Developing therapeutic relationships with people living with HIV: exploring the nurse-patient relationship.

BACKGROUND: The care paradigm for HIV has changed from one of an infectious, life-limiting disease to that of a chronic manageable condition. This shift poses challenges for practitioners working in this area when providing care that is both person centred and reflective of the demands placed on an evolving disease area. OBJECTIVES: The overall aim of this study was to explore how therapeutic relationships are developed and their subsequent use within person-centred care. DESIGN: An interpretative phenomenological analysis research design was used to collect data from 10 purposively recruited HIV specialist nurses in the north-west region of the UK. In-depth, semistructured interviews were used to collect the data. RESULTS: Data analysis revealed three themes that captured person-centredness in HIV care. These were: ways of being; the nurse-patient relationship; and the influence of stigma. CONCLUSION: The research illuminates key features that are important when developing therapeutic relationships and offers a framework to explain how these features were also key elements of person-centred care.

How events in emergency medicine impact doctors' psychological well-being.

BACKGROUND: Emergency medicine is a high-pressured specialty with exposure to disturbing events and risk. We conducted a qualitative study to identify which clinical events resulted in emotional disruption and the impact of these events on the well-being of physicians working in an ED. METHODS: We used the principles of naturalistic inquiry to conduct narrative interviews with physicians working in the ED at Central Manchester University Hospitals NHS Foundation Trust, between September and October 2016. Participants were asked, 'Could you tell me about a time when an event at work has continued to play on your mind after the shift in which it occurred was over?' Data were analysed using framework analysis. The study had three a priori themes reported here. Other emergent themes were analysed separately. RESULTS: We interviewed 17 participants. Within the first a priori theme ('clinical events') factors associated with emotional disruption included young or traumatic deaths, patients or situations that physicians could relate to, witnessing the impact of death on relatives, the burden of responsibility (including medical error) and conflict in the workplace. Under theme 2 (psychological and physical effects), participants reported substantial upset leading to substance misuse, sleep disruption and neglecting their own physical needs through preoccupation with caring. Within theme 3 (impact on relationships), many interviewees described becoming withdrawn from personal relationships following clinical events, while others described feeling isolated because friends and family were non-medical. CONCLUSIONS: Clinical events encountered in the ED can affect a physician's psychological and physical well-being. For many participants these effects were negative and long lasting.

The meaning of living with uncertainty for people with motor neurone disease.

AIMS AND OBJECTIVES: To explore the meaning of living with uncertainty for people diagnosed with motor neurone disease (MND). BACKGROUND: Motor neurone disease is a progressive neurodegenerative condition resulting in multiple needs, arising from the complex nature of the disease trajectory. People with MND are often required to make decisions for symptom management and end-of-life care. Research into the lived experience of MND has previously highlighted the following: the shock of receiving such a diagnosis and prognosis; subsequent concerns relating to the future and loss; and the existential suffering for a person with MND. The lived experiences of MND accentuate the devastating nature of the disease, and this can impact upon how people respond to care. DESIGN: Hermeneutic (interpretive) phenomenology: suitable for studying lifeworld experiences. METHOD: Life story interviews were conducted with four participants and subjected to interpretive analysis. RESULTS: Three phases of the MND illness trajectory emerged: "body failing prematurely and searching for answers," "body deterioration and responses to care" and "body nearing its end and needing to talk." These phases highlight the phenomenon under study, all relating to uncertainty for people living with MND. CONCLUSIONS: This study showed that people with MND are living with uncertainty and other concerns throughout their illness trajectory. People are having to turn to palliative care professionals who are more able to meet their concerns than those caring for other aspects of their disease. RELEVANCE TO CLINICAL PRACTICE: Motor neurone disease is a complex disease, and it is important that professionals continue to provide holistic care throughout the illness trajectory. The identification of three distinct phases of the MND illness trajectory will help nurses and other professionals to better understand the meaning of uncertainty and other concerns for people with MND.

"My mentor didn't speak to me for the first four weeks": Perceived Unfairness experienced by nursing students in clinical practice settings.

