Describing, predicting and explaining adherence to total skin self-examination (TSSE) in people with melanoma: a 12-month longitudinal study.

OBJECTIVES: To describe trajectories in melanoma survivors' adherence to monthly total skin self-examination (TSSE) over 12 months, and to investigate whether adherence trajectories can be predicted from demographic, cognitive or emotional factors at baseline. DESIGN: A longitudinal observational study nested within the intervention arm of the ASICA (Achieving Self-Directed Integrated Cancer Aftercare) randomised controlled trial. SETTING: Follow-up secondary care in Aberdeen and Cambridge UK. PARTICIPANTS: n=104 adults (48 men/56 women; mean age 58.83 years, SD 13.47, range 28-85 years; mean Scottish Index of Multiple Deprivation score 8.03, SD 1.73, range 2-10) who had been treated for stage 0-IIC primary cutaneous melanoma in the preceding 60 months and were actively participating in the intervention arm of the ASICA trial. INTERVENTIONS: All participants were using the ASICA intervention-a tablet-based intervention designed to support monthly TSSE. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was adherence to guideline recommended (monthly) TSSE over 12 months. This was determined from time-stamped TSSE data recorded by the ASICA intervention app. RESULTS: Latent growth mixture models identified three TSSE adherence trajectories (adherent -41%; drop-off -35%; non-adherent -24%). People who were non-adherent were less likely to intend to perform TSSE as recommended, intending to do it more frequently (OR=0.21, 95% CI 0.06 to 0.81, p=0.023) and were more depressed (OR=1.31, 95% CI 1.06 to 1.61, p=0.011) than people who were adherent. People whose adherence dropped off over time had less well-developed action plans (OR=0.78, 95% CI 0.63 to 0.96, p=0.016) and lower self-efficacy about TSSE (OR=0.92, 95% CI 0.86 to 0.99, p=0.028) than people who were adherent. CONCLUSIONS: Adherence to monthly TSSE in people treated for melanoma can be differentiated into adherent, drop-off and non-adherent trajectories. Collecting information about intentions to engage in TSSE, depression, self-efficacy and/or action planning at outset may help to identify those who would benefit from additional intervention. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Registry (NCT03328247).

How can we better prepare new doctors for the tasks and challenges of ward rounds?: An observational study of junior doctors' experiences.

PURPOSE: Ward rounds play a crucial role in the delivery of patient care in inpatient settings, but involve a complex mix of tasks, skills and challenges for junior doctors to negotiate. This study informs the development of high-quality training by identifying the activities that junior doctors perform, and those associated with stress during real-life ward rounds. MATERIALS AND METHODS: All activities performed by FY1 doctors (n = 60) over 2 ward rounds were coded in real-time by a trained observer using the work observation method by activity timing (WOMBAT). Doctors' heart rate was continuously recorded and non-metabolic peaks in heart rate used as a physiological indicator of stress. RESULTS: During ward rounds, FY1 doctors commonly engaged in indirect patient care, professional communication, documentation and observation. Very little time was spent on direct patient care (6%) or explicit supervision/education (0.01%). Heart rate data indicated that stress was highest during administrative tasks while interacting directly with patients while stepping out of rounds to complete personal tasks, when answering bleeps and while multi-tasking. CONCLUSIONS: Training that specifically covers the activities involved, skills required, and challenges inherent in real-life ward rounds may better prepare FY doctors for this complex area of practice.

Development of an online tool for linking behavior change techniques and mechanisms of action based on triangulation of findings from literature synthesis and expert consensus.

