Examining factors associated with excess mortality in older people (age ≥ 70 years) with diabetes - a 10-year cohort study of older people with and without diabetes.

AIMS: To compare all-cause mortality in older people with or without diabetes and consider the associated risk of comorbidity and polypharmacy. METHODS: A 10-year cohort study using data from the Health Innovation Network database (2003-2013) comparing mortality in people aged ≥ 70 years with diabetes (DM cohort) (n = 35 717) and without diabetes (No DM cohort) (n = 307 918). RESULTS: The mean age of the DM cohort was 78.1 ± 5.8 years vs. 79.0 ± 6.3 years in the No DM cohort. Mean diabetes duration was 8.2 ± 8.1 years, and 30% had diabetes for > 10 years. The DM cohort had a greater comorbidity load and people in this cohort were prescribed more therapies than the No DM cohort. The 5- and 10-year survival rates were lower in the DM cohort at 64% and 39%, respectively, compared with 72% and 50% in the No DM cohort. The excess mortality in the DM cohort was greatest in those aged < 75 years with longer duration diabetes, the relative hazard for mortality was higher in females. Although comorbidity and polypharmacy were associated with increased mortality risk in the DM cohort, this risk was lower compared with the No DM cohort. The hazard ratios (95% confidence interval) for comorbidities > 4 and medicines ≥ 7 were 1.29 (1.19 to 1.41) and 1.34 (1.25 to 1.43) in the DM cohort and 1.63 (1.57 to 1.70) and 1.48 (1.40 to 1.56) in the No DM cohort, respectively. CONCLUSIONS: There is significant excess mortality in older people with diabetes, which is unexplained by comorbidity or polypharmacy. This excess is greatest in the younger old with longer disease duration, suggesting that it may be related to the effect of diabetes exposure.

A prospective randomized controlled study of a virtual clinic integrating primary and specialist care for patients with Type 2 diabetes mellitus.

AIMS: To investigate the effectiveness of a diabetes virtual clinic to enhance diabetes in primary care by developing clinical management plans for patients with suboptimal metabolic control and/or case complexity. METHODS: A prospective study with randomized allocation to virtual clinic or usual care. Patients with Type 2 diabetes (n = 208) were recruited from six general practices in South London. The primary outcome for the study was glycaemic control, secondary outcomes included: lipids, blood pressure, weight (kg and BMI) and renal function (eGFR). Data were collected from participants' records at baseline and 12 months. We also considered process measures including therapy optimization. RESULTS: The 12-month data show equivalence between the virtual clinic and control groups for glycaemic control with both achieving clinically significant reductions in HbA1c of 8 mmol/mol (0.6 ± 1.7%) and 10 mmol/mol (0.8 ± 1.9%), respectively (P = 0.4). The virtual clinic group showed superiority over the intervention group for blood pressure control with a mean reduction in systolic blood pressure of 6 ± 16 mmHg compared with an increased of 2 ± 18 mmHg in the control group (P = 0.008). There were no significant differences between the groups in terms of cholesterol, weight and renal function. Process measures showed an increased level of therapy adjustment in the virtual clinic group. CONCLUSION: The virtual clinic model explored in this study showed a clinically important improvement in glycaemic control. Although this improvement was not superior to that observed in the control participants, this might be attributable to the systemic impact of the virtual clinic on the practice as a whole.

Enhancing the experience of carers in the chemotherapy outpatient setting: an exploratory randomised controlled trial to test impact, acceptability and feasibility of a complex intervention co-designed by carers and staff.

PURPOSE: Supporting someone through chemotherapy can be emotionally and physically demanding. However, research has yet to establish the type of support carers require or the best way to provide this. This study tested the feasibility and acceptability of a complex intervention for carers that was co-designed by staff and carers of patients starting chemotherapy. METHODS: Forty-seven carers were recruited, randomised between the intervention (n = 24) and control (n = 23) groups. A questionnaire was completed pre- and post-intervention measuring knowledge of chemotherapy and its side effects, experience of care, satisfaction with outpatient services, coping and emotional wellbeing. The intervention process was evaluated by carers and healthcare professionals (HCPs) in focus groups. RESULTS: Recruitment to the study was unproblematic and attrition from it was low, suggesting the intervention and study processes were acceptable to patients and carers. Carers in receipt of the 'Take Care' intervention reported statistically significantly better understanding of symptoms and side effects and their information needs being more frequently met than carers in the control. Confidence in coping improved between baseline and follow-up for the intervention group and declined for the control although differences were insufficient to achieve statistical significance. There was no significant difference between the two groups' emotional wellbeing. HCP and carer focus groups confirmed the feasibility and acceptability of the intervention. CONCLUSIONS: The 'Take Care' intervention proved acceptable to carers and HCPs and demonstrates considerable promise and utility in practice. Study findings support the conduct of a fully powered RCT to determine the intervention's effectiveness and cost-effectiveness.

