciences, University of Southampton , Southampton, UK
| | - Emma Dures
- School of Health and Social Wellbeing, Faculty of Health and Applied Sciences, University of the West of England
- Academic Rheumatology, University Hospitals Bristol and Weston NHS Foundation Trust , Bristol
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Bridgewater S, Shepherd MA, Dawson J, Richards P, Silverthorne C, Ndosi M, Almeida C, Black RJ, Cheah JTL, Dures E, Ghosh N, Hoon EA, Lyne S, Navarro-Millan I, Pearce-Fisher D, Ruediger C, Tieu J, Yip K, Mackie S, Goodman S, Hill C, Robson JC. P092 Patients’ perceptions of glucocorticoid therapy impact on health-related quality of life during treatment for rheumatic diseases: international development of a treatment-specific patient-reported outcome measure (the Steroid PRO). Rheumatology (Oxford) 2022. [DOI: 10.1093/rheumatology/keac133.091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background/Aims
Glucocorticoids (GCs) are widely used to treat inflammatory rheumatic diseases. GCs carry a range of adverse effects of concern to patients and clinicians. The objective of this study was to explore the impact of GC therapy on health-related quality of life (HRQoL) during treatment for rheumatic diseases, as a basis for development of a patient-reported outcome measure (PROM) to be used in clinical trials and practice.
Methods
Patients from the UK, USA and Australia who were treated with GCs in the last two years for a rheumatic condition were invited to take part in semi-structured qualitative interviews. A steering committee of patient research partners, clinicians and methodologists devised an initial conceptual framework, which informed interview prompts and cues. Interviews identified physical and psychological symptoms and salient aspects of HRQoL in relation to treatment with GCs. Purposive sampling was used to include a range of demographic and disease features. The interview data were organised using NVivo, and inductive analysis identified initial themes and domains. Candidate questionnaire items were developed and refined using cognitive interviewing, linguistic assessment, and input from patient research partners.
Results
Sixty semi-structured qualitative interviews were conducted (UK n = 34, USA n = 10, Australia n = 16). Mean participant age was 58 years; 39 (66.1%) were female. Detailed demographic and GC use information is provided in Table 1.
The following initial domains were developed to identify key themes relating to treatment using GCs and their impact on HRQoL: benefits of steroids; physical symptoms; psychological symptoms; psychological impact of steroids; impact of steroids on participation and on relationships.
Forty-one candidate questionnaire items were developed from the individual themes. These were tested and refined by piloting with patient research partners, iterative rounds of cognitive interviews with patients with a range of rheumatic conditions from the UK, USA and Australia, and a linguistic translatability assessment, to define a draft questionnaire.
Conclusion
This international qualitative study underpins the development of candidate items for a treatment-specific PROM for patients with rheumatic diseases. The draft questionnaire is now ready for testing in an online large-scale survey to determine the final scale structure, possible item reduction, and measurement properties.
Disclosure
S. Bridgewater: None. M.A. Shepherd: None. J. Dawson: None. P. Richards: None. C. Silverthorne: None. M. Ndosi: None. C. Almeida: None. R.J. Black: None. J.T.L. Cheah: None. E. Dures: None. N. Ghosh: None. E.A. Hoon: None. S. Lyne: None. I. Navarro-Millan: None. D. Pearce-Fisher: None. C. Ruediger: None. J. Tieu: None. K. Yip: None. S. Mackie: None. S. Goodman: None. C. Hill: None. J.C. Robson: None.