Researchers, practitioners, and policymakers develop interventions to change behavior based on their understanding of how behavior change techniques (BCTs) impact the determinants of behavior. A transparent, systematic, and accessible method of linking BCTs with the processes through which they change behavior (i.e., their mechanisms of action [MoAs]) would advance the understanding of intervention effects and improve theory and intervention development. The purpose of this study is to triangulate evidence for hypothesized BCT-MoA links obtained in two previous studies and present the results in an interactive, online tool. Two previous studies generated evidence on links between 56 BCTs and 26 MoAs based on their frequency in literature synthesis and on expert consensus. Concordance between the findings of the two studies was examined using multilevel modeling. Uncertainties and differences between the two studies were reconciled by 16 behavior change experts using consensus development methods. The resulting evidence was used to generate an online tool. The two studies showed concordance for 25 of the 26 MoAs and agreement for 37 links and for 460 "nonlinks." A further 55 links were resolved by consensus (total of 92 [37 + 55] hypothesized BCT-MoA links). Full data on 1,456 possible links was incorporated into the online interactive Theory and Technique Tool (https://theoryandtechniquetool.humanbehaviourchange.org/). This triangulation of two distinct sources of evidence provides guidance on how BCTs may affect the mechanisms that change behavior and is available as a resource for behavior change intervention designers, researchers and theorists, supporting intervention design, research synthesis, and collaborative research.

Analysing N-of-1 observational data in health psychology and behavioural medicine: a 10-step SPSS tutorial for beginners.

Background: N-of-1 observational studies can be used to describe natural intra-individual changes in health-related behaviours or symptoms over time, to test behavioural theories and to develop highly personalised health interventions. To date, N-of-1 observational methods have been under-used in health psychology and behavioural medicine. One reason for this may be the perceived complexity of statistical analysis of N-of-1 data. Objective: This tutorial paper describes a 10-step procedure for the analysis of N-of-1 observational data using dynamic regression modelling in SPSS for researchers, students and clinicians who are new to this area. The 10-step procedure is illustrated using real data from an N-of-1 observational study exploring the relationship between pain and physical activity. Conclusion: The availability of a user-friendly and robust statistical technique for the analysis of N-of-1 data using SPSS may foster increased awareness, knowledge and skills and establish N-of-1 designs as a useful methodological tool in health psychology and behavioural medicine.

Clinical decisions and time since rest break: An analysis of decision fatigue in nurses.

OBJECTIVE: The present study investigates whether nurses working for a national medical telephone helpline show evidence of "decision fatigue," as measured by a shift from effortful to easier and more conservative decisions as the time since their last rest break increases. METHOD: In an observational, repeated-measures study, data from approximately 4,000 calls to 150 nurses working for the Scottish NHS 24 medical helpline (37% of the national workforce) were modeled to determine whether the likelihood of a nurse's decision to refer a patient to another health professional the same day (the clinically safest but most conservative and resource inefficient decision) varied according to the number of calls taken/time elapsed since a nurse's last rest break and/or since the start of shift. Analyses used mixed-effect logistic regression. RESULTS: For every consecutive call taken since last rest break, the odds of nurses making a conservative management decision (i.e., arranging for callers to see another health professional the same day) increased by 5.5% (p = .001, 95% confidence interval [CI: 2.2, 8.8]), an increase in odds of 20.5% per work hour (p < .001, 95% CI [9.1, 33.2]) or 49.0% (on average) from immediately after 1 break to immediately before the next. Decision-making was not significantly related to general or cumulative workload (calls or time elapsed since start of shift). CONCLUSIONS: Every consecutive decision that nurses make since their last break produces a predictable shift toward more conservative, and less resource-efficient, decisions. Theoretical models of cognitive fatigue can elucidate how and why this shift occurs, helping to identify potentially modifiable determinants of patient care. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Are Processes in Acceptance & Commitment Therapy (ACT) Related to Chronic Pain Outcomes Within Individuals Over Time? An Exploratory Study Using n-of-1 Designs.