Epidemiology of adolescent substance use in Norfolk schools.

BACKGROUND: The pattern of alcohol and substance use is changing, with the introduction of novel psychoactive substances, the internet as a means of acquisition and variations in drug purity and price. Alcohol and substance use among adolescents is associated with behavioural, mental health, health and social difficulties; arising at a vulnerable period in their development. Little is known about adolescent substance use in the UK, especially in rural areas. AIM: To investigate the prevalence of substance use amongst young people, aged 16-21 years, in Norfolk schools. DESIGN: Cross sectional questionnaire survey. METHOD: Pupils from two, sixth form colleges in Norfolk answered a self-report questionnaire designed to measure prevalence, age of onset and frequency of use for alcohol, tobacco, illicit substances including new psychoactive substances as well as demographic data. RESULTS: A total of 482 students completed the survey (68% participation rate). Life-time use of alcohol was reported by 442 (91.7%) students and over half the pupils had tried tobacco (52.5%, n=253). About 40.7% reported cannabis use and nearly one-fifth (18.9%, n=91) reported using 3,4-methylenedioxymethamphetamine (MDMA); 41.1% (n=198) students reported using 'any drug' and 23.2% (n=112) 'using an illicit drug other than cannabis' and 8.7% (n=42) reported the use of a novel psychoactive substance. CONCLUSION: The most widely used substances were alcohol, tobaccos and cannabis; in keeping with European trends. Over the past decade a decline in alcohol and drug use by adolescents has been seen in the UK. However, since 2010 this decline has slowed with an increase in substance use noted in the past 2 years. This study provides evidence to support this trend. The findings demonstrate differences between the use of substances by pupils in this Norfolk sample compared to national surveys and more urbanized areas. These regional differences can be used to assist the development of local interventions targeting substance use among adolescents.

How mental health nursing can best improve service users' experiences and outcomes in inpatient settings: responses to a national consultation.

Despite a number of national developments in the past few years, concerns remain about the experience and outcomes for service users in inpatient care settings. As part of a national review of mental health nursing in England, a consultation exercise was carried out to ascertain the opinions of a wide range of stakeholders in order to inform subsequent recommendations. The consultation question specifically related to inpatient care was 'How can mental health nurses best improve service users' experiences, and outcomes, in inpatient care settings?' The consultation generated a total of 326 written responses, mostly from groups and organizations. Responses were subject to content analysis and the three largest categories were 'Service users influencing services' (n = 80, 31%), 'Service users involved in own care' (n = 74, 29%) and 'Direct clinical time' (n = 68, 26%), including respondents citing the need for protected therapeutic engagement time. Many of the themes raised in the consultation were subsequently reflected in the recommendations made in 'From values to action; the Chief Nursing Officer's review of mental health nursing'.

Healthcare professionals' attitudes, knowledge and self-efficacy levels regarding the use of self-hypnosis in childbirth: A prospective questionnaire survey.

