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1.
BMJ Open ; 11(10): e047255, 2021 10 19.
Artigo em Inglês | MEDLINE | ID: mdl-34666999

RESUMO

OBJECTIVES: To identify aspects of the organisation and delivery of acute inpatient services for people with dementia that are associated with shorter length of hospital stay. DESIGN AND SETTING: Retrospective cohort study of patients admitted to 200 general hospitals in England and Wales. PARTICIPANTS: 10 106 people with dementia who took part in the third round of National Audit of Dementia. MAIN OUTCOME MEASURE: Length of admission to hospital. RESULTS: The median length of stay was 12 days (IQR=6-23 days). People with dementia spent less time in hospital when discharge planning was initiated within 24 hours of admission (estimated effect -0.24, 95% CI: -0.29 to -0.18, p<0.001). People from ethnic minorities had shorter length of stay (difference -0.066, 95% CI: -0.13 to -0.002, p=0.043). Patients with documented evidence of discussions having taken place between their carers and medical staff spent longer in hospital (difference 0.26, 95% CI: 0.21 to 0.32, p<0.001). These associations held true in a subsample of 669 patients admitted with hip fracture and data from 74 hospitals with above average carer-rated quality of care. CONCLUSIONS: The way that services for inpatients with dementia are delivered can influence how long they spend in hospital. Initiating discharge planning within the first 24 hours of admission may help reduce the amount of time that people with dementia spend in hospital.


Assuntos
Demência , Demência/terapia , Inglaterra , Hospitais Gerais , Humanos , Tempo de Internação , Estudos Retrospectivos , País de Gales
3.
Bone Joint J ; 103-B(5): 830-839, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33683139

RESUMO

AIMS: Many surgeons choose to perform total knee arthroplasty (TKA) surgery with the aid of a tourniquet. A tourniquet is a device that fits around the leg and restricts blood flow to the limb. There is a need to understand whether tourniquets are safe, and if they benefit, or harm, patients. The aim of this study was to determine the benefits and harms of tourniquet use in TKA surgery. METHODS: We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled trials, and trial registries up to 26 March 2020. We included randomized controlled trials (RCTs), comparing TKA with a tourniquet versus without a tourniquet. Outcomes included: pain, function, serious adverse events (SAEs), blood loss, implant stability, duration of surgery, and length of hospital stay. RESULTS: We included 41 RCTs with 2,819 participants. SAEs were significantly more common in the tourniquet group (53/901 vs 26/898, tourniquet vs no tourniquet respectively) (risk ratio 1.73 (95% confidence interval (CI) 1.10 to 2.73). The mean pain score on the first postoperative day was 1.25 points higher (95% CI 0.32 to 2.19) in the tourniquet group. Overall blood loss did not differ between groups (mean difference 8.61 ml; 95% CI -83.76 to 100.97). The mean length of hospital stay was 0.34 days longer in the group that had surgery with a tourniquet (95% CI 0.03 to 0.64) and the mean duration of surgery was 3.7 minutes shorter (95% CI -5.53 to -1.87). CONCLUSION: TKA with a tourniquet is associated with an increased risk of SAEs, pain, and a marginally longer hospital stay. The only finding in favour of tourniquet use was a shorter time in theatre. The results make it difficult to justify the routine use of a tourniquet in TKA surgery. Cite this article: Bone Joint J 2021;103-B(5):830-839.


Assuntos
Artroplastia do Joelho , Perda Sanguínea Cirúrgica/prevenção & controle , Hemostasia Cirúrgica/instrumentação , Torniquetes , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Amplitude de Movimento Articular , Torniquetes/efeitos adversos
4.
Autism ; 25(6): 1553-1564, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33722069

RESUMO

LAY ABSTRACT: Most autism spectrum condition research addresses the neurological and biological causes of autism spectrum condition, focusing upon deficits associated with autism spectrum condition and behavioural interventions designed to minimise these deficits. Little is known about the lived experiences of adult women on the autism spectrum and how they navigate social expectations around gender, autism spectrum condition and gendered understandings of autism spectrum condition. The lived experiences of eight women on the AS will be shared here, with attention to how gendered expectations influence women's experiences of autism spectrum condition, their sense of self and well-being. Findings showed these women struggled to reconcile the expectations of others, particularly early in life. The women had difficultly conforming to stereotypical ideals of femininity, yet as they aged, they felt less need to conform, valuing their unique style and behaviours. The women also rejected deficit-oriented descriptions of autism spectrum condition generated by the medical community, preferring to focus on their strengths and unique characteristics. It is hoped this article helps psychologists and the wider community to understand and meet the needs of women on the AS.


