Negotiating new roles in general practice: a qualitative study of clinical pharmacists.

BACKGROUND: To address general practice workforce shortages, policy in England has supported the recruitment of 'non-medical' roles through reimbursement funding. As one of the first to receive funding, the clinical pharmacist role offers insight into the process of new role negotiation at general practice level. AIM: To identify factors influencing clinical pharmacist role negotiation at practice level, comparing the process under two different funding and employment models. DESIGN AND SETTING: Qualitative interview study with staff involved in the following schemes: 1) the national NHS England (NHSE) Clinical Pharmacists in General Practice scheme; and 2) a local clinical commissioning group-funded scheme, providing clinical pharmacist support to general practices in one area of Greater Manchester in the UK. METHOD: Semi-structured interviews with purposive and snowball sampling of pharmacists, GPs, and practice staff took place. The interviews were analysed using template analysis. RESULTS: In total, 41 interviews were conducted. The following four factors were found to influence role negotiation: role ambiguity; competing demands and priorities; potential for (in)appropriate utilisation of clinical skills; and level of general practice control over the role. Key differences between the two funding and employment models were the level of influence GPs had in shaping the role and how adaptable pharmacists could be to practice needs. The potential for inappropriate utilisation was reported under both schemes, but most apparent under the role reimbursement, direct employment model of the NHSE scheme. CONCLUSION: This study has highlighted lessons applicable for the introduction of non-medical roles more widely in general practice. It has provided insight into the factors that can influence role negotiation at practice level and how different funding and/or employment models can impact on this process.

Implementation, uptake and use of a digital COVID-19 symptom tracker in English care homes in the coronavirus pandemic: a mixed-methods, multi-locality case study.

BACKGROUND: COVID-19 spread rapidly in UK care homes for older people in the early pandemic. National infection control recommendations included remote resident assessment. A region in North-West England introduced a digital COVID-19 symptom tracker for homes to identify early signs of resident deterioration to facilitate care responses. We examined the implementation, uptake and use of the tracker in care homes across four geographical case study localities in the first year of the pandemic. METHODS: This was a rapid, mixed-methods, multi-locality case study. Tracker uptake was calculated using the number of care homes taking up the tracker as a proportion of the total number of care homes in a locality. Mean tracker use was summarised at locality level and compared. Semi-structured interviews were conducted with professionals involved in tracker implementation and used to explore implementation factors across localities. Template Analysis with the Consolidated Framework for Implementation Research (CFIR) guided the interpretation of qualitative data. RESULTS: Uptake varied across the four case study localities ranging between 13.8 and 77.8%. Tracker use decreased in all localities over time at different rates, with average use ranging between 18 and 58%. The implementation context differed between localities and the process of implementation deviated over time from the initially planned strategy, for stakeholder engagement and care homes' training. Four interpretative themes reflected the most influential factors appearing to affect tracker uptake and use: (1) the process of implementation, (2) implementation readiness, (3) clarity of purpose/perceived value and (4) relative priority in the context of wider system pressures. CONCLUSIONS: Our study findings resonate with the digital solutions evidence base prior to the COVID-19 pandemic, suggesting three key factors that can inform future development and implementation of rapid digital responses in care home settings even in times of crisis: an incremental approach to implementation with testing of organisational readiness and attention to implementation climate, particularly the innovation's fit with local contexts (i.e. systems, infrastructure, work processes and practices); involvement of end-users in innovation design and development; and enabling users' easy access to sustained, high-quality, appropriate training and support to enable staff to adapt to digital solutions.

The use and impact of digital COVID-19 tracking in adult social care: a prospective cohort study of care homes in Greater Manchester.