OBJECTIVE: to examine healthcare professionals' attitudes, knowledge and levels of self-efficacy regarding the use of self-hypnosis in childbirth. DESIGN: a prospective survey. SETTING: two large maternity units in London, England. PARTICIPANTS: healthcare professionals (n=129) involved in the care of childbearing women (anaesthetists, midwives and obstetricians). METHODS: online questionnaire assessing healthcare professionals' experience, knowledge, attitudes and self-efficacy relating to self-hypnosis in childbirth. MAIN OUTCOME MEASURES: attitude, self-efficacy and knowledge. FINDINGS: over half of the participants surveyed (56%) reported they had minimal or no knowledge of hypnosis. Higher levels of knowledge were associated with higher levels of self-efficacy (p<0.001) and also with more positive attitudes (p<.001). Midwives reported significantly higher levels of knowledge, more positive attitudes (7.25, 95% CI: 4.60-9.89) and higher levels of self-efficacy (3.48, 95% CI: 1.46-5.51) than doctors. Midwives also reported more exposure to/experience of hypnosis than doctors, and more exposure was significantly associated with higher levels of self-efficacy (midwives p<.001; doctors p=.001). Professionals who would plan to use self-hypnosis in their own or partners' births had significantly higher self-efficacy scores (p<.001). KEY CONCLUSIONS: if healthcare professionals are to effectively support women using self-hypnosis in childbirth, they need to be confident in their ability to facilitate this method. Previous research has established that self-efficacy is a strong indicator of performance. IMPLICATIONS FOR PRACTICE: Professionals with more knowledge of self-hypnosis are also more confident in supporting women using this technique in childbirth. Multi-disciplinary staff training which aims to increase knowledge, and which includes exposure to hypnosis in labour, may be beneficial in assisting staff to support women choosing to use self-hypnosis in labour.

The contribution of clinical and psychosocial factors to fatigue in 182 patients with inflammatory bowel disease: a cross-sectional study.

BACKGROUND: Fatigue is a frequently reported and predominant symptom experienced by patients with inflammatory bowel disease (IBD) and its impact has been associated with poorer quality of life (QoL). The complex interplay between disease-related variables and potentially modifiable psychosocial factors in IBD-fatigue has yet to be unravelled. AIM: To evaluate the contribution of clinical, sociodemographic and psychosocial factors to the severity and impact of IBD-fatigue and QoL. METHOD: In a cross-sectional study, 182 patients with IBD were recruited from three tertiary referral hospitals' out-patient clinics in London. Fatigue was assessed utilising the Inflammatory Bowel Disease-Fatigue Scale (IBD-F), the Multidimensional Fatigue Inventory (MFI); and QoL by the Inflammatory Bowel Disease Questionnaire (IBDQ). Patients completed self-report questionnaires evaluating emotional, cognitive and behavioural factors potentially correlated with fatigue. Sociodemographic data were collected. Disease-related and laboratory data were retrieved from patients' hospital electronic medical records. RESULT: In hierarchical regression models, disease activity was the only clinical factor consistently associated with severity and impact of fatigue and QoL (P = 0.01). More negative fatigue perceptions were significantly associated with greater IBD-F1 scores (P = 0.01). When controlling for clinical factors (disease activity and anti-TNF therapy), negative perceptions of fatigue, and all-or-nothing and avoidance behaviours explained an additional 41% of the variance in fatigue impact (IBD-F2). CONCLUSIONS: Apart from disease activity, emotional and behavioural factors and patients' negative fatigue perceptions may be key factors to be addressed. Further exploration of these factors in longitudinal and intervention studies may help to develop effective models of fatigue management.

Changes in blood pressure and body weight over ten years in men selected for glucose intolerance.

Relative changes in body weight and blood pressure over ten years of observation are reported in men recruited for a trial of therapy in relation to the natural history of glucose intolerance. Half were recommended a diet restricting carbohydrate to 120 g daily (diet group) and half were recommended to 'limit use of table sugar' (no diet). In both groups average weight and blood pressure fell over the 12 to 18 months after treatment allocation, the decline being proportionately greater for both variables in the diet group. Subsequently, average weight remained constant up to the end of the ten year study, but blood pressure levels rose, though remaining below baseline levels in the diet group. Statistical analysis of changes in blood pressure and weight between initial (pre-treatment) and third follow-up visit measurement indicated that the proportional change in blood pressure was related principally to change in weight, with little relation to initial level of blood pressure. Although a reduction in weight results in a fall in blood pressure, it does not necessarily prevent a subsequent age related increase in blood pressure.

Month of birth of men with malignant germ cell tumours of the testis.

A recent paper has suggested that there is a temporal cycle in birth rates of men with testis cancer with a peak in April/May. We have investigated the suggestion using data from the South Thames and Los Angeles cancer registries. There is some slight evidence of a peak in August, which is confined to teratomas. The effects demonstrated are, however, too small and inconsistent to provide any real clue to the aetiology of testis cancer.

