Strengthening the role of the executive nurse director: A qualitative interview study.

AIM: To explore the challenges and opportunities facing executive nurse directors in the UK and identify factors to strengthen their role and support more effective nurse leadership. DESIGN: A qualitative descriptive study using reflexive thematic analysis. METHODS: Semi-structured, telephone interviews were carried out with 15 nurse directors and 9 nominated colleagues. RESULTS: Participants described a uniquely complex role with a broader scope than any other executive board member. Seven themes were identified: preparation for the role, length of time in role, role expectations, managing complexity, status, being political and influencing. Strengthening factors included successful working relationships with other board colleagues, development of political skills and personal status, coaching and mentoring, working within a supportive team culture and having strong professional networks. CONCLUSION: Executive nurse leaders are key to the transmission of nursing values and the delivery of safety and quality in healthcare settings. To strengthen this role, the limiting factors and the recommended shared learning identified here should be recognized and addressed at an individual, organizational and professional level. IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE: Given the pressure on all health systems to retain nurses, the role of executive nurse leaders needs to be seen as an important source of professional leadership and their value in actioning health policy into practice recognized. IMPACT: New insights have been provided into the executive nurse director role across the UK. Findings have demonstrated challenges and opportunities to strengthen the executive nurse director role. These include recognition of the need for support, preparation, networking and more realistic expectations of this unique nursing role. REPORTING METHOD: The study adhered to the Consolidated Criteria for Reporting Qualitative Research. PATIENT OR PUBLIC CONTRIBUTION: There was no patient or public contribution.

Electrospinning Drug-Loaded Alginate-Based Nanofibers towards Developing a Drug Release Rate Catalog.

Electrospinning natural polymers represents a developing interest in the field of biomaterials. Electrospun nanofibers have been shown to facilitate tissue regeneration and emulate body tissue, making them ideal for modern biomedical applications. These water-soluble natural polymers including alginate, have also shown promise as drug delivery vehicles. However, many biopolymers including alginate are inherently charged, making the formation of nanofibers difficult. To better understand the potential of natural polymer-based fibers in drug delivery applications, fiber formulations and drug loading concentrations of alginate-based scaffolds were investigated. It was found electrospinning poly(vinyl alcohol) with alginate facilitated fiber formation while the co-polymer agarose showed minor improvement in terms of alginate electrospinnability. Once uniform fibers were formed, the antibiotic ciprofloxacin was added into the polymer electrospinning solution to yield drug-loaded nanofibers. These optimized parameters coupled with small molecule release rate data from the drug-loaded, alginate-based fibers have been used to establish a catalog of small molecule release profiles. In the future, this catalog will be further expanded to include drug release rate data from other innately charged natural polymer-based fibers such as chitosan. It is anticipated that the cataloged profiles can be applied in the further development of biomaterials used in drug delivery.

Enhancing Nurse Practitioner Students' Understanding of Political Processes through Stakeholder Collaboration Using Deliberative Dialogue.

The nurse practitioner's (NP's) role exemplifies the expertise needed to be leaders, researchers and policy influencers. Academia is called upon to provide teaching environments conducive to engaging scholarship that addresses leadership, research and change management skills. By providing opportunities that focus on political processes and policy development, NP students learn and engage in activities that provide a foundation in the development of political savvy, including advocacy and systems change. Deliberative, dialogue-based methods can enhance knowledge of the issues surrounding the NP role and develop students' understanding of political processes needed for policy change in furthering the NP role.

Evidence-informed practice versus evidence-based practice educational interventions for improving knowledge, attitudes, understanding, and behavior toward the application of evidence into practice: A comprehensive systematic review of UG student.