BACKGROUND: To support proactive care during the coronavirus pandemic, a digital COVID-19 symptom tracker was deployed in Greater Manchester (UK) care homes. This study aimed to understand what factors were associated with the post-uptake use of the tracker and whether the tracker had any effects in controlling the spread of COVID-19. METHODS: Daily data on COVID-19, tracker uptake and use, and other key indicators such as staffing levels, the number of staff self-isolating, availability of personal protective equipment, bed occupancy levels, and any problems in accepting new residents were analysed for 547 care homes across Greater Manchester for the period April 2020 to April 2021. Differences in tracker use across local authorities, types of care homes, and over time were assessed using correlated effects logistic regressions. Differences in numbers of COVID-19 cases in homes adopting versus not adopting the tracker were compared via event design difference-in-difference estimations. RESULTS: Homes adopting the tracker used it on 44% of days post-adoption. Use decreased by 88% after one year of uptake (odds ratio 0.12; 95% confidence interval 0.06-0.28). Use was highest in the locality initiating the project (odds ratio 31.73; 95% CI 3.76-268.05). Care homes owned by a chain had lower use (odds ratio 0.30; 95% CI 0.14-0.63 versus single ownership care homes), and use was not associated with COVID-19 or staffing levels. Tracker uptake had no impact on controlling COVID-19 spread. Staff self-isolating and local area COVID-19 cases were positively associated with lagged COVID-19 spread in care homes (relative risks 1.29; 1.2-1.4 and 1.05; 1.0-1.1, respectively). CONCLUSIONS: The use of the COVID-19 symptom tracker in care homes was not maintained except in Locality 1 and did not appear to reduce the COVID-19 spread. COVID-19 cases in care homes were mainly driven by care home local-area COVID-19 cases and infections among the staff members. Digital deterioration trackers should be co-produced with care home staff, and local authorities should provide long-term support in their adoption and use.

The challenges of integrating signposting into general practice: qualitative stakeholder perspectives on care navigation and social prescribing in primary care.

BACKGROUND: A national policy focus in England to address general practice workforce issues has led to a commitment to employ significant numbers of non-general practitioner (GP) roles to redistribute workload. This paper focuses on two such roles: the care navigation (CN) and social prescribing link worker (SPLW) roles, which both aim to introduce 'active signposting' into primary care, to direct patients to the right professional/services at the right time and free up GP time. There is a lack of research exploring staff views of how these roles are being planned and operationalised into general practice and how signposting is being integrated into primary care. METHODS: The design uses in-depth qualitative methods to explore a wide range of stakeholder staff views. We generated a purposive sample of 34 respondents who took part in 17 semi-structured interviews and one focus group (service leads, role holders and host general practice staff). We analysed data using a Template Analysis approach. RESULTS: Three key themes highlight the challenges of operationalising signposting into general practice: 1) role perception - signposting was made challenging by the way both roles were perceived by others (e.g. among the public, patients and general practice staff) and highlighted inherent tensions in the expressed aims of the policy of active signposting; 2) role preparedness - a lack of training meant that some receptionist staff felt unprepared to take on the CN role as expected and raised patient safety issues; for SPLW staff, training affected the consistency of service offer across an area; 3) integration and co-ordination of roles - a lack of planning and co-ordination across components of the health and care system challenged the success of integrating signposting into general practice. CONCLUSIONS: This study provides new insights from staff stakeholder perspectives into the challenges of integrating signposting into general practice, and highlights key factors affecting the success of signposting in practice. Clarity of role purpose and remit (including resolving tensions inherent the dual aims of 'active signposting'), appropriate training and skill development for role holders and adequate communication and engagement between stakeholders/partnership working across services, are required to enable successful integration of signposting into general practice.

'We're the First Port of Call' - Perspectives of Ambulance Staff on Responding to Deaths by Suicide: A Qualitative Study.

