Nurses' and surgeons' views and experiences of surgical wounds healing by secondary intention: A qualitative study.

AIMS AND OBJECTIVES: To explore surgeons' and nurses' perspectives of managing surgical wounds healing by secondary intention. BACKGROUND: Every year, more than 10 million surgical operations are performed in the NHS in the UK. Most surgical wounds heal by primary intention, where the edges of the wound are brought together with staples, sutures, adhesive glue or clips. Sometimes wounds are deliberately left open to heal, from the base up, known as "healing by secondary intention." These wounds are often slow to heal, prone to infection and complex to manage. DESIGN: A qualitative, descriptive approach, using semi-structured interviews. METHODS: Interviews with five (general, vascular and plastic) surgeons and 7 nurses (3 tissue viability nurses, 2 district and 1 community nurse, and 1 hospital nurse) working in hospital and community care settings in two locations in the north of England. Data analysis followed the recommended sequential steps of "Framework" approach. Consolidated criteria for reporting qualitative research guided the study report. RESULTS: Participants reported that the main types of wounds healing by secondary intention that they manage are extensive abdominal cavity wounds; open wounds relating to treatment for pilonidal sinus; large open wounds on the feet of patients with diabetes; and axilla and groin wounds, associated with removal of lymph nodes for cancer. Infection and prolonged time to healing were the main challenges. Negative pressure wound therapy was the most favoured treatment option. CONCLUSIONS: Negative pressure wound therapy was advocated by professionals despite a lack of research evidence indicating clinical or cost-effectiveness. Our findings underscore the need for rigorous evaluation of negative pressure wound therapy, and other wound care treatments, through studies that include economic evaluation. RELEVANCE FOR CLINICAL PRACTICE: Clinical decision-making in wound care could be optimised through further robust studies to inform practitioners about the cost-effectiveness of available treatments.

Perspectives of bereaved relatives of patients with haematological malignancies concerning preferred place of care and death: A qualitative study.

BACKGROUND: People with haematological malignancies have different end-of-life care patterns from those with other cancers and are more likely to die in hospital. Little is known about patient and relative preferences at this time and whether these are achieved. AIM: To explore the experiences and reflections of bereaved relatives of patients with leukaemia, lymphoma or myeloma, and examine (1) preferred place of care and death; (2) perceptions of factors influencing attainment of preferences; and (3) changes that could promote achievement of preferences. DESIGN: Qualitative interview study incorporating 'Framework' analysis. SETTING/PARTICIPANTS: A total of 10 in-depth interviews with bereaved relatives. RESULTS: Although most people expressed a preference for home death, not all attained this. The influencing factors include disease characteristics (potential for sudden deterioration and death), the occurrence and timing of discussions (treatment cessation, prognosis, place of care/death), family networks (willingness/ability of relatives to provide care, knowledge about services, confidence to advocate) and resource availability (clinical care, hospice beds/policies). Preferences were described as changing over time and some family members retrospectively came to consider hospital as the 'right' place for the patient to have died. Others shared strong preferences with patients for home death and acted to ensure this was achieved. No patients died in a hospice, and relatives identified barriers to death in this setting. CONCLUSION: Preferences were not always achieved due to a series of complex, interrelated factors, some amenable to change and others less so. Death in hospital may be preferred and appropriate, or considered the best option in hindsight.

Palliative care specialists' perceptions concerning referral of haematology patients to their services: findings from a qualitative study.

