Heart failure patients' attitudes, beliefs, expectations and experiences of self-management strategies: a qualitative synthesis.

OBJECTIVES: To develop a model of heart failure patients' attitudes, beliefs, expectations, and experiences based on published qualitative research that could influence the development of self-management strategies. METHODS: A synthesis of 19 qualitative research studies using the method of meta-ethnography. RESULTS: This synthesis offers a conceptual model of the attitudes, beliefs, and expectations of patients with heart failure. Patients experienced a sense of disruption before developing a mental model of heart failure. Patients' reactions included becoming a strategic avoider, a selective denier, a well-intentioned manager, or an advanced self-manager. Patients responded by forming self-management strategies and finally assimilated the strategies into everyday life seeking to feel safe. DISCUSSION: This conceptual model suggests that there are a range of interplaying factors that facilitate the process of developing self-management strategies. Interventions should take into account patients' concepts of heart failure and their subsequent reactions.

What do hospital staff in the UK think are the causes of penicillin medication errors?

BACKGROUND: Medication errors are a potential major threat to patient's health, and allergic reactions occurring in patients with known allergies are an important preventable form of adverse drug event. The use of penicillin antibiotics in patients who are allergic to penicillin, in particular, is a major concern. AIM: To survey staff attitudes and beliefs to incidents involving penicillin allergic patients who are prescribed and administered penicillin antibiotics. SETTING: A 650 bed teaching hospital in England. METHOD: Using individual and (focus) group interview proceedings with a purposive sample of doctors, nurses and pharmacists, an electronic questionnaire was administered hospital wide to all clinical staff. No reminders were issued. MAIN OUTCOME MEASURES: Clinical staff's views on the causes of penicillin medication errors. RESULTS: The electronic survey was completed by 235 members of the clinical staff. Half the respondents definitely considered themselves knowledgeable about which antibiotics contain penicillin medicines, though approximately 90 % of respondents considered that misinformation or lack of knowledge on which antibiotics contain penicillin medicines was an issue for some or most colleagues. Various organisational issues such as the use of red wrist bands, the wearing of red tabards by the nurse during the medicines round, and a busy work environment were recurrently highlighted as systems factors that could be improved upon. CONCLUSION: Our study elucidated concerns amongst clinical staff relating to the scenario of a penicillin allergic patient receiving a penicillin antibiotic. The resulting local learning and feedback about staff beliefs pertaining to this one specific type of error will be used to consider the nature and type of local action to be taken to help improve patient safety.

Influences on older people's decision making regarding choice of topical or oral NSAIDs for knee pain: qualitative study.

OBJECTIVE: To explore the factors that influence older people's decision making regarding use of topical or oral ibuprofen for their knee pain. DESIGN: Qualitative interview study nested within a randomised controlled trial and a patient preference study that compared advice to use oral or topical non-steroidal anti-inflammatory drugs (NSAIDs) for knee pain in older people. SETTING: 11 general practices. PARTICIPANTS: 30 people aged > or =50 with knee pain. RESULTS: Participants' decision making was influenced by their perceptions of the associated risk of adverse effects, presence of other illness, nature of their pain, advice received, and practicality. Although participants' understanding of how the medications worked was sometimes poor their decision making about the use of NSAIDs seemed logical and appropriate. Participants' model for treatment was to use topical NSAIDs for mild, local, and transient pain and oral NSAIDs for moderate to severe, generalised, and constant pain (in the absence of other more serious illness or risk of adverse effects). Participants showed marked tolerance and normalisation of adverse effects. CONCLUSION: Participants had clear ideas about the appropriate use of oral and topical NSAIDs. Taking such views into account when prescribing may improve adherence, judgment of efficacy, and the doctor-patient relationship. Tolerance and normalisation of adverse effects in these patients indicate that closer monitoring of older people who use NSAIDs might be needed.

Back, chest and abdominal pain - is it spinal referred pain?