INTRODUCTION: Exposure to suicide is a known risk factor for suicide. Ambulance staff are exposed to work-related stressors including attending suicides, which may elevate their risk for mental health problems/suicide. Little is known about ambulance staff's perspectives on how they experience these events and whether they feel equipped to respond to bereaved families at the scene of death. This study explores the perspectives of ambulance staff about responding to deaths by suicide. MATERIALS AND METHODS: A convenience sample of ambulance staff recruited from one ambulance service in England. In-depth, qualitative, semi-structured face-to-face interviews conducted with nine ambulance staff (six male, three female) to explore experiences of responding to suicide. Data analyzed using thematic analysis. RESULTS: Participants reported the experience of job-related strain including exposure to the suicide/suicidal ideation of colleagues; they described suppressing their distress despite significant emotional impact. All participants had been personally bereaved by suicide and responding to suicide was a common part of their job. They were often the first professionals at the scene, and undertook varied and often conflicting roles: negotiating with patients in crisis; informing individuals of the death of a loved one; preserving the body/potential crime scene; dealing with the intense emotional reactions of bereaved individuals. Participants reported long-term, salient memories of these events; however, there was a reported lack of acknowledgment in the workplace that suicides may be traumatic and no guidance for staff on how to cope. Opportunities to debrief were reportedly rare, and there was reluctance to access work-based liaison services. Training in how to respond to individuals bereaved by suicide was also lacking. DISCUSSION: The study is the first to reveal the complex challenges faced by ambulance staff in responding to suicide without adequate training and support. It demonstrates the potential impact that responding to suicide can have personally and professionally on staff, and emphasizes the need for employers to support staff wellbeing in better ways. Training and postvention support could enable better coping among staff, more effective support for bereaved individuals and reduce the risk of death by suicide both in those bereaved by suicide and in ambulance staff.

Evaluation of the Impact of the PABBS Suicide Bereavement Training on Clinicians' Knowledge and Skills.

Background: Health-care professionals do not routinely receive training on how best to support parents bereaved by suicide. Evidence-based training - Postvention Assisting Those Bereaved by Suicide (PABBS) - was designed to address this gap. Aims: The study aimed (a) to pilot PABBS training and evaluate its perceived effectiveness (impact on self-reported knowledge, skills and confidence) in managing suicide bereavement; and (b) to explore training acceptability. Method: A pre- and postevaluation design was used. Professionals attended intensive, structured 1-day PABBS training comprising: didactic/interactive teaching; practice-orientated activities supported with real-life materials and a manual/workbook. Evaluation forms completed immediately before and after training analyzed: (a) self-reported changes in knowledge, skills, and confidence (perceived effectiveness of training); and (b) the acceptability of training. Results: In total, 62 professionals completed training. Perceived knowledge, skills, and confidence improved after training as did self-reported understanding, motivation to learn more, and intention to change practice. Training was highly rated, particularly the evidence-based, real-life materials, with some suggestions for improvement. Limitations: Self-selected sample and reliance on self-report measures are the study's limitations. Conclusion: PABBS training may help address gaps in professionals' capacity to support parents bereaved by suicide. The evidence-based content was highly acceptable and appeared to be a key ingredient in effecting self-reported changes in attitudes/intentions.

Investigation of the demand for a 7-day (extended access) primary care service: an observational study from pilot schemes in England.

OBJECTIVES: To understand how the uptake of an extended primary care service in the evenings and weekend varied by day of week and over time. Secondary objectives were to understand patient demographics of users of the service and how these varied by type of appointment and to core hour users. DESIGN: Observational study. SETTING: Primary care extended access appointments data in 13 centres in Greater Manchester, England, during 2016. PARTICIPANTS: Appointments could be booked by 1 261 326 patients registered with a family practitioner in five Clinical Commissioning Group geographic areas. MAIN OUTCOME MEASURES: Primary outcome measure was whether an appointment was used (booked and attended), secondary outcome measures included whether used appointments were prebooked or booked the same day, and delivered by a family or nurse practitioner. Additional analyses compared patient demographics with patients reporting the use of core hour primary care services. RESULTS: 65.33% of 42 472 appointments were booked and attended (used). Usage of appointments was lowest on a Sunday at 46.73% (18.07 percentage points lower usage than on Mondays (95% CI -32.46 to -3.68)). Prebooked appointments were less likely to be booked among age group 0-9 and to result in patients not attending an appointment. Family practitioner appointments were increasingly less likely to be booked with age in comparison to nurse appointments. Patients attending extended access appointments tended to be younger in comparison to core hour patients. CONCLUSIONS: There is spare capacity in the extended access service, particularly on Sundays, suggesting reconfigurations of the service may be needed to improve efficiency of delivering the service. Patient demographics suggest the service is used by a relatively younger population than core hour services. Patient demographics varied with the types of appointment provided, these findings may help healthcare providers improve usage by tailoring appointment provision to local populations.

Skill-mix change in general practice: a qualitative comparison of three 'new' non-medical roles in English primary care.

