Barriers to belonging: the need for relatedness amongst people living with severe asthma.

BACKGROUND: Severe asthma, that is, asthma that is relatively refractory to conventional therapy, affects 3-10% of the asthma population. It is associated with a significant burden affecting social and working life. Supporting the need for relatedness facilitates health behavior change and improves overall well-being. However, this has not been closely examined from the patients' perspective. This study examines relatedness in patients' narratives about their experiences of living with and managing severe asthma. METHODS: Rigorous and systematic qualitative research methods were used to conduct in-depth semi-structured interviews. Participants were included if they were ≥18 years old and diagnosed with severe asthma. Interviews were video and/or audio recorded, transcribed, and analyzed inductively and deductively informed by the self-determination theory construct of relatedness. Thirty-eight face-to-face interviews, lasting 1.5 - 4 hours, were conducted around Australia. RESULTS: Our findings show that living with a debilitating and unpredictable illness challenged participants' sense of relatedness. Two themes emerged: 1) the desire to be understood: feeling isolated and 2) the desire to be accepted: 'I'm supposed to be like everybody else'. For people living with severe asthma, feeling cared for, understood, connected to others and having a sense of belonging was valued. Their overall psychological well-being was dependent upon their sense of connection to others. CONCLUSION: Future research should consider our findings of the challenges faced to preserve their sense of relatedness, when developing and implementing patient-driven self-management interventions for those living with severe asthma.

Pharmacist non-medical prescribing in primary care. A systematic review of views, opinions, and attitudes.

BACKGROUND: Uptake of non-medical prescribing by pharmacists working in primary care has been slow. This is despite benefits such as quicker and more efficient access to medicines for patients, a reduction in doctor workload, and enhanced professional satisfaction. This systematic review explores the views, opinions, and attitudes of pharmacists and graduates towards non-medical prescribing. METHODS: Medline, ScienceDirect, Embase, and the University of Reading Summon Service were searched to identify qualitative and mixed methods papers that examined the views, opinions, and attitudes of pharmacists and graduates towards non-medical prescribing. Papers published between January 2003 and September 2017 were included. Studies were quality assessed using the CASP checklist and then analysed using thematic synthesis. RESULTS: After 85 full-text articles were assessed, a final 14 studies were eligible for inclusion. The included studies assessed pharmacists who currently prescribe, and other pharmacists and graduates with familiarity of non-medical prescribing. Thematic synthesis identified two themes: (1) practice environment, and (2) pharmacist's role. Non-medical prescribing was considered a natural extension to the role of a pharmacist despite difficulties in completing the required training. The ability to then prescribe was dependent on funding and access to medical records, time, and support staff. Pharmacists experienced professional rivalry with both support and resistance from members of the primary care team. The provision of training was frequently referred to as unsatisfactory. Pharmacists were motivated to prescribe, deriving increased job satisfaction and a sense of professionalism; however, they often felt underprepared for the reality of unsupervised practice. Furthermore, pharmacists reported a cautious approach with a fear of making errors frequently discussed. CONCLUSIONS: This review has identified themes and subsequent barriers and facilitators to non-medical prescribing. Many of the barriers are more perceived than real and are diminishing. Consideration of these will assist and advance pharmacist prescribing in primary care, leading to positive outcomes for both patient care and the pharmacy profession.

Pregnant women's experiences with the management of hypertensive disorders of pregnancy: a qualitative study.

