"It was a reflection of myself, that i was weak": The impact of depression on the sense of self - An interpretive phenomenological analysis

The World Health Organisation states that more than 350 million people experience depression globally. The phenomenological changes in individuals experiencing depression are profound Phenomenological research can further researchers' and clinicians' understanding of this experience. This study aimed to gain a phenomenological understanding of how individuals with depression understood and made sense of their experiences. A methodology of interpretative phenomenological analysis was adopted. In-depth semi-structured interviews explored the lived experience of depression for eight individuals. Data were analysed into the superordinate theme Broken Self - Transforming the Self. The superordinate theme developed from the subordinate themes of 'unknown self, loss of self and one's identity', 'desperate for a way out', and thirdly, 'conflict with self and what's known', which related directly to how individuals made sense of their experience of depression. These research findings highlight the human implications of the experience of depression and the limitations of viewing depression from a biological or medical model lens. Understanding the human impact is essential for the effective, holistic practice of mental health nursing.

Instruments measuring practitioner performance of the complete examination and screening of neonates: A systematic review

AIM

The complete examination and screening of the neonate is a recommended assessment of neonatal well-being conducted by appropriately trained medical, midwifery and nursing personnel at specific intervals during the first 6-week post-birth. Our aim was to identify and critically evaluate instruments that measure practitioner performance of this important assessment of neonatal health.

METHODS

Using the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) methodology, a systematic review was undertaken.

RESULTS

Four studies were identified as suitable for data extraction and analysis. This paper briefly describes the four instruments, discusses and compares the COSMIN analysis and ratings of each instrument. A recommendation for the instrument identified as the most suitable to measure practitioner performance is provided.

CONCLUSION

Most instruments were designed by educators to measure the performance of practitioners developing competence in the complete examination and screening of the neonate. Further development and piloting of instruments designed to measure the performance and continuing competence of qualified practitioners of the newborn examination are required.

'It will dictate how many children I will have"- Women's decision-making in pregnancy following a previous caesarean birth (CB)

Vaginal birth after caesarean (VBAC) is supported in systematic reviews (Wu et al., 2019) and national guidelines (RCOG, 2015) and women are expected to be involved in the decision-making process for either a repeat caesarean birth or planned VBAC.

AIM

To develop a Grounded Theory (GT) of women's decision making of their birth choices in pregnancy following a previous caesarean birth (CB) OBJECTIVE: To explore what determines women's birth choice and their decision making for birth following a previous CB.

DESIGN

Semi structured interviews with pregnant women were undertaken in order to develop a Glasserian Grounded Theory SETTING: Antenatal clinics and wards in a large tertiary level maternity hospital.

FINDINGS

The theory of 'Mentalizing Possibilities' is a substantive theory which explains pregnant women's decision making about their birth choices after a previous CB. Women's main concern is to achieve a positive experience. The core category of 'Mentalizing Possibilities' explains how women process their previous experience, adapt to uncertainty and deal with the decisional conflict. There are behavioural and cognitive strategies which women use to go through this process.

CONCLUSION

Women want a positive birth experience after a previous CB and require support and continuity in decision making to help them decide the optimal birth choice for their current pregnancy.

Increasing the use of perioperative risk scoring in emergency laparotomy: nationwide quality improvement programme

Background

Emergency laparotomy is associated with high morbidity and mortality. The early identification of high-risk patients allows for timely perioperative care and appropriate resource allocation. The aim of this study was to develop a nationwide surgical trainee-led quality improvement (QI) programme to increase the use of perioperative risk scoring in emergency laparotomy.

Methods

The programme was structured using the active implementation framework in 15 state-funded Irish hospitals to guide the staged implementation of perioperative risk scoring. The primary outcome was a recorded preoperative risk score for patients undergoing an emergency laparotomy at each site.

Results

The rate of patients undergoing emergency laparotomy receiving a perioperative risk score increased from 0–11 per cent during the exploratory phase to 35–100 per cent during the full implementation phase. Crucial factors for implementing changes included an experienced central team providing implementation support, collaborator engagement, and effective communication and social relationships.

Conclusions

A trainee-led QI programme increased the use of perioperative risk assessment in patients undergoing emergency laparotomy, with the potential to improve patient outcomes and care delivery.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Efficacy and cost-effectiveness of Stem Cell injections for symptomatic relief and strUctural improvement in people with Tibiofemoral knee OsteoaRthritis: protocol for a randomised placebo-controlled trial (the SCUlpTOR trial)

INTRODUCTION

Knee osteoarthritis (KOA) is a highly prevalent disabling joint disease. Intra-articular stem cell therapy is increasingly being used for treating KOA with little high-quality evidence to support its use. The aim of this study is to investigate the efficacy, safety and cost-effectiveness of allogeneic mesenchymal stem cells (Cymerus MSCs) for treating symptomatic tibiofemoral KOA and improving knee structure over 24 months.

METHODS AND ANALYSIS

The Stem Cell injections for symptomatic relief and strUctural improvement in people with Tibiofemoral knee OsteoaRthritis study is a phase III, multi-centre, parallel, superiority, randomised, double-blind, placebo-controlled trial, which will be conducted in Sydney and Hobart, Australia. 440 participants (220 per arm) aged over 40 years with painful KOA and mild to moderate structural change on X-ray (Kellgren and Lawrence grade 2 or 3) with medial minimum joint space width between 1 and 4 mm in the study knee will be recruited from the community and randomly allocated to receive either intra-articular MSCs or saline at baseline, week 3 and week 52. The coprimary outcomes will be the proportion of participants achieving patient-acceptable symptom state for knee pain at 24 months and quantitative central medial femorotibial compartment cartilage thickness change from baseline to 24 months. Main secondary outcomes include change in knee pain, Patient Global Assessment, physical function, quality of life and other structural changes. Additional data for cost-effectiveness analysis will also be recorded. Adverse events will be monitored throughout the study. The primary analysis will be conducted using modified intention-to-treat.