BACKGROUND: General practice is currently facing a significant workforce challenge. Changing the general practice skill mix by introducing new non-medical roles is recommended as one solution; the literature highlights that organisational and/or operational difficulties are associated with skill-mix changes. AIM: To compare how three non-medical roles were being established in general practice, understand common implementation barriers, and identify measurable impacts or unintended consequences. DESIGN AND SETTING: In-depth qualitative comparison of three role initiatives in general practices in one area of Greater Manchester, England; that is, advanced practitioner and physician associate training schemes, and a locally commissioned practice pharmacist service. METHOD: Semi-structured interviews and focus groups with a purposive sample of stakeholders involved in the implementation of each role initiative were conducted. Template analysis enabled the production of pre-determined and researcher-generated codes, categories, and themes. RESULTS: The final sample contained 38 stakeholders comprising training/service leads, role holders, and host practice staff. Three key themes captured participants' perspectives: purpose and place of new roles in general practice, involving unclear role definition and tension at professional boundaries; transition of new roles into general practice, involving risk management, closing training-practice gaps and managing expectations; and future of new roles in general practice, involving demonstrating impact and questions about sustainability. CONCLUSION: This in-depth, in-context comparative study highlights that introducing new roles to general practice is not a simple process. Recognition of factors affecting the assimilation of roles may help to better align them with the goals of general practice and harness the commitment of individual practices to enable role sustainability.

'I should have taken that further' - missed opportunities during cardiovascular risk assessment in patients with psoriasis in UK primary care settings: a mixed-methods study.

BACKGROUND: Unhealthy lifestyle is common in psoriasis, contributing to worsening disease and increased cardiovascular disease (CVD) risk. CVD risk communication should improve patients' understanding of risk and risk-reducing behaviours; however, the effectiveness of risk screening is debated and evaluation currently limited. OBJECTIVE: To examine the process of assessing for and communicating about CVD risk in the context of psoriasis. DESIGN: Mixed-methods study in English general practices to (i) determine proportions of CVD risk factors among patients with psoriasis at risk assessment and (ii) examine patient and practitioner experiences of risk communication to identify salient 'process' issues. Audio recordings of consultations informed in-depth interviews with patients and practitioners using tape-assisted recall, analysed with framework analysis. PARTICIPANTS: Patients with psoriasis (n = 287) undergoing CVD risk assessment; 29 patients and 12 practitioners interviewed. RESULTS: A high proportion of patients had risk factor levels apparent at risk assessment above NICE recommendations: very high waist circumference (52%), obesity (35%), raised blood pressure (29%), smoking (18%) and excess alcohol consumption (18%). There was little evidence of personalized discussion about CVD risk and behaviour change support in consultations. Professionals reported a lack of training in behaviour change, while patients wanted to discuss CVD risk/risk reduction and believed practitioners to be influential in supporting lifestyle management. CONCLUSIONS: Despite high levels of risk factors identified, opportunities may be missed in consultations to support patients with psoriasis to understand CVD risk/risk reduction. Practitioners need training in behaviour change techniques to capitalize on 'teachable moments' and increase the effectiveness of risk screening.

Communicating Cardiovascular Disease Risk to People with Psoriasis: What Techniques do Practitioners Use?

BACKGROUND: Psoriasis can be associated with unhealthy lifestyle behaviours such as smoking, excess alcohol use and insufficient physical activity, consequently increasing cardiovascular disease (CVD) risk. Health care practitioners are expected to discuss lifestyle risk factors with patients with a view to reducing health-related risk for patients. However, little is known about the techniques used to communicate information about risk to patients with psoriasis. PURPOSE: We aimed to examine how primary care practitioners communicate risk information when conducting CVD risk assessments. METHOD: Consultations (n = 44) between primary care practitioners (general practitioners and practice nurses) and patients with psoriasis across 10 practices were audio-recorded and analysed using content analysis. A coding frame was used to record specific techniques used by practitioners to communicate risk information. RESULTS: Most frequently used communication methods were verbal descriptors of risk factors accompanied by numerical data (n = 28) rather than verbal descriptors alone (n = 16). Practitioners did not use numerical risk communication methods alone. Where CVD risk factors were discussed with patients (n = 156 occasions across all consultations), interpretations of this information was provided to patients on 131 (84 %) occasions. However, specific advice about behaviour/risk modification was only given on 60 (38.5 %) out of a possible 156 occasions. CONCLUSIONS: Specific advice about how to change lifestyle behaviour to modify CVD risk factors was not always given by the practitioner, particularly when discussing behavioural risk factors. Developing a best practice for communicating complex health risk information would ensure that people with psoriasis are empowered to make lifestyle modifications to reduce CVD risk.

