Healthcare professionals' perspectives on use of PCSK9 inhibitors in cardiovascular disease: an in-depth qualitative study.

AIM: Injectable medicines such as PCSK-9 inhibitors are increasingly used to manage risk factors for cardiovascular events with little information around the perceptions of healthcare professionals (HCPs) on the administrative and clinical practicalities. The aim was to identify the facilitators and barriers on the use of injectable therapies with CV benefits through interviews with HCPs. METHODS AND RESULTS: Qualitative interviews were conducted in the United Kingdom (London and Leeds) and Italy (Rome and Milan) in 2021. Coding was undertaken using NVivo and thematic analysis performed. A total of 38 HCPs were interviewed, 19 in each country composing of physicians (n = 18), pharmacists (n = 10), nurses (n = 9) and pharmacy technician (n = 1). Four themes emerged: (i) Clinicians' previous experiences with injectable therapies (ii) Challenges with patients' behaviours and beliefs (iii) Clinicians' knowledge of injectable therapies and therapeutic inertia and (iv) Organisational and governance issues. The behaviour and beliefs from healthcare professionals focused on facilitating behaviour change as well as the poor interdisciplinary working and collaboration. Therapeutic inertia was raised where physicians either lacked awareness of injectable therapies or were unwilling to prescribe them. The importance of facilitating patient education on injection techniques was highlighted while organisational and governance issues identified the lack of guidance to inform practice. Clear pathways are required to identify those who were eligible for injectable therapies as well as on how injectables should be prescribed. CONCLUSION: If medicine optimisation is to be achieved, there needs to be structured processes in place to identify eligible patients and the development of educational material.

Patients' perceptions on the facilitators and barriers using injectable therapies in dyslipidaemia: An empirical qualitative descriptive international study.

BACKGROUND: Injectable medicines are increasingly used to manage abnormal levels of lipids, which is a major risk factor for cardiovascular events. Enhancing our understanding of patients' perceptions of these injectables, can inform practice with the aim of increasing uptake and medication adherence. AIM: To explore patient's experiences of using injectables and to identify potential facilitators and barriers to using injectable therapies in dyslipidaemia. DESIGN: A qualitative descriptive study using semi-structured interviews was conducted with patients who were using injectables to manage their cardiovascular conditions. METHODS: A total of 56 patients, 30 from the United Kingdom and 26 from Italy, were interviewed online from November 2020 to June 2021. Interviews were transcribed and schematic content analysis performed. RESULTS: Four distinct themes emerged from interviews with patients and caregivers: (i) Their behaviours and personal beliefs; (ii) Knowledge and education about injectable medication; (iii) Clinical skills and previous experiences and (iv) Organizational and governance. Participants expressed initial fears such as needle phobia, and their concerns about commencing therapy were compounded by a lack of accessible information. However, patients' pre-existing knowledge of lipid lowering medication, previous experience with statins and history of adverse side effects informed their decision-making regarding using injectables. Organization and governance-related issues were primarily around the distribution and management of medication supply within primary care, and the lack of a standardized clinical support monitoring system. CONCLUSION: Changes are needed in clinical practice to better educate and support patients to improve the uptake of injectables and optimize their use of these medications in the management of dyslipidaemia. IMPACT: This study suggests that injectable therapies were acceptable to people with cardiovascular disease. However, healthcare professionals need to play a key role in improving education and providing support to aid patients' decision-making regarding commencing and adhering to injectable therapies. REPORTING METHOD: The study adhered to the Consolidated Criteria for Reporting Qualitative Research. PATIENT OR PUBLIC CONTRIBUTION: There was no patient or public contribution.

Multimorbid management in atrial fibrillation: The Polish perspective in the EHRA-PATHS study.