BACKGROUND: Haematological malignancies (leukaemias, lymphomas and myeloma) are complex cancers that are relatively common, affect all ages and have divergent outcomes. Although the symptom burden of these diseases is comparable to other cancers, patients do not access specialist palliative care (SPC) services as often as those with other cancers. To determine the reasons for this, we asked SPC practitioners about their perspectives regarding the barriers and facilitators influencing haematology patient referrals. METHODS: We conducted a qualitative study, set within the United Kingdom's (UK's) Haematological Malignancy Research Network (HMRN: www.hmrn.org ), a population-based cohort in the North of England. In-depth, semi-structured interviews were conducted with 20 SPC doctors and nurses working in hospital, community and hospice settings between 2012 and 2014. Interviews were digitally audio-recorded, transcribed and analysed for thematic content using the 'Framework' method. RESULTS: Study participants identified a range of barriers and facilitators influencing the referral of patients with haematological malignancies to SPC services. Barriers included: the characteristics and pathways of haematological malignancies; the close patient/haematology team relationship; lack of role clarity; late end of life discussions and SPC referrals; policy issues; and organisational issues. The main facilitators identified were: establishment of inter-disciplinary working patterns (co-working) and enhanced understanding of roles; timely discussions with patients and early SPC referral; access to information platforms able to support information sharing; and use of indicators to 'flag' patients' needs for SPC. Collaboration between haematology and SPC was perceived as beneficial and desirable, and was said to be increasing over time. CONCLUSIONS: This is the first UK study to explore SPC practitioners' perceptions concerning haematology patient referrals. Numerous factors were found to influence the likelihood of referral, some of which related to the organisation and delivery of SPC services, so were amenable to change, and others relating to the complex and unique characteristics and pathways of haematological cancers. Further research is needed to assess the extent to which palliative care is provided by haematology doctors and nurses and other generalists and ways in which clinical uncertainty could be used as a trigger, rather than a barrier, to referral.

Priorities for the professional development of registered nurses in nursing homes: a Delphi study.

Objective: To establish a consensus on the care and professional development needs of registered nurses (RNs) employed by UK care homes. Design: Two-stage, online modified Delphi study. Setting and Participants: A panel (n = 352) of individuals with experience, expertise or interest in care home nursing: (i) care home nurses and managers; (ii) community healthcare professionals (including general practitioners, geriatricians, specialist and district nurses); and (iii) nurse educators in higher education. Results: RNs employed by nursing homes require particular skills, knowledge, competence and experience to provide high-quality care for older residents. The most important responsibilities for the nursing home nurse were: promoting dignity, personhood and wellbeing, ensuring resident safety and enhancing quality of life. Continuing professional development priorities included personal care, dementia care and managing long-term conditions. The main barrier to professional development was staff shortages. Nursing degree programmes were perceived as inadequately preparing nurses for a nursing home role. Nursing homes could improve by providing supportive learning opportunities for students and fostering challenging and rewarding careers for newly RNs. Conclusion: If nurses employed by nursing homes are not fit for purpose, the consequences for the wider health and social-care system are significant. Nursing homes, the NHS, educational and local authorities need to work together to provide challenging and rewarding career paths for RNs and evaluate them. Without well-trained, motivated staff, a high-quality care sector will remain merely an aspiration.

Health professionals' perceptions of the barriers and facilitators to providing smoking cessation advice to women in pregnancy and during the post-partum period: a systematic review of qualitative research.

BACKGROUND: Reducing smoking in pregnancy is a policy priority in many countries and as a result there has been a rise in the development of services to help pregnant women to quit. A wide range of professionals are involved in providing these services, with midwives playing a particularly pivotal role. Understanding professionals' experiences of providing smoking cessation support in pregnancy can help to inform the design of interventions as well as to improve routine care. METHODS: A synthesis of qualitative research of health professionals' perceptions of the barriers and facilitators to providing smoking cessation advice to women in pregnancy and the post-partum period was conducted using meta-ethnography. Searches were undertaken from 1990 to January 2015 using terms for maternity health professionals and smoking cessation advisors, pregnancy, post-partum, smoking, and qualitative in seven electronic databases. The review was reported in accordance with the 'Enhancing transparency in reporting the synthesis of qualitative research' (ENTREQ) statement. RESULTS: Eight studies reported in nine papers were included, reporting on the views of 190 health professionals/key informants, including 85 midwives and health visitors. The synthesis identified that both the professional role of participants and the organisational context in which they worked could act as either barriers or facilitators to an individual's ability to provide smoking cessation support to pregnant or post-partum women. Underpinning these factors was an acknowledgment that the association between maternal smoking and social disadvantage was a considerable barrier to addressing and supporting smoking cessation CONCLUSIONS: The review identifies a role for professional education, both pre-qualification and in continuing professional development that will enable individuals to provide smoking cessation support to pregnant women. Key to the success of this education is recognising the centrality of the professional-client/patient relationship in any interaction. The review also highlights a widespread professional perception of the barriers associated with helping women give up smoking in pregnancy, particularly for those in disadvantaged circumstances. Improving the quality and accessibility of evidence on effective healthcare interventions, including evidence on 'what works' to support smoking cessation in disadvantaged groups, should therefore be a priority. PROSPERO 2013: CRD42013004170.