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Affiliation(s)
- Susan Bridgewater
- Faculty of Health and Applied Sciences, University of the West of England - UWE Bristol, Bristol, UNITED KINGDOM
- Academic Rheumatology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UNITED KINGDOM
| | - Michael A Shepherd
- Faculty of Health and Applied Sciences, University of the West of England - UWE Bristol, Bristol, UNITED KINGDOM
- Academic Rheumatology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UNITED KINGDOM
| | - Jill Dawson
- Nuffield Department of Population Health, University of Oxford, Oxford, UNITED KINGDOM
| | - Pamela Richards
- Academic Rheumatology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UNITED KINGDOM
| | - Christine Silverthorne
- Faculty of Health and Applied Sciences, University of the West of England - UWE Bristol, Bristol, UNITED KINGDOM
- Academic Rheumatology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UNITED KINGDOM
| | - Mwidimi Ndosi
- Faculty of Health and Applied Sciences, University of the West of England - UWE Bristol, Bristol, UNITED KINGDOM
- Academic Rheumatology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UNITED KINGDOM
| | - Celia Almeida
- Faculty of Health and Applied Sciences, University of the West of England - UWE Bristol, Bristol, UNITED KINGDOM
- Academic Rheumatology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UNITED KINGDOM
| | - Rachel J Black
- Discipline of Medicine, The University of Adelaide, Adelaide, AUSTRALIA
- Rheumatology Unit, Royal Adelaide Hospital, Adelaide, AUSTRALIA
| | - Jonathan T. L Cheah
- Department of Medicine, Division of Rheumatology, University of Massachusetts Medical School, Worcester, MA
| | - Emma Dures
- Faculty of Health and Applied Sciences, University of the West of England - UWE Bristol, Bristol, UNITED KINGDOM
- Academic Rheumatology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UNITED KINGDOM
| | - Nilasha Ghosh
- Division of Rheumatology, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY
| | - Elizabeth A Hoon
- Discipline of General Practice, The University of Adelaide, Adelaide, AUSTRALIA
- School of Public Health, The University of Adelaide, Adelaide, AUSTRALIA
| | - Suellen Lyne
- Discipline of Medicine, The University of Adelaide, Adelaide, AUSTRALIA
| | - Iris Navarro-Millan
- Division of Rheumatology, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY
- Division of General Internal Medicine, Weill Cornell Medicine, New York, NY
| | - Diyu Pearce-Fisher
- Division of Rheumatology, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY
| | - Carlee Ruediger
- Department of Rheumatology, The Queen Elizabeth Hospital, Adelaide, AUSTRALIA
| | - Joanna Tieu
- Rheumatology Unit, Lyell McEwin Hospital, Adelaide, AUSTRALIA
- Department of Rheumatology, The Queen Elizabeth Hospital, Adelaide, AUSTRALIA
| | - Kevin Yip
- Division of Rheumatology, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY
| | - Sarah Mackie
- Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UNITED KINGDOM
- Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UNITED KINGDOM
| | - Susan Goodman
- Division of Rheumatology, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY
| | - Catherine Hill
- Discipline of Medicine, The University of Adelaide, Adelaide, AUSTRALIA
- Department of Rheumatology, The Queen Elizabeth Hospital, Adelaide, AUSTRALIA
| | - Joanna C Robson
- Faculty of Health and Applied Sciences, University of the West of England - UWE Bristol, Bristol, UNITED KINGDOM
- Academic Rheumatology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UNITED KINGDOM
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Bridgewater S, Dawson J, Ndosi M, Black RJ, Cheah JTL, Dures E, Ghosh N, Hoon EA, Navarro-Millan I, Pearce-Fisher D, Richards P, Ruediger C, Silverthorne C, Tieu J, Mackie S, Goodman S, Hill C, Robson J. AB0834 DEVELOPMENT OF A CONCEPTUAL FRAMEWORK FOR A PATIENT REPORTED OUTCOME MEASURE TO CAPTURE PATIENTS’ PERCEPTIONS OF GLUCOCORTICOID THERAPY DURING TREATMENT FOR RHEUMATIC DISEASES. Ann Rheum Dis 2021. [DOI: 10.1136/annrheumdis-2021-eular.164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:Glucocorticoids (GCs) are a key treatment for the autoimmune rheumatic diseases; however, they produce numerous physical and psychological side effects.1 The Outcome Measures in Rheumatology (OMERACT) Glucocorticoid