A randomised controlled feasibility trial of Group Cognitive Behavioural Therapy for people with severe asthma.

OBJECTIVES: Evidence for the efficacy of Cognitive Behavioural Therapy (CBT) in asthma is developing but it is not known if this translates to benefits in severe asthma or if a group approach is acceptable to this patient group. This study aimed to assess the feasibility and acceptability of Group-CBT in severe asthma. METHOD: This was a two-centre, randomised controlled parallel group feasibility study. Eligible participants (patients with severe asthma and a clinically significant diagnosis of anxiety and/or depression - Hospital Anxiety and Depression Scale (HAD) score greater than 8 for the anxiety or depression sub-scale) received Group-CBT in weekly sessions for eight consecutive weeks and usual care or usual care only. Follow-up was for 16 weeks and end points were: Asthma Quality of Life Questionnaire, Asthma Control Questionnaire, HAD, Dyspnoea-12, EuroQual-5D and EuroQuol-VAS. RESULTS: 51 patients were randomised: 36% (51 out of 140) consent rate and attrition at week 16 was 12. Screening logs indicated that study take-up was influenced by patients living long distances from the treatment centre and inability to commit to the weekly demands of the programme. Drop-out was higher in Group-CBT compared due to inability to commit to the weekly programme because of poor health. Participants who contributed to focus group discussions reported that Group-CBT contributed to a better understanding of their illness and related approaches to anxiety management and acceptance of their asthma condition. Although weekly face-to-face sessions were challenging, this was the preferred method of delivery for these participants. CONCLUSIONS: This feasibility study shows that Group-CBT warrants further investigation as a potentially promising treatment option for patients with severe asthma. It has been possible but not easy to recruit and retain the sample. Options for a less demanding intervention schedule, such as less frequent face-to-face visits and the use of web-based interventions, require careful consideration.

Assessment of dyspnea in asthma: validation of The Dyspnea-12.

BACKGROUND: Dyspnea is a prominent symptom in asthma. The Dyspnea-12 (D-12), an instrument that quantifies breathlessness using 12 descriptors that tap the physical and affective aspects, has shown promise for the measurement of dyspnea in cardiorespiratory disease. OBJECTIVE: We report the results of a study designed to test the validity and reliability of the D-12 in a population of patients with asthma. METHODS: This cross-sectional study included 102 patients with asthma. Subjects completed the D-12, Hospital Anxiety and Depression scale, St. George's Respiratory Questionnaire (SGRQ), and Medical Research Council scale. Confirmatory factor analysis confirmed the two-component structure of the D-12 (i.e., seven items that tap the physical aspects of breathlessness and five items that tap the affective aspects). RESULTS: The D-12 subscales had excellent internal reliability (Cronbach's alpha for the "physical" score was 0.94 and the affective score was 0.95). The D-12 physical component was more strongly correlated with SGRQ Symptoms (r = 0.648), SGRQ Activities (r = 0.635) and Medical Research Council grade (r = 0.636), while the affective component was more strongly correlated with SGRQ Impacts (r = 0.765) and Hospital Anxiety and Depression scale scores (anxiety r = 0.641 and depression r = 0.602). CONCLUSION: This study supports validity of the D-12 for use in the assessment of dyspnea of patients with asthma. It assesses one of the most pertinent symptoms of asthma from two viewpoints-physical and affective.

Vantage point.

I STOOD back to allow the bed to pass as a young boy, accompanied by his mother, was wheeled into theatre. He was solemn and did not return my smile, no doubt controlling his fear. His mother, having made her decision to go ahead with the operation, was concentrating on him.

Patient centred leadership in practice.