Aetiological factors in cutaneous malignant melanomas seen at a UK skin clinic.

A clinic-based case-control study was set up in 1961 to examine a variety of aetiological factors in malignant melanoma cases compared with controls with other non-malignant skin conditions. The 268 cases and 1577 controls showed odds ratios of 1.9 for red hair, 2.0 for skin that burns in the sun, and no difference between indoor and outdoor workers or between Celts and other Europeans, consistent with the results of more recent studies. Exposure to 16 specific chemicals was recorded in the study and, among these, men exposed to cutting oils were found to have a significantly raised odds ratio of 1.91. Other statistically significant findings were an elevated risk among women diabetics, particularly in the postmenopausal age group, and a reduced risk of 0.7 among cigarette smokers.

Developing a career in the mental health services: guidance for student nurses.

Current concern about a shortage of nurses has led to attention focusing on the provision of career guidance as a strategy to facilitate retention in the workforce. This paper presents findings on career guidance provided for psychiatric nursing students, and thus adds to the very small volume of research that exists on guidance in nursing generally. Questionnaires were sent to 556 Registered Mental Nurses shortly after qualification; 80% responded. This represented the first phase of a longitudinal study of these nurses' careers. Participants were asked whether they had received information about career pathways that might be pursued, educational opportunities available and work experience outside the NHS. If not they were asked whether they had wanted such information. They were also asked whether they had been given advice about planning their own career. Only a minority of respondents had received information or advice, but the majority would have liked to have done so. The findings are discussed in the context of whether there is a need for career guidance and, if so, by whom it should be provided.

Deciding to pursue nurse education: sources of information, influence and encouragement.

Current concerns about a shortage of nurses means attention may again be focusing on recruitment strategies. This paper presents findings on aspects of the decision to take nurse training, and contributes to available information upon which recruitment strategies can be formulated. Questionnaires were sent to 1164 registered general nurses shortly after qualification; this represented the first phase of a longitudinal study of these nurses' careers. Participants were asked about the effect of the following on their decision to take nurse training: written information about nursing; discussions with staff of educational institutions; personal involvement in health care work or caring activities, and having relatives qualified in health care. Findings for the 87% who returned the questionnaire, showed that respondents were more likely to report that these events had a positive than a negative effect on their decision. Participants were also asked how encouraging educational staff, careers staff, family and friends had been about their decision to take nurse training. The implications of the findings for those responsible for nurse recruitment are discussed.

How new nurses manage work and family responsibilities.

The predominantly female nursing workforce means that issues such as combining work and child care responsibilities are central to people's careers and to workforce planning. A questionnaire survey of newly qualified registered general nurses provided valuable information about the circumstances, experiences and plans of 936 women. Implications for the availability of flexible working, career guidance and opportunities for professional development are discussed.

Research, audit and networking: who's in the lead?

This article compares the progress made by nursing development units compared with matched units without NDU status on research, audit and networking activities. Research and dissemination is significantly greater in NDUs than in comparators. Research in NDUs focuses on local attempts to improve practice and has some way to go before it can be generalised to health care settings beyond the unit where it was carried out. There is no difference in number of audits undertaken by NDUs and comparators but NDUs carried out more audits to evaluate nursing work and comparators did proportionately more on practice topics and user issues. There is no association between research and audit activity; more audit does not result in less research Networking activity by staff is significantly greater for NDUs, suggesting they are seen as a resource for other centres. NDUs are active in research and networking--significantly more so than comparators.

Sampling for a longitudinal study of the careers of nurses qualifying from the English pre-registration Project 2000 diploma course.

This paper describes the processes involved in selecting a sample, from the eight English regional health authorities, of nurse qualifiers from all four branches of the Project 2000 pre-registration diploma course, for a longitudinal study of nurses' careers. A simple random sample was not feasible since accurate information about the population could not be obtained and the study design involved recruiting participants by personal visit. A multi-stage approach was therefore adopted in which 'college of nursing' was taken as the primary sampling unit. Sampling was further complicated by the fact that adult branch students could generally only be visited in larger groups than was ideal. Information obtained during pilot work about the accuracy of data about the population, course completion rates and the proportion of students who were likely to agree to participate was used to calculate required sampling fractions. The final sample was therefore a function of this information and the practicalities of recruiting nurses into the study.