Patients' perceptions and experiences of venous leg ulceration and their attitudes to larval therapy: an in-depth qualitative study.

BACKGROUND: Venous leg ulcers are a common and distressing condition that can impair quality of life. Larval therapy has been widely promoted for the treatment of different types of chronic wounds, yet little is known about its acceptability to patients. OBJECTIVES: To explore patients' experiences of venous leg ulceration and of the acceptability of larval therapy as a treatment. DESIGN: Qualitative study, using semi-structured interviews alongside a randomized controlled trial. Interview data were transcribed and analysed for thematic content. Data were collected from April 2007 to July 2007. SETTING AND PARTICIPANTS: Eighteen people (12 men, 6 women), aged between 29 and 93 years (median age 64 years), with at least one venous leg ulcer, took part in the study. Fourteen people were recruited from two vascular clinics (one attached to a hospital and the other located in a community setting). A further four people were recruited through referral from a team of community nurses. FINDINGS: Participants portrayed lives blighted by the presence of one or more leg ulcers. The majority were willing to try 'maggots' (larvae) and able to overcome feelings of squeamishness because of their strong desire to heal their ulcers. Five people treated with larvae were included in the study. Initial improvements in the condition of their ulcers were not sustained, and two participants experienced severe pain. DISCUSSION AND CONCLUSIONS: Patients may hold unrealistic expectations that larval therapy will effect a longed-for cure for their leg ulcer(s) but an absence of healing may lead to feelings of disappointment or despair.

The barriers and facilitators to smoking cessation experienced by women's partners during pregnancy and the post-partum period: a systematic review of qualitative research.

BACKGROUND: Smoking in pregnancy can cause substantial harm and, while many women quit, others continue to smoke throughout pregnancy. The role of partners is an important but relatively under-researched factor in relation to women's smoking in pregnancy; partner's smoking status and attitudes to smoking cessation are important influences in a pregnant women's attempt to quit. Further understanding of how partners perceive the barriers and facilitators to smoking cessation in pregnancy is needed, particularly from qualitative studies where participants describe these issues in their own words. METHODS: A synthesis of qualitative research of partners' views of smoking in pregnancy and post-partum was conducted using meta-ethnography. Searches were undertaken from 1990 to January 2014 using terms for partner/household, pregnancy, post-partum, smoking, qualitative in seven electronic databases. The review was reported in accordance with the 'Enhancing transparency in reporting the synthesis of qualitative research' (ENTREQ) statement. RESULTS: Nine studies reported in 14 papers were included, detailing the experience of 158 partners; the majority were interviewed during the post-partum period. Partners were all male, with a single exception. Socioeconomic measures indicated that most participants were socially disadvantaged. The synthesis identified recurring smoking-related perceptions and experiences that hindered (barriers) and encouraged (facilitators) partners to consider quitting during the woman's pregnancy and into the post-partum period. These were represented in five lines of argument relating to: smoking being an integral part of everyday life; becoming and being a father; the couple's relationship; perceptions of the risks of smoking; and their harm reduction and quitting strategies. CONCLUSIONS: The cluster of identified barriers and facilitators to quitting offers pointers for policy and practice. The workplace emerges as an important space for and influence on partners' smoking habits, suggesting alternative cessation intervention locations for future parents. Conversely, health and community settings are seen to offer little support to fathers. Interventions centred on valued personal traits, like will-power and autonomy, may have particular salience. The review points, too, to the potential for health information that directly addresses perceived weaknesses in official advice, for example, around causal mechanisms and effects and around contrary evidence of healthy babies born to smokers. SYSTEMATIC REVIEW REGISTRATION: PROSPERO 2013: CRD42013004170.