Assuntos
Transtorno do Espectro Autista , Transtorno Autístico , Adulto , Idoso , Feminino , Identidade de Gênero , Humanos , Pesquisa Qualitativa
5.
Pain Med ; 22(6): 1333-1344, 2021 06 04.
Artigo em Inglês | MEDLINE | ID: mdl-33751119

RESUMO

OBJECTIVE: There is a large body of research exploring what it means for a person to live with chronic pain. However, existing research does not help us understand what it means to recover. We aimed to identify qualitative research that explored the experience of living with chronic pain published since 2012 and to understand the process of recovery. DESIGN: A synthesis of qualitative research using meta-ethnography. METHODS: We used the seven stages of meta-ethnography. We systematically searched for qualitative research, published since 2012, that explored adults' experiences of living with, and being treated for, chronic pain. We used constant comparison to distill the essence of ideas into themes and developed a conceptual model. RESULTS: We screened 1,328 titles and included 195 studies. Our conceptual model indicates that validation and reconnection can empower a person with chronic pain to embark on a journey of healing. To embark on this journey requires commitment, energy, and support. CONCLUSIONS: The innovation of our study is to conceptualize healing as an ongoing and iterating journey rather than a destination. Health interventions for chronic pain would usefully focus on validating pain through meaningful and acceptable explanations; validating patients by listening to and valuing their stories; encouraging patients to connect with a meaningful sense of self, to be kind to themselves, and to explore new possibilities for the future; and facilitating safe reconnection with the social world. This could make a real difference to people living with chronic pain who are on their own healing journeys.


Assuntos
Dor Crônica , Adulto , Antropologia Cultural , Dor Crônica/terapia , Atenção à Saúde , Humanos , Pesquisa Qualitativa
6.
BMC Geriatr ; 21(1): 91, 2021 01 31.
Artigo em Inglês | MEDLINE | ID: mdl-33517904

RESUMO

BACKGROUND: There is little evidence about the lived experience of older people who have completed a falls prevention exercise programme and their life beyond their intervention. METHOD: A phenomenological interview study with 23 participants (12 females), mean age 81 years (range 74-93 years), residing in their own homes across England, who had participated in a falls prevention exercise intervention within the Prevention of Falls Injury Trial (PreFIT). The aims were to explore their experiences of: i. being in a clinical trial involving exercise. ii. exercise once their falls prevention intervention had finished. Interpretative data analysis was informed by van Manen's (1997) framework for phenomenological data. RESULTS: Analysis of interviews about experiences of participating in PreFIT and what happened once the falls intervention ended identified five themes: Happy to help; Exercise behaviours; "It keeps me going"; "It wasn't a real fall"; and Loss. Participants did not continue their specific exercises after they had completed the intervention. They preferred walking as their main exercise, and none reported preventing falls as a motivator to continue exercising. Participant experiences suggest that they have their own ideas about what constitutes a fall and there is disparity between their interpretation and the definition used by healthcare professionals and researchers. CONCLUSION: Despite good intentions and perceived benefits, on-going participation in falls prevention exercises beyond a structured, supervised intervention was not a priority for these older people. Promoting continuation of falls prevention exercises post-intervention is just as challenging as promoting uptake to and adherence during exercise programmes.


Assuntos
Acidentes por Quedas , Vida Independente , Acidentes por Quedas/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Inglaterra , Exercício Físico , Terapia por Exercício , Feminino , Humanos
7.
Trials ; 22(1): 8, 2021 Jan 06.
Artigo em Inglês | MEDLINE | ID: mdl-33407804

RESUMO

OBJECTIVES: The primary objective is to determine which of two interventions: 1) an eight week, online, home-based, supervised, group rehabilitation programme (REGAIN); or 2) a single online session of advice (best-practice usual care); is the most clinically and cost-effective treatment for people with ongoing COVID-19 sequelae more than three months after hospital discharge. TRIAL DESIGN: Multi-centre, 2-arm (1:1 ratio) parallel group, randomised controlled trial with embedded process evaluation and health economic evaluation. PARTICIPANTS: Adults with ongoing COVID-19 sequelae more than three months after hospital discharge Inclusion criteria: 1) Adults ≥18 years; 2) ≥ 3 months after any hospital discharge related to COVID-19 infection, regardless of need for critical care or ventilatory support; 3) substantial (as defined by the participant) COVID-19 related physical and/or mental health problems; 4) access to, and able/supported to use email and internet audio/video; 4) able to provide informed consent; 5) able to understand spoken and written English, Bengali, Gujarati, Urdu, Punjabi or Mandarin, themselves or supported by family/friends. EXCLUSION CRITERIA: 1) exercise contraindicated; 2) severe mental health problems preventing engagement; 3) previous randomisation in the present study; 4) already engaged in, or planning to engage in an alternative NHS rehabilitation programme in the next 12 weeks; 5) a member of the same household previously randomised in the present study. INTERVENTION AND COMPARATOR: Intervention 1: The Rehabilitation Exercise and psycholoGical support After covid-19 InfectioN (REGAIN) programme: an eight week, online, home-based, supervised, group rehabilitation programme. Intervention 2: A thirty-minute, on-line, one-to-one consultation with a REGAIN practitioner (best-practice usual care). MAIN OUTCOMES: The primary outcome is health-related quality of life (HRQoL) - PROMIS® 29+2 Profile v2.1 (PROPr) - measured at three months post-randomisation. Secondary outcomes include dyspnoea, cognitive function, health utility, physical activity participation, post-traumatic stress disorder (PTSD) symptom severity, depressive and anxiety symptoms, work status, health and social care resource use, death - measured at three, six and 12 months post-randomisation. RANDOMISATION: Participants will be randomised to best practice usual care or the REGAIN programme on a 1:1.03 basis using a computer-generated randomisation sequence, performed by minimisation and stratified by age, level of hospital care, and case level mental health symptomatology. Once consent and baseline questionnaires have been completed by the participant online at home, randomisation will be performed automatically by a bespoke web-based system. BLINDING (MASKING): To ensure allocation concealment from both participant and REGAIN practitioner at baseline, randomisation will be performed only after the baseline questionnaires have been completed online at home by the participant. After randomisation has been performed, participants and REGAIN practitioners cannot be blind to group allocation. Follow-up outcome assessments will be completed by participants online at home. NUMBERS TO BE RANDOMISED (SAMPLE SIZE): A total of 535 participants will be randomised: 263 to the best-practice usual care arm, and 272 participants to the REGAIN programme arm. TRIAL STATUS: Current protocol: Version 3.0 (27th October 2020) Recruitment will begin in December 2020 and is anticipated to complete by September 2021. TRIAL REGISTRATION: ISRCTN:11466448 , 23rd November 2020 FULL PROTOCOL: The full protocol Version 3.0 (27th October 2020) is attached as an additional file, accessible from the Trials website (Additional file 1). In the interests of expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol. The study protocol has been reported in accordance with the Standard Protocol Items: Recommendations for Clinical Interventional Trials (SPIRIT) guidelines.