Background: To produce graduates with strong knowledge and skills in the application of evidence into healthcare practice, it is imperative that all undergraduate health and social care students are taught, in an efficient manner, the processes involved in applying evidence into practice. The two main concepts that are linked to the application of evidence into practice are "evidence-based practice" and "evidence-informed practice." Globally, evidence-based practice is regarded as the gold standard for the provision of safe and effective healthcare. Despite the extensive awareness of evidence-based practice, healthcare practitioners continue to encounter difficulties in its implementation. This has generated an ongoing international debate as to whether evidence-based practice should be replaced with evidence-informed practice, and which of the two concepts better facilitate the effective and consistent application of evidence into healthcare practice. Objectives: The primary objective of this systematic review was to evaluate and synthesize literature on the effectiveness of evidence-informed practice versus evidence-based practice educational interventions for improving knowledge, attitudes, understanding, and behavior of undergraduate health and social care students toward the application of evidence into practice. Specifically, we planned to answer the following research questions: (1) Is there a difference (i.e., difference in content, outcome) between evidence-informed practice and evidence-based practice educational interventions? (2) Does participating in evidence-informed practice educational interventions relative to evidence-based practice educational interventions facilitate the application of evidence into practice (as measured by, e.g., self-reports on effective application of evidence into practice)? (3) Do both evidence-informed practice and evidence-based practice educational interventions targeted at undergraduate health and social care students influence patient outcomes (as measured by, e.g., reduced morbidity and mortality, absence of nosocomial infections)? (4) What factors affect the impact of evidence-informed practice and evidence-based practice educational interventions (as measured by, e.g., course content, mode of delivery, multifaceted interventions, standalone intervention)? Search Methods: We utilized a number of search strategies to identify published and unpublished studies: (1) Electronic databases: we searched Academic Search Complete, Academic search premier, AMED, Australian education index, British education index, Campbell systematic reviews, Canada bibliographic database (CBCA Education), CINAHL, Cochrane Library, Database of Abstracts of Reviews on Effectiveness, Dissertation Abstracts International, Education Abstracts, Education complete, Education full text: Wilson, ERIC, Evidence-based program database, JBI database of systematic reviews, Medline, PsycInfo, Pubmed, SciELO (Scientific Electronic Library Online), and Scopus; (2) A web search using search engines such as Google and Google scholar; (3) Grey literature search: we searched OpenGrey (System for Information on Grey Literature in Europe), System for information on Grey Literature, the Society for Research on Educational Effectiveness, and Virginia Henderson Global Nursing e-Repository; (4) Hand searching of journal articles; and (5) Tracking bibliographies of previously retrieved studies. The searches were conducted in June 2019. Selection Criteria: We planned to include both quantitative (including randomized controlled trials, non-randomized controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies) and qualitative primary studies (including, case series, individual case reports, and descriptive cross-sectional studies, focus groups, and interviews, ethnography, phenomenology, and grounded theory), that evaluate and compare the effectiveness of any formal evidence-informed practice educational intervention to evidence-based practice educational intervention. The primary outcomes were evidence-informed practice and evidence-based practice knowledge, attitudes, understanding, and behavior. We planned to include, as participants, undergraduate pre-registration health and social care students from any geographical area. Data Collection and Analysis: Two authors independently screened the search results to assess articles for their eligibility for inclusion. The screening involved an initial screening of the title and abstracts, and subsequently, the full-text of selected articles. Discrepancies were resolved through discussion or consultation with a third author. We found no article eligible for inclusion in this review. Main Results: No studies were found which were eligible for inclusion in this review. We evaluated and excluded 46 full-text articles. This is because none of the 46 studies had evaluated and compared the effectiveness of evidence-informed practice educational interventions with evidence-based practice educational interventions. Out of the 46 articles, 45 had evaluated solely, the effectiveness of evidence-based practice educational interventions and 1 article was on evidence-informed practice educational intervention. Hence, these articles were excluded as they did not meet the inclusion criteria. Authors' Conclusions: There is an urgent need for primary studies evaluating the relative effectiveness of evidence-informed practice and evidence-based practice educational interventions targeted at improving undergraduate healthcare students' competencies regarding the application of evidence into practice. Such studies should be informed by current literature on the concepts (i.e., evidence-informed practice and evidence-based practice) to identify the differences, similarities, as well as appropriate content of the educational interventions. In this way, the actual effect of each of the concepts could be determined and their effectiveness compared.

Long-term improvements following a residential combined physical and psychological programme for chronic low back pain.