ETHICS AND DISSEMINATION

This protocol has been approved by The University of Sydney (USYD) Human Research Ethics Committee (HREC) #: 2020/119 and The University of Tasmania (UTAS) HREC #: H0021868. All participants will be required to provide informed consent. Dissemination will occur through conferences, social media, and scientific publications.

TRIAL REGISTRATION NUMBERS

Australian New Zealand Clinical Trials Registry (ACTRN12620000870954); U1111-1234-4897.

Factors influencing women's perceptions of choice and control during pregnancy and birth: a cross-sectional study

BACKGROUND

Women across the world value choice and control throughout their maternity care experiences. In response to this health policy and frameworks are adapting and developing. The concepts of choice and control are extrinsically complex and open to interpretation by healthcare professionals and service users, with the two not necessarily aligning. Depending on a number of factors, women's experiences of choice and control within the same maternity care system may be very different. This study aimed to investigate the factors influencing women's perceptions of choice and control during pregnancy and birth in Ireland.

METHODS

We conducted a cross-sectional study using an adapted version of the UK national maternity experience survey (National Perinatal Epidemiology Unit). During March - July 2017, a sample of 1277 women were recruited from the postnatal wards of three maternity units and a tertiary maternity hospital. Poisson regression was used to assess the association between twelve factors and a series of measures of the women's perception of choice and control.

RESULTS

Most women reported not having choice in the model or location of their maternity care but most reported being involved enough in decision-making, especially during birth. Women who availed of private maternity care reported higher levels of choice and control than those who availed of public maternity care. This factor was the most influential factor on almost all choice and control measures.

CONCLUSION

Most women experiencing maternity care in Ireland report not having choice in the model and location of care. These are core elements of the Irish maternity strategy and significant investment will be required if improved choice is to be provided. Availing of private maternity care has the strongest influence on a woman's perceived choice and control but many women cannot afford this type of care, nor may they want this model of care.

Innovations for the future of breast surgery

BACKGROUND

Future innovations in science and technology with an impact on multimodal breast cancer management from a surgical perspective are discussed in this narrative review. The work was undertaken in response to the Commission on the Future of Surgery project initiated by the Royal College of Surgeons of England.

METHODS

Expert opinion was sought around themes of surgical de-escalation, reduction in treatment morbidities, and improving the accuracy of breast-conserving surgery in terms of margin status. There was emphasis on how the primacy of surgical excision in an era of oncoplastic and reconstructive surgery is increasingly being challenged, with more effective systemic therapies that target residual disease burden, and permit response-adapted approaches to both breast and axillary surgery.

RESULTS

Technologies for intraoperative margin assessment can potentially half re-excision rates after breast-conserving surgery, and sentinel lymph node biopsy will become a therapeutic procedure for many patients with node-positive disease treated either with surgery or chemotherapy as the primary modality. Genomic profiling of tumours can aid in the selection of patients for neoadjuvant and adjuvant therapies as well as prevention strategies. Molecular subtypes are predictive of response to induction therapies and reductive approaches to surgery in the breast or axilla.

CONCLUSION

Treatments are increasingly being tailored and based on improved understanding of tumour biology and relevant biomarkers to determine absolute benefit and permit delivery of cost-effective healthcare. Patient involvement is crucial for breast cancer studies to ensure relevance and outcome measures that are objective, meaningful, and patient-centred.

Failure or progress?: The current state of the professionalisation of midwifery in Europe

INTRODUCTION

Throughout Europe midwives called for increasing professionalisation of midwifery during the 1980s and 1990s. While the Bologna Declaration, in 1999, supported this development in education and research, it remains unclear how other fields, such as practice, have fared so far. This study therefore aimed to explore the current state of professionalisation of midwifery in Europe.

METHODS

An exploratory inquiry was conducted with an on-line semi-structured questionnaire. Its content was based on the Greenwood sociological criteria for a profession. Descriptive statistics and thematic content analysis were used to analyse the data. Participants were national delegates from member countries to the European Midwives Association.

RESULTS

Delegates from 29 European countries took part. In most countries, progress towards professionalisation of midwifery has been made through the move of education into higher education, coupled with opportunities for postgraduate education and research. Lack of progress was noted, in particular in regard to midwifery practice, regulation, and leadership in health care provision and education. Most countries had a code of ethics for midwives as well as a midwifery association. Based on organisational collaborations with other disciplines, the sustainability of a distinct professional culture was unclear. An increased focus on future development of midwifery practice was proposed.

CONCLUSIONS

Progress in midwifery education and research has taken place. However, midwives’ current roles in practice as well as leadership and their influence on healthcare culture and politics are matters of concern. Future efforts for advancing professionalisation in Europe should focus on the challenges in these areas.

Perceived importance and performance of clinical leadership in practice: A cross-sectional study of nurses and midwives of all grades

AIM

To explore the differences in perceived importance and actual performance of clinical leadership for all grades of nurses and midwives engaged in clinical practice.

BACKGROUND

Clinical leadership is central to the provision of person-centred care. However, little is known about how nurses and midwives perceive this in practice.

METHODS

Data were collected on a sample of nurses and midwives in the Republic of Ireland, using a cross-sectional study design (n = 324). The clinical leadership needs analysis instrument was used to measure perceived importance and performance of clinical leadership in practice. Grades of nurses/midwives included; staff, manager, advanced practitioner and senior manager.