Working Group have identified that there are no Patient Reported Outcome Measures (PROMs) for assessing the impact of systemic GC therapy across multiple rheumatic diseases from the patient’s perspective.2,3Objectives:The aim is to explore the impact of GCs on the symptoms and health-related quality of life of adults with rheumatic inflammatory diseases, to inform items for inclusion in a PROM. Key considerations will include patient perceptions of GC therapy at diagnosis and over the course of treatment, for use in future randomised controlled trials or in clinical practice.Methods:An international steering committee comprising researchers, rheumatology clinicians, methodologists and patient partners in the UK, Australia and USA developed an initial conceptual framework informed by a review of the literature. Semi-structured interviews were conducted in each country with patients who had an autoimmune rheumatic disease and had received GC therapy. The interviews explored salient aspects of health-related quality of life associated with being treated with GCs.Results:Interviews have been completed in three continents with patients who had a range of demographic features, rheumatological conditions and duration and dosage of GC therapy. Figure 1 shows the initial conceptual framework for developing the GC PROM (Steroid PRO).Figure 1.Conclusion:This conceptual framework will act as an evolving guide in the development of a PROM for assessing patients’ perspectives of systemic glucocorticoid therapy. Future work will include inductive analysis of qualitative transcripts to inform candidate questionnaire items, cognitive interviewing, linguistic translatability assessment, and an international validation survey to define the final PROM questionnaire and its measurement properties.References:[1]Cheah JTL, Robson JC, Black RJ, et al. The patient’s perspective of the adverse effects of glucocorticoid use: A systematic review of quantitative and qualitative studies. From an OMERACT working group. Semin Arthritis Rheum. 2020 Oct; 50(5):996-1005.[2]Black RJ, Robson JC, Goodman SM, et al. A Patient-reported Outcome Measure for Effect of Glucocorticoid Therapy in Adults with Inflammatory Diseases Is Needed: Report from the OMERACT 2016 Special Interest Group. J Rheumatol. 2017; 44(11):1754-8.[3]Cheah JTL, Black RJ, Robson JC, et al. Toward a Core Domain Set for Glucocorticoid Impact in Inflammatory Rheumatic Diseases: The OMERACT 2018 Glucocorticoid Impact Working Group. J Rheumatol. 2019; 46(9):1179-1182.Disclosure of Interests:Susan Bridgewater Grant/research support from: Grant from Vifor Pharma for an independent investigator-led study to develop a PRO for steroids, Jill Dawson: None declared, Mwidimi Ndosi: None declared, Rachel J Black: None declared, Jonathan T.L. Cheah: None declared, Emma Dures: None declared, Nilasha Ghosh: None declared, Elizabeth A Hoon: None declared, Iris Navarro-Millan Consultant of: Received consultant fees from SOBI, Diyu Pearce-Fisher: None declared, Pamela Richards: None declared, Carlee Ruediger: None declared, Christine Silverthorne: None declared, Joanna Tieu Grant/research support from: Vifor Pharma, Sarah Mackie Consultant of: Consultancy on behalf of institution for Roche/Chugai, Sanofi, AbbVie and AstraZeneca, Grant/research support from: Educational grant from Roche to attend EULAR2019, Susan Goodman: None declared, Catherine Hill: None declared, Joanna Robson Speakers bureau: Vifor Pharma for educational webinar, Grant/research support from: Grant from Vifor Pharma for an independent investigator-led study to develop a PRO for steroids
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Bridgewater S, Lomax J, Abbott B, Adams J, Berry A, Creanor S, Ewings P, Hewlett S, McCracken L, Ndosi M, Thorn J, Urban M, Dures E. O26 Testing an intervention to reduce fatigue impact in inflammatory arthritis: design and outcomes of a single-arm feasibility study. Rheumatology (Oxford) 2021. [DOI: 10.1093/rheumatology/keab246.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background/Aims
Patients with inflammatory arthritis report that fatigue can be a challenging symptom to manage, with little support available. In response, we developed a brief one-to-one cognitive-behavioural manualised intervention, delivered by rheumatology health professionals (RHPs), to help patients manage their fatigue.