BACKGROUND: Hypertensive disorders are a leading cause of mortality and morbidity during pregnancy. Despite multiple national and international clinical guidelines and a plethora of research in the field of optimising management, there has been limited research describing the perspectives and experiences of pregnant women with the management of hypertensive disorders of pregnancy (HDP). Understanding these perceptions and experiences is imperative to the optimisation of HDP management. METHODS: A qualitative study involving face-to-face, in-depth interviews were undertaken with 27 pregnant women diagnosed with and being treated for HDP to explore their perspectives of and experiences with clinical management. Written consent was obtained individually from each participant, and the interviews ranged from 16 to 54 min. Inductive codes were generated systematically for the entire data set. Line-by-line analysis was then performed and nodes were created within NVivo, a qualitative data management software. Data collection was continued until thematic saturation was reached. Thematic analysis was employed to interpret the data. RESULTS: Three major descriptive themes were discerned regarding the women's perspectives on and experiences with the management of HDP: attitudes towards monitoring of HDP, attitudes and perceptions towards development and management of complications, and perceptions of pregnant women with chronic hypertension. Trust in the hospital system, positive attitudes towards close blood pressure monitoring as well as self-monitoring of blood pressure, and a realistic approach to emergency antenatal hospital admissions contributed to a positive attitude towards monitoring of HDP. Women with prior experiences of HDP complications, including pre-eclampsia, were more confident in their clinical management and knew what to expect. Those without prior experience were often in shock when they developed pre-eclampsia. Some women with chronic hypertension displayed limited understanding of the potential risks that they may experience during pregnancy and thus lacked comprehension of the seriousness of the condition. CONCLUSIONS: The clinical management experiences of pregnant women with HDP were varied. Many women did not feel that they were well informed of management decisions and had a desire to be more informed and involved in decision-making. Clear, concise information about various facets of HDP management including blood pressure monitoring, prescription of the appropriate antihypertensive agent, and planning for potential early delivery are required.

Patients' experiences of pharmacists in general practice: an exploratory qualitative study.

BACKGROUND: Since 2015, pharmacists have been integrating into English general practices and more recently into primary care networks. General practice-based pharmacists provide a range of patient-facing services, such as medication reviews, management of long-term conditions and minor ailments, prescribing duties and answering queries over the telephone. Literature reports patients' satisfaction with general practice-based pharmacists' services, however, previous research captured only limited experiences. The aim of the current study was to pursue an extensive exploration of patients' experiences of pharmacists in general practice. METHODS: General practice-based pharmacists, working in practices in West London, Surrey and Berkshire, handed invitation packs to patients seen during consultations. Patients that wanted to take part in the study were invited to undertake a qualitative, in-depth, face-to-face, semi-structured interview within the practice with which each patient was registered. Interviews lasted from 15 min to more than 1 h and were audio-recorded. Recruitment continued until data saturation. Audio-recordings were transcribed verbatim and transcripts analysed thematically. RESULTS: Twenty participants were interviewed. Four themes were discerned: awareness ("I had been coming to this practice for 24 years and I didn't know that there was a pharmacist"); accessibility ("People ring for a GP [general practitioner] appointment … it's Monday and they [receptionist] tells you 'We can slot you in on Friday' … with a pharmacist on board, they can [instantly] look at you"); interactions ("I've always had a really good interaction with them [pharmacists] and they listen and they take on board what I'm trying to say"); and feedback ("It's easier [to collect feedback instantly] because I could have forgotten half of what they [pharmacists] have told me in an hour or so's time"). CONCLUSIONS: Findings indicate that pharmacists' integration into general practices could improve accessibility to, and the quality of, care received. The findings will assist policy development to provide general practice-based pharmacists' services as per patients' needs.

'There is no choice apart from antibiotics ': Qualitative analysis of views on urinary infections in pregnancy and antimicrobial resistance.

BACKGROUND: Antimicrobial resistance (AMR) is a health risk as it can lead to life-threatening infections. There has been a rise in resistant urinary tract infections (UTIs) which is the most common infection in pregnancy. This can be challenging in pregnancy due to the additional need to safeguard foetal development. The study's aim was to explore views about AMR in women who experienced UTIs in pregnancy. DESIGN: Fifteen semi-structured interviews were conducted in the UK and analysed using thematic analysis. RESULTS: Results highlighted two themes: conceptualization of AMR and pregnancy as a deviation from the norm, with an overarching theme of 'self-efficacy'. Results show that participants were concerned about AMR but uncertain about the effect on society compared to individual's taking antibiotics and about completing antibiotic courses. Participants reported an unsparing use of antibiotics was justified in pregnancy, and behaviours like drinking adequate water were ineffective at preventing UTIs. In summary, women had low self-efficacy regards tackling AMR and managing their health. CONCLUSION: Misconceptions about how AMR affects society vs the individual translated into viewing it as a future problem to be tackled by the health-care sector. Consequently, AMR requires reconceptualization as a current problem requiring collective action. This research also indicates women endorse a biomedical model of UTIs in pregnancy which attributes resolving illness to interventions such as medicines, implying an automatic reliance on antibiotics. Subsequently, there is a need for self-efficacy by focusing on a behavioural model which emphasizes behaviours for infection prevention, thus reducing the need for antibiotics.

