Antecedents of unfinished nursing care: a systematic review of the literature.

BACKGROUND: Unfinished Nursing Care (UNC) concept, that express the condition when nurses are forced to delay or omit required nursing care, has been largely investigated as tasks left undone, missed care, and implicit rationing of nursing care. However, no summary of the available evidence regarding UNC antecedents has been published. The aim of this study is to identify and summarise antecedents of UNC as documented in primary studies to date. METHODS: A systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted. MEDLINE, CINAHL, SCOPUS, and PROSPERO databases were searched for quantitative studies reporting the relationships between antecedents and UNC published after 2004 up to 21 January 2020. The reference lists of secondary studies have been scrutinised to identify additional studies. Two reviewers independently identified studies and evaluated them for their eligibility and disagreements were resolved by the research team. The quality appraisal was based on the Joanna Briggs Institute Critical Appraisal tools, according to the study designs. A data extraction grid was piloted and then used to extract data. The antecedents that emerged were thematically categorised with an inductive approach. RESULTS: Fifty-eight studies were included; among them, 54 were cross-sectional, three were cohort studies, and one was a quasi-experimental study. They were conducted mainly in the United States and in hospital settings. The UNC antecedents have been investigated to date at the (a) unit (e.g., workloads, non-nursing tasks), (b) nurse (e.g., age, gender), and (c) patient levels (clinical instability). CONCLUSIONS: At the unit level, it is highly recommended to provide an adequate staff level, strategies to deal with unpredictable workloads, and to promote good practice environments to reduce or minimise UNC. By contrast, at the nurse and patient levels, there were no clear trends regarding modifiable factors that could decrease the occurrence of UNC. The map of antecedents that emerged can be used to design interventional studies aimed at changing research from merely descriptive to that which evaluates the effectiveness of interventions.

Interventions to prevent or reduce rationing or missed nursing care: A scoping review.

AIMS: To collate and synthesize published research on interventions developed and tested to prevent or reduce the rates of rationed or missed nursing care in healthcare institutions. BACKGROUND: Rationed and missed nursing care has been widely studied, including its predictors and associations with patient and nurse outcomes. DESIGN: Scoping review. DATA SOURCES: We searched for eligible studies, published between 1980-2019, in six electronic databases. REVIEW METHODS: Researchers independently screened the abstracts of the retrieved studies using the inclusion and exclusion criteria. The decision of whether or not to include any given study was consensus-based. RESULTS: The search yielded 1,815 records, of which 13 were included. Three studies reported structural interventions, namely increased nurse staffing and improved nursing teamwork, both resulted in significant reductions in the rates of rationed or missed nursing care. The remaining 10 studies reported on process interventions: four concerned reminders (via technology or designated persons) and seven described interventions to change or optimize the relevant care processes. All 10 process interventions contributed to significant reductions in the rates of missed nursing care. CONCLUSIONS: The results of the scoping review indicate that specific interventions can positively influence the performance of a selected nursing care activity, for example fall prevention. There is no evidence of a global reduction of rationed and missed nursing care through these interventions. IMPACT: Clinicians, managers and researchers can use the results for adapting and implementing interventions to reduce rationed and missed nursing care.

Strategies to prevent missed nursing care: An international qualitative study based upon a positive deviance approach.

AIM: To identify the strategies to prevent missed nursing care (MNC) that can be implemented by nurse managers/directors on a daily basis. BACKGROUND: Only few recommendations have been established to date aiming at supporting nurse managers/ directors in preventing MNC. However, several strategies are implemented on a daily basis, suggesting that a body of tacit, practical and wise knowledge is already in place. METHOD(S): An international qualitative descriptive study based on the positive deviance approach conducted in 2019-2020 and reported according to the Consolidated Criteria for Reporting Qualitative Research. A purposeful sample of 35 nurse managers/directors working in hospitals in Cyprus, Italy, Germany and Switzerland was involved. Codes were extracted from each country, and a thematic analysis was performed at the transnational level to identify strategies and interventions preformed to prevent MNC. RESULTS: Eight strategies and 22 interventions, mainly with preventive intent and designed at the hospital level, affecting both the processes and the structural dimensions, have been reported as effective in preventing MNC. CONCLUSION: Nurse leaders are involved daily in implementing strategies to minimise MNC at the nursing and at the hospital system levels, integrated with each other. IMPLICATIONS FOR NURSING MANAGEMENT: Preventing MNC should be a core value of the entire hospital, and not merely a nursing issue. Therefore, complex interventions at the system level are required.