OBJECTIVES: Evaluate the outcomes and explore experiences of patients undergoing a residential combined physical and psychological programme (CPPP) for chronic low back pain. DESIGN: A longitudinal observational cohort design, with a parallel qualitative design using semistructured interviews. SETTING: Residential, multimodal rehabilitation. PARTICIPANTS: 136 adults (62 male/74 female) referred to the CPPP, 100 (44 male/56 female) of whom completed the programme, during the term of the study. Ten (2 male/8 female) participated in the qualitative evaluation. INTERVENTION: A 3-week residential CPPP. OUTCOME MEASURES: Primary outcome measures were the STarT Back screening tool score; pain intensity-11-point Numerical Rating Scale; function-Oswestry Disability Index (ODI); health status/quality of life-EQ-5D-5L EuroQol five-Dimension-five level; anxiety-Generalised Anxiety Disorder-7; depression-Patient Health Questionnaire-9. Secondary outcome measures were the Global Subjective Outcome Scale; National Health Service Friends and Family Test;. RESULTS: At discharge, 6 and 12 months follow ups, there were improvements from baseline that were greater than minimum clinically important differences in each of the outcomes (with the sole exception of ODI at discharge). At 12 months, the majority of people considered themselves a lot better (57%) and were extremely likely (86%) to recommend the programme to a friend. The qualitative data showed praise for the residential nature of the intervention and the opportunities for interaction with peers and peer support. There were testimonies of improvements in understanding of pain and how to manage it better. Some participants said they had reduced, or stopped, medication they had been taking to manage their pain. CONCLUSIONS: Participants improved, and maintained long term, beyond minimum clinically important differences on a wide range of outcomes. Participants reported an enhanced ability to self-manage their back pain and support for the residential setting.

Exploring the origin of pain subclassification, with emphasis on low back pain: a scoping review.

OBJECTIVE: This scoping review aimed to explore the different working definitions for the duration of acute, subacute, and chronic pain, with emphasis on low back pain, and to establish where these definitions originated and the rationale provided for the time frames used. INTRODUCTION: From a global perspective, low back pain is a major social and economic problem. One of the most commonly used methods to stratify and manage low back pain is the traditional duration-based classification (acute, subacute, and chronic). Where these time points lie to differentiate these transitions continues to be debated within the scientific community, which may engender a degree of heterogeneity in study findings. Therefore, applying these findings to clinical practice may be somewhat challenging. This review encapsulates the historical origins of the different duration categories to provide an understanding of how these variations were derived. INCLUSION CRITERIA: Studies that included participants with low back pain were the focus of this review. Sources that included children or other specific pain pathologies, such as cancer pain, were excluded. The main concept of interest was that the publication proposed an original definition of the duration of acute, subacute, or chronic low back pain. All study designs were included provided they gave a rationale for the duration that they used. METHODS: The following databases were searched: MEDLINE, Embase, CINAHL, and PsycINFO, from the inception of each database until September 18, 2019. This review was limited to studies published in English. Two independent reviewers screened the retrieved articles against the eligibility criteria. Additional studies were searched from the reference lists of studies to find the original source. Some original sources overlapped with general pain duration literature. This led to a deviation from the scoping review protocol, which originally intended to focus on definitions of low back pain duration only. Data extraction was undertaken using a charting table developed specifically for the review objectives. The findings were presented using narrative synthesis. RESULTS: Nineteen records were included in this review, and comprised three book chapters, four review articles, four articles that arose following pain expert group discussions, seven primary research studies, and a spinal guideline. Data were extracted from the included studies and categorized into four themes based on the origin of the classification of the duration. The themes included i) work/employment setting, ii) empirical studies, iii) expert reasoning, and iv) pathophysiological explanation. CONCLUSIONS: This scoping review compiled the existing literature on the working definitions of the duration of acute, subacute, and chronic low back pain and found a wide variation. These ranged from seven days, 14 days, and seven weeks for the acute and subacute transition points, and seven weeks to three years for chronic low back pain. The duration definitions specifically referring to the general pain literature focused on three and/or six months for the transition to chronic. Better integration of reasoning between the identified themes could facilitate the establishment of more ideal duration definitions in the future. Although inconclusive, the definition most commonly cited, with most consensus, was three months for the transition to chronic low back pain.