Methods
We designed a single-arm feasibility study called FREE-IA (Fatigue - Reducing its Effects through individualised support Episodes in Inflammatory Arthritis). Patients were eligible if they were ≥18 years, had a clinician confirmed diagnosis of inflammatory arthritis, scored ≥6/10 on the BRAF NRS Fatigue Impact with fatigue that they considered recurrent, frequent, and/or persistent, and were not accessing support for their fatigue.
Following training, RHPs delivered 2-4 one-to-one sessions to participants. The initial two core sessions were delivered face-to-face in clinic; participants then had the option of up to two further sessions, either in clinic, by telephone or online. We proposed delivering sessions 1 and 2 within two weeks of each other, and sessions 3 and 4 in the following two weeks. Baseline data were collected before the first session (T0), and outcomes at six weeks (T1) and six months (T2). The primary outcome was fatigue impact (BRAF NRS Fatigue Effect), collected by telephone. Secondary outcomes included fatigue severity, fatigue coping, multi-dimensional impact of fatigue, disease impact and disability and measures of therapeutic mechanism (self-efficacy, and perceived confidence and autonomy to manage health). These outcomes were collected by post.
This study allowed us to test the feasibility and acceptability of RHP training, study design and materials, intervention delivery and outcome collection, ahead of a possible RCT to determine intervention effectiveness.
Results
Eight RHPs at five hospitals delivered 113 sessions to 46 participants. Four sessions were delivered by phone and none online. Session 2 was only delivered within the two-week time frame for 37% of participants attending both core sessions. Out of a potential 138 primary and secondary outcome responses at T0, T1 and T2, there were 13 missing primary outcome responses and 27 missing secondary outcome responses. Results indicated improvements in all measures except disability at either T1 or T2, or both, with confidence intervals supporting an interpretation of improvement.
Conclusion
We were able to design and deliver FREE-IA training to RHPs, deliver FREE-IA sessions to patients, and collect outcomes at three time points with low levels of attrition. Outcomes in all measures except disability were in a direction to suggest improvement at T1, T2, or both. Study numbers were small, there was no control group and regression to the mean was a possibility. However, outcomes were in the direction to cautiously suggest benefit, and there is evidence of promise of the intervention. A definitive RCT is the next step to test clinical and cost effectiveness of the intervention.
Disclosure
S. Bridgewater: None. J. Lomax: None. B. Abbott: None. J. Adams: None. A. Berry: None. S. Creanor: None. P. Ewings: None. S. Hewlett: None. L. McCracken: None. M. Ndosi: None. J. Thorn: None. M. Urban: None. E. Dures: None.
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Affiliation(s)
- Susan Bridgewater
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UNITED KINGDOM
- Academic Rheumatology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UNITED KINGDOM
| | - Joe Lomax
- Faculty of Health, University of Plymouth, Plymouth, UNITED KINGDOM
| | - Bryan Abbott
- Academic Rheumatology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UNITED KINGDOM
| | - Jo Adams
- Health Sciences, University of Southampton, Southampton, UNITED KINGDOM
| | - Alice Berry
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UNITED KINGDOM
- Academic Rheumatology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UNITED KINGDOM
| | - Siobhan Creanor
- College of Medicine and Health, University of Exeter, Exeter, UNITED KINGDOM
| | - Paul Ewings
- Department of Research, Somerset NHS Foundation Trust, Taunton, UNITED KINGDOM
| | - Sarah Hewlett
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UNITED KINGDOM
| | - Lance McCracken
- Department of Psychology, Uppsala University, Uppsala, SWEDEN
| | - Mwidimi Ndosi
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UNITED KINGDOM
| | - Joanna Thorn
- Bristol Medical School, University of Bristol, Bristol, UNITED KINGDOM
| | - Marie Urban
- Academic Rheumatology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UNITED KINGDOM
| | - Emma Dures
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UNITED KINGDOM
- Academic Rheumatology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UNITED KINGDOM
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Berry A, Bridgewater S, Abbott B, Adams J, Dures E. P200 Acceptability of a brief fatigue intervention for patients with inflammatory arthritis: a qualitative process evaluation. Rheumatology (Oxford) 2021. [DOI: 10.1093/rheumatology/keab247.195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Background/Aims
Patients with inflammatory arthritis report fatigue as a primary symptom that affects everyday life. FREE-IA (Fatigue - Reducing its Effects through individualised support Episodes in Inflammatory Arthritis) is a feasibility study of a brief intervention (2-4 sessions of 20-30 minutes) designed to reduce fatigue impact. The intervention designed with patients and health professionals is delivered by rheumatology practitioners in one-to-one sessions, after training and using a manual. The aim of this process evaluation was to understand the perspectives of patients and practitioners in FREE-IA.