Assuntos
COVID-19/reabilitação , Terapia por Exercício/métodos , Intervenção Baseada em Internet/economia , Sistemas de Apoio Psicossocial , Encaminhamento e Consulta/economia , Adulto , COVID-19/diagnóstico , COVID-19/psicologia , COVID-19/virologia , Análise Custo-Benefício , Terapia por Exercício/economia , Feminino , Humanos , Masculino , Estudos Multicêntricos como Assunto , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , SARS-CoV-2/isolamento & purificação , Índice de Gravidade de Doença , Resultado do Tratamento , Reino Unido
9.
Implement Sci ; 15(1): 104, 2020 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-33261621

RESUMO

BACKGROUND: Clinical leadership is fundamental in facilitating service improvements in healthcare. Few studies have attempted to understand or model the different approaches to leadership which are used when promoting the uptake and implementation of evidence-based interventions. This research aims to uncover and explain how distributed clinical leadership can be developed and improved to enhance the use of evidence in practice. In doing so, this study examines implementation leadership in orthopaedic surgery to explain leadership as a collective endeavour which cannot be separated from the organisational context. METHODS: A mixed-method study consisting of longitudinal and cross-sectional interviews and an embedded social network analysis will be performed in six NHS hospitals. A social network analysis will be undertaken in each hospital to uncover the organisational networks, the focal leadership actors and information flows in each organisation. This will be followed by a series of repeated semi-structured interviews, conducted over 4 years, with orthopaedic surgeons and their professional networks. These longitudinal interviews will be supplemented by cross-sectional interviews with the national established surgical leaders. All qualitative data will be analysed using a constructivist grounded theory approach and integrated with the quantitative data. The participant narratives will enrich the social network to uncover the leadership configurations which exist, and how different configurations of leadership are functioning in practice to influence implementation processes and outcomes. DISCUSSION: The study findings will facilitate understanding about how and why different configurations of leadership develop and under what organisational conditions and circumstances they are able to flourish. The study will guide the development of leadership interventions that are grounded in the data and aimed at advancing leadership for service improvement in orthopaedics. The strength of the study lies in the combination of multi-component, multi-site, multi-agent methods to examine leadership processes in surgery. The findings may be limited by the practical challenges of longitudinal qualitative data collection, such as ensuring participant retention, which need to be balanced against the theoretical and empirical insights generated through this comprehensive exploration of leadership across and within a range of healthcare organisations.


Assuntos
Prática Clínica Baseada em Evidências , Liderança , Estudos Transversais , Atenção à Saúde , Hospitais , Humanos
10.
Cochrane Database Syst Rev ; 12: CD012874, 2020 12 08.
Artigo em Inglês | MEDLINE | ID: mdl-33316105