BACKGROUND: Atrial fibrillation (AF) is the most common arrhythmia and places a significant burden on individuals as well as the healthcare system. AF management requires a multidisciplinary approach in which tackling comorbidities is an important aspect. AIMS: To evaluate how multimorbidity is currently assessed and managed and to determine if interdisciplinary care is undertaken. METHODS: A 21-item online survey was undertaken over four weeks as part of the EHRA-PATHS study examining comorbidities in Atrial Fibrillation and distributed to European Heart Rhythm Association members in Europe. RESULTS: A total of 341 eligible responses were received of which 35 (10%) were from Polish physicians. Compared to other European locations, the rates of specialist services and referrals varied but were not significantly different. However, there were higher numbers of specialised services reported in Poland compared to the rest of Europe for hypertension (57% vs. 37%; P = 0.02) and palpitations/arrhythmias (63% vs. 41%; P = 0.01) and the rates of sleep apnea services tended to be lower (20% vs. 34%; P = 0.10) and comprehensive geriatric care (14% vs. 36%; P = 0.01). The only statistical difference between Poland and the rest of Europe in reasons for referral rates was the barrier relating to insurance and financial reasons (31% vs. 11%; P <0.01, respectively). CONCLUSIONS: There is a clear need for an integrated approach to patients with AF and associated comorbidities. Prepardeness of Polish physicians to deliver such care seems to be similar to other European countries but may be hampered by financial obstacles.

Research placements: are they a suitable alternative for student nurses?

COVID-19 has affected those undertaking courses in higher education, especially programmes in health care with clinical placements. Many student nurses were unable to undertake their planned clinical placements and had to adjust to self-directed learning and an increase in simulated learning. As a suitable alternative to clinical placements, a research placement for two second-year BSc adult nursing students was trialled, and this article presents an account from one placement. The academic team devised specific questions for students to consider for their research electives and provided a template for their written work with the aim of writing up a weekly report to reflect their learning. In particular, the students had to identify how their learning related to the UK Nursing and Midwifery Council code of conduct. The research placement was successful and shows great potential, offering students tangible opportunities to seek out the evidence for themselves and use it to inform their clinical practice.

Advanced practice and clinical supervision: An exploration of perceived facilitators and barriers in practice.

AIM AND OBJECTIVES: The aim of this study was to investigate current advanced practice Masters students' experience of clinical supervision, to explore how clinical supervision works in practice and to identify students' perceptions of the facilitators and barriers to clinical supervision in their workplace. BACKGROUND: Advanced practitioners, and in particular nurses, play a pivotal role in delivering health care across acute and primary care settings. These non-medical professionals fulfil a rapidly expanding proportion of roles traditionally undertaken by medically qualified staff within the National Health Service in the United Kingdom and often lead specialist clinics and services. To prepare for the advanced practice role, individuals are required to undertake a Master's in advanced practice to develop the required skills and knowledge and work in clinical practice with a clinical assessor/supervisor to demonstrate competence and performance. DESIGN: A mixed method study using an online descriptive cross-sectional survey and qualitative data were collected via focus groups and has been reported using the Good Reporting of a Mixed Methods Study checklist. RESULTS: A total of 79 students completed the online survey (from 145 AP students), a response rate of 55%. Most respondents were nurses (n = 73) with 49 (62%) in a formal advanced practice trainee role, and the majority believed their clinical supervisor had a good understanding of advanced practice and the advanced practice role. Two focus groups were held with 16 participants in total. Thematic analysis revealed five themes: (a) perceived level and amount of support from clinical supervisors, (b) skill level of clinical supervisors, (c) physicians and their perceptions on supervising, Advanced practitioners (d) clinical supervisors' preparation for the role and (e) transition from trainee to qualified advanced practitioner. CONCLUSION: The survey revealed that advanced practitioner students perceived that clinical supervisors and workplace colleagues had a good understanding of the advanced practice role with good levels of support in practice. A more coherent approach is required for clinical supervision and an implementation framework that can be formally evaluated. RELEVANCE TO CLINICAL PRACTICE: Several significant barriers to clinical supervision for advanced practitioner students were identified, and there are currently more barriers (including COVID-19) than facilitators.

The complex pathophysiology of cardiac cachexia: A review of current pathophysiology and implications for clinical practice.