INTRODUCTION: Acceptance & Commitment Therapy (ACT) explicitly postulates experiential avoidance (EA) and values-based living (VBL) as essential treatment processes. As outcomes from between-subject studies cannot readily be generalized to within-subject processes in individuals, we explored the unfolding of, and relationship between, EA and VBL and levels of pain interference in daily life and emotional well-being within individuals experiencing chronic pain. METHODS: Using n-of-1 designs, three participants following a multidisciplinary treatment program filled out a 12-item daily questionnaire (87-110 days). After multiple imputation of missing data, McKnight Time-series analysis procedures were performed for each participant separately. The interrelationships of EA, VBL and pain intensity, and the relationship of EA and VBL beyond pain intensity with both chronic pain outcomes were assessed both concurrently (same day) and prospectively (consecutive days). RESULTS: Both EA and VBL were associated with at least one of five outcome variables (four domains of pain interference and emotional well-being) beyond pain intensity in two participants, but not in the third participant. These associations primarily existed for concurrent, but not consecutive, days. In contrast to VBL, EA was not associated with emotional well-being for any of the three participants. CONCLUSIONS: Although the finding that ACT-processes were associated with pain outcomes on concurrent days is consistent with ACT theory, the absence of such associations on consecutive days means that alternative explanations cannot be rule out. One possibility is that pain interference fluctuates within days at a higher variability rate than was currently assessed. Future research should consider using a higher measurement frequency to be able to grasp time-lagged effects.

Why does work cause fatigue? A real-time investigation of fatigue, and determinants of fatigue in nurses working 12-hour shifts.

BACKGROUND: One of the striking regularities of human behavior is that a prolonged physical, cognitive, or emotional activity leads to feelings of fatigue. Fatigue could be due to (1) depletion of a finite resource of physical and/or psychological energy or (2) changes in motivation, attention, and goal-directed effort (e.g. motivational control theory). PURPOSE: To contrast predictions from these two views in a real-time study of subjective fatigue in nurses while working. METHODS: One hundred nurses provided 1,453 assessments over two 12-hr shifts. Nurses rated fatigue, demand, control, and reward every 90 min. Physical energy expenditure was measured objectively using Actiheart. Hypotheses were tested using multilevel models to predict fatigue from (a) the accumulated values of physical energy expended, demand, control, and reward over the shift and (b) from distributed lag models of the same variables over the previous 90 min. RESULTS: Virtually all participants showed increasing fatigue over the work period. This increase was slightly greater when working overnight. Fatigue was not dependent on physical energy expended nor perceived work demands. However, it was related to perceived control over work and perceived reward associated with work. CONCLUSIONS: Findings provide little support for a resource depletion model; however, the finding that control and reward both predicted fatigue is consistent with a motivational account of fatigue.

Intention, beliefs and mood assessed using electronic diaries predicts attendance at cardiac rehabilitation: An observational study.

BACKGROUND: Cardiac rehabilitationis effective in promoting physical/psychological recovery following acute coronary syndrome. Yet, rates of attendance at outpatient cardiac rehabilitation by eligible patients are low. OBJECTIVES: This study examined the determinants of attendance at outpatient cardiac rehabilitation in acute coronary syndrome patients following discharge until cardiac rehabilitation commencement. DESIGN: A weekly electronic diary measured cardiac-related cognitions and mood and examined their relation to attendance at outpatient cardiac rehabilitation. SETTINGS: Three United Kingdom National Health Service secondary care settings in two Health Board areas in Scotland. PARTICIPANTS: Acute coronary syndrome patients were recruited from March 2012 to June 2013 prior to hospital discharge. Of 488 eligible patients referred for cardiac rehabilitation, 214 consented. METHODS: Consecutive patients completed a pre-hospital discharge questionnaire targeting age, diagnosis, social class and smoking history. Acute coronary syndrome patients then completed a weekly electronic diary from the first week of discharge until the start of cardiac rehabilitation. Multilevel structural equation models estimated the effects of initial, i.e. baseline and rate of change in cardiac-related cognition and mood on attendance. Intention to attend cardiac rehabilitation was reflected, log transformed, reported thereafter as "do not intend". The role of "do not intend" was explored as a mediator of the relationship between cardiac-related cognition and mood on attendance. RESULTS: 166 participants provided, on average, 5 weeks of diary entries before cardiac rehabilitation commenced. High intention (i.e. low "do not intend") to attend CR and its rate of increase over time predicted attendance. Low negative emotional representation, high perceived necessity, high confidence in maintaining function, low negative affect, and high positive affect following discharge predicted attendance at cardiac rehabilitation. The rate of change in cardiac-related mood and these cognitions was not predictive. Baseline and rate of change in "do not intend" entirely mediated relationships between a) perceived necessity, b) negative affect and attendance at cardiac rehabilitation. CONCLUSIONS: Negative affect in the first weeks following discharge represents the key challenge to a patient maintaining their intention to attend cardiac rehabilitation. Intervention to improve attendance should focus on improving intention to attend following discharge and during recovery by improving patient understanding of cardiac rehabilitation and reducing negative affect.