RESULTS

Senior managers were more likely to report significantly higher scores than staff grades for perceived importance of Technology & Care Initiatives (p < .01) and Financial & Service Management (p = .02). Performance of Staff & Care Delivery was significantly higher for senior managers than staff grades [F(5,309) = 6.06 p < .01].

CONCLUSION

There was a mismatch between the perceived importance and actual performance of clinical leadership in practice between different grades of staff.

IMPLICATIONS FOR NURSING MANAGEMENT

Leadership training for all grades and mentoring of staff grades can promote the building of confidence and empower staff in leading clinical practice.

Developing a new health-related policy analysis tool: An action research cooperative inquiry approach

AIM

To develop a tool for the analysis of nursing, midwifery and health-related policy and professional guidance documents.

BACKGROUND

Analysis tools can aid both policy evaluation and policy development. However, no framework for analysing the content of professional regulation and guidance documents among health care professionals currently exists.

METHOD

This study used an action research, cooperative inquiry design. Data were generated from two integrative literature reviews and discussions held during the cooperative inquiry meetings.

RESULTS

A set of key themes to be considered in the development or evaluation of health policy or professional regulation and guidance documents were identified. These themes formed the basis of the six domains considered by the Health-related Policy Analysis Tool (HrPAT): Context, Process, Content, Stakeholder Consultation, Implementation and Evaluation.

CONCLUSION

Use of the HrPAT can assist in policy development, evaluation and implementation, as well as providing some retrospective analytical insights into existing health policies.

IMPLICATION FOR NURSING MANAGEMENT

Professional regulation documents, guidelines and policy reports should be capable of being scrutinized for their content, quality and developmental process. The HrPAT can assist relevant stakeholders in the development, analysis and evaluation of such documents, including local, service-level policies and guidelines.

Abstract P3-03-14: Clinical utility of one-step nucleic acid amplification (OSNA) in axillary surgery after neoadjuvant chemotherapy (NAC)

Introduction

NAC has been used for downsizing of the tumour in breast and axilla to allow more conservative surgery. In the NAC setting, intraoperative assessment of sentinel lymph node(s) (SLN) is still considered necessary1. Current awareness of the prognostic value for axillary nodal down-staging has renewed interest in analysis of SLN post-NAC.

In this study we want to examine the clinical utility of OSNA (based on CK19 mRNA detection) as a method of intra-operative analysis of SLN to assist real-time decision-making for axillary surgery post-NAC in early breast cancer (EBC).

Methods

Retrospective analysis of prospective data on 399 consecutive patients with EBC who received NAC followed by breast surgery with SLN biopsy (408 axillae) and assessment by OSNA, from September 2011 to January 2018 at the Royal Marsden Hospital (UK). OSNA readouts from the Sysmex RD-100i were collected separate to and blinded from clinico-pathological data. A negative or benign pre-treatment axillary ultrasound scan or indeterminate ultrasound with negative or benign axillary cytology/histology prior to NAC was considered cN0. Univariate analysis (significance at p&lt;0.05) was used to identify risk of recurrence. Patients had a median (mean) follow up of 32.5 (36) months.

Results

The median age at diagnosis was 49 years, median BMI 26, 41 EBC (10%) were screen-detected, 292 (72%) were grade 3 and the most frequent phenotype was receptor triple negative (n=132, 32%).

Of 408 axillae, 248 (60%) were initially cN0, of which 113 (46%) had a pathological complete response (pCR) in the breast. SLN in 54 (22%) cN0 patients were positive on OSNA, of which only 6 (9%) had further involved axillary nodes all 6 of which were ER+ Her2-.

The remaining 160 (40%) axillae were cN1 of which 87 (54%) had conversion to ypN0 including 55 (34%) with both ypT0ypN0.

Axillary lymphadenectomy (AL) was performed in 79 (19%) patients overall, of which n=22 (28%) were cN0 and 57 (72%) were cN1. Of these, 30 (53%) of the cN1 and 6 of 22 (45%) of cN0 had at least 1 additional positive AL node.

Overall 59 (14.4%) patients relapsed. A significantly worse rate of relapse was observed in cN1 compared to cN0 patients (37/159 (23.3%) versus 22/244 (9%), p&lt;0.001). Combined pCR of both breast and axilla (in cN1, n=54) was associated with a significantly reduced risk of relapse and death (p&lt;0.001) compared to those without pCR of either breast or axilla (n=62). Of the latter 18 (29%) relapsed (including 10 deaths).

The mean of both the single highest node tumour load (and total nodal tumour load), as measured by CK19mRNA copies/ul on OSNA, were significantly higher at 90,000 (98,300) for those who relapsed versus 23,100 (25,100) for those without relapse (p=0.027).

Conclusions

The OSNA assay is an accurate tool for axillary SLN analysis in patients after NAC and was helpful in intra-operative axillary management. OSNA reduces the need for a second surgery for AL in 20% of breast cancer patients with a positive-SLN after NAC and might offer additional prognostic value.

Reference

1. NCCN. National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology Breast Cancer.2016.Version 2.2016.

Citation Format: Muscara F, Christaki G, Richardson C, O'Connell R, Padmanabhan P, Warwick J, Lee Y, Smith I, Nerurkar A, Osin P, Krupa K, Rusby J, Roche N, Gui G, MacNeil F, Barry P. Clinical utility of one-step nucleic acid amplification (OSNA) in axillary surgery after neoadjuvant chemotherapy (NAC) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-03-14.

Development and psychometric testing of the clinical leadership needs analysis (CLeeNA) instrument for nurses and midwives

AIM

The aim of this study is to report the development and psychometric testing of the clinical leadership needs analysis instrument (CLeeNA).

BACKGROUND

Limited emphasis is placed on the clinical leadership needs of nurses and midwives that are fundamental to supporting the delivery of high quality, safe patient care.