Community pharmacy teams' experiences of general practice-based pharmacists: an exploratory qualitative study.

BACKGROUND: In England, since 2015, there has been a formal drive to integrate pharmacists into general practice as a new healthcare service. Research efforts have offered insights into how general practice-based professionals and patients view the service, however, they took no account of community pharmacy teams' opinions. There have been anecdotal statements about opposition from community pharmacies to the service, due to fears of losing business. The aim of the current study was to identify the experiences and perceptions of community pharmacy teams regarding pharmacists' presence in general practice. METHODS: The National Health Service Choices website was used to identify community pharmacies within a radius of two miles from eight West London general practices. The search resulted in 104 community pharmacies which were all contacted via telephone. Pharmacy staff who verbally expressed their interest to participate were then provided with the study's documents. Qualitative, face-to-face, semi-structured interviews were conducted inside the pharmacy from which each participant was recruited. Interviews lasted 30 to 45 min and were audio-recorded. Audio-recordings were transcribed verbatim and transcripts analysed thematically. RESULTS: Forty-eight community pharmacy staff participated. Four themes were discerned: awareness ("I knew that [pharmacists] have already been implemented [in general practice] but I haven't really followed it … where does the pharmacist role come?"); interactions ("I'm just so pleased that there's a pharmacist professional in the general practice … because we speak the same language!"); patient care ("if I was a patient knowing that there is a general practitioner and a pharmacist [in general practice], I would … think 'nothing can go wrong at the moment'"); and funding challenges ("if general practices take on the extra responsibility of stop smoking or flu vaccination campaigns … financially, this would affect this pharmacy"). CONCLUSIONS: The current study revealed the perceived impact of general practice-based pharmacists on community pharmacies would be improved communication between pharmacies and practices. Findings will inform policy so that any future framing of pharmacists' presence in general practice considers the needs of community pharmacies.

Resilient Health Care: a systematic review of conceptualisations, study methods and factors that develop resilience.

BACKGROUND: Traditional approaches to safety management in health care have focused primarily on counting errors and understanding how things go wrong. Resilient Health Care (RHC) provides an alternative complementary perspective of learning from incidents and understanding how, most of the time, work is safe. The aim of this review was to identify how RHC is conceptualised, described and interpreted in the published literature, to describe the methods used to study RHC, and to identify factors that develop RHC. METHODS: Electronic searches of PubMed, Scopus and Cochrane databases were performed to identify relevant peer-reviewed studies, and a hand search undertaken for studies published in books that explained how RHC as a concept has been interpreted, what methods have been used to study it, and what factors have been important to its development. Studies were evaluated independently by two researchers. Data was synthesised using a thematic approach. RESULTS: Thirty-six studies were included; they shared similar descriptions of RHC which was the ability to adjust its functioning prior to, during, or following events and thereby sustain required operations under both expected and unexpected conditions. Qualitative methods were mainly used to study RHC. Two types of data sources have been used: direct (e.g. focus groups and surveys) and indirect (e.g. observations and simulations) data sources. Most of the tools for studying RHC were developed based on predefined resilient constructs and have been categorised into three categories: performance variability and Work As Done, cornerstone capabilities for resilience, and integration with other safety management paradigms. Tools for studying RHC currently exist but have yet to be fully implemented. Effective team relationships, trade-offs and health care 'resilience' training of health care professionals were factors used to develop RHC. CONCLUSIONS: Although there was consistency in the conceptualisation of RHC, methods used to study and the factors used to develop it, several questions remain to be answered before a gold standard strategy for studying RHC can confidently be identified. These include operationalising RHC assessment methods in multi-level and diverse settings and developing, testing and evaluating interventions to address the wider safety implications of RHC amidst organisational and institutional change.

" I've said I wish I was dead, you'd be better off without me": A systematic review of people's experiences of living with severe asthma.