RESUMO

BACKGROUND: Many surgeons prefer to perform total knee replacement surgery with the aid of a tourniquet. A tourniquet is an occlusive device that restricts distal blood flow to help create a bloodless field during the procedure. A tourniquet may be associated with increased risk of pain and complications. OBJECTIVES: To determine the benefits and harms of tourniquet use in knee replacement surgery. SEARCH METHODS: We searched MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) up to 26 March 2020. We searched clinicaltrials.gov, the World Health Organization trials portal, and several international registries and joint registries up to March 2020. SELECTION CRITERIA: We included randomised controlled trials (RCTs) comparing knee replacement with use of a tourniquet versus without use of a tourniquet and non-randomised studies with more than 1000 participants. Major outcomes included pain, function, global assessment of success, health-related quality of life, serious adverse events (including venous thromboembolism, infection, re-operation, and mortality), cognitive function, and survival of the implant. Minor outcomes included blood loss, economic outcomes, implant stability, and adverse events. DATA COLLECTION AND ANALYSIS: Two review authors screened abstracts and full texts, extracted data, performed risk of bias assessments, and assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS: We included 41 RCTs with 2819 participants. Trials included from 20 to 199 participants. Mean age ranged between 58 and 84 years. More than half of the RCTs had unclear risk of selection bias and unclear risk of performance and detection bias due to absence of blinding of participants and surgeons. Major outcomes Pain: at postoperative day 1, pain (on a scale from zero to 10, with higher scores indicating worse pain) was ranked at 4.56 points after surgery without a tourniquet and at 1.25 points (MD) higher (95% CI 0.32 higher to 2.19 higher) with a tourniquet (8 studies; 577 participants), for an absolute difference of 12.5% higher pain scores (95% CI 3.2% higher to 21.9% higher) and a relative difference of 19% higher pain scores (95% CI 3.4% higher to 49% higher) with a tourniquet. Evidence for these findings was of moderate certainty, downgraded due to risk of bias. Knee replacement with a tourniquet probably led to higher postoperative pain scores at day 1, although this difference may or may not be noticeable to patients (based on a minimal clinically important difference (MCID) of 1.0). Function: at 12 months, tourniquet use probably makes little or no difference to function, based on an MCID of 5.3 for Knee Society Score (KSS) and 5.0 for Oxford Knee Score (OKS). Mean function (on a scale from 0 to 100, with higher scores indicating better outcomes) was 90.03 points after surgery without a tourniquet and was 0.29 points worse (95% CI 1.06 worse to 0.48 better) on a 0 to 100 scale, absolute difference was 0.29% worse (1.06% worse to 0.48% better), with a tourniquet (5 studies; 611 participants). This evidence was downgraded to moderate certainty due to risk of bias. Global assessment of success: low-certainty evidence (downgraded due to bias and imprecision) indicates that tourniquet use may have little or no effect on success. At six months, 47 of 50 (or 940 per 1000) reported overall successful treatment after surgery without a tourniquet and 47 of 50 (or 940 per 1000) with a tourniquet (risk ratio (RR) 1.0, 95% CI 0.91 to 1.10) based on one study with 100 participants. Health-related quality of life: at six months, tourniquet may have little or no effect on quality of life. The 12-Item Short Form Survey (SF-12) score (mental component from zero to 100 (100 is best)) was 54.64 after surgery without a tourniquet and 1.53 (MD) better (95% CI 0.85 worse to 3.91 better) with a tourniquet (1 study; 199 participants); absolute difference was 1.53% better (0.85% worse to 3.91% better). Evidence was of low certainty, downgraded due to risk of bias and small number of participants. Serious adverse events: the risk of serious adverse events was probably higher with tourniquet; 26 of 898 (29 per 1000) reported events following surgery without a tourniquet compared to 53 of 901 (59 per 1000) with a tourniquet (RR 1.73, 95% CI 1.10 to 2.73) in 21 studies (1799 participants). Twenty-nine more per 1000 patients (95% CI 3 to 50 more per 1000 patients) had a serious adverse event with a tourniquet. Forty-eight (95% CI 20 to 345) participants would need to have surgery without a tourniquet to avoid one serious adverse event. This evidence was downgraded to moderate certainty due to risk of bias. Cognitive function: one study reported cognitive function as an outcome; however the data were incompletely reported and could not be extracted for analysis. Survival of implant: it is uncertain if tourniquet has an effect on implant survival due to very low certainty evidence (downgraded for bias, and twice due to very low event rates); 2 of 107 (19 per 1000) required revision surgery in the surgery with a tourniquet group compared to 1 of 107 (9 per 1000) without a tourniquet group at up to two years' follow-up (RR 1.44, 95% CI 0.23 to 8.92). This equates to a 0.4% (0.7% lower to 7% more) increased absolute risk in surgery with a tourniquet. AUTHORS' CONCLUSIONS: Moderate certainty evidence shows that knee replacement surgery with a tourniquet is probably associated with an increased risk of serious adverse events. Surgery with a tourniquet is also probably associated with higher postoperative pain, although this difference may or may not be noticeable to patients. Surgery with a tourniquet does not appear to confer any clinically meaningful benefit on function, treatment success or quality of life. Further research is required to explore the effects of tourniquet use on cognitive function and implant survival, to identify any additional harms or benefits. If a tourniquet continues to be used in knee replacement surgery, patients should be informed about the potential increased risk of serious adverse events and postoperative pain.