[Effective interventions enacted by Nurse Managers in daily practice to prevent and/or minimize the missed nursing care: ?ndings from an Italian qualitative study]. / Interventi attuati da infermieri con ruoli manageriali nella pratica quotidiana per prevenire e minimizzare le Missed Nursing Care: risultati di uno studio qualitativo italiano.

INTRODUCTION: Missed Nursing Care is widely recognized as affecting patient safety and healthcare outcomes. Theoretical frameworks, antecedents and consequences have been extensively studied while interventions aimed at preventing the Missed Nursing Care remain little investigated to date. Nurse Managers and Nurse Directors play a main role in promoting interventions at the unit, hospital and at the policy levels. However, few evidences are available to date, thus limiting an evidence-based approach. The aim of this study was to emerge interventions used on a daily basis by Nurse Managers and Directors to prevent and/or minimize Missed Nursing Care. METHODS: A qualitative descriptive study design based upon a positive deviance approach was adopted. Twelve Nurse Managers and Nurse Directors were purposefully selected, working at Hospital, Healthcare Trust or Nursing Home levels, in Italy. Participants were interviewed in two focus group sessions. A thematic analysis of the audio-recorded interviews was performed by two researchers. RESULTS: The following interventions have been reported as effective in preventing and/or minimizing the Missed Nursing Care: (a) Expanding the nursing care capacity; (b) Ensuring the standard of care and an early detection of failures; (c) Monitoring the processes of care; (d) Promoting a shared decision-making; (e) Redesigning the layout of the hospital systems; (f) Promoting a culture towards the Missed Nursing Care prevention, and (g) Realigning the nurse management to the care of patients. DISCUSSION: Several interventions based mainly on process dimension and with preventive intents are daily enacted by Nurse Managers and Directors to prevent and/or minimize Missed Nursing Care. Measuring the effect of these interventions through rigorous studies could help in expanding the evidence available to contrast a phenomenon that threatens patient safety.

Investigation into the metric properties of the workplace social capital questionnaire and its association with self-rated health and psychological distress amongst Greek-Cypriot registered nurses: cross-sectional descriptive study.

BACKGROUND: Social capital can been described as an individual or a collective attribute, with structural and cognitive components, and a bonding, bridging and linking typology. While extensively studied in the community, studies in occupational settings are sparse by comparison. Furthermore, there is no uniformity in its measurement. This study investigated the construct validity of a Workplace Social Capital questionnaire (WSC), originally developed in the Finnish Public Sector occupational cohort, in a different socio-cultural setting (Cyprus), language (Greek) and occupational group (Registered Nurses). It also explored its criterion concurrent validity according to observed association with self-rated health and psychological distress. METHODS: Participants were 10% of all registered nurses (N = 362) who responded to the 8-item WSC scale during a nationwide educational programme. A unidimensional model was compared with the postulated two-factor (structural vs cognitive) and three-factor model (bonding, bridging, linking) in Confirmatory Factor Analyses. The association with self-rated health (0-100 Visual Analogue Scale) and mental distress (GHQ-12 ≥ 4) was assessed in linear and logistic regression models. RESULTS: A bonding (Cronbach's a = 0.76), bridging (a = 0.78) and linking (a = 0.89) structure explained 77.6% of the variance and was a better fit as indicated by goodness of fit indices. Elevated odds of mental distress and poorer self-rated health were observed among participants with the lowest levels of perceived workplace social capital. In adjusted models, associations appeared stronger with bonding social capital (adjOR of mental distress = 2.71 95% CI = 1.08, 6.79) while those with the highest scores rated their health higher by 8.0 points on average (95% CI = 2.1, 13.8). Low linking social capital was also associated with poorer health but no consistent associations were observed with bridging. CONCLUSION: While associations appeared stronger with bonding and linking, this may reflect a weakness of the measure to fully capture bridging social capital. Even though, this aspect might need strengthening, the WSC showed good metric properties in a different setting, language and occupational group. Cross-national and cognitive validation studies are needed.

Ethical climate and missed nursing care in cancer care units.

