Stress, a reflective self and an internal locus of control: On the everyday clinical placement experiences of older undergraduate radiographers in the UK.

INTRODUCTION: Extant evidence indicates that the stresses experienced by younger undergraduate radiographers and their older counterparts vary considerably. Much of this difference has, however, emerged from analyses of the academic component of a radiography degree whereas little work has focused to date upon the specific business of clinical placement. Given this, the research herein reports findings from a qualitative study of how older undergraduate radiography students in the UK assemble their stress and stressors around clinical placement. METHODS: An Interpretative Phenomenological Analysis was employed. N = 6 older undergraduate students undergoing their final year placement were purposively recruited from a variety of hospitals. With full institutional ethical approval, a semi-structured interview was conducted with each participant. RESULTS: Four superordinate themes emerged. These were: (1) Self-identity and perceived competence; (2) Understaffing, instability and affect; (3) Episodic experience and feeling 'thrown-in'; (4) Unpreparedness for the challenging patient. Critically, each theme describes an interaction between stressor, experience of stress and self. CONCLUSION: While familiar stressors were apparent, the older participating students actively made sense of them in terms of their manageability. This provides a strong contrast with existing literature, which tends to imply a more externalised locus of control among (largely younger) students. IMPLICATIONS FOR PRACTICE: Stress in the NHS is a continuing issue and there is a clear rationale for further investigation to ascertain the level of clinical support available and to determine whether further improvements could assist students on clinical placement. Collaboration between academic institutions and clinical sites would allow open discussion around clinical stress experienced by radiography students, with locus of control a potential point of focus, fostering a proactive partnership approach to stress-management and identification of difficulties before they exacerbate.

Managing discomfort and developing participation in non-emergency MRI: Children's coping strategies during their first procedure.

INTRODUCTION: Building on existing work, this paper aims to develop a detailed analysis of the practical coping strategies developed by children who had not previously experienced an MRI, regarding a non-emergency examination of the brain. METHODS: Semi-structured interviews with 22 children, aged between eight and sixteen years, were conducted immediately post-procedure. Emergent data were thematically analysed in line with the core precepts of Grounded Theory, and triangulated against interview data with their parents where pertinent. RESULTS: The primary concern among interviewees related to how they had coped with the discomfort of an unfamiliar medical procedure; this was recurrently managed through a process herein termed Participation Development. This comprised three phases. The first, preparative participation, describes the children's reported attempts to ready themselves for the examination (with parents) ahead of arriving in hospital. The second, enabling participation, describes how the children (with input from parents and radiographers) endeavoured to understand what was to come, and select viable distraction techniques. Finally, sustaining participation describes the children's reports of actualizing their preparations during the examination itself. Where the overall process of participation development was successful, the children reported a sense of mastery, growth and even joy. CONCLUSION: While much work in the domain portrays children as relatively 'passive' agents during an MRI procedure, the findings herein point to how they can (with varying degrees of success) actively and constructively work with others. This, it is contended, has direct import for the improvement of support, both prior to and within a procedure itself.

Personnel flux and workplace anxiety: Personal and interpersonal consequences of understaffing in UK ultrasound departments.

INTRODUCTION: By 2013, the UK government's Migration Advisory Committee had determined sonography to be a formal shortage speciality, and understaffing remains a key concern for research in the domain. This paper, emergent of a qualitative study funded by Health Education North West, explores unit managers' perspectives on the present state of UK ultrasound. The focus herein falls upon the personal and interpersonal consequences of this circumstance for individuals working in specific understaffed departments. METHODS: A thematic analysis informed by a Straussian model of Grounded Theory was utilised; N = 20 extended accounts provided by ultrasound department leads in public (n = 18) and private (n = 2) units were collected and analysed accordingly. RESULTS: The global themes addressed herein describe (a) how both inter-departmental movement of senior sonographers and early retirement, within a nationally understaffed picture, impacts upon local knowledge economies, and (b) how such staffing instabilities can undermine the day-to-day confidence of managerial staff and practicing sonographers alike. CONCLUSIONS: It is personnel flux, rather than simple short-staffing, that is reported to cause the greatest social-psychological problems for both managers and sonographers. The issues raised herein require further examination from the perspective of sonographers themselves, in order to corroborate the views of the managers interviewed.

Informing radiography curriculum development: The views of UK radiology service managers concerning the 'fitness for purpose' of recent diagnostic radiography graduates.

INTRODUCTION: Recent years have seen significant changes in the way medical imaging services are delivered, rapid changes in technology and big increases in the number and ranges of examinations undertaken. Given these changes the study aimed to critically evaluate the fitness for purpose of newly qualified diagnostic radiography. METHOD: The study employed a grounded theory approach to analyse the interviews of 20 radiology managers from a range of medical imaging providers across the UK. RESULTS: Four key themes emerged from the analysis. These were: curriculum content and structure review; diversification in the role of the radiographer; professionalism and coping and the reformation of career structures. CONCLUSION: The results indicate the role of the radiographer is now in a state of flux and challenge radiology managers and educators to design curricula and career structures which are better matched the role of the radiographer in the very rapidly changing technological, organisational and social contexts of modern society.