OBJECTIVE: Our aim was to conduct a systematic review and synthesis of qualitative evidence exploring the lived experience of adults with severe asthma. DATA SOURCES: We searched MEDLINE via OvidSP, PsycINFO via OvidSP, PubMed, CINAHL, EMBASE, Sociological Abstracts, Google Scholar, the journals Qualitative Health Research and Qualitative Research, and a study of experiences of living with asthma by the Health Experiences Research group. STUDY SELECTIONS: Studies were included if they used qualitative methods and explored the subjective experiences of adults (≥18 years) with a clear diagnosis of severe asthma. RESULTS: From 575 identified studies, five met the inclusion criteria. Synthesis revealed an overarching theme of efforts that people living with severe asthma engage in to achieve personal control over their condition. Individuals 'strive for autonomy' through dealing with symptoms and treatment, acquiring knowledge, making decisions and reclaiming identity. CONCLUSION: This systematic review found a paucity of qualitative studies reporting on people's perspectives of living with severe asthma, and a focus on clinical rather than personal issues. Our synthesis reveals that severe asthma was disempowering, and a threat to identity and life roles. What was important to people living with severe asthma was striving to achieve a greater level of personal control over their condition, but these efforts received little support from their healthcare providers. Thus, more attention should be paid to understanding the self-management strategies and personal goals of people living with severe asthma. This may assist in designing interventions to better support patient self-management and improve health outcomes.

Urinary tract infections and antibiotic use in pregnancy - qualitative analysis of online forum content.

BACKGROUND: Antibiotics are standard treatment for asymptomatic and symptomatic urinary tract infections (UTIs) in pregnancy. Their overuse, however, can contribute to antimicrobial resistance (AMR) and expose the foetus to drugs that might affect its development. Preventative behaviours are currently the best option to reduce incidences of UTIs and to avoid the use of antibiotics in pregnancy. The aim of this study was to explore women's experiences of UTIs in pregnancy to develop an understanding of their concerns and to optimise and encourage behaviours that facilitate appropriate use of antibiotics. METHODS: An online pregnancy forum in the United Kingdom (UK) was used to collect data on women's discussions of UTIs. A total of 202 individual threads generated by 675 different usernames were selected for analysis. The data was organised using NVivo 11® software and then analysed qualitatively using inductive thematic analysis. RESULTS: Women's perceptions of UTIs and antibiotic use in pregnancy were driven by their pre-natal attachment to the foetus. UTIs were thought to be common and high risk in pregnancy, which meant that antibiotics were viewed as essential in the presence of suspected symptoms. The dominant view about antibiotics was that their use was safe and of little concern in pregnancy. Women reported an emotional reaction to developing a UTI. They coped by seeking information about behaviour change strategies to assist with recovery and through emotional support from the online forum. CONCLUSIONS: Women face dual risks when they experience UTIs; the risk from the infection and the risk from antibiotic treatment. Pre-natal attachment to the foetus is highlighted in the decision making process. The focus is on the shorter term risk from UTIs while undermining the longer term risks from antibiotic use, especially the risk of AMR. A balanced view needs to be presented, and evidence-based infection prevention strategies should be promoted, to women to ensure appropriate antibiotic use in pregnancy, to address the global challenge of AMR.

Villains or victims? An ethnography of Afghan maternity staff and the challenge of high quality respectful care.

BACKGROUND: Healthcare providers are the vital link between evidence-based policies and women receiving high quality maternity care. Explanations for suboptimal care often include poor working conditions for staff and a lack of essential supplies. Other explanations suggest that doctors, midwives and care assistants might lack essential skills or be unaware of the rights of the women for whom they care. This ethnography examined the everyday lives of maternal healthcare providers working in a tertiary maternity hospital in Kabul, Afghanistan between 2010 and 2012. The aim was to understand their notions of care, varying levels of commitment, and the obstacles and dilemmas that affected standards. METHODS: The culture of care was explored through six weeks of observation, 41 background interviews, 23 semi-structured interviews with doctors, midwives and care assistants. Focus groups were held with two diverse groups of women in community settings to understand their experiences and desires regarding care in maternity hospitals. Data were analysed thematically. RESULTS: Women related many instances of neglect, verbal abuse and demands for bribes from staff. Doctors and midwives concurred that they did not provide care as they had been taught and blamed the workload, lack of a shift system, insufficient supplies and inadequate support from management. Closer inspection revealed a complex reality where care was impeded by low levels of supplies and medicines but theft reduced them further; where staff were unfairly blamed by management but others flouted rules with impunity; and where motivated staff tried hard to work well but, when overwhelmed with the workload, admitted that they lost patience and shouted at women in childbirth. In addition there were extreme examples of both abusive and vulnerable staff. CONCLUSIONS: Providing respectful quality maternity care for women in Afghanistan requires multifaceted initiatives because the factors leading to suboptimal care or mistreatment are complex and interrelated. Standards need enforcing and abusive practices confronting to provide a supportive, facilitating environment for both staff and childbearing women. Polarized perspectives such as 'villain' or 'victim' are unhelpful as they exclude the complex realities of human behaviour and consequently limit the scope of problem solving.