AIMS AND OBJECTIVES: To explore the perceived unfairness experienced by student nurses during their undergraduate clinical placements. BACKGROUND: It is important that student nurses feel supported by practice staff during their clinical placement education experiences. However, it has been reported that learners can feel ignored, unsupported and bullied by others in the clinical environment and this has a detrimental effect on their learning. It is important to understand the student nurse perspective and explore ways in which their feelings of belongingness might be enhanced in the clinical area. DESIGN: A descriptive narrative approach was used to explore the qualitative data generated by the survey and interviews. Limited closed-question survey data were acquired to explore a selection of quantified survey responses about placements and mentorship. METHODS: A survey was conducted with 1,425 student nurses from adult and mental health degree nursing pathways, across nine institutions in the North West of England, UK. Unstructured interviews were undertaken with 22 student nurses from across these nine institutions. The data generated from both methods (free-text survey responses and interview) were thematically analysed. RESULTS: There were times when student nurses felt that they had been treated unfairly by various members of the healthcare team during their clinical placements. Unfairness was related to being ignored and unsupported or being used as an "extra pair of hands" and having their supernumerary status ignored. Student nurses want to have feelings of belongingness in the clinical area and value enthusiasm for teaching from mentors. Certain positive mentor qualities were identified through the data in this study. These have been used to inform a tiered model of mentorship, to inform future thinking about student nurse education. CONCLUSION: Student nurses can feel like they are being treated unfairly in the clinical area in numerous ways. Identifying ways in which mentorship practice can be developed to adequately support education is important. This can lead to satisfaction and development on both sides of the student/educator relationship. RELEVANCE TO PRACTICE: Exploring student nurse perceptions of their learning is important when attempting to enhance educational practice in the clinical setting.

Fact or fiction: exploring the use of real stories in place of vignettes in interviews with informal carers.

AIM: To consider the development and use of real stories rather than vignettes in interviews. BACKGROUND: Effective interprofessional working critically informed by the perspectives of informal carers was considered by the research team to be under-researched. It was proposed initially to use fictional vignettes as triggers in interviews with informal carers. It could be argued that the vignette does not represent the voice of the individual or may only represent a particular experience. Stories acknowledge a person's expertise in his or her experiences. A decision was made early in the design process to use real stories instead of vignettes. DATA SOURCES: A descriptive naturalistic design using a participatory approach. Two stories were developed by the researcher and two informal carers, and then used in interviews with other carers to explore their experiences and perceptions of interprofessional working. REVIEW METHODS: The paper provides a discussion of an alternative approach to data collection. DISCUSSION: The stories promoted a sense of support for the participants, which they gained from listening to and sharing stories of caring. This approach offered a different experience for the carers from the standard interview format. CONCLUSION: The paper describes the use of real stories in interviews, which is not a commonly reported method. Carers were involved in both the development and the use of the stories in the interviews. Those interviewed valued the credibility gained by using these real stories, as opposed to constructed vignettes. IMPLICATIONS FOR RESEARCH/PRACTICE: Using stories in this way contributes to methodological development, which allows perceptions and experiences to be captured.

The changing face of newspaper representations of the mentally ill.

BACKGROUND: Negative stereotypes presented in the media may contribute to the stigma associated with mental illness. People's attitudes towards the mentally ill are initially influenced and subsequently maintained in part by the frequent media presentation of negative stereotypes of mental illness. This could result in social rejection of individuals with mental illnesses. AIM: To explore how four main U.K. national newspapers reported on mental health/mental illness stories over a 10-year period. METHOD: This study utilised content analysis to identify words, themes and trends of representation related to the mentally ill in articles from the four newspapers. RESULTS: The findings indicated that there was an increase in the number of articles related to mental health/illness over the time of the study. The rate of increase was far greater than that for the increase in the total number of articles carried in the press over this time period. It was also identified that pejorative terms were used, in a number of the articles, to describe the mentally ill person. CONCLUSION: Many of the newspaper reports highlighted the need for protection of the general public from the mentally ill, and that the mentally ill were in some way different to the general public. In particular, both the words "violence" and "drugs" were linked to mental health/mental illness in these articles.

Assessing the impact of Instagram use and deliberate self-harm in adolescents: A scoping review.

The use of Instagram by adolescents to access deliberate self-harm content is a growing concern among scholars, mental health professionals and families, with many adolescents (10-19-year-olds) imitating offline what they have seen online. This scoping review aims to investigate the extent to which Instagram use impacts the mental health of its adolescent users, identifying whether there is a relationship between time spent on Instagram and engagement in deliberate self-harm. The databases, PubMed, Web of Science, Google scholar, APA PsycInfo, CINAHL and child development and adolescent studies were explored, and after applying the inclusion/exclusion criteria, 15 papers were included in this review. Thematic analysis indicated that there was a relationship between time spent on Instagram and deliberate self-harm; desensitization of deliberate self-harm resulting in normalization; social contagion and that Instagram provided a sense of belonging to its users who engaged in deliberate self-harm. Implications of this research is that it is quickly outdated as new social media platforms are developed and that the reliance on self-reports does not have high validity or reliability.