Student radiographers' attitudes towards the older patient - A longitudinal study.

INTRODUCTION: To design, implement and evaluate the effect of an educational intervention on student radiographer attitudes across their educational tenure. METHODS: In the first phase, an educational intervention that involved didactic lectures, reflective exercises and simulation suits, aimed at improving student radiographer attitudes towards the older person, was designed and implemented. Kogan's attitudes towards older people (KoP) scale was administrated at five test points; pre-intervention; post-intervention; 6 months post intervention; 12 months post intervention and 24 months post intervention. At the final test point these quantitative data was supplemented with qualitative data for triangulation of the findings. RESULTS: Students held positive attitudes towards older people pre intervention, these increased significantly post intervention (p = 0.01). However, this increase in positive scores was not noted at 6 months and 12-months post intervention. At 24-months post intervention, although there was a slight increase in positive attitudes when compared to the 6 and 12 month scores, this increase was not found to be significant (p = 0.178) CONCLUSION: The results post-intervention suggested that an educational intervention can have a significant impact on student radiographer's attitudes towards older people. However, the qualitative data suggests that experiences on initial clinical placement can be detrimental to attitudinal scores, particularly if the intervention does not include Dementia care strategies.

Leadership and the everyday practice of Consultant Radiographers in the UK: Transformational ideals and the generation of self-efficacy.

INTRODUCTION: This paper outlines findings from a broader, two-year project investigating the role of Consultant Radiographers (CRs) in the UK, focussing specifically on the leadership aspect of that role. METHODS: Using a qualitative-thematic approach, the leadership-related experiences of a purposive sample of six participating CRs are explored, alongside the systems through which they evaluated how successful they had been as leaders. RESULTS: It is evidenced that many of the ways in which participants describe their own leadership practice, particularly in the intra-team domain, is consistent with the precepts of the Transformational Leadership Model. For example, they highlight how they have asserted positive influence and encouraged collective action and decision-making. However, the experiential focus of the analysis reveals that in specific examples of practice, the transformational approach was not always seen as the most useful route to a productive outcome given constrictions on time and other resources within real professional environments. More 'direct' managerial approaches were sometimes deemed necessary, and at others leadership was reduced to simply 'solving other people's problems'. It was also found that the manner in which participants evaluated their own success as leaders was a practical concern, based in part upon having satisfied 'hard' institutional goals, but also on the more personal business of having affirmatively 'surprised' oneself, or a general sense of feeling trusted by colleagues. CONCLUSION: These findings may help support CRs in the business of real leadership, not least through better understanding how even apparently mundane outcomes can have significant impacts on professional self-efficacy.

Obesity, heuristic reasoning and the organisation of communicative embarrassment in diagnostic radiography.

This paper, the second of three arising from a broader qualitative study, explores difficulties emerging around radiographer-patient communication regarding obesity in hospital-based encounters, and the situated strategies found by experienced radiographers for handling such situations. Semi-structured interviews with eight clinicians working in plain radiography (mean experience = 21.56 years) were analysed using Interpretative Phenomenological Analysis (IPA), so as to highlight the practical, nuanced and real-world experiences of these individuals regarding obesity communication. Participants generally viewed communicating with obese patients as a potential interpersonal 'minefield'. Most reported having had negative experiences in which patients had acted with denial or outright aggression during examinations but, conversely, all reported cases in which patients had been frank and open about their obesity, and even been happy to joke about it. Equally, all participants were able to document a range of communicative strategies for effectively handling potentially difficult situations. Results further indicate that the documented communicative problems and embarrassment for the patient only generally arose within specific material contexts; i.e. when equipment is inadequate or multiple exposures are necessary. It is concluded that, while participants largely expected any interaction about obesity with a patient to be embarrassing for both parties, their actual experience was much more varied. This indicates a more complex communicative environment than may be expected, and also a potential metacognitive availability heuristic in play - something that might be clarified with future quantitative investigation.

'Dale': an interpretative phenomenological analysis of a service user's experience with a crisis resolution/home treatment team in the United Kingdom.