Cardiac cachexia is a muscle wasting process that often develops in those with chronic heart failure resulting in weight loss, low levels of physical activity, reduced quality of life, and is associated with a poor prognosis. The pathology of cardiac cachexia is complex with new evidence emerging that implicates several body systems. This review describes the pathophysiology associated with cardiac cachexia and addresses: 1) hormonal changes- neurohormonal abnormalities and metabolic hormone imbalance; 2) mechanisms of muscle wasting in cardiac cachexia, and the integral mechanisms between changed hormones due to cardiac cachexia and muscle wasting processes, and 3) associated abnormalities of gastrointestinal system that contribute to cardiac cachexia. These pleiotropic mechanisms demonstrate the intricate interplay between the affected systems and account for why cardiac cachexia is difficult to manage clinically. This review summarises current pathophysiology of cardiac cachexia and highlights symptoms of cardiac cachexia, implications for clinical practice and research gaps.

A Current Review of the Uses of Bioelectrical Impedance Analysis and Bioelectrical Impedance Vector Analysis in Acute and Chronic Heart Failure Patients: An Under-valued Resource?

BACKGROUND: There is a need to detect and prevent fluid overload and malnutrition in heart failure. Bioelectrical impedance analysis and bioelectrical impedance vector analysis are medical instruments that can advance heart failure management by generating values of body composition and body water, assisting clinicians to detect fluid and nutritional status. However, there is a lack of evidence to summarise how they have been used among heart failure patients. METHOD: A systematic search was conducted. RESULT: Two hundred and four papers were screened. Forty-eight papers were reviewed, and 46 papers were included in this review. The literature shows that bioelectrical impedance analysis and bioelectrical impedance vector analysis were mostly used to assess fluid and nutritional status, together with diagnostic and prognostic values. Contraindication of using BIA and implications for practice are also demonstrated. CONCLUSION: The findings suggest that bioelectrical impedance vector analysis is superior to bioelectrical impedance analysis when assessing hydration/nutritional status in heart failure. Assessing a patient using bioelectrical impedance analysis /bioelectrical impedance vector analysis, together with natriuretic peptide -heart failure biomarkers, increases the diagnostic accuracy of heart failure. Further studies are required to examine the cost effectiveness of using these instruments in clinical practice.

Advanced Practice Nursing Roles: A Comparison Between Mexico and the United Kingdom.

The COVID-19 pandemic has placed nursing at the forefront of public attention across the globe and has highlighted the critical role of nursing in healthcare service provision. Advanced practice nursing has been recognized for more than 50 years, but the rate of its growth and development varies significantly across the world. One of the key aims of the Better Health Programme Mexico, which commenced in 2019, was to develop advanced practice nursing in Mexico. The Programme was based on the United Kingdom model, where advanced practice nursing has been in place-though not subject to statutory regulation-for more than 40 years. The aim of this article is to compare the frameworks that underpin advanced practice nursing in the United Kingdom and in Mexico. In the present article, current practice in both countries was researched, and the structure, systems, and processes relating to nursing regulation and the frameworks to support advanced practice nursing were examined. A gap analysis report undertaken as part of the Better Health Programme identified challenges in developing advanced practice nursing in Mexico and the United Kingdom and highlighted the need for stakeholders to agree on an approach toward a rigorous regulatory framework in both settings. In summary, this article highlights the issues facing nurses and regulators in both countries in terms of advanced practice nursing and identifies strategies that can be used to strengthen the advanced practice nurse role.

What do cardiac surgical assistants in the Kingdom of Saudi Arabia think about their job? A cross-sectional survey of job and work characteristics.