The role of personal models in clinical management: Exploring health care providers' beliefs about psoriasis.

OBJECTIVES: Individuals' illness representations, including beliefs about psoriasis (a complex immune-mediated condition), and their emotional responses to the condition guide self-management behaviour. It is also plausible that health care providers' illness representations guide their own management of psoriasis. Patients commonly report poor health care experiences related to psoriasis, and the role of health care providers' beliefs, emotions, as well as their knowledge, experiences and behaviours ('personal models') in this is unexplored. This study aimed explore health care providers' personal models of psoriasis. DESIGN AND METHODS: Qualitative analysis of 23 semi-structured interviews with health care professionals providing care for psoriasis patients was performed. Purposive sampling achieved maximum variation regarding participant discipline, level of experience, gender and age. The self-regulatory/common sense model informed data collection and initial data analysis. Principles of framework analysis were used to generate predetermined and emergent key issues related to practitioners' personal models. RESULTS: Three types of personal model emerged. Sophisticated-Linear Model: 70% of practitioners recognized psoriasis as a complex condition but managed it as a skin condition. Mixed Model: 17% of practitioners recognized/managed some elements of psoriasis as complex and some as a skin condition. Sophisticated-Sophisticated Model: 13% recognized and managed psoriasis as a complex condition. Across the data set, five themes emerged illustrating key patterns underpinning these different models including (1) Recognising complexity, (2) Putting skin first, (3) Taking on the complexities of psoriasis with the patient, (4) Aiming for clearance, and (5) Affective experiences within psoriasis consultations. CONCLUSIONS: Health care providers recognized psoriasis as a complex condition but commonly reported managing psoriasis as a simple skin condition. Providers' beliefs and management approaches varied in the extent to which they were consistent with one another; and their emotional experiences during consultations may vary depending upon their personal model. Findings could inform future dermatology training programmes by highlighting the role of health care providers' illness representations in clinical management of the condition. STATEMENT OF CONTRIBUTION: What is already known on this subject? Health behaviour is predicted by underlying beliefs and emotions associated with an illness and its treatment. Few studies have examined health care providers' beliefs and emotions about the illnesses they manage in clinical practice. Many patients are dissatisfied with dermatology consultations and wish to be treated holistically. What does this study add? Qualitative exploration of health care providers' beliefs/emotions revealed their personal models of psoriasis. Providers' personal models of psoriasis vary in coherence and are often skin rather than whole person focused. Further investigation of health care providers' models of psoriasis and their impact on health outcomes is needed.

Do English healthcare settings use 'Choice Architecture' principles in promoting healthy lifestyles for people with psoriasis? An observational study.

BACKGROUND: The influence of environmental factors in shaping behaviour is becoming increasingly prominent in public health policy, but whether health promotion strategies use this knowledge is unknown. Health promotion is important in the management of psoriasis, a long-term inflammatory skin condition, and health centre waiting areas are ideal places to promote health information to such patients. We systematically examined patient information materials containing either general, or specific, health messages for patients with psoriasis. METHODS: An observation schedule was used to record the frequency and quality of leaflets and posters addressing lifestyle behaviour change in health centre waiting areas. Content analysis was used to analyse: frequency, characteristics and standard of the materials. RESULTS: Across 24 health centres 262 sources of lifestyle information were recorded (median per site = 10; range = 0-40). These were mainly: generic posters/displays of lifestyle support (n = 113); and generic materials in waiting areas (n = 98). Information quality was poor and poorly displayed, with no high quality psoriasis-specific patient materials evident. CONCLUSIONS: There is little attempt to promote healthy lifestyle as an important aspect of psoriasis management in the clinic environment. Evidence about using environmental cues/techniques to prompt behaviour change in people with psoriasis does not currently inform the design and display of such information in standard health centre settings, which are prime locations for communicating messages about healthy lifestyle. Future research should test the efficacy and impact of theory-informed, high quality health promotion messages on health outcomes for patients with psoriasis.