The need to consider 'temporality' in person-centred care of people with motor neurone disease.

AIMS AND OBJECTIVES: The overall aim of this paper is to provide practical insight into the way that professionals caring for a person with motor neurone disease (MND) can recognise, respect and respond to that person's temporality; that is, the person that they have been, that they are now and that they will be in the future. BACKGROUND: MND is an umbrella term for a group of four rare, devastating neurodegenerative terminal diseases of middle/later life. Previously, we have acknowledged the importance of different time periods in the trajectory of MND as an illness, for example, during the diagnosis stage through to end of life and decision-making at that time. Living with MND can cause anxiety at all stages of the disease trajectory especially as it can be difficult for people living with MND to communicate their desires and concerns to professionals and carers. It is important that professionals continue to provide holistic care throughout the illness trajectory and the aim of this paper is to explore past research about caring for someone with MND in relation to the concept of person-centred care. METHOD: The paper is based on the concatenated exploration of the findings of a hermeneutic phenomenological project. Thus, this discursive paper links elements/studies which have been published previously to develop a model of person-centred care for people with MND which recognises and respects their temporality. CONCLUSIONS: We suggest MND has a significant impact on a person's lifeworld. The proposed person-centred care model focuses on understanding (interpreting) a person in a wider temporal frame and beyond the context of their illness. The expected collaborative outcomes are that: a person is acknowledged as more than a 'patient with MND' and that a professional is providing person-centred care based on individuality of the person, through a temporal lens. This requires a collaborative approach between the person, others and professionals. Such person-centred care, focused on individuality, may prevent a person experiencing life in crisis and suffering towards the end of life.

Earthquake slip weakening and asperities explained by thermal pressurization.

An earthquake occurs when a fault weakens during the early portion of its slip at a faster rate than the release of tectonic stress driving the fault motion. This slip weakening occurs over a critical distance, D(c). Understanding the controls on D(c) in nature is severely limited, however, because the physical mechanism of weakening is unconstrained. Conventional friction experiments, typically conducted at slow slip rates and small displacements, have obtained D(c) values that are orders of magnitude lower than values estimated from modelling seismological data for natural earthquakes. Here we present data on fluid transport properties of slip zone rocks and on the slip zone width in the centre of the Median Tectonic Line fault zone, Japan. We show that the discrepancy between laboratory and seismological results can be resolved if thermal pressurization of the pore fluid is the slip-weakening mechanism. Our analysis indicates that a planar fault segment with an impermeable and narrow slip zone will become very unstable during slip and is likely to be the site of a seismic asperity.

Making her end of life her own: further reflections on supporting a loved one with motor neurone disease.

BACKGROUND: People can live for many months without knowing why their body is failing prematurely before being diagnosed with motor neurone disease (MND); a terminal neurodegenerative disease which can be experienced as 'devastating' for the person and their family. AIM: This study aimed to explore the meaning of supporting a loved one with MND to die. METHODS: This study uses reflection and autobiographical story to connect with broader cultural, political and social meaning and understandings of dying. FINDINGS: Four themes were identified relating to the end-of-life trajectory of MND. Loss of person (lived body experienced in silence); loss of relationships (lived relations are challenged); loss of home and loss of time (lived space and lived time take on new meaning); loss of future (dying-facing it alone). CONCLUSION: Dying with MND is a complex phenomenon. When a person can no longer move and communicate, relationships between those involved in end-of-life care are challenging. A person with MND needs the support from those acting as power of attorney to make their end of life their own, and they themselves need support to find meaning in their suffering. This autoethnographic reflection provides vicarious experiences for nurses and other healthcare professionals working with people with MND and similar conditions.

Development of an academic identity through PhD supervision-an issue for debate.

This paper provides reflection on the journey of completing a PhD by using emergent themes that occurred in supervision sessions as recorded in a reflective journal. The paper highlights the need to reflect and accept decisions that can be challenging. The paper also indicates examples where past understandings are questioned and newer insights have to be explored. A conclusion related to accepting responsibility for what happens as a consequence of supervision sessions is debated. Finally a new insight into identity is arrived at.

Students' perceptions of their learning experiences: A repeat regional survey of healthcare students.