Developing the nursing contribution to the management of the mental health services.

The importance of management and leadership in mental health nursing has been stressed in an extensive review of the role of the profession in the mental health services. Drawing from a longitudinal study of the careers of a cohort of registered mental nurses, this paper presents data relevant to developing the management capability of the profession. The data were obtained from a questionnaire sent to the cohort at qualification, 80% of whom responded. Findings showed that 14% thought that at some stage they would definitely seek a management post and 19% thought it likely. Only 18% had received information during the course about developing a career in management. Sixty-nine per cent of those who had not received such information would have liked to have had some. Just over half (51%) felt that their course had prepared them well for aspects of ward management and 46% held this view in relation to management of other nursing staff. A statistical modelling approach as used to explore the relationships between these three aspects of management and a range of demographic and course perception variables considered as possible predictors of seeking a post in management. These analyses demonstrated that likelihood of seeking such a post was significantly associated with sex of respondent, with receipt of information about developing a career in management, and with being encouraged by the course to want to work as a psychiatric nurse. Strategies to encourage an early orientation towards management posts are considered in the light of the findings.

Getting started: choice and constraint in obtaining a post after qualifying as a registered mental nurse.

AIMS: To explore the extent to which obtaining a post after qualifying as a registered mental nurse (RMN) is a matter of exercising choice or experiencing constraints. BACKGROUND: The paper is drawn from the first phase of a longitudinal study of the careers of RMNs, commissioned in response to concerns about attrition from the mental health nursing workforce. METHODS: Questionnaires were sent to all RMNs (n = 550) qualifying from 3-year and post-registration courses in four regional health authorities; 80% (447) responded. FINDINGS: Some 73% had obtained a National Health Service (NHS) psychiatric nursing post shortly after qualifying; 95% had hoped to do so. Of those with a post, 71% had obtained their first choice of client group. A wide range of professional and personal constraints emerged as affecting job choice; lack of NHS posts in preferred location and/or speciality was cited most often. CONCLUSIONS: Support and guidance may be helpful for nurses experiencing delays in obtaining a post, or who are starting careers in a post which is not their first choice.

Pursuing a career in nursing: differences between men and women qualifying as registered general nurses.

Much interest currently focuses on differences in the career intentions and career pathways of men and women nurses. This study seeks to add to existing knowledge on this subject with findings from a survey of newly qualified registered general nurses. Questionnaires were sent to a cohort of 1164 nurses, 87% of whom responded. Data from the 936 women and 79 men were compared in relation to educational and employment background, routes into nursing and career intentions at qualification. Procedures for modelling of categorical data were applied to these data within the constraints of the study design. Findings showed that men were less likely than women to have entered nursing as a first choice and less likely to intend working in the community after qualification. Men were more likely than women to plan to move out of clinical practice and more likely to plan pursuing a postgraduate qualification. Other differences between men and women were suggested, but limitations of the study design mean that drawing of conclusions had to be more tentative. Consequently, further research on this subject is warranted.

Constructing career pathways in nursing: some issues for research and policy.

Nurses currently construct careers in a climate of continuing occupational and organizational change. A longitudinal project is in progress which is documenting the post-qualification histories of a cohort of registered general nurses, and studying the extent to which their careers represent occupational choice, a response to organizational constraints, or a combination of both. Three elements comprise the core of the research: questions which provide information on the cohort's career plans, charts which document their career histories and questions which explore the relationship between the two. The basis of the design is the first element, and this paper focuses on the problems encountered in designing the questions and routing structures which enabled all cohort members to describe their plans for the future. The importance of extensive pilot work is demonstrated in the development of options tailored for each potential career pathway and to allow expressions of uncertainty to emerge at points when appropriate to respondents. Of the 1164 members of the cohort, 1015 returned the questionnaire; a response rate of 87%. Findings are presented on the cohort's plans at qualification. The majority of respondents (86%) saw themselves as remaining in nursing and in clinical practice in the early post-qualification period. Eighteen per cent said they intended to practise abroad at some point, 30% foresaw a likelihood of working in the private sector, 59% wanted to take one or more English National Board courses and 42% expressed interest in obtaining an undergraduate or postgraduate degree.