Qualitative systematic review: barriers and facilitators to smoking cessation experienced by women in pregnancy and following childbirth.

AIM: To explore barriers and facilitators to smoking cessation experienced by women during pregnancy and postpartum by undertaking a synthesis of qualitative studies. BACKGROUND: The majority of pregnant women are aware that smoking in pregnancy compromises maternal and infant health. Despite this knowledge, quit rates among pregnant women remain low, particularly among women in disadvantaged circumstances; disadvantage also increases the chances of living with a partner who smokes and returning to smoking after birth. A deeper understanding of what hinders and what helps pregnant smokers to quit and remain ex-smokers postpartum is needed. DESIGN: A synthesis of qualitative research using meta-ethnography. DATA SOURCES: Five electronic databases (January 1990-May 2013) were searched comprehensively, updating and extending the search for an earlier review to identify qualitative research related to the review's aims. REVIEW METHODS: Following appraisal, 38 studies reported in 42 papers were included and synthesized following the principles of meta-ethnography. Over 1100 pregnant women were represented, the majority drawn from disadvantaged groups. RESULTS: Four factors were identified that acted both as barriers and facilitators to women's ability to quit smoking in pregnancy and postpartum: psychological well-being, relationships with significant others, changing connections with her baby through and after pregnancy; appraisal of the risk of smoking. CONCLUSION: The synthesis indicates that barriers and facilitators are not fixed and mutually exclusive categories; instead, they are factors with a latent capacity to help or hinder smoking cessation. For disadvantaged smokers, these factors are more often experienced as barriers than facilitators to quitting.

Assessing quality of life with incontinence.

This article reports on an evaluation of commonly recommended questionnaires to measure symptom severity and quality of life in women with urinary incontinence. Three questionnaires outperform the others and a robust assessment concludes that the International Consultation of Incontinence Questionnaire is the most practical tool for the busy practitioner.

An evaluative review of questionnaires recommended for the assessment of quality of life and symptom severity in women with urinary incontinence.

AIMS AND OBJECTIVES: To provide an up-to-date assessment of the quality of commonly recommended questionnaires for measuring symptom severity and quality of life in women with urinary incontinence and also to consider their application to practice. BACKGROUND: Urinary incontinence is a common problem for women. In addition to various physical symptoms, there is a known effect on quality of life. Psychometrically robust questionnaires are reported to be the best way to measure an individual's perceptions of symptom severity and quality of life, and a number of different ones are recommended for use in international and national guidance, which can be confusing for clinicians. Moreover, there are concerns over the applicability of some of these instruments in clinical practice. DESIGN: An evaluative review was carried out examining selected questionnaires measuring symptom severity and/or quality of life. METHODS: Selection of questionnaires for inclusion in the review was based on the recommendations of evidence-based guidance, followed by systematic scrutiny of the characteristics of the individual recommended questionnaires. RESULTS: Thirteen questionnaires were included in the review, of which three appeared to 'outperform' the remainder in terms of their psychometric properties and other characteristics. CONCLUSIONS: This review provides the most up-to-date and comprehensive analysis of the quality and applicability of the included questionnaires and offers the practitioner advice on which to select for use in practice. RELEVANCE TO CLINICAL PRACTICE: This review aims to help the practitioner choose a questionnaire based on a sound evaluation of the quality of the questionnaire and its applicability to the clinical setting.

Patient safety: threats and solutions.

The recent landmark report into the care failings at Stafford Hospital has called for sweeping changes to end the NHS's neglect of patient safety (Francis 2013). The report calls for a 'fundamental change' in culture so that patients are always put first, and it makes 290 recommendations covering a broad range of issues relating to patient care and safety in the NHS. This article explores issues surrounding patient safety, including the terminology associated with harm and error. The types of patient safety incidents that occur in different care environments are discussed. It offers insight into why patient safety incidents occur and describes some of the underlying factors. It also discusses preventive strategies and the role of patients and family members in enhancing safety.