BACKGROUND: Previous research has linked missed nursing care to nurses' work environment. Ethical climate is a part of work environment, but the relationship of missed care to different types of ethical climate is unknown. RESEARCH OBJECTIVES: To describe the types of ethical climate in adult in-patient cancer care settings, and their relationship to missed nursing care. RESEARCH DESIGN: A descriptive correlation design was used. Data were collected using the Ethical Climate Questionnaire and the MISSCARE survey tool, and analyzed with descriptive statistics, Pearson's correlation and analysis of variance. Participants and research context: All nurses from relevant units in the Republic of Cyprus were invited to participate. Ethical considerations: The research protocol has been approved according to national legislation, all licenses have been obtained, and respondents participated voluntarily after they have received all necessary information. FINDINGS: Response rate was 91.8%. Five types identified were as follows: caring (M = 3.18, standard deviation = 1.39); law and code (M = 3.18, standard deviation = 0.96); rules (M = 3.17, standard deviation = 0.73); instrumental (M = 2.88, standard deviation = 1.34); and independence (M = 2.74, standard deviation = 0.94). Reported overall missed care (range: 1-5) was M = 2.51 (standard deviation = 0.90), and this was positively (p < 0.05) related to instrumental (r = 0.612) and independence (r = 0.461) types and negatively (p < 0.05) related to caring (r = -0.695), rules (r = -0.367), and law and code (r = -0.487). DISCUSSION: The reported levels of missed care and the types of ethical climates present similarities and differences with the relevant literature. All types of ethical climate were related to the reported missed care. CONCLUSION: Efforts to reduce the influence of instrumental and independence types and fostering caring, law and code, and rules types might decrease missed nursing care. However, more robust evidence is needed.

Primary care randomised controlled trial of a tailored interactive website for the self-management of respiratory infections (Internet Doctor).

OBJECTIVE: To assess an internet-delivered intervention providing advice to manage respiratory tract infections (RTIs). DESIGN: Open pragmatic parallel group randomised controlled trial. SETTING: Primary care in UK. PARTICIPANTS: Adults (aged ≥18) registered with general practitioners, recruited by postal invitation. INTERVENTION: Patients were randomised with computer-generated random numbers to access the intervention website (intervention) or not (control). The intervention tailored advice about the diagnosis, natural history, symptom management (particularly paracetamol/ibuprofen use) and when to seek further help. OUTCOMES: Primary: National Health Service (NHS) contacts for those reporting RTIs from monthly online questionnaires for 20 weeks. Secondary: hospitalisations; symptom duration/severity. RESULTS: Results 3044 participants were recruited. 852 in the intervention group and 920 in the control group reported one or more RTIs, among whom there a modest increase in NHS Direct contacts in the intervention group (intervention 44/1734 (2.5%) versus control 24/1842 (1.3%); multivariate Risk Ratio (RR) 2.53 (95% CI 1.10 to 5.82, p=0.029)). Conversely reduced contact with doctors occurred (283/1734 (16.3%) vs 368/1845 (20.0%); risk ratio 0.71, 0.53 to 0.95, p=0.019). Reduction in contacts occurred despite slightly longer illness duration (11.3 days versus 10.9 days respectively; multivariateestimate 0.48 days longer (-0.16 to 1.12, p=0.141) and more days of illness rated moderately bad or worse illness (0.53 days; 0.12 to 0.94, p=0.012). The estimate of slower symptom resolution in the intervention group was attenuated when controlling for whether individuals had used webpages which advocated ibuprofen use (length of illness 0.22 days, −0.51 to 0.95, p=0.551; moderately bad or worse symptoms 0.36 days, −0.08 to 0.80, p=0.105). There was no evidence of increased hospitalisations (risk ratio 0.13; 0.02 to 1.01; p=0.051). CONCLUSIONS: An internet-delivered intervention for the self-management of RTIs modifies help-seeking behaviour, and does not result in more hospital admissions due to delayed help seeking. Advising the use of ibuprofen may not be helpful. TRIAL REGISTRATION NUMBER: ISRCTN91518452.

Translation and Validation of the Revised Professional Practice Environment Questionnaire in the Greek Language.

BACKGROUND AND PURPOSE: Professional practice environments have been correlated with quality of care, patient, and nurse outcomes. There is a lack of translated versions of established instruments such as the Revised Professional Practice Environment questionnaire and this study presents the validation of this questionnaire in Greek. METHODS: Translation, cultural adaptation, and factor analysis of the instrument were carried out. Three hundred ninety-three nurses from 5 hospitals of the Republic of Cyprus completed the instrument. RESULTS: A 7-factor solution with 39 items accounted for 55.03% variance. The overall Cronbach's alpha was .89 and ranged between .69 and .84 for the individual factors. CONCLUSIONS: The testing of the translated version of the RPPE into Greek provides support for the validity and internal consistency of the instrument.

The Impact of Pain Assessment on Critically Ill Patients' Outcomes: A Systematic Review.