Assuntos
Artroplastia do Joelho/efeitos adversos , Torniquetes/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Artroplastia do Joelho/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor/métodos , Dor Pós-Operatória/diagnóstico , Falha de Prótese , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Viés de Seleção , Resultado do Tratamento
11.
BMC Pulm Med ; 20(1): 143, 2020 May 19.
Artigo em Inglês | MEDLINE | ID: mdl-32429969

RESUMO

BACKGROUND: Supervised cardio-pulmonary rehabilitation may be safe and beneficial for people with pulmonary hypertension (PH) in groups 1 (pulmonary arterial hypertension) and 4 (chronic thromboembolic disease), particularly as a hospital in-patient. It has not been tested in the most common PH groups; 2 (left heart disease), 3 (lung disease), or 5 (other disorders). Further it has not been evaluated in the UK National Health Service (NHS) out-patient setting, or with long-term follow-up. The aim of this randomised controlled trial (RCT) is to test the clinical and cost-effectiveness of a supervised exercise rehabilitation intervention with psychosocial support compared to best practice usual care for people with PH in the community/outpatient setting. METHODS: This multi-centre, pragmatic, two-arm RCT with embedded process evaluation aims to recruit 352 clinically stable adults with PH (groups 1-5) and WHO functional class II-IV. Participants will be randomised to either the Supervised Pulmonary Hypertension Exercise Rehabilitation (SPHERe) intervention or control. The SPHERe intervention consists of 1) individual assessment and familiarisation sessions; 2) 8-week, twice-weekly, supervised out-patient exercise training; 3) psychosocial/motivational support and education; 4) guided home exercise plan. The control intervention consists of best practice usual care with a single one-to-one practitioner appointment, and general advice on physical activity. Outcomes will be measured at baseline, 4 months (post-intervention) and 12 months by researchers blinded to treatment allocation. The primary outcome is the incremental shuttle walk test at 4 months. Secondary outcomes include health-related quality of life (HRQoL), time to clinical worsening and health and social care use. A purposive sample of participants (n = 20 intervention and n = 20 control) and practitioners (n = 20) will be interviewed to explore experiences of the trial, outcomes and interventions. DISCUSSION: The SPHERe study is the first multi-centre clinical RCT to assess the clinical and cost effectiveness of a supervised exercise rehabilitation intervention compared to usual care, delivered in the UK NHS, for people in all PH groups. Results will inform clinicians and commissioners as to whether or not supervised exercise rehabilitation is effective and should be routinely provided for people with PH. TRIAL REGISTRATION: ISRCTN no. 10608766, prospectively registered on 18th March 2019.


Assuntos
Terapia por Exercício/métodos , Hipertensão Pulmonar/reabilitação , Análise Custo-Benefício , Humanos , Hipertensão Pulmonar/economia , Hipertensão Pulmonar/fisiopatologia , Estudos Multicêntricos como Assunto , Pacientes Ambulatoriais , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Medicina Estatal , Reino Unido , Teste de Caminhada
12.
Artigo em Inglês | MEDLINE | ID: mdl-32337065

RESUMO

Background: Working in good jobs is associated with good health. High unemployment rates are reported in those disabled with musculoskeletal pain. Supported employment interventions work well for helping people with mental health difficulties to gain and retain employment. With adaptation, these may be useful for people with chronic pain. We aimed to develop and explore the feasibility of delivering such an adapted intervention. Methods: We developed an intervention and recruited unemployed people with chronic pain from NHS pain clinics and employment services. We trained case managers to assess participants and match them to six-week work placements in the Midlands and provide ongoing support to them and their managers. Participants attended a two-day work preparation session prior to placement. Outcome measures included quality of life at baseline, six- weeks, 14-weeks, and six-months, and return to work at 14-weeks and six-months. We held focus groups or interviews with stakeholders to examine acceptability and experiences of the intervention. Results: We developed an intervention consisting of work preparation sessions, work experience placements, and individualised employment support. We enrolled 31 people; 27 attended work preparation sessions, and 15 attended placements. Four of our participants started jobs during the study period. We are aware of two others starting jobs shortly after cessation of follow-up. We experienced challenges to recruitment in one area where we had many and diverse placement opportunities and good recruitment in another area where we had a smaller range of placement opportunities. All stakeholders found the intervention acceptable, and it was valued by those given a placement. While there was some disappointment among those not placed, this group still valued the work preparation sessions. Conclusions: The developed intervention was acceptable to participants and partners. Trialling the developed intervention could be feasible with attention to three main processes. To ensure advanced availability of a sufficiently wide range of work placements in each area, multiple partners would be needed. Multiple recruitment sites and focus on employment services will yield better recruitment rates than reliance on NHS pain clinics. Maintaining an adequate follow-up response rate will likely require additional approaches with more than the usual effort.