METHODS

A development and validation study of CLeeNA was undertaken using cross-sectional data. A sample of 324 registered nurses and midwives completed the questionnaire using a 7-point adjectival scale. Principal component analysis was conducted to explore scale grouping of items (n = 103 items).

RESULTS

Principal component analysis, item reduction and parallel analysis on the items of the instrument resulted in seven factors consisting of 56 items. These factors were identified as: Staff and Care Delivery; Technology and Care Initiatives; Self and Team Development; Standards of Care; Financial and Service Management; Leadership and Clinical Practice; Patient Safety and Risk Management.

CONCLUSION

The identified factors are reflective of an ever-changing health care environment.

IMPLICATIONS FOR NURSING MANAGEMENT

Potentially, after further testing, this instrument could be used by nursing management and educators to measure clinical leadership needs, inform the design of clinical leadership training programmes and provide valuable information about health care leadership development.

Establishing a Europe-wide foundation for high quality midwifery education: The role of the European Midwives Association (EMA)

A cornerstone of European policy involves freedom of movement of individuals between member countries, which applies equally to those who use and provide maternity care. To promote and support safe, high quality maternity care, minimum standards for midwifery education and practice have been published, including Directives EEC/80/154 and EEC/80/155 which support the recognition of professional qualifications. These Directives established a minimum standard for midwifery education, including the duration and content of theoretical and practical education. Annex V of the Directives established a framework of professional activities to define and guide the scope of midwifery practice in EU member countries. The Directives were updated in 2013, with the European Midwives Association (EMA) an important partner in this process. While the degree of implementation of the Directives at individual country level varies, EMA has an ongoing role in ensuring, promoting and advancing high quality midwifery education and practice throughout the EU.

Discursive constructions of professional identity in policy and regulatory discourse

AIM

To examine and describe disciplinary discourses conducted through professional policy and regulatory documents in nursing and midwifery in Ireland.

BACKGROUND

A key tenet of discourse theory is that group identities are constructed in public discourses and these discursively constructed identities become social realities. Professional identities can be extracted from both the explicit and latent content of discourse. Studies of nursing's disciplinary discourse have drawn attention to a dominant discourse that confers nursing with particular identities, which privilege the relational and affective aspects of nursing and, in the process, marginalize scientific knowledge and the technical and body work of nursing.

DESIGN

We used critical discourse analysis to analyse a purposive sample of nursing and midwifery regulatory and policy documents.

METHOD

We applied a four-part, sequential approach to analyse the selected texts. This involved identifying key words, phrases and statements that indicated dominant discourses that, in turn, revealed latent beliefs and assumptions. The focus of our analysis was on how the discourses construct professional identities.

FINDINGS

Our analysis indicated recurring narratives that appeared to confer nurses and midwives with three dominant identities: "the knowledgeable practitioner," the "interpersonal practitioner" and the "accountable practitioner." The discourse also carried assumptions about the form and content of disciplinary knowledge.

CONCLUSIONS

Academic study of identity construction in discourse is important to disciplinary development by raising nurses' and midwives' consciousness, alerting them to the ways that their own discourse can shape their identities, influence public and political opinion and, in the process, shape public policy on their professions.

Comparative study of image contrast in scanning electron microscope and helium ion microscope

Images of Ga⁺ -implanted amorphous silicon layers in a 110 n-type silicon substrate have been collected by a range of detectors in a scanning electron microscope and a helium ion microscope. The effects of the implantation dose and imaging parameters (beam energy, dwell time, etc.) on the image contrast were investigated. We demonstrate a similar relationship for both the helium ion microscope Everhart-Thornley and scanning electron microscope Inlens detectors between the contrast of the images and the Ga⁺ density and imaging parameters. These results also show that dynamic charging effects have a significant impact on the quantification of the helium ion microscope and scanning electron microscope contrast.

Accuracy of self-report of HIV viral load among people with HIV on antiretroviral treatment

OBJECTIVES

The aim of the study was to assess, among people living with HIV, knowledge of their latest HIV viral load (VL) and CD4 count.

METHODS

Agreement between self-report and clinic record was assessed among 2771 HIV-diagnosed individuals on antiretroviral treatment (ART) in the UK Antiretrovirals, Sexual Transmission Risk and Attitudes Study (2011-2012). A confidential self-completed questionnaire collected information on demographic, socioeconomic, HIV-related and health-related factors. Participants were asked to self-report their latest VL [undetectable (≤ 50 copies/mL), detectable (> 50 copies/mL) or "don't know"] and CD4 count (< 200, 200-350, 351-500 or > 500 cells/μL, or "don't know"). Latest clinic-recorded VL and CD4 count were documented.

RESULTS

Of 2678 participants on ART, 434 (16.2%) did not accurately report whether their VL was undetectable. Of 2334 participants with clinic-recorded VL ≤ 50 copies/mL, 2061 (88.3%) correctly reported undetectable VL; 49 (2.1%) reported detectable VL; 224 (9.6%) did not know their VL. Of 344 participants with clinic-recorded VL > 50 copies/mL, 183 (53.2%) correctly reported detectable VL; 76 (22.1%) reported undetectable VL; 85 (24.7%) did not know their VL. Of 2137 participants who reported undetectable VL, clinic-recorded VL was ≤ 50 copies/mL for 2061 (96.4%) and <1000 copies/mL for 2122 (99.3%). In analyses adjusted for gender/sexual orientation, ethnicity, age and time since starting ART, factors strongly associated with inaccurate self-report of VL (including "don't know") included socioeconomic disadvantage [prevalence ratio (95% CI) for "not" vs. "always" having enough money for basic needs: 2.4 (1.9, 3.1)], poor English fluency [3.5 (2.4, 5.1) vs. UK born], nondisclosure of HIV status [1.7 (1.3, 2.1)], ART nonadherence [2.1 (1.7, 2.7) for three or more missed doses vs. none in the past 2 weeks] and depressive symptoms (PHQ-9 score ≥ 10) [1.9 (1.6, 2.2)]. Overall, 612 (22.9%) of 2667 participants on ART did not accurately self-report whether or not their CD4 count was ≤ 350 cells/μL.

