Using in situ simulation to improve care of the acutely ill patient by enhancing interprofessional working: a qualitative proof of concept study in primary care in England.

OBJECTIVE: Acutely unwell patients in the primary care setting are uncommon, but their successful management requires involvement from staff (clinical and non-clinical) working as a cohesive team. Despite the advantages of interprofessional education being well documented, there is little research evidence of this within primary care. Enhancing interprofessional working could ultimately improve care of the acutely ill patient. This proof of concept study aimed to develop an in situ simulation of a medical emergency to use within primary care, and assess its acceptability and utility through participants' reported experiences. SETTING: Three research-active General Practices in south east England. Nine staff members per practice consented to participate, representing clinical and non-clinical professions. METHODS: The intervention of an in situ simulation scenario of a cardiac arrest was developed by the research team. For the evaluation, staff participated in individual qualitative semistructured interviews following the in situ simulation: these focused on their experiences of participating, with particular attention on interdisciplinary training and potential future developments of the in situ simulation. RESULTS: The in situ simulation was appropriate for use within the participating General Practices. Qualitative thematic analysis of the interviews identified four themes: (1) apprehension and (un)willing participation, (2) reflection on the simulation design, (3) experiences of the scenario and (4) training. CONCLUSIONS: This study suggests in situ simulation can be an acceptable approach for interdisciplinary team training within primary care, being well-received by practices and staff. This contributes to a fuller understanding of how in situ simulation can benefit both workforce and patients. Future research is needed to further refine the in situ simulation training session.

Understanding alcohol-related liver disease patients' illness beliefs and views about their medicine.

BACKGROUND: people with alcohol-related liver disease require complex treatment plans that often include the need for medication for the rest of their lives. Between 30% and 50% of all patients do not take their treatment as prescribed, leading to a significantly increased risk of morbidity and mortality. AIM: to consider the factors which influence beliefs held by patients with alcohol-related liver disease about their medication to provide an evidence base to support interventions to reduce medication non-adherence. METHOD: an observational cross-sectional patient survey. RESULTS: statistically significant associations were found between positive attitudes towards medication and the illness representation dimensions of 'illness identity' and 'illness comprehension'. CONCLUSIONS: medication adherence in patients with alcohol-related liver disease is likely to be improved by an intervention that strives to improve the patient's understanding of their illness condition and their perception of their illness symptoms.

Predicting and preventing alcohol relapse in alcohol-related liver disease.

BACKGROUND: despite a 450% increase in UK alcohol-related liver disease mortality over the past 30 years, little evidence-based guidance exists regarding preventing recidivism post-liver transplant for alcohol-related liver disease. METHOD: a systematic literature review was conducted to identify demographic variables predictive of alcohol relapse and effective psychosocial interventions for alcohol-related liver disease patients post-liver transplant. RESULTS: variables most significantly predictive of alcohol relapse post-transplant were-less than 12 months pre-liver transplant abstinence; patients with children; poor pre-liver transplant psychosomatic evaluation; non-compliance with post-liver transplant treatment plan; and patients with active insurance policies. Structured management was the most effective psychosocial intervention in preventing alcohol relapse. CONCLUSION: findings should be interpreted cautiously, due to limited and poor-quality evidence. Rigorously designed further research of the psychosocial interventions targeting predictive demographic variables is recommended.

Personalised discharge care planning for postmyocardial infarction patients through the use of the Personalised Patient Education Protocol - implementing theory into practice.

AIMS AND OBJECTIVES: This study aims to evaluate the service impact of the integration of an evidence-based instrument - the Personalised Patient Education Protocol - into an existing postmyocardial infarction care pathway. BACKGROUND: Recent research indicates that while better patient health outcomes can be achieved when care planning is personalised, delivery staff feel less satisfied and less confident in its provision. To achieve a shift to personalised care, innovations are needed to enable an effective transition for staff. DESIGN: A service evaluation using a patient survey and nurse interviews. METHOD: A longitudinal patient survey measured changes in patient illness beliefs, cardiac diet and exercise self-efficacy, anxiety, depression and quality of life study of a patient cohort of 74. Paired t-tests analysed the effects before and after the implementation of the Personalised Patient Education Protocol. Cardiac rehabilitation nurses who implemented the Personalised Patient Education Protocol were interviewed and a patient survey identified perceptions of the usefulness of the service innovation. RESULTS: Analysis of change from baseline to three months results showed statistically significant changes in Illness Belief component 'Understanding' and the Dartmouth Quality of Life 'General Health'. The integration of the Personalised Patient Education Protocol into the existing discharge process identified service improvements for cardiac nurse training and care pathway delivery, while patients identified the level and frequency of their use of the protocol following discharge. CONCLUSION: The introduction of the Personalised Patient Education Protocol succeeded in increasing patient engagement, facilitated a more patient-centred service by enabling practitioners to systematically provide personalised patient education, and gave patients a postdischarge structure to better follow-up their illness concerns with health professionals in the community. RELEVANCE TO CLINICAL PRACTICE: Integration of the Personalised Patient Education Protocol into an existing postmyocardial infarction care pathway enabled nurses to systematically respond to individual patients' illness beliefs and expectations.