BACKGROUND: Student experience is an international concern and recent research has focused on initiatives to improve students' learning experiences and ultimately reduce attrition levels. OBJECTIVE: To determine similarities and differences between students' perceptions of their learning experiences between 2011 and 2015 in relation to campus-based learning, placement-based learning and personal circumstances. DESIGN: A repeat online survey in 2011 and 2015; using a questionnaire developed from thematic analysis of narrative interviews with a subsample of the target population. SETTINGS: Nine universities in the North West of England. PARTICIPANTS: A total of 1080 students completed the survey in 2011 and 1983 students in 2015 from a target population of all students studying on commissioned pre-registration healthcare education programmes. METHODS: An online survey was made available to all undergraduate students studying on Health Education funded programmes within the region and survey respondents were invited to give demographic information and rate their agreement to statements on four-point Likert-type responses. RESULTS: Responses to a repeat survey of healthcare studying in the North West of England in 2015 were strikingly similar overall to those of an original 2011 survey. Although the students were positive overall about their experiences, a number were dissatisfied with some aspects of their experiences - particularly in relation to initial support on campus and whilst studying on placement. Four years on from the original survey, despite a considerable investment in improving students' experiences across the region, there appears to be little change in students' perceptions of their learning experiences CONCLUSION: In the short-term monitoring of student experience needs to be continued; and links to attrition (potential or actual) noted and acted upon. However, given that attrition from these courses has been a long-term problem and the complexity of its resolution a recurrent finding in the literature; new ways of framing and resolving the problem need to be considered.

Young Asians and drug use.

It is considered that child health professionals should have sufficient knowledge of patterns of substance (mis)use in young people to enable them to respond appropriately if faced with a client who is, or is suspected of, (mis)using substances. Whilst there is an increasing amount of literature relating to young people's substance misuse in general, there is a paucity of knowledge relating to substance (mis)use amongst young people from an ethnic minority background. In this article the findings of qualitative studies carried out at two sites in Greater Manchester are presented, which suggest that whilst patterns of substance (mis)use amongst Asians may be similar in many ways to those for the general population, they occur within a different cultural context. It is suggested therefore, that there is a need for child health professionals to be culturally sensitive in working with young people who are, or are suspected of, (mis)using drugs - although unfortunately practical examples of such cultural sensitivity have yet to be provided.

The case for interactive interviewing.

It is reported in the Penguin Book of Interviews ( 1 ) that Marlon Brando recalled an interview with Truman Capote as follows: 'The little bastard spent half the night telling me all his problems, I figured the least I could do was tell him a few of mine.' In sharing experiences with his interviewee, Capote had managed to extract information he would otherwise not have gained.

The meaning of emotion work to student nurses: a Heideggerian analysis.

BACKGROUND: Providing patients with emotional support can be challenging to student nurses, as it is seen as a less tangible aspect of care when compared to other acts of caring. OBJECTIVES: The underpinning objective of this study was to explore the meaning of emotional relationships between pre-registration nursing students and patients admitted to a clinical setting in the United Kingdom. DESIGN: Using an interpretive phenomenological approach data were collected using in depth unstructured interviews, with nine purposively recruited pre-registration student nurses at a University in the United Kingdom. RESULTS: The structure of emotion work for these nurses, was found to consist of three constituents; (a) the need for an emotional "balance;" (b) feeling the need to cry; (c) feeling the need to talk. We portray this phenomenon as "emotional nurse being" using Heideggerian hermeneutic phenomenology. CONCLUSIONS: The insights gained from this study could be used to understand and support pre-registration student nurses in this aspect of their practice.

Should I stay or should I go? A study exploring why healthcare students consider leaving their programme.

BACKGROUND: Attrition in healthcare programmes is a growing concern internationally. Students leave for a variety of reasons but it is difficult to understand the complex interactions that eventually lead to attrition. OBJECTIVES: The objectives of this study were to identify the factors that prompted students to consider leaving their programme, and to make recommendations regarding strategies to reduce attrition. DESIGN: One aspect of a larger survey, which itself was part of a larger sequential mixed methods study. SETTINGS: Nine universities in the North West of England. METHODS: An online survey developed as part of a mixed methods sequential exploratory study was completed by students on nursing and allied-health programmes. The detailed responses obtained for a question relating to if the students have ever considered leaving their current programme were analysed both quantitatively (content analysis) and qualitatively (framework analysis). RESULTS: 1080 students completed the survey (an estimated 11% response rate); of this group 999 students answered the question 'have you ever considered leaving your current programme?' 465 students (47%) indicated that they had considered leaving and provided detailed comments explaining the circumstances that induced them to deliberate whether or not to stay. A thematic analysis of the data found three distinct themes: dissatisfaction with academic workload and support; difficulties associated with clinical placements, and personal concerns and challenges. A significant number of student comments combined two or more of these themes. A number of students also detailed why they decided to stay. CONCLUSIONS: Those students that had considered leaving frequently described how a combination of diverse factors accumulated to lead to them contemplating leaving their programme. Strategies to reduce attrition in healthcare students need to consider the student lifecycle from recruitment to graduation, to set reasonable student expectations and ensure that a career within healthcare is both desired and valued.