WHAT IS KNOWN ABOUT THE SUBJECT?: This paper describes crisis resolution/home treatment (CRHT) teams, which are part of mental health services in the United Kingdom. CRHT is expected to assist individuals in building resilience and work within a recovery approach. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This paper arises from an interview with one individual, Dale, as part of a larger study exploring service users' experiences of CRHT. It adds to the body of narrative knowledge in CRHT through Dale's co-authorship of this paper, reflecting on his original interview 4 years later, with co-authors providing critical interpretation of his experience, in turn supported by cognate literature. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Implications for practice are considered, themselves mediated through Dale's own descriptions of how CRHT interventions impacted upon him. These impacts are analysed with respect to three themes: Resilience, Recovery and Power. It is centrally contended that clinicians need to more clearly comprehend three core matters. First, what resilience 'is' for service users as well as the complex process through which these individuals move in developing resilience. Second, the distinction that service users might make between 'recovery' and 'functionality', and how this in turn can impact on individuals both in personal and socioeconomic sense. Finally, the mechanics of power within CRHT contexts and how these interpersonal dynamics can affect the relationship between service user and clinician in practice. ABSTRACT: Introduction and Aim The central purpose of this paper, part of a larger study exploring the experiences of Service Users (SUs) with CRHT, is to emphasise the importance of the SU voice itself within the domain. Following an interrogation of the historical contexts of CRHT. Method This paper uses interpretative phenomological approach around detailed thematic examination of an extended, semi-structured with a single SU: Dale. Moreover, four years after the interview was originally conducted, Dale was himself invited to reflect upon, and critically re-evaluate, his initial participation as a co-author of this paper. In this way, a genuinely participant-centred narrative on experiences with CRHT could be generated. Implications for Practice This resulted in Dale describing what 'crisis' meant to him, and his personal journey within that crisis. Although framing some experiences as negative, he primarily argues that the CRHT team was very personable, affirming his personal values and beliefs, and encouraging him to use coping skills that he had utilised effectively in prior periods of crisis. Analysis highlights three major themes permeating Dale's narrative: Resilience, Recovery and Power. It is contended that this analysis begins to demonstrate implications for practice and highlight that (and how) CRHT clinicians might more clearly engage with what resilience 'is' for SUs, and also the complex process through which these individuals move in developing it. Equally, it is proposed that practitioners should be mindful of the distinction that SUs might make between 'recovery' and 'functionality', and how this in turn can impact on individuals both in personal and socio-economic sense. Finally, the mechanics of power within CRHT contexts are foregrounded, and how these interpersonal dynamics can affect the working relationship between SU and clinician.

Importance of Fungicide Seed Treatment and Environment on Seedling Diseases of Cotton.

The importance of fungicide seed treatments on cotton was examined using a series of standardized fungicide trials from 1993 to 2004. Fungicide seed treatments increased stands over those from seed not treated with fungicides in 119 of 211 trials. Metalaxyl increased stands compared to nontreated seed in 40 of 119 trials having significant fungicide responses, demonstrating the importance of Pythium spp. on stand establishment. Similarly, PCNB seed treatment increased stands compared to nontreated seed for 44 of 119 trials with a significant response, indicating the importance of Rhizoctonia solani in stand losses. Benefits from the use of newer seed treatment chemistries, azoxystrobin and triazoles, were demonstrated by comparison with a historic standard seed treatment, carboxin + PCNB + metalaxyl. Little to no stand improvement was found when minimal soil temperatures averaged 25°C the first 3 days after planting. Stand losses due to seedling pathogens increased dramatically as minimal soil temperatures decreased to 12°C and rainfall increased. The importance of Pythium increased dramatically as minimal soil temperature decreased and rainfall increased, while the importance of R. solani was not affected greatly by planting environment. These multi-year data support the widespread use of seed treatment fungicides for the control of the seedling disease complex on cotton.

A randomized trial of endoscopic versus open saphenous vein harvest in coronary bypass surgery.

BACKGROUND: The purpose of this study was to determine whether or not endoscopic vein harvest is a reliable, beneficial, and cost-effective method for saphenous vein harvest in coronary bypass surgery (CABG). METHODS: A total of 100 patients having primary CABG were prospectively randomized to either endoscopic (EVH; n = 47) or open saphenous vein harvest (OVH; n = 50). Three patients in the EVH group required both techniques and were excluded from analysis. RESULTS: The groups did not differ in preoperative characteristics, including: age, gender, left ventricular function, height, weight, percent over ideal body weight, incidence of diabetes, peripheral vascular disease, or preoperative laboratory values (creatinine, albumin, or hematocrit). The EVH group had longer vein harvest and preparation times than the OVH group, while the incision length was significantly shorter. There was no difference between groups in mortality, perioperative myocardial infarction, intensive care unit or postoperative length of stay, blood product utilization, or discharge laboratory measures. There was more drainage noted from leg incisions at hospital discharge in the OVH (34%) versus EVH group (8%; p = 0.001), but more ecchymosis in the EVH group. Although there was a trend towards reduced leg incision pain in the EVH group, there was no statistically significant difference in pain or in the quality of life measure at any point in time. There was no difference between groups in readmission to hospital, administration of antibiotics, or incidence of leg infection. While mean hospital charges for the EVH group were approximately $1,500 greater than for OVH, this difference did not reach statistical significance. CONCLUSIONS: EVH is a safe, reliable, and cost-neutral method for saphenous vein harvest. The best indication for EVH may be in patients who are at increased risk for wound infection and in those for whom cosmesis is a major concern.