The state of the art and future opportunities for using longitudinal n-of-1 methods in health behaviour research: a systematic literature overview.

n-of-1 studies test hypotheses within individuals based on repeated measurement of variables within the individual over time. Intra-individual effects may differ from those found in between-participant studies. Using examples from a systematic review of n-of-1 studies in health behaviour research, this article provides a state of the art overview of the use of n-of-1 methods, organised according to key methodological considerations related to n-of-1 design and analysis, and describes future challenges and opportunities. A comprehensive search strategy (PROSPERO:CRD42014007258) was used to identify articles published between 2000 and 2016, reporting observational or interventional n-of-1 studies with health behaviour outcomes. Thirty-nine articles were identified which reported on n-of-1 observational designs and a range of n-of-1 interventional designs, including AB, ABA, ABABA, alternating treatments, n-of-1 randomised controlled trial, multiple baseline and changing criterion designs. Behaviours measured included treatment adherence, physical activity, drug/alcohol use, sleep, smoking and eating behaviour. Descriptive, visual or statistical analyses were used. We identify scope and opportunities for using n-of-1 methods to answer key questions in health behaviour research. n-of-1 methods provide the tools needed to help advance theoretical knowledge and personalise/tailor health behaviour interventions to individuals.

The physical environment and health-enhancing activity during the school commute: global positioning system, geographical information systems and accelerometry.

Active school travel is in decline. An understanding of the potential determinants of health-enhancing physical activity during the school commute may help to inform interventions aimed at reversing these trends. The purpose of this study was to identify the physical environmental factors associated with health-enhancing physical activity during the school commute. Data were collected in 2009 on 166 children commuting home from school in Scotland. Data on location and physical activity were measured using global positioning systems (GPS) and accelerometers, and mapped using geographical information systems (GIS). Multi-level logistic regression models accounting for repeated observations within participants were used to test for associations between each land-use category (road/track/path, other man-made, greenspace, other natural) and moderate-to-vigorous physical activity (MVPA). Thirty-nine children provided 2,782 matched data points. Over one third (37.1%) of children's school commute time was spent in MVPA. Children commuted approximately equal amounts of time via natural and man-made land-uses (50.2% and 49.8% respectively). Commuting via road/track/path was associated with increased likelihood of MVPA (Exp(B)=1.23, P <0.05), but this association was not seen for commuting via other manmade land-uses. No association was noted between greenspace use and MVPA, but travelling via other natural land-uses was associated with lower odds of MVPA (Exp(B)=0.32, P <0.05). Children spend equal amounts of time commuting to school via man-made and natural land-uses, yet man-made transportation route infrastructure appears to provide greater opportunities for achieving health-enhancing physical activity levels.

Stress in telephone helpline nurses is associated with failures of concentration, attention and memory, and with more conservative referral decisions.

Nurses working for telephone-based medical helplines must maintain attentional focus while quickly and accurately processing information given by callers to make safe and appropriate treatment decisions. In this study, both higher levels of general occupational stress and elevated stress levels on particular shifts were associated with more frequent failures of attention, memory, and concentration in telephone nurses. Exposure to a stressful shift was also associated with a measurable increase in objectively assessed information-processing errors. Nurses who experienced more frequent cognitive failures at work made more conservative decisions, tending to refer patients on to other health professionals more often than other nurses. As stress is associated with cognitive performance decrements in telephone nursing, stress-reduction interventions could improve the quality and safety of care that callers to medical helplines receive.

Testing an integrated behavioural and biomedical model of disability in N-of-1 studies with chronic pain.