Nurses' perceptions and experiences of work role transitions: a mixed methods systematic review of the literature.

AIM: To understand nurses' perceptions and experiences of work role transitions. BACKGROUND: Globally an uncertain healthcare landscape exists and when changing work roles nurses experience periods of transition when they may not cope well. A greater understanding of work role transitions may help facilitate workforce retention and successful careers. DESIGN: Mixed methods systematic review. DATA SOURCES: Six data bases were searched for peer reviewed primary empirical research, published in English language between January 1990 and December 2014, supplemented by hand and citation searching. REVIEW METHODS: Evidence for Policy and Practice Information and Co-ordinating Centre methods for systematic reviews principles were followed. Analysis and synthesis of the qualitative and quantitative papers was conducted separately using thematic analysis. A third synthesis combined the narrative findings and a narrative synthesis of results is presented. RESULTS: Twenty-six papers were included. Across nurses' work role transitions two pathways were found: Novice and Experienced. 'Novice' comprises pre-registration and newly qualified nurses. 'Experienced' comprises, Enrolled/Licensed Practical Nurse to Registered Nurse, experienced to specialist nurse and clinical role changes. Each pathway results in different emphasizes of two themes; 'Striving for a new professional self' includes emotional upheaval and identity while 'Know how' includes competence and boundaries. Novice nurses are more susceptible to the extremes of emotional upheaval while experienced nurses' competence eases aspects of transitions while boundary issues pervade. CONCLUSION: Informed work and educational environments are required for all groups of nurses. Using existing models of transition can facilitate successful individual transitions and develop the workplace.

Patients with alcohol-related liver disease--beliefs about their illness and factors that influence their self-management.

AIM: To determine the association between illness belief and self-efficacy to provide the evidence-base to develop a personalized framework to support self-management in patients with alcohol-related liver disease. BACKGROUND: Research in a variety of long-term illnesses suggests patients' illness beliefs are a more influential factor for patient recovery than the severity of the illness. However, research into illness belief and self-efficacy of patients with alcohol-related liver disease is sparse. DESIGN: A cross-sectional survey. METHODS: A cohort of 159 patients with alcohol-related liver disease who attended the Liver Outpatient Clinics at a London Hospital (October 2012-November 2013) completed a set of validated instruments measuring illness beliefs, self-efficacy, emotional states and quality of life. FINDINGS: The mean age of enrolled patients was 52 years, 67% male, 26% live on their own, 61% had no previous history of other chronic illness and average Model for End-Stage Liver Disease and The AUDIT Alcohol Consumption Questions scores were 11·0 and 3·5 respectively. After adjusting for demographic and illness characteristic components, multiple regression analysis shows that the three illness belief components 'Symptoms', 'Understanding' and 'Concerns' made a significant contribution to their confidence to self-manage their liver condition and the 'Symptoms' component makes a signification contribution across to all outcome measures: Anxiety, Depression, Quality of Life and Self-Efficacy. CONCLUSION: Interventions designed to improve these patients' understanding of their illness and strategies to manage their symptoms are likely to improve their self-management, quality of life and reduce anxiety and depression.

Illness perception, self-care behaviour and quality of life of heart failure patients: a longitudinal questionnaire survey.