Using benzodiazepines and Z-drugs for managing primary insomnia in adults in Saudi Arabia: an e-Delphi study to aid the development of clinical guidelines.

PURPOSE: This study aims to obtain consensus statements required for the development of clinical guidelines for the use of benzodiazepines (BZDs) and Z-drugs for the management of primary insomnia in adults in Saudi Arabia. METHODS: Three rounds of the e-Delphi technique using a Bristol Online Survey (BOS) were conducted between May and August 2018. The Director of the Saudi Sleep Medicine Group helped recruit the country's sleep medicine experts. Snowballing was used to forward invitation emails, information sheets, and the survey to known sleep medicine experts and physicians deemed to be interested in the field. All participants' details were anonymised except to the researcher. RESULTS: Fifteen experts from four different regions and specialities in Saudi Arabia participated in Round 1. Twenty-one statements originated from participants' responses. In Round 2, there were 17 respondents and 16 of the statements obtained the required consensus of 70% or higher. Eleven experts participated in Round 3 and eight statements received 100% agreement, two received 91%, and six received 82%. Having obtained the required consensus of 80% or higher in Round 3, these 16 statements fulfilled the criteria to be included in future guidelines. The five statements that failed to attain the required consensus were rejected as inappropriate for inclusion in Saudi Arabian clinical guidelines. CONCLUSIONS: The items that achieved the required consensus can be included in future guidelines for the use of BZDs and Z-drugs in the treatment of primary insomnia in adults to standardize best practices in sleep medicine in Saudi Arabia.

The impact of severe asthma on patients' autonomy: A qualitative study.

BACKGROUND: People living with severe asthma may have ongoing debilitating symptoms despite high-dose treatment. Clinical guidelines for severe asthma recommend concepts such as patient centeredness, shared decision making and self-management, at the heart of which lies autonomy. OBJECTIVE: This study aimed to explore the role of autonomy in patients' narratives about their experiences of living with and managing severe asthma. METHODS: In-depth semi-structured interviews were video- and/or audio-recorded and transcribed. Data were categorized using a hybrid approach to analysis incorporating both inductive and deductive methods, informed by the self-determination construct of autonomy. Analysis and comparison across and within categories were conducted to develop final themes. RESULTS: Twenty-nine face-to-face interviews, lasting 1.5-4 hours, were conducted across Australia. Patients' autonomy was enacted or challenged in a range of situations, such as interacting with health-care providers, maintaining employment, managing symptoms, and dealing with threats to self-identity. Two main themes were discerned from the analysis: (a) the desire to live an "unconstrained" life; and (b) preservation of self-identity. CONCLUSION: Our findings suggest that autonomy is broader than conventional medical concepts such as decision making and information seeking. Future research should consider these findings when developing and implementing patient-driven self-management interventions for those living with severe asthma.

How do pharmacists in English general practices identify their impact? An exploratory qualitative study of measurement problems.