BACKGROUND: Previous research has supported an integrated biomedical and behavioural model explaining activity limitations. However, further tests of this model are required at the within-person level, because while it proposes that the constructs are related within individuals, it has primarily been tested between individuals in large group studies. We aimed to test the integrated model at the within-person level. METHOD: Six correlational N-of-1 studies in participants with arthritis, chronic pain and walking limitations were carried out. Daily measures of theoretical constructs were collected using a hand-held computer (PDA), the activity was assessed by self-report and accelerometer and the data were analysed using time-series analysis. RESULTS: The biomedical model was not supported as pain impairment did not predict activity, so the integrated model was supported partially. Impairment predicted intention to move around, while perceived behavioural control (PBC) and intention predicted activity. PBC did not predict activity limitation in the expected direction. CONCLUSIONS: The integrated model of disability was partially supported within individuals, especially the behavioural elements. However, results suggest that different elements of the model may drive activity (limitations) for different individuals. The integrated model provides a useful framework for understanding disability and suggests interventions, and the utility of N-of-1 methodology for testing theory is illustrated.

Stress in nurses: stress-related affect and its determinants examined over the nursing day.

BACKGROUND: Nurses are a stressed group and this may affect their health and work performance. The determinants of occupational stress in nurses and other occupational groups have almost invariably been examined in between subject studies. PURPOSE: This study aimed to determine if the main determinants of occupation stress, i.e. demand, control, effort and reward, operate within nurses. METHODS: A real time study using personal digital-assistant-based ecological momentary assessment to measure affect and its hypothesised determinants every 90 min in 254 nurses over three nursing shifts. The measures were negative affect, positive affect, demand/effort, control and reward. RESULTS: While the effects varied in magnitude between people, in general increased negative affect was predicted by high demand/effort, low control and low reward. Control and reward moderated the effects of demand/effort. High positive affect was predicted by high demand/effort, control and reward. CONCLUSIONS: The same factors are associated with variations in stress-related affect within nurses as between.

Goal conflict and goal facilitation as predictors of daily accelerometer-assessed physical activity.

OBJECTIVE: To test whether perceptions of conflicting and facilitating personal goals, and actual daily time spent in their pursuit, predict accelerometer-assessed physical activity (PA). METHODS: A prospective multilevel design with a daily accelerometer-based assessment of PA over 1 week was used (N = 106). Participants' personal goals were elicited using personal projects analysis. Participants then rated their personal goals in terms of how they were perceived to facilitate and conflict with their regular PA. Items assessing PA-specific intention and perceived behavioral control (PBC) were also embedded within the baseline measures. For the subsequent 7 consecutive days, participants completed a daily diary based on the day reconstruction method, indicating the time spent in daily episodes involving each of their personal goals, and wore an RT3 tri-axial accelerometer. MAIN OUTCOME MEASURE: The main outcome was accelerometer-assessed daily time spent in moderate to vigorous physical activity (MVPA). RESULTS: Random intercept multilevel models indicated that perceived goal facilitation, but not perceived goal conflict, predicted MVPA over and above intention and PBC. Daily time pursuing conflicting goals negatively predicted MVPA when subsequently added to the model and in so doing, attenuated the association between perceived goal facilitation and MVPA. CONCLUSION: Perceived goal facilitation predicts objectively measured PA over and above intention and PBC, but daily time spent in pursuit of conflicting personal goals provides a better account of how alternative goals relate to engaging in regular PA.

Assessing acute coronary syndrome patients' cardiac-related beliefs, motivation and mood over time to predict non-attendance at cardiac rehabilitation.