The effect of organisational culture on patient safety.

This article explores the links between organisational culture and patient safety. The key elements associated with a safety culture, most notably effective leadership, good teamwork, a culture of learning and fairness, and fostering patient-centred care, are discussed. The broader aspects of a systems approach to promoting quality and safety, with specific reference to clinical governance, human factors, and ergonomics principles and methods, are also briefly explored, particularly in light of the report of the public inquiry into care failings at Mid Staffordshire NHS Foundation Trust.

Experiences and preferences for psychosocial support: a qualitative study exploring the views of patients with chronic haematological cancers.

OBJECTIVES: Patients with chronic haematological cancers are often treated on a relapsing-remitting pathway, which may extend for many years. Such diagnoses are associated with uncertainties that often cause anxiety and distress, meaning patients (and families) are susceptible to potentially prolonged emotional difficulties, across the cancer journey. Experiences and preferences regarding psychosocial needs and support over time are relatively unexplored, which this study aimed to address. SETTING AND DESIGN: Set within the UK's Haematological Malignancy Research Network (an ongoing population-based cohort that generates evidence to underpin improved clinical practice) a qualitative, exploratory study was conducted, using semistructured interviews. Reflexive thematic analysis was used to assess the interview data via an exploratory, inductive approach, underpinned by the research questions. PARTICIPANTS: Thirty-five patients were included with chronic lymphocytic leukaemia, follicular lymphoma, marginal zone lymphoma or myeloma; 10 of whom were interviewed alongside a relative. RESULTS: Five themes were identified from the data: (1) accessing support, (2) individual coping behaviour affecting support preferences, (3) divergent and fluctuating thoughts on patient support forums, (4) the role, influence and needs of family and friends and (5) other sources of support and outstanding needs. Findings suggest that patients' individual attitudes towards support varied over time. This also influenced whether support was perceived to be available, and if it was then used. CONCLUSION: This study highlighted the variation in preferences towards psychosocial support among patients with chronic haematological cancers. As patients can live for many years with significant emotional difficulties, they may benefit from frequent monitoring of their psychosocial well-being, as well as signposting to holistic support, if this is needed.

Patient perspectives of 'Watch and Wait' for chronic haematological cancers: Findings from a qualitative study.

PURPOSE: Chronic blood cancers are incurable, and characterised by unpredictable, remitting-relapsing pathways. Management often involves periods of observation prior to treatment (if required), and post-treatment, in an approach known as 'Watch and Wait'. This study aimed to explore patient experiences of 'Watch and Wait'. METHODS: In-depth interviews with 35 patients (10 accompanied by relatives) with chronic lymphocytic leukaemia, follicular lymphoma, marginal zone lymphoma or myeloma. Data were analysed using descriptive qualitative techniques. RESULTS: Patient views of Watch and Wait ranged along a continuum, from immediate acceptance, to concern about treatment deferral. Significant ongoing anxiety and distress were described by some, due to the uncertain pathways associated with Watch and Wait. Infrequent contact with clinical staff was said to exacerbate this, as there was limited opportunity to ask questions and seek reassurance. Patients indicated that the impact of their malignancy could be underestimated by clinicians; possibly due to them comparing chronic and acute subtypes. Most patients lacked knowledge of blood cancers. Support from clinicians was considered greater among treated patients, possibly due to increased contact, and many drew on relatives for aid. Most patients were satisfied with their time-allocation with haematology staff, although experiences could be improved by greater access to clinical nurse specialists, counselling services, and community-based facilities. CONCLUSION: Experiences varied. Anxiety about unpredictable futures could be more distressing than any physical symptoms and have a greater impact on quality of life. Ongoing assessment could facilitate identification of difficulties, and is particularly important among individuals without supportive networks.

Chronic myeloid leukaemia: A qualitative interview study exploring disease impact from patient and practitioner perspectives.