BACKGROUND: In patients with pain in the back, chest or abdomen, it may be difficult to differentiate nonmusculoskeletal causes from musculoskeletal causes. OBJECTIVE: This article discusses the mechanisms of musculoskeletal referred pain and the key clinical features that help the practitioner differentiate such pain from nonmusculoskeletal pain, thereby informing appropriate management. DISCUSSION: Patterns of pain referred from musculoskeletal structures in the back have been well documented from experimentally induced pain. The key features on history that point to spinal referred pain are pain on movement, tenderness and tightness of musculoskeletal structures at a spinal level supplying the painful area, and an absence or paucity of symptoms suggestive of a nonmusculoskeletal cause. Radiological investigations are often of little value in confirming a musculoskeletal cause. A positive response to therapy directed at the musculoskeletal source supports - but does not prove - a diagnosis of musculoskeletal referred pain.

Homelessness and mental illness: a literature review and a qualitative study of perceptions of the adequacy of care.

BACKGROUND: Homelessness and mental illness together confer significant morbidity and mortality because of physical health problems. Healthcare provision is undergoing significant review, and, as part of the Department of Health's policy reforms, the service user's view is central to the future restructuring of NHS services. MATERIAL: A literature review of homeless service users' perceptions of services for homeless mentally ill people was supplemented by a qualitative in-depth survey of 10 homeless people. This article reports on their views about the services they receive. Mismatch between expectations and provision, disputes with healthcare providers, dissatisfaction with the degree to which they have choice in their care, and suspicions about the intentions of health professionals demonstrate the extent to which powerlessness and social exclusion are replicated in healthcare economies. The inadequacy of hostels and their staff are also emphasised, with some recommendations for services. DISCUSSION AND CONCLUSIONS: There are few data on homeless people's perceptions of services for mental health problems. Homeless people have strong views about the adequacy of services to meet their needs. They were particularly concerned about stigma, prejudice and the inadequacy and complexity of services that they have to use. This article reports their recommendations for change.

TOIB Study. Are topical or oral ibuprofen equally effective for the treatment of chronic knee pain presenting in primary care: a randomised controlled trial with patient preference study. [ISRCTN79353052].

BACKGROUND: Many older people have chronic knee pain. Both topical and oral non- steroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat this. Oral NSAIDS are effective, at least in the short term, but can have severe adverse effects. Topical NSAIDs also appear to be effective, at least in the short term. One might expect topical NSAIDs both to be less effective and to have fewer adverse effects than oral NSAIDs. If topical NSAIDs have fewer adverse effects this may outweigh both the reduction in effectiveness and the higher cost of topical compared to oral treatment. Patient preferences may influence the comparative effectiveness of drugs delivered via different routes. METHODS: TOIB is a randomised trial comparing topical and oral ibuprofen, with a parallel patient preference study. We are recruiting people aged 50 or over with chronic knee pain, from 27 MRC General Practice Research Framework practices across the UK. We are seeking to recruit 283 participants to the RCT and 379 to the PPS. Participants will be followed up for up to two years (with the majority reaching one year). Outcomes will be assessed by postal questionnaire, nurse examination, laboratory tests and medical record searches at one and two years or the end of the study. DISCUSSION: This study will provide new evidence on the overall costs and benefits of treating chronic knee pain with either oral or topical ibuprofen. The use of a patient preference design is unusual, but will allow us to explore how preference influences response to a medication. In addition, it will provide more information on adverse events. This study will provide evidence to inform primary care practitioners, and possibly influence practice.

Treatment and the process of care in musculoskeletal conditions. A multidisciplinary perspective and integration.

Chronic musculoskeletal pain for which there is not an obvious underlying physical cause is one of the most common reasons for long-term disability. There is a need to develop better ways of managing these problems. Improving the understanding of the basis for decision making, the processes of care, and the beliefs and expectations of patients and health care professionals seems as fundamental as basic laboratory science is to understanding inflammatory arthopathies. Little is known about the beliefs and expectations of patients and health care professionals, nor the multitude of factors such as traditions within professional groups, education, and language that professionals use in decision making. When better understanding of these factors and the mismatch between professionals and patients is achieved, then theoretical frameworks, treatment approaches, and the education of professionals in appropriate management will be improved.