CONCLUSIONS

There is a high level of accuracy of a self-report of undetectable VL in people on ART in the UK. Overall, accurate knowledge of personal VL level varied according to demographic, socioeconomic, HIV-related and health-related factors. Active identification of people who may benefit from increased levels of support and engagement in care is important.

Conceptualising a model to guide nursing and midwifery in the community guided by an evidence review

Background

Successful models of nursing and midwifery in the community delivering healthcare throughout the lifespan and across a health and illness continuum are limited, yet necessary to guide global health services. Primary and community health services are the typical points of access for most people and the location where most care is delivered. The scope of primary healthcare is complex and multifaceted and therefore requires a practice framework with sound conceptual and theoretical underpinnings.

The aim of this paper is to present a conceptual model informed by a scoping evidence review of the literature.

Methods

A scoping evidence review of the literature was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Databases included CINAHL, MEDLINE, PsycINFO and SocINDEX using the EBSCO platform and the Cochrane Library using the keywords: model, nursing, midwifery, community, primary care. Grey literature for selected countries was searched using the Google ‘advanced’ search interface. Data extraction and quality appraisal for both empirical and grey literature were conducted independently by two reviewers. From 127 empirical and 24 non-empirical papers, data extraction parameters, in addition to the usual methodological features, included: the nature of nursing and midwifery; the population group; interventions and main outcomes; components of effective nursing and midwifery outcomes.

Results

The evidence was categorised into six broad areas and subsequently synthesised into four themes. These were not mutually exclusive: (1) Integrated and Collaborative Care; (2) Organisation and Delivery of Nursing and Midwifery Care in the Community; (3) Adjuncts to Nursing Care and (4) Overarching Conceptual Model. It is the latter theme that is the focus of this paper. In essence, the model depicts a person/client on a lifespan and preventative-curative trajectory. The health related needs of the client, commensurate with their point position, relative to both trajectories, determines the nurse or midwife intervention. Consequently, it is this need, that determines the discipline or speciality of the nurse or midwife with the most appropriate competencies.

Conclusion

Use of a conceptual model of nursing and midwifery to inform decision-making in primary/community based care ensures clinical outcomes are meaningful and more sustainable. Operationalising this model for nursing and midwifery in the community demands strong leadership and effective clinical governance.

Electronic supplementary material

The online version of this article (doi:10.1186/s12912-017-0225-3) contains supplementary material, which is available to authorized users.

Consent for routine neonatal procedures: A study of practices in Irish neonatal units. How do we compare with the gold standard BAPM guidelines?

The Irish National Consent Policy (NCP) proposes that the legal requirement for consent extends to all forms of interventions, investigations and treatment, carried out on or behalf of the Health Service Executive (HSE). This study employs a quantitative descriptive approach to investigate the practices for obtaining consent for an identified group of routine neonatal procedures in neonatal facilities throughout Ireland. The BAPM (British Association of Perinatal Medicine) guidelines were identified as 'gold standard' for the purposes of this study. The results indicated a lack of consistency between participating units pertaining to the modes of consent utilised and notable variances from 'gold standard' guidelines. Unanimity was evident for 3 procedures only (administering BCG, 6-in-1, and donor breast milk to infant). Significant findings related to EEG with video recordings, MRI/CT and gastro intestinal imaging, screening of an infant with suspected substance abuse or retinopathy of prematurity screening (ROP), administration of Vitamin K, and the carrying out of a lumbar puncture.

Detailed thermodynamic analysis of the activation parameters for the simple hydrolysis of acetic anhydride in the acetonitrile/water cosolvent system

A plot ofvs. Tfor the acetonitrile/water system. Terms such as this one are crucial for a thermodynamic analysis of Eyring activation parameters.

Incorporating HIV/hepatitis B virus/hepatitis C virus combined testing into routine blood tests in nine UK Emergency Departments: the "Going Viral" campaign

OBJECTIVES

Routine HIV screening is recommended in those UK hospitals and primary care settings where the HIV prevalence is > 0.2%. For hepatitis B virus (HBV) and hepatitis C virus (HCV), however, testing is targeted at at-risk groups. We investigated the prevalence of these blood-borne viruses (BBVs) during a routine testing pilot in UK Emergency Departments (EDs).

METHODS

During the "Going Viral" campaign (13-19 October 2014), nine UK EDs in areas of high HIV prevalence offered routine tests for HIV, HBV and HCV to adults having blood taken as part of routine care. Patients who tested positive were linked to care.

RESULTS

A total of 7807 patients had blood taken during their ED visit; of these, 2118 (27%) were tested for BBVs (range 9-65%). Seventy-one BBV tests were positive (3.4%) with 32 (45.1%) new diagnoses. There were 39 HCV infections (15 newly diagnosed), 17 HIV infections (six newly diagnosed), and 15 HBV infections (11 newly diagnosed). Those aged 25-54 years had the highest prevalence: 2.46% for HCV, 1.36% for HIV and 1.09% for HBV. Assuming the cost per diagnosis is £7, the cost per new case detected would be £988 for HCV, £1351 for HBV and £2478 for HIV.

CONCLUSIONS

In the first study in the UK to report prospectively on BBV prevalence in the ED, we identified a high number of new viral hepatitis diagnoses, especially hepatitis C, in addition to the HIV diagnoses. Testing for HIV alone would have missed 54 viral hepatitis diagnoses (26 new), supporting further evaluation of routine BBV testing in UK EDs.