AIM: To explore patient centred leadership at every level in an organisation and provide practical examples of how this was demonstrated in an acute tertiary NHS Trust. BACKGROUND: There is a direct relationship between leadership and quality of care. With increasing expansion of their role nurses are in a key position to influence and lead colleagues to improve patient care. EVALUATION: The Leadership Qualities Framework (NHS Institute of Innovation and Improvement 2006) is used to illustrate the various qualities used by clinical leaders in examples of leadership in practice. KEY ISSUE: Leadership development with the emphasis on the patient drives improvements in service delivery and patient safety. CONCLUSION: Patient centred leadership is demonstrated when there is support at the top of the organisation. Politically aware nurses make effective patient centred leaders. Leadership development programmes provide staff with opportunities to acquire essential skills and qualities in order to contribute to the vision of the organisation. IMPLICATIONS FOR NURSING MANAGEMENT: Managers should support staff and take risks in order to empower nurses to implement initiatives which improve patient care. A process of communication using a variety of tools can have a impact on a range of staff. Patient centred leaders are role models for tomorrow's leaders, their impact has lasting effect and wider implications within an organisation and beyond.

How to undertake a root cause analysis investigation to improve patient safety.

RATIONALE AND KEY POINTS: Root cause analysis is a tool that can be used when determining how and why a patient safety incident has occurred. Incidents that usually require a root cause analysis include the unexpected death of a patient, serious pressure ulcers, falls that result in injury, and some infections and medication errors. This article outlines the stages of the investigation process for undertaking a root cause analysis. REFLECTIVE ACTIVITY: 'How to' articles can help update your practice and ensure it remains evidence-based. Apply this article to your practice. Reflect on and write a short account of.

A systematic review of psychological interventions for children with asthma.

AIM: Psychological factors may influence the symptoms and management of asthma in children in many ways. It is, therefore, suggested that psychological interventions may be appropriate for this population. This paper reports a systematic review assessing the efficacy of psychological interventions in improving health outcomes for children with asthma. METHODOLOGY: A review of Randomized Controlled Trials (RCT) was designed. RCTs assessing the effects of a psychological intervention in child participants were included in the review. Outcome measures included healthcare utilization, lung function, asthma symptoms, and psychological health status. The search was conducted until April 2005. RESULTS: Twelve studies, involving 588 children, were included in the review; however, study quality was poor and sample sizes were frequently small. A meta-analysis was performed on two studies, examining the effects of relaxation therapy on PEFR which favored the treatment group (SD 0.82, CI 0.41-1.24). No other meta-analysis could be performed due to the diversity of interventions and the outcomes assessed. In addition, many studies reported insufficient data. CONCLUSIONS: This review was unable to draw firm conclusions for the role of psychological interventions for children with asthma. We recommend that valid outcome measures for evaluating the effectiveness of psychological interventions for children with asthma need to address adjustment to and coping with asthma, as well as other psychological indicators. The absence of an adequate evidence base is demonstrated, highlighting the need for well-conducted RCTs in this area.

Psychological interventions for adults with asthma: a systematic review.

AIM: The purpose of this study was to conduct a systematic review of randomized controlled trials where the efficacy of psychological interventions in modifying health and behavioural outcomes for adults with asthma was investigated. METHOD: A review of randomized controlled trials was designed. The literature search was conducted until May 2005. RESULTS: Fourteen studies, involving 617 adults, were included in the review. The use of 'as needed' medications was reduced by relaxation therapy (OR 4.47, CI 1.22-16.44), quality of life, measured using the Asthma Quality of Life Questionnaire, showed a positive effect following cognitive behavioural therapy (WMD 0.71, CI 0.23-1.19), and peak expiratory flow outcome data indicated a significant difference in favour of bio-feedback therapy (SMD 0.66, CI 0.09-1.23). CONCLUSIONS: Some promising results did emerge from meta-analyses performed. However, due to heterogeneity and the low quality of included studies, this review was unable to draw firm conclusions for the role of psychological interventions in asthma. We recommend that larger and well-conducted randomized trials use valid outcome measures to evaluate the effectiveness of psychological interventions for adults with asthma.

