Predictors of outcomes of recovery following total hip replacement surgery: A prospective study.

OBJECTIVES: To investigate psychosocial and biomedical outcomes following total hip replacement (THR) and to identify predictors of recovery from THR. METHODS: Patients with osteoarthritis (OA) on the waiting list for primary THR in North West England were assessed pre-operatively and at six and 12 months post-operatively to investigate psychosocial and biomedical outcomes. Psychosocial outcomes were anxiety and depression, social support and health-related quality of life (HRQoL). Biomedical outcomes were pain, physical function and stiffness. The primary outcome was the Short-Form 36 (SF-36) Health Survey Total Physical Function. Potential predictors of outcome were age, sex, body mass index, previous joint replacement, involvement in the decision for THR, any comorbidities, any complications, type of medication, and pre-operative ENRICHD Social Support Instrument score, Hospital Anxiety and Depression scores and Western Ontario and McMaster Universities osteoarthritis index score. RESULTS: The study included 206 patients undergoing THR. There were 88 men and 118 women with a mean age of 66.3 years (sd 10.4;36 to 89). Pain, stiffness and physical function, severity of OA, HRQoL, anxiety and depression all improved significantly from pre-operative to 12-month assessment (all p < 0.001), with the greatest improvement occurring in the first six months (all p < 0.001). The predictors that were found to influence recovery six months after THR were: pain (p < 0.001), anxiety (p = 0.034), depression (p = 0.001), previous joint replacement (p = 0.006) and anti-inflammatory drugs (p = 0.012). CONCLUSIONS: The study identified the key psychosocial and biomedical predictors of recovery following THR. By identifying these predictors, we are able to identify and provide more support for patients at risk of poor recovery following THR. Cite this article: Bone Joint Res 2013;2:248-54.

Exploring the needs, concerns and behaviours of people with existing respiratory conditions in relation to the H1N1 'swine influenza' pandemic: a multicentre survey and qualitative study.

BACKGROUND: People with respiratory conditions are a 'high-risk' group for H1N1 pandemic swine influenza ('swine flu'), hence they and their families may have information needs, worries and concerns regarding the condition. Health-related behaviours, including vaccination, are recommended during the pandemic; understanding uptake of these is important. OBJECTIVES: To explore and compare information needs, worries and concerns, and health-related behaviours regarding swine flu in people with respiratory conditions and their family members. METHODS: Mixed-methods study - cross-sectional survey (253 patients, 101 family members); one-to-one interviews (13 patients, seven family members) and focus groups (n = three groups, 30 participants). Data collected October 2009-January 2010 from hospital chest clinics (n = 7) and patient support groups (n = 10) in North West England. RESULTS: Most patients (P) and family members (FM) wanted more information (n = 158, 62.5% P; n = 55, 54.4% FM), but few felt completely uninformed (n = 15, 5.9% P; n = 3, 3.0% FM). Most had already received information about swine flu (n = 187, 73.9% P; n = 78, 77.2% FM), mainly via a leaflet delivered to their home (n = 125, 49.4% P; n = 55, 54.5% FM). Information received was considered helpful (n = 154, 60.9% P; n = 77, 72.6% FM), but many wanted more condition-specific information (n = 141, 55.7% P; n = 60, 59.4% FM). More patients were worried (n = 147, 58.3%) than not worried (n = 99, 39.3%) about swine flu. FM were less often concerned about personal risk (n = 47, 46.6% worried) than about risk to patients (n = 76, 77.6%). Two-thirds (n = 161, 63.6% P; 65, 65.6% FM) incorrectly believed patients had increased risk of developing swine flu, but most (n = 204, 81.0% P; 89, 89.9% FM) correctly identified patients' greater risk of developing complications. Commonly adopted preventative measures were more frequent hand-washing (107, 42.8% P; 38, 37.6% FM) and greater use of sanitising hand gel (n = 100, 40.5% P; 37, 36.6% FM). In total, 212 patients (83.8%) and 69 family members (68.3%) were very/fairly likely to take up swine flu vaccination. Qualitative data mirrored survey findings. CONCLUSIONS: Participants were generally well-informed about swine flu, but more targeted information would have been welcomed. Participants were not highly anxious about swine flu, but did recognise risks for patients. Behaviour change was modest, but in line with recommendations. Vaccination intent was high. STUDY REGISTRATION: The study has been registered as REC/IRAS (Ref 09/H1015/76) and NIHR CSP (Ref 32483).

A longitudinal study exploring pain control, treatment and service provision for individuals with end-stage lower limb osteoarthritis.

OBJECTIVE: To investigate the level of pain control, treatment and service provision amongst individuals with end-stage lower limb osteoarthritis who were on the waiting list for hip or knee joint replacement. METHODS: A total of 105 patients on a waiting list for primary knee or hip replacement from a regional orthopaedic centre in the UK were recruited. The study was longitudinal and based on direct interviews at baseline and 6 months, with a postal questionnaire at 3 months. Data were collected on pain by a visual analogue scale (VAS) and the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index. In addition, medication and the use of services and treatments were recorded. RESULTS: Participants experienced high levels of pain as measured by VAS [mean 7.0; 95% confidence interval (CI) 6.6-7.5] and WOMAC pain (mean 11.2; 95% CI 10.6-11.9). The majority of participants (78, 74%) was taking analgesics more than once a day. Primary care utilization was variable. Of the 74 (70%) participants who had consulted their GP in the previous 3 months, 41 (55%) had not discussed their pain or osteoarthritis during these consultations. Just below one-third of participants (31, 30%) reported to have received information on osteoarthritis. CONCLUSIONS: Pain appears to be difficult to manage in individuals with end-stage lower limb osteoarthritis. Individuals appeared not to be taking appropriate levels of analgesia in relation to levels of pain. Improvements are required in the provision of information on pain and osteoarthritis. Patients would benefit from more proactive management by health professionals (especially by GPs).