Downsizing. Use intravenous clinicians to maintain quality venous access care.

Many authors demonstrate the cost effectiveness of using intravenous teams to provide quality venous access care. Despite this evidence, many hospitals are dissolving their i.v. teams as a way of cutting costs. This article provides a guide for downsizing while maintaining quality i.v. therapy. The article chronicles events before and after the disbanding of the i.v. team of the San Francisco Veteran's Administration Medical Center. The focus of the article demonstrates how creating two advanced practice positions is instrumental to maintaining quality i.v. care. Quality is defined as line-associated bacteriemia rates and compliance rates to i.v. care standards, remaining unchanged or better after the downsizing of the i.v. team. Line-associated bacteriemia rates are presented in terms of infections per 1000 line days when possible. Compliance percentages are obtained by auditing compliance to site changes, central line policy. The data are provided in chart form, and definitely show a sharp decline in line-associated bacteremias after the advent of the i.v. clinician role. These data provide clear evidence to support the Intravenous Nurses Society position on the role of the intravenous nurse specialist. Conclusions emphasize the need for i.v. nurse clinicians to provide critical care coverage, ongoing educational programs, outcome auditing, and nursing research in vascular access and i.v. therapy.

Traumatic adult respiratory distress syndrome.

ARDS is the pulmonary manifestation of both direct and indirect insults to the lung. Trauma patients are at particular risk for ARDS from the direct effects of their injuries, as well as from complications that may occur during their hospital courses. ARDS prevention can be enhanced through diverse areas of medical focus. Public health issues addressing trauma prevention, improved understanding and treatment of trauma-related pathophysiology, as well as a better understanding of basic pathophysiology of this disease process will allow refinement and improvement of our management practices. Newer modes of mechanical ventilation may help us to avoid ventilator-induced exacerbation of lung injury. As we define the role of nonconventional therapies, such as anti-inflammatory and anticytokine therapies, our ability to actively interrupt and reverse the progression of the inflammatory cascade will be enhanced. As yet, ARDS continues to be a challenging disease process to both fully understand and successfully treat in our critically ill patients.

Cutaneous micrographic surgery: Mohs procedure.

Skin cancer is an increasingly serious public health issue that affects a high percentage of the population. Surgical resection is still standard treatment for skin cancer, but for difficult cases, cutaneous micrographic surgery, originally described by Mohs, is our preferred technique because of the routine methodic accuracy for evaluation of the surgical margin, the high rate of oncologic cure, and the tissue-sparing quality of the procedure. We report the Mayo Clinic experience with cutaneous micrographic surgery from July 29, 1986, through June 30, 1991, which consisted of 3,355 cases (principally basal cell and squamous cell carcinoma). Herein we discuss practical concerns about this procedure: duration of the technique, reconstruction, cure rates, tumors best treated by cutaneous micrographic surgery, and cost. In addition, we review the Mayo Clinic multidisciplinary management of difficult skin cancers.

Focal mucinosis (myxoid cyst). Surgical therapy.

Myxoid cysts typically arise in association with distal interphalangeal joint arthritis. When myxoid cysts become problematic, surgical excision is a standard treatment with a high cure rate and few complications. The origin, anatomy, and alternative medical and surgical treatment options are discussed.

Diagnostic and therapeutic nail surgery.

The function of the nail unit is as a protective covering over the dorsal distal end of the digit. Some basic disease processes affecting the nail unit and the surgical techniques used for diagnosis and treatment are reviewed.

Localized muscle fatigue and dynamic balance.

This investigation was designed for the purpose of ascertaining if one muscle group (dorsi flexors, abdominals, plantar flexors, or knee and hip flexors and extensors) could be identified which most significantly affects dynamic balance. The dependent variable was the dynabalometer. Subjects were 100 male volunteers, between the ages of 19 and 25 yr. Subjects were randomly assigned to a control or 1 of 4 treatment groups. Testing was counterbalanced over time and day. Controls had a practice period and 3 performance trials; other Ss had a practice period, localized fatigue of a muscle group followed by 3 performance trials. Analysis of variance indicated a significant difference between treatment groups (F = 312.09, p less than .01). Multiple comparisons of treatment means showed that only one muscle group, the knee and hip flexors and extensors, differed significantly from all other groups (q = 4.75, p less than .01). Results indicate strongly that the knee and hip flexors and extensors can be considered a most important muscle group for performance by ordinary male college students on the dynabalometer.