Vantage point.

YOU MAY have noticed the recent launch of new government consultation on the prescribing of controlled drugs by nurses and pharmacists under the headline, Pain Relief Made Easier.

Mistakes happen, but we can change our response to them.

It's a heart-sinking feeling when you realise an error has been made, either by yourself or a colleague.

What's your story?

A phenomena increasingly recognised is that the experiences of healthcare staff influence the patient experience.

How nurses can improve quality while controlling costs.

Health care is expensive, and nurses, like everyone else, must use resources responsibly. At the start of a new financial year there is usually a focus on budgets: how much was spent last year, what is available for next year and how savings will be made.

Look after yourself.

Nurses in all sectors are under pressure as they respond to the rising number of patients, often with multiple problems, and the complexities of care. It is therefore important to look after yourself, both in and outside of work.

A profession to be proud of.

We have to admire the responses of individuals and organisations to the Grenfell Tower fire and the recent terrorist attacks, where major incident plans were activated. Our colleagues, nurses and the wider healthcare teams showed heroism, expertise, compassion and commitment.

Grow your own career.

I recently read an advertisement with the headline 'Goodbye job, hello career'. Although it was for an accountancy course, the same message could easily apply to nursing.

The nurse director role is more challenging than ever.

I was a nurse director for more than 20 years, initially at Royal Brompton Hospital, then at Royal Brompton and Harefield NHS Foundation Trust. It was a complex role and an overwhelmingly positive experience. Over the years, however, much has changed, and today the average tenure is about three years.

Ringing the changes.

We all have a choice about how to handle change. Whether to welcome it or resist it, whether to lead or follow, or take a negative attitude and disrupt the changes others wish to make.

Nurses can learn a lot from the patient's experience.

If nurses are to recognise good practice, identify problems and make improvements, they have to be sensitive to patients' views. That said, how can any of us truly understand a situation from another person's perspective, and see things as others do?

Exploring the adoption of Schwartz Center Rounds as an organisational innovation to improve staff well-being in England, 2009-2015.

OBJECTIVES: Schwartz Center Rounds ('Rounds') are a multidisciplinary forum in which healthcare staff within an organisation discuss the psychological, emotional and social challenges associated with their work in a confidential and safe environment. Implemented in over 375 North American organisations, since 2009, they have been increasingly adopted in England. This study aimed to establish how many and what types of organisations have adopted Rounds in England, and to explore why they did so. SETTING: Public healthcare organisations in England. PARTICIPANTS: Secondary data analysis was used to map and profile all 116 public healthcare organisations that had adopted Rounds in England by July 2015. Semistructured telephone interviews were conducted with 45 Round coordinators within adopting organisations. RESULTS: The rate of adoption increased after a major national report in 2013. Rounds were typically adopted in order to improve staff well-being. Adopting organisations scored better on staff engagement than non-adopters; among adopting organisations, those performing better on patient experience were more likely to adopt earlier. Most adoption decision-making processes were straightforward. A confluence of factors-a generally favourable set of innovation attributes (including low cost), advocacy from opinion leaders in different professional networks, active dissemination by change agents and a felt need to be seen to be addressing staff well-being-initially led to Rounds being seen as 'an idea whose time had come'. More recent adoption patterns have been shaped by the timing of charitable and other agency funding in specific geographical areas and sectors, as well as several forms of 'mimetic pressure'. CONCLUSIONS: The innate attributes of Rounds, favourable circumstances and the cumulative impact of a sequence of distinct informal and formal social processes have shaped the pattern of their adoption in England.

More than the sum of its parts.

The headlines that followed the Nuffield Trust's report on reshaping the workforce published in May ( www.nuffieldtrust.org.uk/node/4651 ), concentrated on advanced nursing roles to fill gaps in the medical workforce.

Reflection with a purpose.

Much has been written about reflection in nursing, especially recently given its role in the revalidation process.