Concerns about job design of the cardiac surgical assistant workforce such as role autonomy and job dissatisfaction have been outlined in the literature, although scant empirical research has examined these concerns from the perspective of cardiac surgical assistants themselves. This study surveyed the job design of cardiac surgical assistants in the Kingdom of Saudi Arabia using Morgeson and Humphrey's Work Design Questionnaire. All scalable items within the questionnaire were reported as satisfactory except for 'autonomy', 'task identity', 'feedback from the job', 'job complexity', 'social support', 'feedback from others', 'ergonomic' and 'work condition'. The results provide insight into aspects of cardiac surgical assistants' role characteristics and contribute to the body of knowledge about their organisational psychology. Given the growth of cardiothoracic operations, the role of the surgical care assistant needs to be further developed to address the job design issues raised.

Perceptions of injectable therapies with cardiovascular benefit: an ACNAP survey of healthcare professionals to explore facilitators and barriers.

AIMS: Injectable medicines are increasingly used to manage risk factors for cardiovascular (CV) events, such as dyslipidaemia and diabetes. These include proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists. Little is known about perceptions of injectable therapies among CV healthcare professionals (HCPs). This study explores their views to identify relevant facilitators and barriers to the use of injectables with CV benefit. METHODS AND RESULTS: A 22-question survey was distributed internationally via online channels. In total, 192 anonymous responses were received (43.7% physicians, 32.6% nurses, 16.8% pharmacists, 6.8% others). Among respondents with experience of these medicines, 69.1% had used an injectable PCSK9 inhibitor and 67.0% had used an injectable GLP-1 receptor agonist. Commonly raised issues were resource problems (36.5%), lack of knowledge among colleagues (32.3%), paperwork (32.3%), and lack of patient knowledge (28.1%). Key barriers respondents felt made patients decline these treatments were fear of injection (56.6%), lack of awareness or education (26.4%), and administration issues (15.1%); potential reasons for discontinuation included side effects (46.4%), perceived lack of benefit (28.6%), and local reactions (21.4%). The main topics around injectables requiring further support included managing non-adherent patients (16.2%), troubleshooting with patients (16.2%), and educating colleagues about injectables (12.2%). Preferred educational methods to support HCPs were face-to-face training (43.5%) and online learning (26.1%); favoured formats were based on role playing and case studies. CONCLUSION: Healthcare professionals highlighted various potential barriers to initiation, continuation, and adherence with injectable therapies in CV medicine. Although some require healthcare system changes, many could be addressed through simple measures based primarily on enhanced training and support for patients and HCPs.

Obstructive sleep apnoea testing and management in atrial fibrillation patients: a joint survey by the European Heart Rhythm Association (EHRA) and the Association of Cardiovascular Nurses and Allied Professions (ACNAP).

Obstructive sleep apnoea (OSA) is highly prevalent in atrial fibrillation (AF) patients and associated with reduced response to rhythm control strategies. However, there is no practical guidance on testing for OSA in AF patients and for OSA treatment implementation. We sought to evaluate current practices and identify challenges of OSA management in AF. A descriptive cross-sectional study was performed with a content-validated survey to evaluate OSA management in AF by healthcare practitioners. Survey review, editing, and dissemination occurred via the European Heart Rhythm Association and the Association of Cardiovascular Nursing and Allied Professions and direct contact with arrhythmia centres. In total, 186 responses were collected. OSA-related symptoms were ranked as the most important reason to test for OSA in AF patients. The majority (67.7%) indicated that cardiologists perform 'ad-hoc' referrals. Only 11.3% initiated systematic testing by home sleep test or respiratory polygraphy and in addition, 10.8% had a structured OSA assessment pathway in place at the cardiology department. Only 6.7% of the respondents indicated that they test >70% of their AF patients for OSA as a component of rhythm control therapy. Various barriers were reported: no established collaboration between cardiology and sleep clinic (35.6%); lack in skills and knowledge (23.6%); lack of financial (23.6%) and personnel-related resources (21.3%). Structured testing for OSA occurs in the minority of AF patients. Centres apply varying methods. There is an urgent need for increased awareness and standardized pathways to allow OSA testing and treatment integration in the management of AF.

An integrative review on facilitators and barriers in delivering and managing injectable therapies in chronic conditions: A part of the ACNAP project 'injectable medicines among patients with cardiovascular conditions'.