In critically ill patients, pain is a major problem. Efficient pain management depends on a systematic, comprehensive assessment of pain. We aimed to review and synthesize current evidence on the impact of a systematic approach to pain assessment on critically ill patients' outcomes. A systematic review of published studies (CINAHL, PUBMED, SCOPUS, EMBASE, and COCHRANE databases) with predetermined eligibility criteria was undertaken. Methodological quality was assessed by the EPHPP quality assessment tool. A total of 10 eligible studies were identified. Due to big heterogeneity, quantitative synthesis was not feasible. Most studies indicated the frequency, duration of pain assessment, and types of pain assessment tools. Methodological quality assessment yielded "strong" ratings for 5/10 and "weak" ratings for 3/10 studies. Implementation of systematic approaches to pain assessment appears to associate with more frequent documented reports of pain and more efficient decisions for pain management. There was evidence of favorable effects on pain intensity, duration of mechanical ventilation, length of ICU stay, mortality, adverse events, and complications. This systematic review demonstrates a link between systematic pain assessment and outcome in critical illness. However, the current level of evidence is insufficient to draw firm conclusions. More high quality randomized clinical studies are needed.

Dementia caregiver burden association with community participation aspect of social capital.

AIMS: This study explores dementia caregiver burden and depression in the context of social capital and investigates the relationship of caregivers' burden with the perceptions of social capital of a non-caregivers' group. BACKGROUND: Social capital is the range of social contact that gives access to social, emotional and practical support, but little is known about dementia patients and their care by the family in that context. DESIGN: A cross-sectional correlational study was undertaken. METHODS: Seventy family dementia caregivers matched to non-caregivers from the same neighbourhood participated in the study; three instruments were used to collect the data: the Zarit Burden Interview, the Centre for Epidemiological Studies-Depression scale and the Social Capital Questionnaire. Paired sample t-tests and correlation analysis were performed to examine all the hypotheses of interest. The data collection period was between October 2010-July 2011. RESULTS: Overall social capital scores were higher for the non-caregivers and lower for the caregivers with significant differences in each group. The correlation between caregiver burden and social capital showed that the overall burden score is significantly negatively related with the social capital factor 'non-caregivers' participation in the community'. CONCLUSION: Understanding the relation between caregiver burden and social capital will enhance nurses' capacity to explore the concept, the meaning and the politics of social capital to the benefit of dementia caregivers in the community.

The ethical dimension of nursing care rationing: A thematic synthesis of qualitative studies.

BACKGROUND: In the face of scarcity, nurses may inevitably delay or omit some nursing interventions and give priority to others. This increases the risk of adverse patient outcomes and threatens safety, quality, and dignity in care. However, it is not clear if there is an ethical element in nursing care rationing and how nurses experience the phenomenon in its ethical perspective. OBJECTIVES: The purpose was to synthesize studies that relate care rationing with the ethical perspectives of nursing, and find the deeper, moral meaning of this phenomenon. RESEARCH DESIGN: A systematic review and thematic synthesis of qualitative studies was used. Searching was based on guidelines suggested by Joana Brigs Institute, while the synthesis has drawn from the methodology described. Primary studies were sought from nine electronic databases and manual searches. The explicitness of reporting was assed using consolidated criteria for reporting qualitative research. Nine studies involving 167 nurse participants were included. Synthesis resulted in 35 preliminary themes, 14 descriptive themes, and four analytical themes (professional challenges and moral dilemmas, dominating considerations, perception of a moral role, and experiences of the ethical effects of rationing). Discussion of relationships between themes revealed a new thematic framework. ETHICAL CONSIDERATION: Every effort has been taken, for the thoroughness in searching and retrieving the primary studies of this synthesis, and in order for them to be treated accurately, fairly and honestly and without intentional misinterpretations of their findings. DISCUSSION: Within limitations of scarcity, nurses face moral challenges and their decisions may jeopardize professional values, leading to role conflict, feelings of guilt, distress and difficulty in fulfilling a morally acceptable role. However, more research is needed to support certain relationships. CONCLUSIONS: Related literature is limited. The few studies found highlighted the essence of justice, equality in care and in values when prioritizing care-with little support to the ethical effects of rationing on nurses. Further research on ethical dimension of care rationing may illuminate other important aspects of this phenomenon.

Linking patient satisfaction with nursing care: the case of care rationing - a correlational study.