OBJECTIVES: To examine the associations between illness perception, self-care behaviour, and quality of life in patients admitted to hospital with a primary diagnosis of heart failure (HF), and the changes in these at 2 and 6 months after discharge. DESIGN: Longitudinal questionnaire-based study. SETTING: Three London hospitals with specialist heart failure services. PARTICIPANTS: A convenience sample of 88 patients (70% male, mean age 70) admitted to hospital with a primary diagnosis of heart failure were recruited prior to discharge. Participants were over the age of 18, able to understand English, and with the cognitive ability to complete the questionnaires. Thirty-eight patients did not provide follow-up data: 21 (24%) died during the 6-month follow-up period, and 17 (19%) did not return their post-discharge questionnaires. METHODS: The Revised Illness Perception Questionnaire, the Self-Care Heart Failure Index, Hospital Anxiety and Depression scale, and the Minnesota Living with Heart Failure (MLHF) Questionnaires were completed prior to discharge from hospital, and 2 and 6 months after discharge. RESULTS: HF symptoms improved over time (MLHF score co-efficient [95%CI] -0.915 [-1.581, -0.250], P<0.001). Patients appeared to believe that many of the causes of their illness were outside their control. Although self-care maintenance (e.g. weighing daily) improved over time, this did not translate into increased involvement in self-care management (e.g. adjusting diuretic dose) or the ability to act on changes in symptoms. Self-care confidence was lower in those who reported a more negative emotional impact of their illness, but was higher in those who had high scores on illness coherence. CONCLUSIONS: Six months following hospital discharge, patients' symptom control had improved. Many continued to believe that their illness was outside their control, and although self-care maintenance improved this was not associated with greater self-care management, particularly if the patient's emotional state was negative, and their understanding of their condition was poor. Our data suggest that a more participative person-centred approach, tailoring the disease management programme to address the patient's illness beliefs and emotional state, assisting the individual to identify barriers and solutions, may help increase self-care confidence and management.

Education and support needs of the older adult with congenital heart disease.

AIM: This article is a report of a study exploring health-related quality of life in adults with congenital heart disease and the extent to which it is associated with patients' illness beliefs and emotional health. BACKGROUND: A reduction in mortality in patients with congenital heart disease has led to an increasingly older population that faces new challenges. Studies in a younger adult population have reported inconsistent findings regarding health-related quality of life. Factors such as, the complexity of the congenital heart defect, have not been found to be associated with quality of life. The association between illness beliefs and health-related quality of life has not previously been reported. METHOD: A cross-sectional questionnaire study of adults with congenital heart disease attending an outpatient clinic in a specialist centre in the United Kingdom between October 2007 and May 2008. RESULTS: The mean age of the study population was 37·2 years. Participants reported poorer physical functioning, role functioning and general health than a general population. High levels of anxiety were reported in 38% and high levels of depression in 17%. In multivariate analysis, higher levels of anxiety and depression were associated with poorer mental functioning and higher levels of depression with poorer physical quality of life. CONCLUSION: We have reported that high levels of anxiety and depression in an older population of patients with congenital heart disease are associated with poorer quality of life. This highlights the need to routinely assess anxiety and depression in this patient group and to provide psychological support appropriately.

Care of patients following liver transplantation.

This article provides an overview of the care of patients following liver transplantation. It focuses on the immediate post-operative care, the role of the transplant co-ordinator in providing support and education and the long-term follow up required to promote health and quality of life in this specific patient group.

Coronary heart disease patients' perception of their symptoms and sense of control are associated with their quality of life three years following hospital discharge.

BACKGROUND: Recent intervention studies have attempted to address cardiac rehabilitation patients' illness beliefs to improve care. Their findings were mainly limited to short-term behaviour changes such as return to work or attendance on rehabilitation programmes. Evidence about what aspects of the patients' illness beliefs influence long-term quality of life in cardiac rehabilitation remains sparse. OBJECTIVE: To examine the association between coronary heart disease patients' illness beliefs and their quality of life three years after hospital discharge. DESIGN: A longitudinal prospective survey. METHODS: Coronary heart disease patients (n = 253) completed validated questionnaires at three points. Patients' illness beliefs were measured twice: before hospital discharge and nine months after discharge - using the Illness Perception Questionnaire. Quality of life was assessed as the outcome measure at three years after discharge, using the Health Survey SF36v2 questionnaire. Demographic, illness characteristics and cardiac rehabilitation attendance were also assessed. RESULTS: Two multiple regression analyses were performed with each of the SF36v2 physical and mental health summary scores as outcome variables. Analysis of baseline data showed 43% of the variance in the physical health summary score at three years was accounted for by a perceived lower number of symptoms, belief that the illness was controllable, admission as an emergency and no previous history of cardiac illness; 22% of the variance in the mental health summary score was accounted for by perceived lower number of symptoms and no previous history of cardiac illness. Repeat analysis using the data collected nine months after discharge showed similar findings. CONCLUSION: Coronary heart disease patients' perception of their symptoms and sense of control at time of discharge were significantly associated with their quality of life three years after discharge. RELEVANCE TO CLINICAL PRACTICE: This study promotes the use of the assessment of patients' illness beliefs as a routine practice to improve care.