BACKGROUND: In England, there is an ongoing national pilot to expand pharmacists' presence in general practice. Evaluation of the pilot includes numerical and survey-based Key Performance Indicators (KPIs) and requires pharmacists to electronically record their activities, possibly by using activity codes. At the time of the study (2016), no national evaluation of pharmacists' impact in this environment had been formally announced. The aim of this qualitative study was to identify problems that English pharmacists face when measuring and recording their impact in general practice. METHODS: All pharmacists, general practitioners (GPs) and practice managers working across two West London pilot sites were invited, via e-mail, to participate in a focus group study. Appropriately trained facilitators conducted two audio-recorded, semi-structured focus groups, each lasting approximately 1 h, to explore experiences and perceptions associated with the KPIs. Audio-recordings were transcribed verbatim and the data analysed thematically. RESULTS: In total, 13 pharmacists, one GP and one practice manager took part in the study. Four major themes were discerned: inappropriateness of the numerical national KPIs ("whether or not we actually have positive impact on KPIs is beyond our control"); depth and breadth of pharmacists' activity ("we see a huge plethora of different patients and go through this holistic approach - everything is looked at"); awareness of practice-based pharmacists' roles ("I think the really important [thing] is that everyone knows what pharmacists in general practice are doing"); and central evaluation versus local initiatives ("the KPIs will be measured by National Health Service England regardless of what we think" versus "what I think is more pertinent, are there some local things we're going to measure?"). CONCLUSIONS: Measures that will effectively capture pharmacists' impact in general practice should be developed, along with a set of codes reflecting the whole spectrum of pharmacists' activities. Our study also points out the significance of a transparent, robust national evaluation, including exploring the needs/expectations of practice staff and patients regarding pharmacists' presence in general practice.

Capturing pharmacists' impact in general practice: an e-Delphi study to attempt to reach consensus amongst experts about what activities to record.

BACKGROUND: In the UK, there is ongoing integration of pharmacists into general practice as a new healthcare service in primary care. Evaluation of the service involves national measures that require pharmacists to record their work, on the general practice clinical computer systems, using electronic activity codes. No national agreement, however, has been established on what activities to record. The purpose of this study was to attempt to reach consensus on what activities general practice-based pharmacists should record. METHODS: The e-Delphi method was chosen as it is an excellent technique for achieving consensus. The study began with an initial stage in which screening of a general practice clinical computer system and discussion groups with pharmacists from two 'pharmacists in general practice' sites identified 81 codes potentially relevant to general practice-based pharmacists' work. Twenty-nine experts (pharmacists and pharmacy technicians from the two sites along with experts recruited through national committees) were then invited by e-mail to participate as a panel in three e-Delphi questionnaire rounds. In each round, panellists were asked to grade or rank codes and justify their choices. In every round, panellists were provided with anonymised feedback from the previous round which included their individual choices along with their co-panellists' views. Final consensus (in Round 3) was defined as at least 80% agreement. Commentaries on the codes from all e-Delphi rounds were pooled together and analysed thematically. RESULTS: Twenty-one individual panellists took part in the study (there were 12 responses in Round 1, 18 in Round 2 and 16 in Round 3). Commentaries on the codes included three themes: challenges and facilitators; level of detail; and activities related to funding. Consensus was achieved for ten codes, eight of which related to activities (general and disease specific medication reviews, monitoring of high-risk drugs and medicines reconciliation) and two to patient outcomes (presence of side effects and satisfactory understanding of medication). CONCLUSIONS: A formal consensus method revealed general practice-based pharmacists' preferences for activity coding. Findings will inform policy so that any future shaping of activity coding for general practice-based pharmacists takes account of pharmacists' actual needs and preferences.

A systematic review of non-antibiotic measures for the prevention of urinary tract infections in pregnancy.

BACKGROUND: Urinary tract infections (UTIs) are common in pregnancy and account for the highest proportion of primary care antibiotic prescriptions issued to pregnant women in the UK. It is well known that antibiotic use is associated with increased antimicrobial resistance and therefore measures to minimise antibiotic use for UTI prevention have been studied. The efficacy and safety of these measures in pregnancy have not been addressed and therefore the aim of this study was to systematically review the literature to identify and evaluate potential measures to prevent UTIs in pregnant women. METHODS: Ten databases (EMBASE, AMED, BNI, CINAHL, Medline, PubMed, PsycINFO, Cochrane Trials, Scopus and Science Direct) were systematically searched in July 2017 for studies reporting non-antibiotic measures to prevent UTIs in pregnancy. The terms ("urinary tract infection" or UTI or bacteriuria or cystitis) AND (prevention) AND (pregnan*) were used. The quality of the publications was appraised using the Critical Appraisal Skills Programme (CASP) checklists for cohort study, case-control study and randomised controlled trial. The results were synthesised using a textual narrative approach. RESULTS: Search results yielded 3276 publications and after reviewing titles and removing duplicates, 57 full text articles were assessed for eligibility and eight were included in the review. Five different approaches (hygiene measures, cranberry juice, immunisation, ascorbic acid and Canephron® N) have been identified, all of which are reported to be safe in pregnancy. CONCLUSION: The quality of the evidence varied considerably and only hygiene measures were supported by evidence to be recommended in practice. Future work needs to concentrate on strengthening the evidence base through improved design and reporting of studies with a focus on immunisation, ascorbic acid and Canephron® N.