BACKGROUND: Implicit rationing of nursing care is the withholding of or failure to carry out all necessary nursing measures due to lack of resources. There is evidence supporting a link between rationing of nursing care, nurses' perceptions of their professional environment, negative patient outcomes, and placing patient safety at risk. The aims of the study were: a) To explore whether patient satisfaction is linked to nurse-reported rationing of nursing care and to nurses' perceptions of their practice environment while adjusting for patient and nurse characteristics. b) To identify the threshold score of rationing by comparing the level of patient satisfaction factors across rationing levels. METHODS: A descriptive, correlational design was employed. Participants in this study included 352 patients and 318 nurses from ten medical and surgical units of five general hospitals. Three measurement instruments were used: the BERNCA scale for rationing of care, the RPPE scale to explore nurses' perceptions of their work environment and the Patient Satisfaction scale to assess the level of patient satisfaction with nursing care. The statistical analysis included the use of Kendall's correlation coefficient to explore a possible relationship between the variables and multiple regression analysis to assess the effects of implicit rationing of nursing care together with organizational characteristics on patient satisfaction. RESULTS: The mean score of implicit rationing of nursing care was 0.83 (SD = 0.52, range = 0-3), the overall mean of RPPE was 2.76 (SD = 0.32, range = 1.28 - 3.69) and the two scales were significantly correlated (τ = -0.234, p < 0.001). The regression analysis showed that care rationing and work environment were related to patient satisfaction, even after controlling for nurse and patient characteristics. The results from the adjusted regression models showed that even at the lowest level of rationing (i.e. 0.5) patients indicated low satisfaction. CONCLUSIONS: The results support the relationships between organizational and environmental variables, care rationing and patient satisfaction. The identification of thresholds at which rationing starts to influence patient outcomes in a negative way may allow nurse managers to introduce interventions so as to keep rationing at a level at which patient safety is not jeopardized.

The hidden ethical element of nursing care rationing.

OBJECTIVE: To explore nurses' experiences and perceptions about prioritizations, omissions, and rationing of bedside nursing care. METHODS: A total of 23 nurses participated in four focus groups. The interviews were based on a semi-structured interview guide; data were analyzed using a thematic analysis approach. FINDINGS: Four themes were developed based on the data: (a) priorities in the delivery of care; (b) professional roles, responsibilities, and role conflicts; (c) environmental factors influencing care omissions; and (d) perceived outcomes of rationing. DISCUSSION: The delivery of nursing care is framed by the biomedical ethos and inter-professional role conflict while the standards of basic care are jeopardized. Organizational and environmental factors appear to exert significant influence on prioritization. Failure to carry out necessary nursing tasks may lead to adverse patient outcomes, role conflict, and an ethical burden on nurses. CONCLUSION: There is a need for further exploration and possible redesign of the nursing role, scope, and responsibilities, as well as addressing the arising ethical issues of rationing in nursing care.

Factors associated with quality of life among family members of patients with dementia in Cyprus.

BACKGROUND: Numerous studies have reported that caring for a person with dementia is a stressful experience. Nevertheless, quality of life (QoL) measures have commonly focused on patients, while factors that influence caregivers' QoL have not been clearly identified. In order to contribute to the understanding of caregivers' QoL, we explored how QoL among caregivers is related to their perceived level of burden, their reported number of depressive symptoms, and the level of care recipients' dependency. METHODS: Seventy-six caregivers referred by the two main referral centers of patients with dementia in Cyprus participated in a cross-sectional survey with a descriptive correlational design. Caregivers completed four instruments, measuring burden (ZBI), depression (CES-D), quality of life-Alzheimer's disease (QoL-AD), and activities of daily living (ADL) of the care recipients and provided socio-demographic information. RESULTS: The majority of the participants scored high levels of burden (M = 43.32/SD = 15.23) and depression (59.2% scored over the cut-off point of 16). QoL was only moderate (M = 30.89/SD = 8.21) and negatively correlated with burden (r = -32, p = 0.01) and depression (r = -0.296, p < 0.05). Only a weak correlation was observed between QoL and ADL (r = 0.167, p = 0.15). Hierarchical multiple regression analyses revealed that overall burden scores and income were associated with QoL, explaining 20% of the overall variance of the caregiver's QoL. CONCLUSION: Further research is necessary to investigate which additional domains determine QoL and further our understanding of the factors that may reduce the burden imposed on dementia caregivers.

Rationing of nursing care and nurse-patient outcomes: a systematic review of quantitative studies.