The relationship between nurse staffing and patient outcomes: a case study.

BACKGROUND: Research has shown a direct relationship between staffing levels and patient outcomes for specific nurse-sensitive indicators, with lower patient to nurse ratios (i.e. less patients per nurse) associated with better outcomes. OBJECTIVES: To explore the relationship between nurse staffing characteristics (the nursing hours worked by permanent and temporary staff and nurse hours per patient day) and patient outcomes: pressure sores, patient falls, upper gastrointestinal bleed, pneumonia, sepsis, shock and deep vein thrombosis. DESIGN: A case study using retrospective hospital data, at ward level. SETTING: A tertiary cardio-respiratory NHS Trust in England, comprising two hospitals. PARTICIPANTS: All patients, including day cases, who were admitted to either hospital as an in-patient over 12 months. METHODS: Data were extracted from corporate hospital systems. The clinical areas were categorised as lower dependency, i.e. wards, or critical care which included ICU and high dependency units. The relationship between nurse staffing characteristics and patient outcomes was assessed using either a Poisson or negative binomial regression model as appropriate. We sought to establish whether the outcomes were affected by the nurse hours per patient day, the permanent nurse hours worked as a percentage of the total hours, and the permanent nurse hours worked as a percentage of the permanent and bank hours combined. RESULTS: In the lower dependency category wards there was only a weak association demonstrated between nurse staffing and the majority of the outcomes. The results from the high dependency critical care areas showed few significant results with only the rate of sepsis being significantly reduced as the ratio of permanent staff hours increased. CONCLUSIONS: The study demonstrated the possibility of using existing hospital data to examine the relationship between nurse staffing and patient outcomes, however the associations found were weak and did not replicate reliably the findings from previous work.

Importance of illness beliefs and self-efficacy for patients with coronary heart disease.

AIM: This paper is a report of a study to assess the association between coronary heart disease patients' illness beliefs and their self-efficacy 3 years after hospital discharge. BACKGROUND: Cardiac rehabilitation guidelines recommend that both the illness representation model and the concept of self-efficacy are relevant frameworks for developing effective psychological support, although little is known about what aspects of patients' illness beliefs influence their self-efficacy. METHOD: In a longitudinal prospective survey, consecutive patients with coronary heart disease were asked to complete questionnaires measuring illness perceptions; self-efficacy and demographic, illness characteristics; and attendance at a cardiac rehabilitation programme. The questionnaire was completed three times between 2001 and 2005. The response rates were 84% at time 1, 77% at time 2 and 72% at time 3. Multiple regression analysis was used to assess the association between illness beliefs and self-efficacy. The data were collected between 2001 and 2005. FINDINGS: The average age of the participants was 65 years, 79% were male, 50% had acute myocardial infarction, 50% had angina and 61% had no previous history of cardiac illness; 55% had been admitted as an emergency and 57% subsequently attended cardiac rehabilitation. At baseline 30% of the variance in the exercise self-efficacy at 3 years after index admission was accounted for by patients' view of their illness being long-term. Data collected 9 months after discharge showed similar findings. CONCLUSION: Early interventions designed to address individuals' sense of control, beliefs about the length of illness and the management of perceived symptoms before hospital discharge could increase rehabilitation programmes effectiveness in sustaining patients' long-term lifestyle changes.

Predicting self-efficacy using illness perception components: a patient survey.