Pharmacists in general practice: a qualitative interview case study of stakeholders' experiences in a West London GP federation.

BACKGROUND: Increased patient demand for healthcare services coupled with a shortage of general practitioners necessitates changes in professional roles and service delivery. In 2016, NHS England began a 3-year- pilot study of pharmacists in general practice, however, this is not an entirely new initiative. There is limited, current, evidence-based, UK research to inform the pilot so studies of pre-existing services must suffice until findings from a formal national evaluation are available. METHODS: The aim of this exploratory, descriptive interview study was to explore the experiences of stakeholders in eight general practices in the Ealing GP Federation, West London, where pharmacy services have been provided for several years. Forty-seven participants, including pharmacy team members (pre-registration and clinical pharmacists, independent prescribers and pharmacy technicians), general practitioners, patients, practice managers, practice nurses and receptionists took part in semi-structured, audio-recorded qualitative interviews which were transcribed verbatim, coded and analysed thematically to extract the issues raised by participants and the practicalities of providing pharmacy services in general practice. RESULTS: Findings are reported under the themes of Complementarity (incorporating roles, skills, education and workloads); Integration (incorporating relationships, trust and communication) and Practicalities (incorporating location and space, access, and costs). Participants reported the need for time to develop and understand the various roles, develop communication processes and build inter-professional trust. Once these were established, however, experiences were positive and included decreased workloads, increased patient safety, improved job satisfaction, improved patient relationships, and enhanced cost savings. Areas for improvement included patients' awareness of services; pharmacists' training; and regular, onsite access for practice staff to the pharmacy team. CONCLUSIONS: Recommendations are made for the development of clear role definitions, identification of training needs, dedication of time for team building, production of educational materials for practice staff members and patients, and provision of on-site, full-time pharmacy services. Future work should focus on evaluation of various models of employing pharmacy teams in general practice; integration of pharmacists and pharmacy technicians into multidisciplinary general practice teams; relationships between local community pharmacy and general practice personnel; and patients' service and information needs. A formal national evaluation of the pilot scheme is overdue.

Integration and impact of pharmacists in general practice internationally: A rapid review.

OBJECTIVE: English general practices have been facing ongoing pressures, arising from complicated health care needs and the recent pandemic. To overcome these pressures and reduce the workload of general practitioners, there have been extensive attempts to integrate pharmacists into general practices. A number of literature reviews, often systematic, have partially explored the topic of general practice-based pharmacists (GPBPs) internationally. Our aim was to further explore the employment/integration models of GPBPs and their actual activities and impact, concepts that have not been thoroughly investigated by previous reviews. METHODS: Two databases were searched from inception to June 2021 for studies published in the English language. Results were independently screened by two reviewers to establish eligibility for inclusion. Original research studies, or protocols where results had not been released at the time of search, that reported on services provided by pharmacists with some sort of integration into general practices were included. The studies were analysed using narrative synthesis. RESULTS: Searches identified 3206 studies in total, of which 75 met the inclusion criteria. The included studies were highly heterogeneous in terms of participants involved and methodologies employed. Integration of pharmacists into general practices has occurred in several countries, with funds originating from multiple sources. Several employment models for GPBPs were described - for example, part-time and full-time work and/or coverage of multiple or single practices. GPBP activities, with some exceptions, were comparable between different countries, with medication reviews being the most common task globally. GPBP impact was identified through both observational and/or interventional research methods, by pursuing a large variety of measures (e.g. activity volume, contact with patients, perceptions/experiences, and patient outcomes). Independent, quantifiable outcomes from GPBP activities were all positive but were of varying statistical significance. CONCLUSIONS: Our findings suggest that GPBP services can lead to positive, quantifiable outcomes, mainly in relation to medication use. This shows the usefulness of GPBP services. The findings of this review can help policy makers decide how best to implement and fund GPBP services, and how to identify and measure GPBP impact.