Does Duration of Pain at Baseline Influence Longer-term Clinical Outcomes of Low Back Pain Patients Managed on an Evidence-Based Pathway?

STUDY DESIGN: Nonrandomized longitudinal observational study. OBJECTIVE: The aim of this study was to evaluate the association between baseline pain duration and medium-to-long term clinical outcomes, in low back pain (LBP) patients enrolled on the North East of England Regional Back Pain and Radicular Pain Pathway (NERBPP). SUMMARY OF BACKGROUND DATA: The NERBPP is based upon National Institute for Health and Care Excellence (NICE) guidelines. These guidelines no longer differentiate management of LBP patients based on pain duration. Medium-to-long term data from the NERBPP is lacking. METHODS: Between May 2015 and December 2019, 786 and 552 LBP patients from the NERBPP returned 6-month and 12-month follow-up outcome measures, respectively. Outcomes included pain (Numerical rating scale), function (Oswestry Disability Index) and quality-of-life (EuroQol five-dimension, five-level questionnaire), analyzed using a series of covariate-adjusted models. Patients were categorized into four groups based upon baseline pain duration: <3 months, ≥3 to <6 months, ≥6 months to <12 months, ≥12 months. RESULTS: Patients with <3 months duration demonstrated clinically important improvements on all outcomes, at both follow-ups. The improvements in outcomes from this group were larger than those in the ≥12 month's duration group (P < 0.05), these group differences in change, in some cases surpassed our threshold for clinical relevance. Functional improvements in those with ≥12 month's duration were not clinically relevant at either follow-up. All patients, regardless of baseline pain duration, reported similar levels of readiness to self-manage at the 12-month follow-up. CONCLUSION: Baseline pain duration would appear to be of clinical importance. Patients with shorter baseline pain duration demonstrated better outcomes. Those with ≥12 month's duration of pain may need additional support during their management to achieve clinically relevant functional improvements in the medium-to-long term. These findings raise questions about the decision by NICE to move away from duration of pain to differentiate management of LBP patients.Level of Evidence: 3.

Acceptability of a cessation intervention for pregnant smokers: a qualitative study guided by Normalization Process Theory.

BACKGROUND: Smoking during pregnancy has serious consequences for maternal and child health. An intervention package to embed National Institute for Health and Care Excellence guidance (babyClear©) was delivered across maternity and stop smoking services (SSS) within an English region, to support pregnant women to stop smoking. We aimed to ascertain acceptability among pregnant smokers receiving the intervention. METHODS: Pregnant smokers who received the intervention and participated in the study were interviewed, first at around 16 weeks of pregnancy (n = 17) and again several weeks later (n = 8) or postpartum (n = 3). Interview schedules were informed by Normalization Process Theory (NPT) and Theoretical Domains Framework; interviews were audio-recorded, transcribed and analysed thematically, using the Framework method and NPT. Findings are grouped according to the four NPT concepts. RESULTS: Coherence: Carbon monoxide monitoring appeared to make sense; women were motivated to quit by being monitored. Cognitive participation: When linked to a professional discourse of caring and concern, some women were prompted to engage with the SS message. Women were more guarded in their reaction to initial contact from the SSS; reporting attending appointments successfully, or in some cases, experiencing problems that decreased engagement and made quitting harder. Collective action: Where women continued to smoke or failed to attend SSS appointments, an extra intervention was delivered, the Risk Perception Tool (RPT), which often prompted pregnant women to act. Reflexive monitoring: Most women accepted the need for a hard-hitting approach (RPT) and, while it distressed them at the time, they claimed they were subsequently grateful for it. SSS intervention post-RPT was seen as supportive, partly because it often involved home visits. Aspects of family inclusion in babyClear© were reported as beneficial. In Trusts where women experienced services as less focused on prioritising the stop smoking message, less well integrated or reported maternity staff as less adept at delivering the RPT, women found babyClear© less acceptable overall. CONCLUSIONS: The babyClear© package was acceptable to pregnant smokers interviewed during and shortly after pregnancy and, in some cases, to promote quitting. However, some contexts were more optimal than others, leading to variation in acceptability overall.