INTRODUCTION: Although preventive health and therapeutics have benefited from advances in drug development and device innovation, translating these evidence-based treatments into real-world practice remains challenging. AIM: The current integrative review aims to identify facilitators and barriers and perceptions in delivering and managing injectable therapies from patient perspectives. METHODS: An integrative review was conducted in the databases of PubMed, CINAHL, PsycINFO and Cochrane. Keywords were used "Injectable therapy", "IV therapy", "SC therapy", "long term injectable therapies", "self-administered injectable therapy", "patients", "caregivers", "family", "carers", "facilitators", "barriers", "perspectives", "needs", "expectations", "chronic disease", "cardiovascular disease" linked with the words "OR" and "AND". The search was limited from January 2000 to July 2019. Inclusion and exclusion criteria were used. RESULTS: Twenty studies were identified from the literature search. Studies followed qualitative, quantitative methodology and mixed methods. Facilitators included: health improvement, prevention of disease complications, taking control of their disease, effectiveness of the medication and convenience in management. Barriers included: fear of needles, insulin will cause harm, poor perception of the benefits of injectable therapies on their quality of life, inconvenience in self-management, social stigma, impact on daily living, financial barriers, lack of education. Perceptions included: 'treatment of last resort', 'life becomes less flexible', 'injectables were punishment/restriction', 'personal failure of self-management'. CONCLUSION: Evidence shows how to create effective communication and shared decision-making relationships to provide best possible care to patients who need injectable therapy and support for self-management. Future research might help guide response to the fears and barriers of the patients using patients' perspectives.

Still too noisy - An audit of sleep quality in trauma and orthopaedic patients.

INTRODUCTION: An adequate amount of sleep is fundamental to health and well-being, especially for individuals recovering from an illness or injury. Trauma patients sustain musculoskeletal and tissue injuries and require a sufficient amount of sleep to promote recovery. However, it is known that patients can face difficulties sleeping in hospitals which impacts on their recovery. AIM: To determine the quality of sleep, influence of sleep quality and the impact of sleep quality on recovery in trauma and orthopaedic patients. METHODOLOGY: An exploratory descriptive design was applied using a clinical audit. As no standardised sleep assessment tool was identified, a sleep audit tool was developed. FINDINGS: A total of 40 patients were recruited from two trauma and orthopaedic wards from a London Hospital in the United Kingdom. Of these 17 patients (43%) rated the quality of sleep as 'poor' and nearly half (n = 19, 46%) reported that the quality of their night-time sleep had affected their recovery. Two-thirds of patients reported noise was the main factor that disrupted their sleep, making it the highest contributing sleep disruptor (n = 26, 65%). CONCLUSION: A significant association between poor quality of sleep and patient recovery was identified in this small sample of trauma and orthopaedic patients. The findings suggest that nurses should try to create a suitable sleeping environment to enhance patient recovery. There is a need for a standardised sleep assessment tool and sleep audit tool so that the quality of patients' sleep can be accurately assessed and documented.

Evaluating the extent of patient-centred care in a selection of ESC guidelines.

AIMS: Patient-centred care (PCC) is the cornerstone for healthcare professionals to promote high quality care for patients with cardiovascular conditions. It is defined as 'Providing care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions'. PCC can improve patient outcomes and allow patients and healthcare professionals to manage care collaboratively using best available evidence. However, there is no clear understanding how extensively guidelines incorporate PCC recommendations. The aim of the study was to evaluate the incorporation of PCC into a selection of guidelines published by the European Society of Cardiology (ESC). METHODS AND RESULTS: Using a narrative literature review and expert consensus, the Science Committee within the Association of Cardiovascular Nursing and Allied Professions (ACNAP) developed a checklist to determine PCC incorporation in clinical guidelines. Nine ESC guidelines were reviewed, with committee members independently evaluating five PCC aspects: patient voice and involvement, multidisciplinary involvement, holistic care recommendations, flexibility to meet patients' needs, and provision of patient tools. The level of congruence in item ratings by experts was then compared. The incorporation of PCC using these respective five categories, ranged from 4% (patient tools) to 53% in the 'multidisciplinary involvement' category. CONCLUSION: Overall, the inclusion of PCC was low, indicating that patient perspectives and needs were less likely to be taken into account when developing, endorsing, or formulating recommendations. Future development of guidelines should ensure better incorporation of patients' perspective, in particular, and other PCC aspects highlighted in this study.