13.
BMJ Open ; 10(2): e032988, 2020 02 18.
Artigo em Inglês | MEDLINE | ID: mdl-32075828

RESUMO

OBJECTIVE: To review qualitative studies on the experience of taking opioid medication for chronic non-malignant pain (CNMP) or coming off them. DESIGN: This is a qualitative evidence synthesis using a seven-step approach from the methods of meta-ethnography. DATA SOURCES AND ELIGIBILITY CRITERIA: We searched selected databases-Medline, Embase, AMED, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Web of Science and Scopus (Science Citation Index and Social Science Citation Index)-for qualitative studies which provide patients' views of taking opioid medication for CNMP or of coming off them (June 2017, updated September 2018). DATA EXTRACTION AND SYNTHESIS: Papers were quality appraised using the Critical Appraisal Skills Programme tool, and the GRADE-CERQual (Grading of Recommendations Assessment, Development and Evaluation working group - Confidence in Evidence from Reviews of Qualitative research) guidelines were applied. We identified concepts and iteratively abstracted these concepts into a line of argument. RESULTS: We screened 2994 unique citations and checked 153 full texts, and 31 met our review criteria. We identified five themes: (1) reluctant users with little choice; (2) understanding opioids: the good and the bad; (3) a therapeutic alliance: not always on the same page; (4) stigma: feeling scared and secretive but needing support; and (5) the challenge of tapering or withdrawal. A new overarching theme of 'constantly balancing' emerged from the data. CONCLUSIONS: People taking opioids were constantly balancing tensions, not always wanting to take opioids, and weighing the pros and cons of opioids but feeling they had no choice because of the pain. They frequently felt stigmatised, were not always 'on the same page' as their healthcare professional and felt changes in opioid use were often challenging. TRIAL REGISTRATION NUMBER: 49470934; Pre-results.


Assuntos
Analgésicos Opioides/uso terapêutico , Atitude , Dor Crônica/tratamento farmacológico , Conflito Psicológico , Prescrições de Medicamentos , Emoções , Síndrome de Abstinência a Substâncias , Antropologia Cultural , Dor Crônica/psicologia , Compreensão , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Pessoal de Saúde , Humanos , Masculino , Relações Médico-Paciente , Pesquisa Qualitativa , Estigma Social
14.
Int J Nurs Stud ; 101: 103436, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31670223

RESUMO

BACKGROUND: Healthcare is delivered in a culture of ongoing change, with many nurses highlighting the impact of this on their own wellbeing. However, there is a dearth of literature focusing on how nurses care for themselves as they try to provide compassionate care in a challenging job. OBJECTIVES: This study explored nurses' experience of self-care and self-compassion and how this may relate to compassionate care giving towards patients. DESIGN: A constructivist grounded theory approach was used to develop a theoretical understanding of nurses' experience. SETTINGS: This study included participants from two National Health Service (NHS) Trusts within the United Kingdom (UK). PARTICIPANTS: Purposive and theoretical sampling were used to recruit general, mental health and learning disability nurses, at different levels of seniority. METHOD: Between September 2015 and March 2016 semi-structured interviews were conducted. Analysis was completed in line with the process set out within constructivist grounded theory. Using constant comparison and memo writing, analysis moved from initial coding to focused coding, through to theoretical coding, resulting in the production of core concepts and categories, and theory development. RESULTS: Thirty participants were included in the study. Three concepts were derived from the data: (1) 'Hardwired to be caregivers' - vocation versus role, (2) needing a stable base, (3) Managing the emotions of caring. All three concepts linked to a core process: needing permission to self-care and be self-compassionate. Nurses needed permission from others and from themselves to be self-caring and self-compassionate. An inability to do this affected their wellbeing and compassionate care giving to others. Interviewees described how they struggled particularly with self-compassion. Helping nurses to be proactively more self-caring and self-compassionate may increase their ability to manage emotions and prevent some of the negative consequences of nursing such as burnout and compassion fatigue. A conceptual framework is proposed which identifies that formal permission (e.g., within nursing guidance) may be necessary for some nurses to look after themselves. CONCLUSION: Findings identified the need for permission as key in enabling nurses to self-care and be self-compassionate, which may facilitate them to address patients' needs. The study highlights the importance of self-care and self-compassion within nursing education and nursing guidance.


Assuntos
Empatia , Processo de Enfermagem , Autocuidado , Teoria Fundamentada , Humanos , Reino Unido
15.
Can J Pain ; 4(3): 61-70, 2020 Sep 24.
Artigo em Inglês | MEDLINE | ID: mdl-33987512

RESUMO

Background: There is very limited research exploring the value and impact of qualitative research in chronic pain despite the large volume of research. Aims: The aim of this study was to find out whether viewers' comments in response to a YouTube film, portraying findings from a qualitative evidence synthesis about living with pain, revealed any potential value or impact to viewers. Methods: We collected online data posted in response to the film Struggling to Be Me. We used themes from a large review of qualitative research as an a priori analytic framework. We used inductive thematic analysis to distil the essence of data that did not fit this framework. A thematic analysis of online comments to evaluate the impact of an arts-based health research film on people living with chronic pain is presented. Results: We developed two inductive themes that explored the value and potential impact of watching the film online: (1) It has given voice to our suffering and (2) it makes me feel that I am not alone. Two subthemes added insight to the a priori framework: First, I have had enough of me added insight to the theme my life is impoverished and confined; second, I am treated like a criminal because I take opioids added insight to the theme lost personal credibility. Conclusions: Our findings indicate that watching the YouTube film has potential value and impact, giving voice to suffering and making people feel that they are not alone. There are specific ethical challenges relating to internet-mediated research.