Identifying the challenges and opportunities of the executive nurse director role in the UK: a scoping review.

The executive nurse director role is complex and there is significant variation in the expectations and responsibilities placed on it. The main function of the role is to deliver the nursing agenda and ensure that safety and quality remain the focus of the executive board. However, it is unclear what evidence exists regarding the challenges and opportunities experienced by executive nurse directors. This scoping review, undertaken as part of the Stronger Study, explores the literature published from 2009 onwards on the challenges and opportunities affecting executive nurse directors' ability to deliver the nursing agenda in the UK. Findings from the review suggest that the importance attached to the executive nurse director role is not matched by the amount of research available. Strengthening the executive nurse director role requires a stronger evidence base and an awareness of the benefits of the role.

Attitudes and perceptions of people with a learning disability, family carers, and paid care workers towards cancer screening programmes in the United Kingdom: A qualitative systematic review and meta-aggregation.

OBJECTIVE: Evidence suggests that people with a learning disability (PwLD) are less likely to attend cancer screening than the general population in the United Kingdom. The aim of this systematic review was to identify and synthesise qualitative studies reporting the attitudes and opinions of PwLD, family carers, and paid care workers towards national cancer screening programmes. METHODS: Five electronic and two grey literature databases were searched. Fourteen thousand eight hundred forty-six papers were reviewed against predetermined inclusion criteria. Included papers were critically appraised. Findings were synthesised using meta-aggregation. RESULTS: Eleven papers met the inclusion criteria, all related to cervical and breast screening. No papers were related to colorectal cancer screening. Findings were clustered into four synthesised findings: (1) supporting women with a learning disability (WwLD) to attend screening, (2) WwLD's awareness of screening and their psychophysical experiences, 3) professional practice barriers including the need for multidisciplinary working and an understanding of the needs of WwLD, and (4) approaches to improve the uptake of cervical and breast cancer screening. The synthesis highlights the significance of WwLD having support to understand the importance of screening to be able to make an informed choice about attending. CONCLUSIONS: WwLD may not attend cancer screening due to fear, concerns over pain, and the potential influence of family carers and paid care workers. The review identified practical mechanisms which could help WwLD attend screening. Future research should focus on identifying potential barriers and facilitators as a proactive measure to promote colorectal cancer screening.

Measuring and Assessing Healthcare Organisational Culture in the England's National Health Service: A Snapshot of Current Tools and Tool Use.

Healthcare Organisational Culture (OC) is a major contributing factor in serious failings in healthcare delivery. Despite an increased awareness of the impact that OC is having on patient care, there is no universally accepted way to measure culture in practice. This study was undertaken to provide a snapshot as to how the English National Health Service (NHS) is currently measuring culture. Although the study is based in England, the findings have potential to influence the measurement of healthcare OC internationally. An online survey was sent to 234 NHS hospital trusts, with a response rate of 35%. Respondents who completed the online survey, on behalf of their representative organisations, were senior clinical governance leaders. The findings demonstrate that the majority of organisations, that responded, were actively measuring culture. Significantly, a wide variety of tools were in use, with variable levels of satisfaction and success. The majority of tools had a focus on patient safety, not on understanding the determining factors which impact upon healthcare OC. This paper reports the tools currently used by the respondents. It highlights that there are deficits in these tools that need to be addressed, so that organisations can interpret their own culture in a standardised, evidence-based way.

What helped and hindered implementation of an intervention package to reduce smoking in pregnancy: process evaluation guided by normalization process theory.