'On the surface': a qualitative study of GPs' and patients' perspectives on psoriasis.

BACKGROUND: Psoriasis is a chronic, inflammatory skin disease affecting approximately 2% of the UK population and is currently incurable. It produces profound effects on psychological wellbeing and social functioning and has significant associated co-morbidities. The majority of patients with psoriasis are managed in primary care, however in-depth patient and GP perspectives about psoriasis management in this setting are absent from the literature. This article reports an in-depth study which compares and contrasts the perspectives of people with psoriasis and of GPs on the challenges of managing psoriasis in primary care. METHODS: In-depth, qualitative semi-structured interviews were conducted with a diverse sample of 29 people with psoriasis and 14 GPs. Interviews were coded using principles of Framework Analysis to enable a comparison of patient and practitioner perspectives on key issues and concepts arising from the data. RESULTS: Patients perceived GPs to be lacking in confidence in the assessment and management of psoriasis and both groups felt lacking in knowledge and understanding about the condition. While practitioners recognised that psoriasis has physical, emotional and social impact, they assumed patients had expertise in the condition and may not address these issues in consultations. This resulted in patient dissatisfaction and sub-optimal assessment of severity and impact of psoriasis by GPs. Patients and GPs recognised that psoriasis was not being managed as a complex long-term condition, however this appeared less problematic for GPs than for patients who desired a shared management with their GP incorporating appropriate monitoring and timely reviews. CONCLUSIONS: The research suggests that current routine practice for psoriasis management in primary care is mismatched with the expressed needs of patients. To address these needs, psoriasis must be recognised as a complex long-term condition involving exacting physical, psychological and social demands, co-morbidity and the development of new treatments.General practitioners need to improve both their knowledge and skills in the assessment and management of psoriasis. This in turn will facilitate management of the condition in partnership with patients. Commissioning multi-disciplinary services, which focus on long-term impacts on wellbeing and quality of life, might address current deficits in care.

Parents' Perspectives of Cleft Lip and/or Palate Services: A Qualitative Interview.

The study aimed to explore in depth the perspectives of parents about their child's cleft services. Purposive and theoretical sampling produced a diverse sample of mothers and fathers with children aged 20 weeks to 21 years. Parents were recruited from a specialist cleft center in the U.K. Qualitative, in-depth, face-to-face interviews were carried out with 35 parents. Interviews were audio-recorded, transcribed, and analyzed using grounded theory to identify salient data categories. Findings revealed that parents' positive views about services rested on their perceptions of cleft-care practitioners as competent and trustworthy, possessing highly developed communication skills and the ability to provide continuity of care to families. At the same time, some mothers and fathers identified unmet support needs relating to information delivery and content as well as the coordination of services across the treatment course. More individualized information about treatment was desired; in particular, some parents had incomplete information about their child's surgical procedures, associated risks, and postsurgical recovery. Parents wanted better coordination of services with regard to communication about surgical cancellations, a child's transition to adult services, and having a key professional to link with throughout their child's treatment course. Routine assessments to gauge parents' needs could be built into cleft-care pathways so that more individualized information and support might be delivered to families in more consistent ways over long-term treatment.

Participants' experiences of care during a randomized controlled trial comparing a lay-facilitated angina management programme with usual care: a qualitative study using focus groups.

AIM: This paper is a report of a qualitative study conducted as part of a randomized controlled trial comparing a lay-facilitated angina management programme with usual care. Its aim was to explore participants' beliefs, experiences, and attitudes to the care they had received during the trial, particularly those who had received the angina management intervention. BACKGROUND: Angina affects over 50 million people worldwide. Over half of these people have symptoms that restrict their daily life and would benefit from knowing how to manage their condition. DESIGN: A nested qualitative study within a randomized controlled trial of lay-facilitated angina management. METHOD: We conducted four participant focus groups during 2008; three were with people randomized to the intervention and one with those randomized to control. We recruited a total of 14 participants to the focus groups, 10 intervention, and 4 control. FINDINGS: Although recruitment to the focus groups was relatively low by comparison to conventional standards, each generated lively discussions and a rich data set. Data analysis demonstrated both similarities and differences between control and intervention groups. Similarities included low levels of prior knowledge about angina, whereas differences included a perception among intervention participants that lifestyle changes were more easily facilitated with the help and support of a lay-worker. CONCLUSION: Lay facilitation with the Angina Plan is perceived by the participants to be beneficial in supporting self-management. However, clinical expertise is still required to meet the more complex information and care needs of people with stable angina.