What are reasonable expectations? Healthcare student perceptions of their programmes in the North West of England.

BACKGROUND: Concerns about current levels of attrition from some healthcare programmes have emphasised the need to gain a greater insight into students' expectations and experiences. OBJECTIVES: The aim of this study was to determine how students in the North West of England perceived their studies and to identify the factors that could contribute to students' dissatisfaction. DESIGN: A mixed methods sequential exploratory study. SETTINGS: Nine universities in the North West of England. METHODS: Phase one used narrative interviews with a purposive sample of 24 students to investigate their expectations and experiences. Data from these interviews were analysed using a thematic framework and direct quotes from key themes were incorporated into online survey for phase 2. Survey respondents were asked to rate their agreement to statements on a four-point Likert-type response format. There was also an opportunity to leave comments through open questions relating to each theme. RESULTS: A total of 1080 respondents completed the online survey in phase 2. The majority of students reported positive experiences of their course. There was strong agreement in the importance of the role of the personal tutor and of a supportive placement mentor. Some students indicated that the workload and academic level were a shock at first. Students identified difficulties around the cost of placement travel and the impact of placements on family life. Financial hardship was a frequently cited issue that students attributed to thoughts of discontinuation. CONCLUSIONS: Most students had positive learning experiences which meet their expectations. Students who have unmet expectations report poor placement experiences, lack of support, unexpectedly high workloads and financial difficulties. Clear guidance on the role of personal tutor and placement mentor is recommended.

'The placement was probably the tipping point' - the narratives of recently discontinued students.

Much has been written on student attrition from healthcare programmes and we know that it is often multifactorial. However in order to reduce attrition we need to gain a greater understanding of how multiple factors impact upon and compound one another to prompt a student to decide to leave. The purpose of this study was to explore healthcare students' experiences of university and the circumstances that initiated their decision to leave their programme. Sixteen students that had recently left healthcare programmes within the North West of England were interviewed by telephone, using a narrative prompt to facilitate them to tell their stories. All the students gave detailed narrative accounts that described their learning experiences, growing dissatisfaction and subsequent attrition. In the majority dissatisfaction and difficulties around clinical placements acted as a tipping point that precipitated departure.

A FABP-ulous 'rule out' strategy? Heart fatty acid binding protein and troponin for rapid exclusion of acute myocardial infarction.

OBJECTIVE: Many Emergency Departments (EDs) utilise 'triple marker' testing with CK-MB, myoglobin and troponin I (cTnI) to exclude acute myocardial infarction (AMI) within hours of presentation. We evaluated the ability of 8 biomarkers to rapidly exclude AMI at the point of presentation and investigated whether 'triple marker' testing represents the optimal multimarker strategy. METHODS: We recruited patients who presented to the ED with suspected cardiac chest pain occurring within 24 h. Blood was drawn at the time of presentation. Diagnostic value was assessed by calculating the area under the ROC curve (AUC) and a multivariate model was constructed by logistic regression. The primary outcome was a diagnosis of AMI, established by ≥12-h troponin testing in all patients. RESULTS: 705 included patients underwent venepuncture a median of 3.5 h after symptom onset. Heart fatty acid binding protein (H-FABP) had an AUC of 0.86 (95% CI 0.82-0.90), which was significantly higher than any other biomarker including cTnI. While no single biomarker could enable exclusion of AMI, multivariate analysis identified cTnI and H-FABP as the optimal biomarker combination. Combined with clinical risk stratification, this strategy had a sensitivity of 96.9%, specificity of 54.7%, PPV 32.4% and NPV 98.8%. CONCLUSIONS: We have derived an algorithm that would enable AMI to be immediately excluded in 315 (44.7%) patients at the cost of missing 6 AMIs per 1000 patients treated. While the risk is likely to be unacceptable for clinical implementation, we have highlighted an area for future development using serial testing and increasingly sensitive assays.