BACKGROUND: Smoking in pregnancy causes harm to mother and baby. Despite evidence from trials of what helps women quit, implementation in the real world has been hard to achieve. An evidence-based intervention, babyClear©, involving staff training, universal carbon monoxide monitoring, opt-out referral to smoking cessation services, enhanced follow-up protocols and a risk perception tool was introduced across North East England. This paper presents the results of the qualitative analyses, reporting acceptability of the system changes to staff, as well as aids and hindrances to implementation and normalization of this complex intervention. METHODS: Process evaluation was used to complement an effectiveness study. Interviews with maternity and smoking cessation services staff and observations of training were undertaken. Normalization Process Theory (NPT) was used to frame the interview guides and analysis. NPT is an empirically-derived theory, developed by sociologists, that uses four concepts to understand the process of routinising new practices. RESULTS: Staff interviews took place across eight National Health Service trusts at a time of widespread restructuring in smoking cessation services. Principally interviewees worked in maternity (n = 63) and smoking cessation services (n = 35). Five main themes, identified inductively, influenced the implementation: 1) initial preparedness of the organisations; 2) staff training; 3) managing partnership working; 4) resources; 5) review and planning for sustainability. CONCLUSIONS: NPT was used to show that the babyClear© package was acceptable to staff in a range of organisations. Illustrated in Themes 1, 2 & 3, staff welcomed ways to approach pregnant women about their smoking, without damaging their professional relationship with them. Predicated on producing individual behaviour change in women, the intervention does this largely through reorganising and standardising healthcare systems that are required to implement best practice guidelines. Changing organisational systems requires belief and commitment from staff, so that they set up and maintain practical adjustments to their practice and are reflective about adapting themselves and the work context as new challenges are encountered. The ongoing challenge is to identify and maintain the elements of the intervention package which are essential for its effectiveness and how to tailor them to local circumstances and resources without compromising its core ingredients.

Exploring the origin of low back pain sub-classification: a scoping review protocol.

OBJECTIVE: This scoping review aims to map the different working definitions currently being used for the duration of acute, subacute and chronic low back pain (LBP), and to establish where these definitions originated and the rationale provided for the timeframes used. INTRODUCTION: Low back pain is a major social and economic problem worldwide. One of the most commonly used approaches to classify and manage patients with LBP is the traditional duration-based classification (acute, subacute and chronic). There are significant differences between studies in the timeframes used for what constitutes acute, subacute and chronic LBP. These discrepancies lead to heterogeneity in study results, making it difficult to compare or summarize findings. INCLUSION CRITERIA: Studies that include participants with non-specific LBP, regardless of sex, will be considered. Studies that include children or participants with specific causes of LBP will be excluded. METHODS: The following electronic databases will be searched: MEDLINE, Embase, CINAHL and PsycINFO. All types of studies will be included, provided they give a rationale for the definition of duration that they use. Studies will be limited to those published in English. Two independent reviewers will screen the retrieved articles against the eligibility criteria for the scoping review. A narrative synthesis will describe the definitions used in the study and the rationale given for the timeframes reported. This scoping review will give an insight into the background of the variation of timeframes used for duration-based classification of LBP.

Getting Students to Value Leadership Early in the Nursing Curriculum: Innovation Makes It Possible.

Introducing leadership content early in a nursing program and weaving related concepts throughout the curriculum allow students opportunities to try on leadership roles and styles and become more skilled in applying leadership concepts. This article describes the implementation and revision of a personal leadership course taught early in an undergraduate nursing curriculum using service-learning, simulation, and team-based learning. The innovative delivery of the course improved student satisfaction and relevance of leadership concepts to second-semester nursing students. The course is foundational and taken in addition to the traditional management and systems leadership course.

Patient reported experiences of using community rehabilitation and/or support services whilst living with a long-term neurological condition: a qualitative systematic review and meta-aggregation.

Objectives: The objective of this study is to identify patient reported experiences of using community rehabilitation and/or support services whilst living with a long-term neurological condition, and perceptions of their impact on quality of life.Methods: Nine electronic databases were searched for peer-reviewed qualitative studies from 2005 to 2016, which met the inclusion criteria. Critical appraisal, data extraction, and quality assessment of 37 included papers were performed by three reviewers. One hundred and one findings were extracted. Meta-aggregation was used to synthesize findings.Findings: Seven 'synthesized findings' [SF] were produced: Interactions with some professionals provide active participation, choice, confidence and autonomy [SF1]; Interactions with some professionals are disempowering and depersonalized [SF2]; Effective communication, specialist knowledge and an individualized approach to information provision is needed [SF3]; Indicators of success vary and may not be clear [SF4]; Informal support from family/friends is valued [SF5]; Opportunities for peer support/social interaction is valued [SF6]; Coordination required to ensure continuity during transition to community [SF7].Conclusion: Patient reported experiences identified common factors associated with process quality (respect, choice, autonomy, information provision, communication) and activities of patient centered care (personalized care, shared decision-making, self-management support) despite heterogeneity of neurological conditions, service configurations, and geographical location. These factors impact quality of life.Implications for RehabilitationPatient reported experiences provide useful information about courtesy, respect, choice, autonomy, information provision, and communication.Outcomes of self-efficacy and self-management are important for people with stable and progressive long-term neurological conditions.Interactions with individual professionals influence engagement, self-efficacy, and self-management for people with long-term neurological conditions.Training for health and social care professionals should develop the advanced communication skills and behavior required to facilitate self-efficacy and self-management.