PURPOSE: Improvements in chronic myeloid leukaemia treatment mean it is now relevant to examine the experiences of living with this cancer over a lifetime. This qualitative study aimed to investigate the impact of chronic myeloid leukaemia, from patient and healthcare practitioner perspectives. METHODS: The research was set within the UK's Haematological Malignancy Research Network; a population-based cohort of patients newly diagnosed with blood cancer, treated at one of fourteen hospitals. Purposive sampling led to interviews with seventeen patients and thirteen health care practitioners. Data were analysed using thematic analysis. RESULTS: Two analytical themes, "Significant impact of disease and treatment" and "Mediators of the impact of disease and treatment", and six sub-themes, were derived from patient interviews and supported with data from practitioners. Chronic myeloid leukaemia was described by patients as having significant widespread impact, which could be mediated by their knowledge, social support, and the quality of healthcare systems. Practitioners reflected patient accounts, but could underestimate the impact of this cancer. They generally viewed chronic myeloid leukaemia as less complex, severe and impactful than acute blood cancers; a message that reassured patients at diagnosis, but could later unintentionally contribute to difficulties discussing side effects and struggles to cope. CONCLUSION: Chronic myeloid leukaemia may significantly impact individuals, particularly as it is experienced over the lifetime. Greater understanding and discussion of the breadth and extent to which patients are affected, including potential mediators, could enhance clinical care.

Treatment decision making (TDM): a qualitative study exploring the perspectives of patients with chronic haematological cancers.

OBJECTIVES: Haematological malignancies are the fifth most common cancer in the UK, with chronic subtypes comprising around a third of all new diagnoses. These complex diseases have some similarities with other cancers, but often require different management. Surgical resection is not possible, and while some are curable with intensive chemotherapy, most indolent subtypes are managed with non-aggressive intermittent or continuous treatment, often over many years. Little is known about the views of patients with chronic haematological cancers regarding treatment decision making (TDM), a deficit our study aimed to address. SETTING AND DESIGN: Set within the Haematological Malignancy Research Network (HMRN: www.hmrn.org), an ongoing population-based cohort that provides infrastructure to support evidence-based research, HMRN data were augmented by qualitative information from in-depth interviews. Data were analysed for thematic content, combining inductive and deductive approaches. Interpretation involved seeking meaning, salience and connections within data. PARTICIPANTS: Thirty-five patients with four chronic subtypes: chronic lymphocytic leukaemia, follicular lymphoma, marginal zone lymphoma, and myeloma. Ten relatives were present and contributed to varying extents. RESULTS: Five themes were discerned: (1) Preference for clinician recommendations; (2) Factors implicated in patient involvement in TDM; (3) Perceptions of proactive/non-proactive approaches to TDM; (4) Experiences of TDM at various points in the disease trajectory; (5) Support from others. Our principal finding relates to a strong preference among interviewees for treatment recommendations from haematologists, based on trust in their expertise and perceptions of empathetic patient-clinician relationships. CONCLUSION: Interviewees wanted to be involved in TDM to varying extents, contingent on complex, inter-related factors, that are dynamic and subject to change according to differing clinical and personal contexts. Patients may benefit from clinicians assessing their shifting preferences for involvement on multiple occasions. Strong preferences for acceptance of recommendations was associated with cancer complexity, trust in clinician expertise and positive perceptions of patient-clinician relationships.

Incurable but treatable: Understanding, uncertainty and impact in chronic blood cancers-A qualitative study from the UK's Haematological Malignancy Research Network.