Methods
One-to-one telephone interviews were conducted with patients who had received the intervention and practitioners who had delivered it. Interviews were audio-recorded, transcribed and anonymised. An inductive thematic analysis approach was used to identify and analyse patterns within each data set.
Results
Twenty-two patients, and eight practitioners across the five sites participated. We identified four patient and three practitioner themes. Patient themes: Collaborative, non-judgemental consultations: participants reported positive relationships in which their fatigue was validated, and they were able to reflect. They expressed their preference for a responsive, flexible approach to sessions, rather than a rigid, ‘protocolised’ approach. Relevant and useful, but not ground-breaking: participants appreciated the opportunity to tailor content to their individual priorities. They found it helpful to visualise fatigue and identified daily dairies as useful. Although the content was not seen as ground-breaking, it provided focus. Insights and self-awareness: sessions increased participants’ awareness of lifestyle factors and patterns influencing their fatigue, which increased their sense of control and confidence to manage fatigue. Degrees of openness to change: sessions prompted some participants to engage in positive behaviour change or make plans for changes. However, some participants expressed frustration, explaining that it was not the right time because their lives were complicated. Practitioner themes: Engagement with the intervention: practitioners liked training face-to-face with peers and their enjoyment of the intervention increased with experience of delivery. However, for practitioners with extensive experience of providing fatigue support, the low level of treatment intensity and the manualised approach limited the perceived usefulness of the intervention. Research versus clinical practice: practitioners expressed concern about fitting sessions into clinic appointments, and it was often a challenge to offer patients a follow-up session within the proposed two-week time frame. Collaborating with patients: practitioners reported that many patients were willing to try the tools and strategies. While some practitioners followed the manual in a linear way, others used it more flexibly.
Conclusion
There is potential for this brief fatigue intervention to benefit patients. Future research will focus on flexibility to fit with local services and creating educational learning resources for practitioners to use in a range of contexts.
Disclosure
A. Berry: None. S. Bridgewater: None. B. Abbott: None. J. Adams: None. E. Dures: None.
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Affiliation(s)
- Alice Berry
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UNITED KINGDOM
- Academic Rheumatology, Bristol Royal Infirmary, Bristol, UNITED KINGDOM
| | - Susan Bridgewater
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UNITED KINGDOM
- Academic Rheumatology, Bristol Royal Infirmary, Bristol, UNITED KINGDOM
| | - Bryan Abbott
- Academic Rheumatology, Bristol Royal Infirmary, Bristol, UNITED KINGDOM
| | - Jo Adams
- Health Sciences, University of Southampton, Southampton, UNITED KINGDOM
| | - Emma Dures
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UNITED KINGDOM
- Academic Rheumatology, Bristol Royal Infirmary, Bristol, UNITED KINGDOM
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Bridgewater S. Nursing and health care in India. Ky Nurse 1983; 31:28-9. [PMID: 6559225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
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Robinson K, Bridgewater S. Named in a grievance: it happened to us. Nurs Outlook 1979; 27:191-4. [PMID: 254051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Bridgewater S. Criteria for selection of nursing textbooks. J Nurs Educ 1976; 15:3-5. [PMID: 1477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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