Listening to the family's voice: evaluation of a tool to improve symptom control and communication.

BACKGROUND:: Acute hospitals provide a high proportion of end-of-life care but some families experience poor communication with clinical staff. AIM:: To evaluate the use of the Family's Voice diary communication tool across nine healthcare settings. METHODS:: A mixed method practice development approach was used incorporating: an audit of the usage of Family's Voice; collation and analysis of written comments; and collation of written feedback from the principal investigators at data collection sites. FINDINGS:: There were 112 completed diaries. Families rated pain and vomiting as well controlled, but agitation and breathlessness were difficult to control. Families were positive about care provided to the patients and themselves. Ten themes were identified from analysis of the families' written comments that echoed national concerns. CONCLUSION:: Evidence for the utility of the diary is building. Future work could focus on strategies for embedding the diary into routine care for all end-of-life patients.

Does Duration of Pain at Baseline Influence Clinical Outcomes of Low Back Pain Patients Managed on an Evidence-based Pathway?

STUDY DESIGN: Longitudinal observational study. OBJECTIVE: To investigate the association between the duration of pain at baseline and the clinical outcomes of patients with low back pain (LBP) enrolled on the North East of England Regional Back Pain and Radicular Pain Pathway (NERBPP). SUMMARY OF BACKGROUND DATA: The NERBPP is a clinical pathway based upon National Institute for Health and Care Excellence (NICE) guidelines (2009) for LBP of <1-year duration. Recent changes to NICE guidelines (2016) advocate the same management for all LBP patients regardless of pain duration. METHODS: Patients with LBP referred onto the NERBPP by their General Practitioner between May 2015 and January 2017 were included. Data from 667 patients, who provided pre- and post data for pain (Numerical rating scale), function (Oswestry Disability Index), quality-of-life (EuroQol five-dimension, five-level questionnaire), anxiety (the Generalized Anxiety Disorder Screener), and depression (the Patient Health Questionnaire), were analyzed using a series of covariate-adjusted models. Patients were categorized into four groups based upon baseline pain duration: <3 months, ≥3 to <6 months, ≥6 months to <12 months, ≥12 months. RESULTS: Each group showed improved outcomes greater than the minimal clinically important difference (MCID) for each measure as defined in NICE guidelines (2016). There was a trend toward better outcomes for those with shorter pain durations. The magnitude of the differences between the groups, in most instances, was below the MCID. For example, mean improvement in function for those with baseline pain duration <3 months was 20 points and 12 points for those of pain duration ≥12 months, both above the MCID of ≥10. CONCLUSION: Patients with different durations of LBP at baseline improved on the NERBPP, supporting the recent modification to NICE guidelines. However, those with shorter durations of pain may have superior outcomes in the short term, suggesting added benefit in getting patients onto the pathway in the early stages of LBP. LEVEL OF EVIDENCE: 3.

Intermittent fasting interventions for treatment of overweight and obesity in adults: a systematic review and meta-analysis.