Asthma during pregnancy: the experiences, concerns and views of pregnant women with asthma.

OBJECTIVE: To investigate how pregnant women manage their asthma during pregnancy and factors influencing their behavior. METHODS: In-depth interviews (telephone or face-to-face) with a purposive sample of 23 asthmatic women at various stages of pregnancy and with varying severity of asthma. RESULTS: Five major themes were discerned relating to health behavior of pregnant women with asthma. Many of the participants decreased or discontinued their asthma medications themselves and refrained from taking doses when necessary during pregnancy without consulting their doctors. Reasons behind their decisions revolved around lack of support and information about what to do, concerns about the safety of the medications, past experiences, and desire for an "all natural" pregnancy. Asthma monitoring during pregnancy was seen as a low priority for some women and their doctors. Communication between pregnant women and health professionals regarding asthma management was poor. The health behavior of pregnant women with asthma could be explained using the Health Beliefs Model. CONCLUSIONS: Pregnant women are not well supported in managing asthma during pregnancy, despite being concerned about outcomes. Interventions, education, and more support are warranted and wanted by pregnant women with asthma to optimize pregnancy and neonatal outcomes.

Modelling the use of variable rate intravenous insulin infusions in hospitals by comparing Work as Done with Work as Imagined.

BACKGROUND: Variable rate intravenous insulin infusions (VRIIIs) are widely used to treat elevated blood glucose (BG) in adult inpatients who are severely ill and/or will miss more than one meal. VRIIIs can cause serious harm to the patient if used incorrectly. Recent safety initiatives have embraced the Resilient Health Care (RHC) approach to safety by understanding how VRIIIs are expected to be used (Work as Imagined, 'WAI') and how it is actually used in everyday clinical care (Work as Done, 'WAD'). OBJECTIVES: To systematically compare WAI and WAD and analyse adaptations used in situ to develop a model explaining VRIII use. METHODS: A qualitative observational study video-recording healthcare practitioners using VRIII. The video data were transcribed and inductively coded to develop a hierarchical task analysis (HTA) to represent WAD. This HTA was compared with a HTA previously developed to represent WAI. The comparison output was used to develop a model of VRIII use. RESULTS: While many of the tasks in the WAD HTA were aligned with the tasks presented in the WAI HTA, some important ones did not. When misalignment was observed, permanent adaptations (e.g. signing as a witness for a changed VRIII's rate without independently verifying whether the new rate was appropriate) and temporary workarounds (e.g. not administering intermediate-acting insulin analogues although the intermediate-acting insulin prescription was not suspended) were the most frequently observed adaptations. The comparison between WAI and WAD assisted in developing a model of VRIII use. The model shed light on strategies used to imagine everyday work (e.g. incident reports, VRIII guidelines), how everyday work was accomplished (e.g. context-dependent adaptations) and how these contributed to both successful and unsuccessful outcomes. CONCLUSIONS: This study provided in-depth understanding of the tasks required while using VRIIIs, and responses and adaptations needed to achieve safer care in a complex environment.

Calling, permission, and fulfillment: the interembodied experience of breastfeeding.

Drawing on examples from in-depth interviews with 49 women, in this article we aim to open up a discursive space for women and health professionals to begin to explore the phenomenon of the interembodied experience of breastfeeding. Although acknowledging that social dimensions partially constitute the lived body, we further the view that the lived body's understanding is embedded in contexts far more complex than those that can be represented by language. We argue that women's narratives of their breastfeeding experience contained instances of the body "understanding" its emotional task at a prelogical, preverbal level. We identified three central, iterative dimensions of the phenomenon­calling, permission, and fulfillment­that occurred prereflexively in the protected space provided by the mother, a space that was easily disrupted by unsupportive postnatal practices. We offer this eidetic understanding and conceptual framework and suggest that it provides new (less damaging) subject positions and ways of behaving.