16.
BMJ Open ; 9(10): e028998, 2019 10 10.
Artigo em Inglês | MEDLINE | ID: mdl-31601587

RESUMO

INTRODUCTION: The Improving the Wellbeing of people with Opioid Treated CHronic Pain (I-WOTCH) randomised controlled trial uses a multicomponent self-management intervention to help people taper their opioid use. This approach is not widely used and its efficacy is unknown. A process evaluation alongside the trial will help to assess how the intervention was delivered, looking at the dose of intervention received and the fidelity of the delivery. We will explore how the intervention may have brought about change through the experiences of the participants receiving and the staff delivering the intervention and whether there were contextual factors involved. METHODS AND ANALYSIS: A mixed methods process evaluation will assess how the processes of the I-WOTCH intervention fared and whether these affected the outcomes. We will collect quantitative data, for example, group attendance analysed with statistical methods. Qualitative data, for example, from interviews and feedback forms will be analysed using framework analysis. We will use a 'following a thread' and a mixed methods matrix for the final integrated analysis. ETHICS AND DISSEMINATION: The I-WOTCH trial and process evaluation were granted full ethics approval by Yorkshire and The Humber-South Yorkshire Research Ethics Committee on 13 September 2016 (16/YH/0325). All data were collected in accordance with data protection guidelines. Participants provided written informed consent for the main trial, and all interviewees provided additional written informed consent. The results of the process evaluation will be published and presented at conferences. TRIAL REGISTRATION NUMBER: ISRCTN49470934; Pre-results.


Assuntos
Analgésicos Opioides/administração & dosagem , Dor Crônica/tratamento farmacológico , Manejo da Dor/métodos , Analgésicos Opioides/uso terapêutico , Feminino , Humanos , Entrevistas como Assunto , Masculino , Ensaios Clínicos Controlados Aleatórios como Assunto , Autogestão , Resultado do Tratamento
17.
BMJ Open ; 9(8): e028937, 2019 08 08.
Artigo em Inglês | MEDLINE | ID: mdl-31399456

RESUMO

INTRODUCTION: Chronic non-malignant pain has a major impact on the well-being, mood and productivity of those affected. Opioids are increasingly prescribed to manage this type of pain, but with a risk of other disabling symptoms, when their effectiveness has been questioned. This trial is designed to implement and evaluate a patient-centred intervention targeting withdrawal of strong opioids in people with chronic pain. METHODS AND ANALYSIS: A pragmatic, multicentre, randomised controlled trial will assess the clinical and cost-effectiveness of a group-based multicomponent intervention combined with individualised clinical facilitator led support for the management of chronic non-malignant pain against the control intervention (self-help booklet and relaxation compact disc). An embedded process evaluation will examine fidelity of delivery and investigate experiences of the intervention. The two primary outcomes are activities of daily living (measured by Patient-Reported Outcomes Measurement Information System Pain Interference Short Form (8A)) and opioid use. The secondary outcomes are pain severity, quality of life, sleep quality, self-efficacy, adverse events and National Health Service (NHS) healthcare resource use. Participants are followed up at 4, 8 and 12 months, with a primary endpoint of 12 months. Between-group differences will indicate effectiveness; we are looking for a difference of 3.5 points on our pain interference outcome (scale 40 to 77). We will undertake an NHS perspective cost-effectiveness analysis using quality adjusted life years. ETHICS AND DISSEMINATION: Full approval was given by Yorkshire & The Humber - South Yorkshire Research Ethics Committee on 13 September, 2016 (16/YH/0325). Appropriate local approvals were sought for each area in which recruitment was undertaken. The current protocol version is 1.6 date 19 December 2018. Publication of results in peer- reviewed journals will inform the scientific and clinical community. We will disseminate results to patient participants and study facilitators in a study newsletter as well as a lay summary of results on the study website. TRIAL REGISTRATION NUMBER: ISRCTN49470934; Pre-results.


Assuntos
Atividades Cotidianas , Analgésicos Opioides/uso terapêutico , Dor Crônica/terapia , Manejo da Dor/métodos , Análise Custo-Benefício , Recursos em Saúde/estatística & dados numéricos , Humanos , Estudos Multicêntricos como Assunto , Manejo da Dor/economia , Medição da Dor , Medidas de Resultados Relatados pelo Paciente , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Projetos de Pesquisa , Autoeficácia , Sono , Suspensão de Tratamento
18.
Int J Older People Nurs ; 14(4): e12263, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31355532