TestMeEast: a campaign to increase HIV testing in hospitals and to reduce late diagnosis

Late diagnosis occurs in almost half of those diagnosed in the UK (HIV Prevention England, 2013. Retrieved June 22, 2014, from HIV Prevention England: http://www.hivpreventionengland.org.uk/Campaigns-Current/National-HIV-Testing-Week ). Testing occurs mainly in sexual health and antenatal clinics despite recommendations to test more broadly [Ellis, S., & Curtis, H. (2012). HIV diagnoses and missed opportunities. Results of the British HIV association (BHIVA) National Audit 2010. Clinical Medicine, 12(5), 430-434]. We report the findings of an HIV-testing week campaign to offer testing to those who have blood tests as part of routine care within outpatient clinics and emergency departments of six London hospitals. The campaign target was to test 500 patients a day during the 2013 National HIV Testing Week (NHTW). Clinic staff and medical students were trained to offer routine HIV testing. Linkage to care was arranged for those who tested HIV-positive. During NHTW we tested 2402 of the planned 2500 test target. 2402/4317 (55.6% 95% CI 54.1-57.1%) of those who had routine blood tests were tested for HIV. There were eight HIV-positive tests; three were new diagnoses (all linked to care). The campaign hashtag #TestMeEast achieved a total Twitter "reach" of 238, 860 and the campaign had widespread news coverage. Our campaign showed that staff and students could be trained and mobilised to do thousands of routine HIV tests during a campaign.

Midwifery education in Ireland--The quest for modernity

Midwifery education in Ireland has undergone significant changes in recent years including the introduction of direct entry midwifery programmes and a transfer of education to the university sector. While this has provided increased educational opportunities for midwives, the challenge for midwife educators is to prepare students for the increasing complexities of maternity care with a focus on obstetric risk and maternal morbidities with the need to educate midwifery students to support normality and provide woman centred care. The Nursing and Midwifery Board of Ireland has recently produced new Standards and Requirements for midwifery education and Practice Standards for midwives. This article provides information on midwifery education in Ireland and the documents that support the development of the profession.

Puts the magic back into life: Fathers' experience of planned home birth

BACKGROUND

In Ireland, planned home birth is seen as an alternative but safe choice of maternity care. Women's experience of home birth is reported as positive but little is known about fathers' thoughts and feelings about planned home birth.

AIM

The aim of the study was to explore fathers' experience of planned home birth.

METHOD

Hermeneutic phenomenology was selected to explore the experiences of eight fathers whose partners had a recent planned home birth. Data were analysed using Interpretative Phenomenological Analysis (IPA).

RESULTS

Themes identified were 'negotiating the decision', 'ownership of the birth' and 'changed way of being'. Fathers overcame their initial reservations about home birth before the decision to plan a home birth was agreed. They were actively involved with their partner in labour which gave themselves a sense of ownership of the experience and a valued post-birth intimacy. Their belief in natural birth was reaffirmed and the experience gave them a new perspective on life.

CONCLUSION

When men have a positive experience of childbirth they benefit personally and emotionally. This experience can strengthen their relationship with their partner and the family. Midwives are ideally placed to involve fathers actively in birth either in a home or hospital setting.

Essential leadership skills for motivating and developing staff

Achieving and sustaining high quality patient care and containing costs are important aspects of a nurse manager's role, and a successful manager needs to have the skills and ability to motivate and develop staff. This article focuses on how effective leadership can increase motivation and empowerment among nurses, examines the relevance of transformational leadership to motivation, and suggests practical ways of maintaining a motivated work environment.

High-dose melphalan and autologous stem cell transplantation for AL amyloidosis: recent trends in treatment-related mortality and 1-year survival at a single institution

Treatment with high-dose melphalan chemotherapy supported by hematopoietic rescue with autologous stem cells produces high rates of hematologic responses and improvement in survival and organ function for patients with AL amyloidosis. Ongoing clinical trials explore pre-transplant induction regimens, post-transplant consolidation or maintenance approaches, and compare transplant to non-transplant regimens. To put these studies into context, we reviewed our recent experience with transplant for AL amyloidosis in the Amyloid Treatment and Research Program at Boston Medical Center and Boston University School of Medicine. Over the past 10 years, there was a steady reduction in rates of treatment-related mortality and improvement in 1-year survival, now approximately 5% and 90%, respectively, based upon an intention-to-treat analysis. Median overall survival of patients treated with this approach at our center exceeds 7.5 years.

An upgraded x-ray spectroscopy diagnostic on MST

An upgraded x-ray spectroscopy diagnostic is used to measure the distribution of fast electrons in MST and to determine Z(eff) and the particle diffusion coefficient D(r). A radial array of 12 CdZnTe hard-x-ray detectors measures 10-150 keV Bremsstrahlung from fast electrons, a signature of reduced stochasticity and improved confinement in the plasma. A new Si soft-x-ray detector measures 2-10 keV Bremsstrahlung from thermal and fast electrons. The shaped output pulses from both detector types are digitized and the resulting waveforms are fit with Gaussians to resolve pileup and provide good time and energy resolution. Lead apertures prevent detector saturation and provide a well-known etendue, while lead shielding prevents pickup from stray x-rays. New Be vacuum windows transmit >2 keV x-rays, and additional Al and Be filters are sometimes used to reduce low energy flux for better resolution at higher energies. Measured spectra are compared to those predicted by the Fokker-Planck code CQL3D to deduce Z(eff) and D(r).