OBJECTIVE: To examine the effectiveness of intermittent energy restriction in the treatment for overweight and obesity in adults, when compared to usual care treatment or no treatment. INTRODUCTION: Intermittent energy restriction encompasses dietary approaches including intermittent fasting, alternate day fasting, and fasting for two days per week. Despite the recent popularity of intermittent energy restriction and associated weight loss claims, the supporting evidence base is limited. INCLUSION CRITERIA: This review included overweight or obese (BMI ≥25 kg/m) adults (≥18 years). Intermittent energy restriction was defined as consumption of ≤800 kcal on at least one day, but no more than six days per week. Intermittent energy restriction interventions were compared to no treatment (ad libitum diet) or usual care (continuous energy restriction ∼25% of recommended energy intake). Included interventions had a minimum duration of 12 weeks from baseline to post outcome measurements. The types of studies included were randomized and pseudo-randomized controlled trials. The primary outcome of this review was change in body weight. Secondary outcomes included: i) anthropometric outcomes (change in BMI, waist circumference, fat mass, fat free mass); ii) cardio-metabolic outcomes (change in blood glucose and insulin, lipoprotein profiles and blood pressure); and iii) lifestyle outcomes: diet, physical activity, quality of life and adverse events. METHODS: A systematic search was conducted from database inception to November 2015. The following electronic databases were searched: MEDLINE, Embase, CINAHL, Cochrane Library, ClinicalTrials.gov, ISRCTN registry, and anzctr.org.au for English language published studies, protocols and trials. Two independent reviewers evaluated the methodological quality of included studies using the standardized critical appraisal instruments from the Joanna Briggs Institute. Data were extracted from papers included in the review by two independent reviewers using the standardized data extraction tool from the Joanna Briggs Institute. Effect sizes were expressed as weighted mean differences and their 95% confidence intervals were calculated for meta-analyses. RESULTS: Six studies were included in this review. The intermittent energy restriction regimens varied across studies and included alternate day fasting, fasting for two days, and up to four days per week. The duration of studies ranged from three to 12 months. Four studies included continuous energy restriction as a comparator intervention and two studies included a no treatment control intervention. Meta-analyses showed that intermittent energy restriction was more effective than no treatment for weight loss (-4.14 kg; 95% CI -6.30 kg to -1.99 kg; p ≤ 0.001). Although both treatment interventions achieved similar changes in body weight (approximately 7 kg), the pooled estimate for studies that investigated the effect of intermittent energy restriction in comparison to continuous energy restriction revealed no significant difference in weight loss (-1.03 kg; 95% CI -2.46 kg to 0.40 kg; p = 0.156). CONCLUSIONS: Intermittent energy restriction may be an effective strategy for the treatment of overweight and obesity. Intermittent energy restriction was comparable to continuous energy restriction for short term weight loss in overweight and obese adults. Intermittent energy restriction was shown to be more effective than no treatment, however, this should be interpreted cautiously due to the small number of studies and future research is warranted to confirm the findings of this review.

Evaluation of a complex healthcare intervention to increase smoking cessation in pregnant women: interrupted time series analysis with economic evaluation.

OBJECTIVES: To evaluate the effectiveness of a complex intervention to improve referral and treatment of pregnant smokers in routine practice, and to assess the incremental costs to the National Health Service (NHS) per additional woman quitting smoking. DESIGN: Interrupted time series analysis of routine data before and after introducing the intervention, within-study economic evaluation. SETTING: Eight acute NHS hospital trusts and 12 local authority areas in North East England. PARTICIPANTS: 37 726 records of singleton delivery including 10 594 to mothers classified as smoking during pregnancy. INTERVENTIONS: A package of measures implemented in trusts and smoking cessation services, aimed at increasing the proportion of pregnant smokers quitting during pregnancy, comprising skills training for healthcare and smoking cessation staff; universal carbon monoxide monitoring with routine opt-out referral for smoking cessation support; provision of carbon monoxide monitors and supporting materials; and an explicit referral pathway and follow-up protocol. MAIN OUTCOME MEASURES: Referrals to smoking cessation services; probability of quitting smoking during pregnancy; additional costs to health services; incremental cost per additional woman quitting. RESULTS: After introduction of the intervention, the referral rate increased more than twofold (incidence rate ratio=2.47, 95% CI 2.16 to 2.81) and the probability of quitting by delivery increased (adjusted OR=1.81, 95% CI 1.54 to 2.12). The additional cost per delivery was £31 and the incremental cost per additional quit was £952; 31 pregnant women needed to be treated for each additional quitter. CONCLUSIONS: The implementation of a system-wide complex healthcare intervention was associated with significant increase in rates of quitting by delivery.