'Doing the "right" thing': how parents experience and manage decision-making for children's 'normalising' surgeries.

Using cleft lip and palate as an exemplar, this article examines parents' decision-making for children in the context of elective treatments which aim to 'normalise' a child's function, appearance, communication or identity. Using purposive and theoretical sampling, 35 parents with children from infancy to young adulthood were recruited through a specialist cleft centre in England. Parents were interviewed in-depth between 2006 and 2008 about their beliefs and motivations in relation to treatment decision-making in this context. A grounded theory approach was used to analyse the data. Findings revealed a core category, 'doing the "right" thing', that encapsulated parents' main concern in relation to their children's treatment and highlighted several emotional, social and cultural considerations underpinning their decision-making stance. Parents fulfilled a perceived 'moral' obligation to be 'good' parents by pursuing the 'normalising' treatments, particularly surgeries, made available to their children. Such treatments were viewed as a way of facilitating their child's social inclusion and helping them reach their full potential. In order to enable their continued pursuit of treatments over the long-term, parents also constructed specialist practitioners as highly competent and particularly trustworthy. This article captures the complexities involved in parents' decision-making for children's elective 'normalising' treatments, where both functional and appearance-related concerns are involved. It suggests that social norms about parenting, physical appearance and healthcare practitioner power may significantly shape decision-making in this context, so that such choices may be viewed primarily as 'moral' rather than social. Services could support parents with such challenges, by gauging their needs for information about surgery and its likely outcomes and providing emotional/decisional support to consider all available options.

Randomized controlled trial of a lay-facilitated angina management programme.

AIMS: This article reports a randomized controlled trial of lay-facilitated angina management (registered trial acronym: LAMP). BACKGROUND: Previously, a nurse-facilitated angina programme was shown to reduce angina while increasing physical activity, however most people with angina do not receive a cardiac rehabilitation or self-management programme. Lay people are increasingly being trained to facilitate self-management programmes. DESIGN: A randomized controlled trial comparing a lay-facilitated angina management programme with routine care from an angina nurse specialist. METHODS: Participants with new stable angina were randomized to the angina management programme (intervention: 70 participants) or advice from an angina nurse specialist (control: 72 participants). Primary outcome was angina frequency at 6 months; secondary outcomes at 3 and 6 months included: risk factors, physical functioning, anxiety, depression, angina misconceptions and cost utility. Follow-up was complete in March 2009. Analysis was by intention-to-treat; blind to group allocation. RESULTS: There was no important difference in angina frequency at 6 months. Secondary outcomes, assessed by either linear or logistic regression models, demonstrated important differences favouring the intervention group, at 3 months for: Anxiety, angina misconceptions and for exercise report; and at 6 months for: anxiety; depression; and angina misconceptions. The intervention was considered cost-effective. CONCLUSION: The angina management programme produced some superior benefits when compared to advice from a specialist nurse.

Parents' emotional and social experiences of caring for a child through cleft treatment.

Little is known about the experiences of parents caring for a child through long-term treatment for cleft lip and/or cleft palate. We conducted in-depth interviews with 35 parents with children between the ages of 20 weeks and 21 years to explore experiences across the treatment program. We analyzed the data using a constructivist grounded theory approach and present in detail in this article one subcategory from the analysis: managing emotions. Throughout childhood and adolescence, parents experienced conflicting emotions about their child's impairment, uncertainty about cleft treatment, and stigmatizing attitudes. Although parents attempted to manage emotional tensions by pursuing cleft treatments, the interventions could themselves be a source of conflict for them. We suggest that routine assessment of parents' emotional and social well-being should be included in cleft treatment programs, and access to psychosocial support made available.