RESUMO

BACKGROUND: The number of older people living with dementia is increasing. Admiral Nurses work with these individuals and their families in the UK to manage challenges associated with the condition, providing guidance, advice and reassurance, alongside practical solutions. AIM: To explore the input of Admiral Nurses as part of people's journey to becoming and being a carer for someone with dementia. DESIGN: A qualitative study was conducted to describe and understand how Admiral Nurses are experienced and encountered by carers as part of their narrative around supporting a relative with dementia. METHODS: Semi-structured interviews were conducted with 19 carers between November 2017-April 2018. They lasted between 45 and 90 min. Thematic analysis was used to interpret data. FINDINGS: An overarching concept of "the unity-division paradox" was derived from the data. This highlights the complex interchange between the carer with (a) the person with dementia, (b) other individuals and (c) external services. Such interactions can make carers feel part of a larger network (unity) but also as if they are on their own, fighting on behalf of the person with dementia (division). This concept was underpinned by the following themes: (a) I becomes we; (b) My private world is encroached by dementia; (c) I'm left navigating an unwieldy system; (d) Are you with or against us?; and (e) Recreating boundaries to rediscover me. CONCLUSION: The identity and unique characteristics and interests of those caring for a person with dementia may be lost as they encounter tensions associated with the unity-division paradox. Admiral Nurses can help carers feel less alone in managing internal and external struggles by supporting them to do their best for a loved one with dementia. IMPLICATIONS FOR PRACTICE: Understanding carers' experience and supporting their work may help to increase and sustain their capacity to provide care.


Assuntos
Cuidadores , Demência/enfermagem , Relações Interpessoais , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Serviços de Saúde para Idosos , Humanos , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , Medicina Estatal , Reino Unido
19.
BMJ Open ; 9(6): e025743, 2019 06 20.
Artigo em Inglês | MEDLINE | ID: mdl-31227529

RESUMO

AIMS: To understand obstacles to returning to work, as perceived by people with chronic non-malignant pain and as perceived by employers, and to develop a conceptual model. DESIGN: Synthesis of qualitative research using meta-ethnography. DATA SOURCES: Eleven bibliographic databases from inception to April 2017 supplemented by citation tracking. REVIEW METHODS: We used the methods of meta-ethnography. We identified concepts and conceptual categories, and developed a conceptual model and line of argument. RESULTS: We included 41 studies. We identified three core categories in the conceptual model: managing pain, managing work relationships and making workplace adjustments. All were influenced by societal expectations in relation to work, self (self-belief, self-efficacy, legitimacy, autonomy and the meaning of work for the individual), health/illness/pain representations, prereturn to work support and rehabilitation, and system factors (healthcare, workplace and social security). A mismatch of expectations between the individual with pain and the workplace contributed to a feeling of being judged and difficulties asking for help. The ability to navigate obstacles and negotiate change underpinned mastering return to work despite the pain. Where this ability was not apparent, there could be a downward spiral resulting in not working. CONCLUSIONS: For people with chronic pain, and for their employers, navigating obstacles to return to work entails balancing the needs of (1) the person with chronic pain, (2) work colleagues and (3) the employing organisation. Managing pain, managing work relationships and making workplace adjustments appear to be central, but not straightforward, and require substantial effort to culminate in a successful return to work.


Assuntos
Dor Crônica/psicologia , Retorno ao Trabalho/psicologia , Antropologia Cultural , Atitude , Comportamento de Busca de Ajuda , Humanos , Manejo da Dor , Estigma Social , Local de Trabalho/organização & administração , Local de Trabalho/psicologia
20.
BMJ Open ; 9(4): e026074, 2019 04 15.
Artigo em Inglês | MEDLINE | ID: mdl-30992291

RESUMO

OBJECTIVES: To review the qualitative literature that explores the barriers and facilitators to continued participation in falls prevention exercise after completion of a structured exercise programme. DESIGN: A systematic literature review with thematic synthesis of qualitative studies exploring older adults' experiences of continued participation in falls prevention exercise. DATA SOURCES: Comprehensive searches were conducted in MEDLINE, PSYCHinfo, AMED, ASSIA, CINAHL and EMBASE from inception until November 2017. Additional studies were identified via searches of reference lists and citation tracking of relevant studies. ELIGIBILITY CRITERIA: Qualitative or mixed methods studies exploring experiences of community-dwelling older adults (65 years and over) participation in a falls prevention exercise programme including their experience of ongoing participation in exercise after the completion of a structured exercise programme. DATA EXTRACTION AND SYNTHESIS: Key characteristics including aim, participant characteristics, method of data collection, underpinning qualitative methodology and analytical approach were extracted and independently checked. Thematic synthesis was used to integrate findings. RESULTS: From 14 studies involving 425 participants, we identified three descriptive themes: identity, motivators/deterrents and nature of the intervention and one overarching analytical theme: agency. CONCLUSIONS: Older people have their own individual and meaningful rationale for either continuing or stopping exercise after completion of a structured falls prevention exercise programme. Exploring these barriers and facilitators to continued exercise is key during the intervention phase. It is important that health care professionals get to know the older person's rationale and offer the best evidence-based practice and support to individuals, to ensure a smooth transition from their structured intervention towards longer-term exercise-related behaviour. PROSPERO REGISTRATION NUMBER: CRD42017082637.


Assuntos
Acidentes por Quedas/prevenção & controle , Terapia por Exercício/métodos , Pesquisa Qualitativa , Idoso , Humanos , Vida Independente
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