AIM: This research protocol describes and justifies a study to assess patients' cardiac-related beliefs (i.e. illness representations, knowledge/misconceptions, cardiac treatment beliefs), motivation and mood over time to predict non-attendance at a cardiac rehabilitation programme by measuring weekly/monthly changes in these key variables. BACKGROUND: Heart disease is the UK's leading cause of death. Evidence from meta-analyses suggests that cardiac rehabilitation facilitates recovery following acute cardiac events. However, 30-60% of patients do not attend cardiac rehabilitation. There is some evidence from questionnaire studies that a range of potentially modifiable psychological variables including patients' cardiac-related beliefs, motivation and mood may influence attendance. DESIGN: Mixed-methods. METHODS: In this study, during 2012-2013, electronic diary data will be gathered weekly/monthly from 240 patients with acute coronary syndrome from discharge from hospital until completion of the cardiac rehabilitation programme. This will identify changes and interactions between key variables over time and their power to predict non-attendance at cardiac rehabilitation. Data will be analysed to examine the relationship between patients' illness perceptions, cardiac treatment beliefs, knowledge/misconceptions, mood and non-attendance of the cardiac rehabilitation programme. The qualitative component (face-to-face interviews) seeks to explore why patients decide not to attend, not complete or complete the cardiac rehabilitation programme. DISCUSSION: The identification of robust predictors of (non-)attendance is important for the design and delivery of interventions aimed at optimizing cardiac rehabilitation uptake. Funding for the study was granted in February 2011 by the Scottish Government Chief Scientist Office (CZH/4/650).

Testing the integration of ICF and behavioral models of disability in orthopedic patients: replication and extension.

OBJECTIVE: Disability from chronic illness is a major problem for society, yet the study of its determinants lacks an overall theoretical paradigm. Johnston (1996) has proposed conceptualizing disability as behavior and integrating biomedical and behavioral predictors. Dixon, Johnston, Rowley, and Pollard (2008) tested a model including constructs from the International Classification of Functioning, Disability and Health (ICF) and the theory of planned behavior (TPB) using structural equation modeling; it fitted better and explained more variance than the ICF or TPB alone. We replicated their study with a new sample from the same population (orthopedic patients awaiting joint replacement) and also tested the model after the patients had surgery. METHODS: Two weeks before surgery, 342 orthopedic patients who had joint pain (most with arthritis) completed a questionnaire, with 228 completing it again 1 year after surgery. The authors tested Dixon et al.'s best-fit models cross-sectionally (before and after surgery) and assessed the goodness of fit of these imposed models to our data using structural equation modeling. RESULTS: Findings strongly supported those of Dixon et al. Before surgery, results were very similar to Dixon et al. with all models accounting for significant variance and fitting well, but the integrated model fitted better and accounted for more variance. One year after surgery, Dixon et al.'s models showed even stronger fit to the data. CONCLUSIONS: Although behavioral and biomedical (ICF) models were supported, the integrated model provided a better explanation of disability in this population than either of these models alone and suggests biopsychosocial interventions to reduce disability.

The use of pedometers in stroke survivors: are they feasible and how well do they detect steps?

OBJECTIVES: To determine (1) the feasibility of pedometers for stroke patients and (2) the level of agreement between pedometers and actual step count. DESIGN: Observational agreement study. SETTING: Six stroke units. PARTICIPANTS: Independently mobile stroke patients (N=50) ready for hospital discharge. INTERVENTIONS: Patients were asked to apply 3 pedometers: 1 around the neck and 1 above each hip. Patients performed a short walk lasting 20 seconds, then a 6-minute walk test 6MWT. Video recordings determined the criterion standard step count. MAIN OUTCOME MEASURE: Agreement between the step count recorded by pedometers and the step count recorded by viewing the criterion standard video recordings of the 2 walks. RESULTS: Five patients (10%) needed assistance to put on the pedometers, and 5 (10%) could not read the step count. Thirty-nine (78%) would use pedometers again. Below a gait speed of about 0.5 m/s, pedometers did not generally detect steps. Agreement analyses showed that even above 0.5 m/s, pedometers undercounted steps for both the short walk and 6MWT; for example, the mean difference between the video recorder and pedometer around the neck was 5.93 steps during the short walk and 32.4 steps during the 6MWT. CONCLUSIONS: Pedometers are feasible but generally do not detect steps at gait speeds below about 0.5 m/s, and they undercount steps at gait speeds above 0.5 m/s.