Bedside rationing in nursing care refers to withholding or failure to carry out certain aspects of care because of limited resources such as time, staffing or skill mix. The absence of previous systematic reviews on nursing care rationing leads to a gap of synthesized knowledge on the factors and processes related to rationing and the potential negative consequences on both patients and nurses. The aim of this study was to gain an in-depth understanding of the factors and processes related to nursing care rationing. Selected papers were methodologically assessed based on their design, sampling, measurement and statistical analysis. Seventeen quantitative studies were reviewed, and findings were categorized into four themes: elements of nursing care being rationed, causes of rationing, nurse outcomes and patient outcomes. Results revealed that communication with patients and families, patient ambulation, and mouth care were common elements of rationed care. Nurse-patient workload and communication barriers were reported as potential causes of rationing. Patient-related outcomes included patient falls, nosocomial infections and low patient satisfaction levels. Nurse-related outcomes included low job and occupational satisfaction. In addition, rationing appears to be an important organizational variable linked with patient safety and quality of care. This review increases understanding of what is actually occurring at the point of care delivery so that managers will be able to improve processes that lead to high quality of care and better patient and nurse outcomes.

Rationing of nursing care within professional environmental constraints: a correlational study.

The purpose of this study was to examine rationing of nursing care and the possible relationship between nurses' perceptions of their professional practice environment and care rationing. A total of 393 nurses from medical and surgical units participated in the study. Data were collected using the Basel Extent of Rationing of Nursing Care (BERNCA) instrument and the Revised Professional Practice Environment (RPPE) Scale. The highest level of rationing was reported for "reviewing of patient documentation" (M = 1.15, SD = 0.94; 31.2% sometimes or often) followed by "oral and dental hygiene" (M = 1.06, SD = 0.94; 31.5% sometimes or often) and "coping with the delayed response of physicians" (M = 1.04, SD = 0.96; 30% sometimes or often). Regression analyses showed that teamwork, leadership and autonomy, and communication about patients accounted in total 18.4% of the variance in rationing. In regard to application, the association between the practice environment and rationing suggests improvements in certain aspects that could minimize rationing.

Depression and perceptions about heart failure predict quality of life in patients with advanced heart failure.

BACKGROUND: Mood is an independent predictor of mortality and quality of life (QoL) for people with heart failure. However, the underlying belief systems involved in mood are unknown. OBJECTIVE: We sought to identify psychological and clinical variables predicting mood and QoL for people diagnosed with heart failure (HF). METHODS: One hundred and forty-six HF patients were assessed with standardized measures, to determine their beliefs about HF, coping styles, mood, and QoL. RESULTS: Patients with more negative beliefs about the consequences of HF and with less perceived control over symptoms showed maladaptive coping styles such as denial and behavioral disengagement, and more severe levels of depression and anxiety. Depression also independently predicted QoL outcomes. CONCLUSIONS: Anxious and depressed patients have more negative beliefs about HF, leading to negative coping behaviors and poor QoL. Our evidence suggests that changing negative beliefs may improve the psychological well-being and QoL of patients, irrespective of disease severity.

Understanding reactions to an internet-delivered health-care intervention: accommodating user preferences for information provision.

BACKGROUND: It is recognised as good practice to use qualitative methods to elicit users' views of internet-delivered health-care interventions during their development. This paper seeks to illustrate the advantages of combining usability testing with 'theoretical modelling', i.e. analyses that relate the findings of qualitative studies during intervention development to social science theory, in order to gain deeper insights into the reasons and context for how people respond to the intervention. This paper illustrates how usability testing may be enriched by theoretical modelling by means of two qualitative studies of users' views of the delivery of information in an internet-delivered intervention to help users decide whether they needed to seek medical care for their cold or flu symptoms. METHODS: In Study 1, 21 participants recruited from a city in southern England were asked to 'think aloud' while viewing draft web-pages presented in paper format. In Study 2, views of our prototype website were elicited, again using think aloud methods, in a sample of 26 participants purposively sampled for diversity in education levels. Both data-sets were analysed by thematic analysis. RESULTS: Study 1 revealed that although the information provided by the draft web-pages had many of the intended empowering benefits, users often felt overwhelmed by the quantity of information. Relating these findings to theory and research on factors influencing preferences for information-seeking we hypothesised that to meet the needs of different users (especially those with lower literacy levels) our website should be designed to provide only essential personalised advice, but with options to access further information. Study 2 showed that our website design did prove accessible to users with different literacy levels. However, some users seemed to want still greater control over how information was accessed. CONCLUSIONS: Educational level need not be an insuperable barrier to appreciating web-based access to detailed health-related information, provided that users feel they can quickly gain access to the specific information they seek.