OBJECTIVE: Most blood cancers are incurable and typically follow unpredictable remitting-relapsing pathways associated with varying need for treatment, which may be distressing for patients. Our objective was to conduct a qualitative study to explore understanding among patients with such malignancies, including the explanations given by HCPs and the impact of uncertain trajectories, to generate evidence that could guide improvements in clinical practice. METHODS: The study is set within a population-based patient cohort (the Haematological Malignancy Research Network), in which care is delivered across 14 hospitals according to national guidelines. In-depth interviews were conducted with 35 patients with chronic lymphocytic leukaemia, follicular lymphoma, marginal zone lymphoma or myeloma; and 10 accompanying relatives. Purposive sampling ensured selection of information-rich participants and the data were interrogated using reflective thematic analysis. RESULTS: Rich data were collected and four themes (11 sub-themes) were identified: 1) Knowledge and understanding of chronic haematological malignancies; 2) Incurable but treatable; 3) Uncertainty about the future; and 4) Treatable (but still incurable): Impact on patients. Patients had rarely heard of blood cancer and many expressed difficulty understanding how an incurable malignancy that could not be removed, was treatable, often for long periods. While some were reassured that their cancer did not pose an immediate survival threat, others were particularly traumatised by the uncertain future it entailed, suffering ongoing emotional distress as a result, which could be more burdensome than any physical symptoms. Nonetheless, most interviewees understood that uncertain pathways were caused by the unpredictability of their disease trajectory, and not information being withheld. CONCLUSIONS: Many participants lacked knowledge about chronic haematological malignancies. HCPs acted to reassure patients about their diagnosis, and while this was appropriate and effective for some, it was less so for others, as the cancer-impact involved struggling to cope with ongoing uncertainty, distress and a shortened life-span.

Promoting patient involvement in safety initiatives.

Between 300,000 and 1.4 million adverse events occur each year in the NHS, and about half of those that occur in inpatient settings are preventable (Department of Health Expert Group on Learning from Adverse Events in the NHS 2000). Strategies to reduce these events have focused mainly on changing systems of care and professional behaviour, but there is growing interest in involving patients in safety initiatives. This stresses the development and use of interventions to promote and support patients' and their representatives' roles in securing their own safety in health care. This article reports the results of a series of linked studies that examined how patients might effectively promote their own safety, and to explore how this might vary by context, place or demography.

Experiences of living with chronic myeloid leukaemia and adhering to tyrosine kinase inhibitors: A thematic synthesis of qualitative studies.

PURPOSE: To investigate the experiences of adults living with chronic myeloid leukaemia and treated with tyrosine kinase inhibitors, with particular reference to factors influencing adherence. METHODS: A thematic synthesis of all published qualitative studies examining adults with chronic myeloid leukaemia, receiving tyrosine kinase inhibitors. Eligible publications were identified by searching five electronic databases using defined criteria. The synthesis involved complete coding of extracted data and inductive theme development. RESULTS: Nine studies were included and three overarching themes defined. Overarching themes were: 1) Disease impacts whole life; 2) Disease management strategies; and 3) Valued aspects of care. Side-effects often required physical and psychological adaptation. Patients developed individual decision-making processes to promote adherence and manage side effects. Unintentional non-adherence occurred due to forgetfulness and system failures. Intentional omission also occurred, which together with side effects, was unlikely to be reported to healthcare professionals (HCPs). HCP reassurance about missed doses could reinforce non-adherence. Information needs varied over time and between individuals. Knowledge among patients about treatment was often lacking and could lead to misunderstandings. Patients valued psychological support from HCPs and suggested an individualised approach, facilitating discussion of symptoms, adherence and their perspectives about living with chronic myeloid leukaemia, would improve care. CONCLUSIONS: Patients with chronic myeloid leukaemia experienced significant side-effects from treatment and changes to their psychological and physical well-being. They developed their own strategies to manage their disease and treatment. This should be recognised in interventions to improve education, support and the delivery of care that is compassionate and adequately resourced.

Supporting nurse decision making in primary care: exploring use of and attitude to decision tools.

Nurses are increasingly working more autonomously in extended roles, yet we know little about the nature of the decisions they make. Decisions vary in terms of complexity, ambiguity and presentation, and the nature of the decision task impacts on the process of decision making, such as the likelihood of using a decision tool. Thus, knowledge about the nature of nursing decisions is essential for development of effective decision tools. This article presents an analysis of 410 nurse-patient consultations and interviews with 76 primary care nurses, and explores the nature of the decisions that primary care nurses make and the impact of that on their use of and attitudes towards decision tools.