A metasynthesis of midwives’ experience of hospital practice in publicly funded settings: compliance, resistance and authenticity

Worldwide, increasing percentages of women are giving birth in centralized hospitals in the belief that this maximizes safety for themselves and their babies. In parallel, there is international recognition that the number of birth interventions used in the routine care of labouring women is rising. This is fuelling concern about iatrogenesis, and, particularly, maternal and infant morbidity and mortality. It also has an adverse impact on the economics of health care. National and international policy characterizes midwives as the guardians of normal childbirth. This guardianship appears to be failing. The objective of this metasynthesis is to explore midwives’ perceptions of hospital midwifery with a focus on labour ward practice to examine professional discourses around midwifery work in the current modernist, risk averse and consumerist childbirth context. Based on an iterative search strategy, 14 studies were selected for the metasynthesis. Three overarching themes were identified: ‘power and control’; ‘compliance with cultural norms’; and ‘attempting to normalize birth’. Most midwives aimed to provide what they characterized as ‘real midwifery’ but this intention was often overwhelmed with heavy workloads and the normative pressure to provide equitable care to all women. This raises questions of authenticity, both in terms of midwives living out their beliefs, and in terms of acknowledgement of the power to resist. The theoretical insights generated by the metasynthesis could have resonance for other professional and occupational groups who wish to offer autonomous individualized services in an increasingly risk-averse target driven global society.

Obstetric surgery for perioperative staff and midwives

Where a pregnant woman experiences trauma or has acute surgical needs there are additional concerns for the well being of both the woman and her foetus. This article explores obstetric procedures for the pregnant woman and discusses the implications for perioperative staff and midwives.

Multipoint Thomson scattering diagnostic for the Madison Symmetric Torus reversed-field pinch

The multipoint Thomson scattering diagnostic on the Madison Symmetric Torus (MST) is now fully operational with 21 spatial points, which cover the entire minor radius. Four full electron temperature profiles can be obtained during each MST discharge, with a variable delay between each profile. This system overcomes challenges that arise from the unique machine design, location, and plasma characteristics of MST. The machine design limits the maximum porthole diameter to 11.4 cm, requiring a compact, re-entrant, seven element lens for scattered light collection. Limited space near MST necessitates a long beam path for the two Nd:YAG lasers requiring a remote beam line adjustment system to suppress drift in the beam position due to thermal expansion of the building. Due to the remote location of the laser head, substantial design effort was put into the creation of a set of safety interlocks for the laser system. The dynamic nature of MST plasmas and the wide range of operating space require a versatile scattered light detection system consisting of filter polychromators with temperature controlled avalanche photodiode detectors. We also implement an insertable integrating sphere, which travels along the laser beam path through the vacuum vessel, for the alignment of both the fiber optics and the lasers.

Optimizing a Thomson scattering diagnostic for fast dynamics and high background

The Madison Symmetric Torus (MST) presents challenging conditions for Thomson scattering (TS) measurements. The MST plasmas are reversed-field pinches (RFPs) with electron density n(e)<3x10(13) cm(-3), typically 1x10(13) cm(-3). The TS system was designed to measure from 10 eV to 2 keV; however, six polychromators were upgraded from four to eight spectral channels to resolve to 10 keV. There is no diverter or vertical field, so wall interaction results in high background light both from ion and neutral bremsstrahlungs and from line radiation. Also during standard plasmas, the RFP exhibits regular reconnection sawteeth events during which the plasma current, density, and temperature profiles are flattened. These events are of interest both due to the reconnection physics and to their contribution to the MST equilibrium and confinement. These events occur over 100 microS and exhibit large changes in background light and fast changes in temperature. During improved confinement plasmas, there are no sawteeth; the background is low but the temperature can be over an order of magnitude higher. Data analysis of the system has been developed to accommodate both the large dynamic range of the temperature, the fast dynamics, and the fast changing, high amplitude background. Special attention has been paid to the sources of error, in particular, the contribution of the background. A response-function method reduces the measured uncertainty by a factor of 2. Numerical techniques have been developed which are extremely robust. Two methods are used, a conventional chi(2) minimization using a Levenberg-Marquardt algorithm coupled with Monte Carlo modeling for the error bar and a Bayesian statistics method. The Bayesian method computes the probability distribution for the measured photons and electron temperature and this information can be used to ensemble data and will allow future integrated data analysis efforts.

Calibration of a Thomson scattering diagnostic for fluctuation measurements

Detailed calibrations of the Madison Symmetric Torus polychromator Thomson scattering system have been made suitable for electron temperature fluctuation measurements. All calibrations have taken place focusing on accuracy, ease of use and repeatability, and in situ measurements wherever possible. Novel calibration processes have been made possible with an insertable integrating sphere (ISIS), using an avalanche photodiode (APD) as a reference detector and optical parametric oscillator (OPO). Discussed are a novel in situ spatial calibration with the use of the ISIS, the use of an APD as a reference detector to streamline the APD calibration process, a standard dc spectral calibration, and in situ pulsed spectral calibration made possible with a combination of an OPO as a light source, the ISIS, and an APD used as a reference detector. In addition a relative quantum efficiency curve for the APDs is obtained to aid in uncertainty analysis.