OBJECTIVES: To assess the measures of illness representation components in predicting measures of self-efficacy in patients with coronary heart disease. DESIGN: A longitudinal design was adopted with predictor variables and dependent variables (general self-efficacy, diet self-efficacy and exercise self-efficacy) measured twice while participants were in hospital and 9 months following discharge. Change scores of the predictor variables can be calculated and dependent variables at baseline can be controlled. METHOD: A cohort sample of 300 patients admitted to hospital with coronary heart disease were given the questionnaire measuring their illness perception (illness representation components: identity, consequences, timeline and control/cure and outcome expectation for diet and exercise); self-efficacy (general, diet and exercise self-efficacy measures), demographic and illness characteristics and attendance on a cardiac rehabilitation programme. The patients were asked to complete the questionnaire in hospital before discharge following their cardiac diagnosis, and again, 9 months later, when participants were expected to be functioning independently of any rehabilitation programme. RESULTS: Demographic and illness characteristics were found to have a more significant relationship with illness representation components than with specific self-efficacy. The relationship between illness representation components and specific self-efficacy changes overtime, consequence and timeline were significantly related to self-efficacy measures initially; however, symptom and control/cure were the variables that were significantly related to self-efficacy measures 9 months later. After statistically controlling individuals' baseline self-efficacy measures, demographic and illness characteristic effects, symptom and control/cure were found to make significant contributions to exercise and diet self-efficacy, respectively, 9 months later. CONCLUSION: A significant relationship exists between illness representation and self-efficacy. There is potential to integrate both approaches to the assessment of psychosocial factors to provide effective individualized care in cardiac rehabilitation.

A conceptual care model for individualized care approach in cardiac rehabilitation--combining both illness representation and self-efficacy.

PURPOSE: This paper analyses the two prominent psychological theories of patient response--illness representation and self-efficacy--and explore the possibilities of the development of a conceptual individualized care model that would make use of both theories. METHODS: Analysis of the literature established common themes that were used as the basis to form a conceptual framework intended to assist in the joint application of these theories to therapeutic settings. RESULTS: Both theories emphasize personal experience, pre-construction of self, individual response to illness and treatment, and that the patients' beliefs are more influential in their recovery than the severity of the illness. Where the theories are most divergent is their application to therapeutic interventions, which reflects the different sources of influence that each theory emphasizes. Based on their similarities and differences it is possible to integrate the two theories into a conceptual care model. CONCLUSION: The Interactive Care Model combines both theories of patient response and provides an explicit framework for further research into the design of effective therapeutic interventions in rehabilitation care.

Relationship between illness representation and self-efficacy.

AIM: This paper reports a patient survey exploring the possible relationship between illness perception and self-efficacy following a cardiac event, and the implications this could have for nursing practice. BACKGROUND: Cardiac rehabilitation guidelines endorse the need to improve psychological care; suggesting that individualized support will improve the effectiveness of cardiac rehabilitation. Surveys, however, continue to identify that psychosocial factors are poorly assessed. Illness representation and self-efficacy are two prominent research approaches that have been developed as separate foci for the treatment of patients. METHOD: A cross-sectional survey with patients diagnosed with either myocardial infarction or angina over an 8-month period in two hospitals. The Illness Perception Questionnaire, General Self-Efficacy Questionnaire, Cardiac Diet Self-efficacy Instrument and Cardiac Exercise Self-efficacy Instrument were used, alongside two specifically-designed scales: the Diet Outcome Expectation and Exercise Outcome Expectation Scales. RESULTS: The results indicate that there is a significant relationship between illness perception and self-efficacy. The greater patients' perceived consequences of the heart condition, the lower was the general self-efficacy available to cope with the condition. Further, the longer the perceived time the condition will affect the patient, the higher the specific self-efficacy to maintain a change of diet or exercise regime. CONCLUSION: The findings identify that, in the initial phase of recovery, nursing practice needs to focus on the key variables of "consequence" and "timeline" in order to increase patients' confidence in their ability to cope (self-efficacy).

Cardiac rehabilitation: the importance of patient expectations--a practitioner survey.

BACKGROUND: Numerous cardiac rehabilitation national guidelines consistently endorse the need for psychological support to create effective individualized care. Recent surveys suggest that the psychological factors remain poorly assessed and the measurement of psychological parameters remains patchy. AIM: To examine cardiac rehabilitation practitioners' perception and understanding of the importance of patient expectations and their capacity to assess and utilize these expectations to develop individualized care. METHODS: A survey of cardiac rehabilitation professionals from 10 hospitals in the south-east of England. The questionnaire used in the survey was developed from content analyses of the current cardiac rehabilitation literature and expectancy theory articulated in Bandura's writings. RESULTS: The results of the study show that cardiac rehabilitation practitioners are very aware of the general importance of patient expectations but have little structured support in the development of techniques to either assess these expectations or to utilize them in a therapeutic context. This leaves them unsure about the extent to which patients do receive individualized care and how best to develop their own practice in this regard. RELEVANCE TO CLINICAL PRACTICE: This study suggests that there is a need for the development of a structured assessment tool, which has a sound theoretical basis to assess patients' expectation if good practice is to be established in providing individualized car in cardiac rehabilitation.