A rapid review of educational preparedness of advanced clinical practitioners.

AIM: The aim of this study was to synthesize available data on current educational provision related to preparation for the advanced clinical practice role. DESIGN: A mixed methods rapid review of the literature. DATA SOURCES: A search of Ovid Medline and Ovid EMBASE for English language papers published 2006-2018 resulted in 38 publications, which met the criteria for inclusion. REVIEW METHODS: Using Tricco's seven-stage process, following an identification of relevant papers and data extraction, a data-based convergent synthesis was used to convert quantitative papers into qualitative data prior to completing a narrative synthesis. RESULTS: The four themes identified from data synthesis were consolidation; theory to practice gap; competency and mentoring. A lack of preparedness for new advanced clinical practitioners completing an educational programme was noted with a need identified for a clinically focussed consolidation period to enable practitioners to develop their skills under supervision in the clinical environment. CONCLUSION: As the needs for different models of health care evolve with the expansion of advanced practice, appropriate education and clinical supervision are important aspects in the delivery of programmes that allow individuals to be competent and confident practitioners providing safe and effective health care. IMPACT: There is a paucity of papers on educational preparedness of advanced clinical practitioners. Our findings demonstrate a lack of preparedness and the need for a clinically focussed consolidation period with good role models and mentors following completion of a Master's programme. Employers and higher education institutions need to ensure a protected period of time is available for newly qualified advanced clinical practitioners to allow consolidation of clinical practice.

Does the @home team reduce local Emergency Department attendances? The experience of one London service.

BACKGROUND: Since 2014, the @home team has been offering patients acute care in their own homes using a multi-disciplinary team with the aim of preventing some Emergency Department (ED) attendances, facilitating early discharges, and preventing acute admissions. By preventing some ED attendances, the @home team aims to contribute to the performance of the two local EDs, both of which are currently failing to meet the ED 4-h operational target. OBJECTIVES: To determine if the @home team reduces ED attendances locally, and if so, by how much, and whether this impacted on the 4-h operational target. METHODS: The number of @home referrals that were prevented from attending either St Thomas's or King's College Hospital EDs was audited using a specially developed audit tool and spatial analysis performed, mapping the home locations of patients referred, and using 'nearest neighbour analysis' to determine the number and percentage of @home referrals prevented from attending the two local EDs. RESULTS: A total of 1084 patients were referred to the @home team in a 3-month period with 755 (72%) referrals accepted. Using Geo-codable data, 387 local ED attendances were prevented (298 from King's College Hospital and 89 from St Thomas's Hospital ED). Over the same time period, King's College Hospital had 71,688 ED attendances and St Thomas's ED had 48,030 attendances. CONCLUSIONS: Although the @home team reduces a small number of ED attendances each month (1 in 300), this number is not high enough to make a significant impact on average performance against the 4-h target at the local EDs alone.

Patient satisfaction with a hospital-in-the-home service.

The hospital-in-the-home (HitH) model is an alternative model of healthcare that allows patients to return home and receive short-term treatment in a familiar environment. The objective of the present study was to evaluate patient satisfaction with the GSTT@home service in the London boroughs of Southwark and Lambeth. A questionnaire comprising 20 questions was developed with 5-point Likert response and free text options. A total of 1426 questionnaires were distributed, of which 206 (14%) were returned. The majority of respondents said they would recommend the @home service (n=200, 97%) and were very satisfied or satisfied with the service (n=203, 99%). Only 48 respondents provided qualitative free text comments, and overall, these were very positive and supportive of the @home service. The findings support the benefits of the @home model of care from the patients' perspective.