Does clinical incident seriousness and receipt of work-based support influence mood experienced by nurses at work? A behavioural diary study.

BACKGROUND: While the relationship between general perceptions of the work environment and negative mood is well detailed, little is known about the effect of specific clinical incident characteristics on the mood experienced at work by nurses. This study examines the effect of incident seriousness and receipt of work-based support in the worst event of a shift from managers and colleagues on the Negative and Positive Affect experienced by nurses at work. METHODS: We approached the total cohort of medical and surgical nurses in 4 large district general hospitals in England, 17% volunteered. Some 171 nurses filled end of shift and standard entry (every 90 min) computerised behavioural diaries over three consecutive shifts. The diaries measured Incident Seriousness, Receipt of Managerial and Co-worker Support, Negative Affect and Positive Affect. Results were analysed using multilevel modelling (MLwiN 2.19). FINDINGS: Following the worst clinical incident of a shift, nurses reported higher Negative Affect (ß=1.28, [95%CI: 0.12, 2.45], z=2.17, p<.05) and lower Positive Affect (ß=-2.39, [95%CI: -3.96, -0.82], z=2.99, p<.005) which persisted for the remainder of the shift. Most critically, Negative Affect was more elevated after serious incidents (ß=0.07, [95%CI: 0.04, 0.10], z=3.5, p<.005). Nurses who reported Receipt of Managerial Support following an incident reported significantly lower levels of Positive Affect compared to those reporting no such contact (ß=-5.30, [95%CI: -9.51, -1.09], z=2.47, p<.05). The interaction between Incident and the Receipt of Work-Based Support on NA was not significant (ß=2.34 [95%CI: -0.82, 3.95], z=1.45, p>.05). Receipt of Colleague Support had no relationship with Negative Affect or Positive Affect. Free text reports mainly revealed the negative impact of managerial support, although there were instances of contact with managers which were sought following exposure to difficult clinical situations. DISCUSSION: Serious clinical incidents have enduring effects on Negative Affect and Positive Affect for the remainder of the shift. Nurse Positive Affect was significantly worse following the worst clinical incident of shift when managerial support was received. Further research is required to determine the positive and negative effects of managerial support on the mood experienced by nurses at work.

Efficacy and cost of an exercise program for functionally impaired older patients with heart failure: a randomized controlled trial.

BACKGROUND: Little is known about the optimum way to deliver exercise to older, functionally impaired patients with heart failure. We tested whether an exercise program tailored to the needs of these patients could improve exercise capacity and quality of life or reduce costs to the National Health Service. METHODS AND RESULTS: The study design was a parallel-group, single-blind, randomized controlled trial. Patients aged ≥70 years with symptomatic heart failure and left ventricular systolic dysfunction were randomized to either 24 weeks of exercise training or usual care. Six-minute walk distance was the primary outcome; markers of physical function, quality of life, health status, and daily activity were measured at baseline and 8 and 24 weeks. Carer strain and healthcare costs were also recorded. A total of 107 participants were randomized (mean age, 80 years; men, 72 [67%]). Six-minute walk distance did not improve compared to that of the control group at 8 weeks (-16.9 m; 95% CI, -41.8 to 7.9 m; P=0.18) or at 24 weeks (-5.3 m; 95% CI, -32.6 to 22.0 m; P=0.70). For secondary outcomes, only the sit-to-stand test improved significantly at 24 weeks (-6.4 s; 95% CI, -12.2 to 0.6 s; P=0.03); there was no difference in change for the Minnesota Living With Heart Failure score (0.1 points; 95% CI, -0.9 to 1.1 points; P=0.83) at 24 weeks. Carer strain did not decrease at 24 weeks (difference, -0.5 points; 95% CI, -8.3 to 7.3 points; P=0.80), and there was no difference in overall healthcare costs. CONCLUSIONS: This exercise intervention did not improve exercise capacity or quality of life in older patients with heart failure and was not cost saving to the National Health Service. Clinical Trial Registration- URL: http://www.controlled-trials.com. Unique identifier: ISRCTN51615566.