A placebo-controlled trial of Sertraline's effects on symptoms, well-being and survival in advanced cancer: The ZEST Trial

9002

Background: Depression, anxiety, fatigue and impaired well-being are common, important and closely related in advanced cancer. We sought to determine the effects of sertraline (a well-tolerated, SSRI antidepressant) on these symptoms and survival in a broad cross-section of people with advanced cancer but without major depression. Methods: 189 participants (pts) were randomly allocated to sertraline 50 mg daily or placebo. Assessments were at baseline; months 1, 2, 4, 6, 9, 12; and, then 3-monthly. Outcome measures rated by pts included the: Centre for Epidemiologic Studies Depression scale (CES-D); Hospital Anxiety and Depression Scale (HADS-A, HADS-D); and the Functional Assessment of Cancer Therapy General and Fatigue scales (FACT-G and FACT-F). Clinicians completed Spitzer's Quality of Life Index (SQLI). Outcomes on all scales are expressed from 0 (worst) to 100 (best). The primary analyses of sertraline's effects on quality of life were based on scores at 4 and 8 weeks adjusted for baseline scores using generalised estimating equations. Efficacy analyses are by intention to treat; toxicity analyses by treatment received. P-values and 95% confidence intervals (CI) are 2-sided. Results: Recruitment was stopped after the first planned interim analysis of 150 pts showed a trend in overall survival favouring placebo (univariable logrank p=0.04; multivariable Cox model hazard ratio 1.61, CI 1.1 to 2.5, p=0.02). This trend was weaker at the final analysis including all 189 patients and longer follow-up (univariable logrank p=0.09); and, after accounting for baseline factors (multivariable Cox model hazard ratio 1.27, CI 0.87 to 1.8, p=0.2). Sertraline had no significant effects (scale: benefit over placebo, 95% CI) on depression (CES-D: 0.4, −2.6 to 3.4), anxiety (HADS-A: 2.0, −1.5 to 5.5), fatigue (FACT-F: 0.3, −4.3 to 4.9), overall quality of life (FACT-G: 1.7, −1.3 to 4.7) or clinicians’ ratings (SQLI: 2.0, −2.5 to 6.5). Subgroup and sensitivity analyses also excluded significant benefits. Sertraline was discontinued more often and earlier than placebo (logrank p = 0.03). The trial was closed for lack of benefit. Conclusions: Sertraline did not improve symptoms, well-being or survival and should be reserved for those with a proven indication.

No significant financial relationships to disclose.

Observation of weak impact of a stochastic magnetic field on fast-ion confinement

Fast ions are observed to be very well confined in the Madison Symmetric Torus reversed field pinch despite the presence of stochastic magnetic field. The fast-ion energy loss is consistent with the classical slowing down rate, and their confinement time is longer than expected by stochastic estimates. Fast-ion confinement is measured from the decay of d-d neutrons following a short pulse of a 20 keV atomic deuterium beam. Ion confinement agrees with computation of particle trajectories in the stochastic magnetic field, and is understood through consideration of ion guiding center islands.

Forms that Inform

OBJECTIVES

Sound medical decisions are easier for clinicians who have essential patient data in the right place at the right time. Our goal was to develop a usable form to guide clinical decisions and then test it using actual cases.

METHODS

The authors designed a form to represent data from patients with chest pain; it was revised several times. We incorporated opinions from clinician-users as well as evidence from the literature to improve usability. To test the design, we filled out forms with actual patient data derived from Emergency Department charts of patients who presented with chest pain. We then validated the design by having house officer reviewers make the decision to admit, observe in the ER for one day, or discharge subjects based entirely on a one-page form.

RESULTS

Thirty-three house officers reviewed our initial design and made suggestions. Our literature search yielded a number of factors discriminating ischemic from non-ischemic chest pain. Sixteen factors were included on a finalized form in the rank order assigned by reviewing physicians. Over 4 days, data from 29 subjects were used to fill out copies of the form. Based purely on the completed forms, house officers made decisions to admit, discharge, or observe all 29 subjects in less than 30 minutes.

CONCLUSIONS

Forms have traditionally been employed to record and organize data. Here we show how principles of usability engineering can be used to create a form to meet the needs of users and even encourage evidence-based practice.

Observation of velocity-independent electron transport in the reversed field pinch

Confinement of runaway electrons has been observed for the first time in a reversed field pinch during improved-confinement plasmas in the Madison Symmetric Torus. Energy-resolved hard-x-ray flux measurements have been used to determine the velocity dependence of the electron diffusion coefficient, utilizing computational solutions of the Fokker-Planck transport equation. With improved-confinement, the fast electron diffusivity drops by 2 orders of magnitude and is independent of velocity. This suggests a change in the transport mechanism away from stochastic magnetic field diffusion.

The Wellcome trust UK-Irish bipolar affective disorder sibling-pair genome screen: first stage report

We have completed the first stage of a two-stage genome wide screen designed to identify chromosomal regions that may harbour susceptibility genes for bipolar affective disorder. The first stage screening sample included 509 subjects from 151 nuclear families recruited within the United Kingdom and Republic of Ireland. This sample contained 154 narrowly defined affected sibling pairs (DSM-IV BPI) and 258 broadly defined affected sibling pairs (DSM-IV BPI, SABP, BPII, BPNOS or MDD(R)), approximately two thirds of all families contained at least one other additional typed individual. All individuals were genotyped using 398 highly polymorphic microsatellite markers from Applied Biosystems's Linkage Mapping Set Version 2. The average inter-marker distance was 9.6 cM and the mean heterozygosity was 0.78. Analysis of these data using non-parametric linkage methods (MAPMAKER/SIBS) found no evidence for loci of major effect and no regions reached genome-wide significance for either suggestive or significant linkage. We identified 19 points across the genome where the MLS exceeded a value set for follow up in our second stage screen (MLS > or = 0.74 (equivalent to a nominal pointwise significance of 5%) under the narrowest diagnostic model). These points were on chromosomes 2, 3, 4, 6, 7, 9, 10, 12, 17, 18 & X. Some of these points overlapped with previous linkage reports both within bipolar affective disorder and other psychiatric illnesses. Under the narrowest diagnostic model, the single most significant multipoint linkage was on chromosome 18 at marker D18S452 (MLS=1.54). Overall the highest MLS was 1.70 on chromosome 2 at marker D2S125, under the broadest diagnostic model.