Changes in patterns of knowing the patient: the case of British district nurses.

British district or home nurses, have until recent years been hidden from the wider context of the British National Health Service. Policy changes in UK over the last two decades of the 20th century have increasingly focussed on Primary Care Services and district nurses (DNs) have seen substantial changes to their workload. This paper addresses the question of how the changes in the organisation of Primary Care Services affected some aspects of DNs' work. Thus, the focus of this paper is an examination of the relationship DNs had with patients through a period of turbulent change. Knowing the patient is a central element of nursing practice. Data are presented here form a multi-site ethnographic study of DNs' work undertaken in four purposively sampled study sites. Applying Carper's (1978) framework, the data presented here show that there has been a shifting emphasis in knowing the patient from aesthetic and personal knowing to knowing about and empirical knowing.

The role of district nursing: perspectives of cancer patients and their carers before and after hospital discharge.

The role of the district nurse (DN) is difficult to define. Knowledge about the perspectives of patients with cancer, and their informal carers, on the roles of DNs and community services is lacking. The aim of this study is to identify the roles of DNs and community services as perceived by patients with cancer and their carers before and after hospital discharge. Seventy-one pre- and post-discharge conversational interviews were conducted with cancer patients and carers, and analysed thematically. Some interviewees lacked knowledge about services, were confused about differential roles and/or held stereotypical views. Some failed to disclose needs to services, received insufficient support or experienced unnecessary and inconvenient visits. Patients with few or no physical care needs were surprised to receive DN visits. Those receiving personal care from agency carers expressed dissatisfaction. Cancer patients and carers may benefit from post-discharge/ongoing assessment by DNs. However, effectiveness could be inhibited by limited disclosure caused by confusion, stereotyping, negative experiences and ideas that other patients have greater needs. Information might diminish these factors but, first, services need to clarify their roles. Organization and delivery of personal care services varies locally and DNs provide personal care during terminal illness. Community services should perform intra- and interservice clarification before publicizing differential roles to cancer patients and carers. This might facilitate disclosure of need to DNs. Patient and carer needs for information on service roles, and patients' preferred roles in self-care are under-researched.

Information and support needs of women with primary relatives with breast cancer: development of the Information and Support Needs Questionnaire.

AIMS OF THE STUDY: The aim was to develop and pilot test a newly developed measure, The Information and Support Needs Questionnaire (ISNQ), for use with women with primary relatives with breast cancer. BACKGROUND/RATIONALE: Breast cancer is a major risk to the health of women in the United Kingdom (UK). Increasingly, research is documenting women's needs for information and support, particularly at the time of diagnosis. However, to date there is little understanding of the information and support needs of women who have a family history of breast cancer. Contributing to the dearth of understanding of female relatives' needs is the lack of valid and reliable instruments for use in descriptive and intervention research with this population. DESIGN/METHODS: The ISNQ and survey items documenting family history, sources of information and support for breast cancer risk, breast self-care practices, and other variables were pilot tested for the acceptability of the measures, appropriateness of the data collection methods, initial psychometric properties of the ISNQ, and time and financial costs of administration. Data were collected from 39 women living in the North-west of England who had primary relatives with breast cancer using mailed questionnaires and follow-up telephone interviews. FINDINGS: The items on the ISNQ were reported to be clear, acceptable to women and to yield relevant data. The psychometric properties of the new measure were satisfactory with a high reliability coefficient alpha. Descriptive findings indicate that women had moderate to high needs for information and support, but reported that these needs were not well met. CONCLUSIONS: The results of this pilot are guiding the development of a larger study in which the information and support needs of women with a family history of breast cancer are explored.

A descriptive study of meaning of illness in chronic renal disease.

AIM: To explore the subjective meaning of illness in a sample of renal patients. BACKGROUND: Patients' illness representations, such as the meaning they attach to illness, may affect their coping and adaptation. Improved understanding in this area may therefore benefit patient care. Meaning of illness has not previously been explored in renal disease. DESIGN AND METHODS: Cross-sectional survey (n=405) in a single regional renal unit in the North of England. Ethical approval was obtained and patients gave written consent. The instrument used was an eight-item schema, based on the work of Lipowski (1970, Psychiatry in Medicine 1, 91-102). Field notes regarding rationale for choice were recorded concurrently, then content analysed to enable identification of themes. The chi-square test (significance level P < 0.05) was used to analyse differences in selected meaning in older and younger patients; males and females; and patient groups (predialysis, haemodialysis and transplant). FINDINGS: 'Challenge' was selected by most patients (n=253, 62.5%), with similar results in all three patient groups. Slightly more older than younger patients selected 'challenge', although the difference was not statistically significant and older patients more commonly had a fatalistic interpretation of the option. More men selected 'challenge' than women. Those selecting 'challenge' and 'value' appeared to have a more positive outlook than other patients. CONCLUSIONS: Patients had identifiable meanings for their illness, and these may be associated with their response to renal disease. The schema appeared to be comprehensive, but is in need of further refinement. Consideration of the possible influence of social desirability is necessary.

Protecting children: intuition and awareness in the work of health visitors.

Protecting children: intuition and awareness in the work of health visitors This paper is based upon an ethnographic study of a group of health visitors engaged in child protection work. The purpose of this paper is to explore the meanings individual health visitors attach to events concerned with identifying children who may be at risk of harm from child abuse, and also the idiosyncratic nature of health visiting in this complex but everyday social situation. The paper focuses on understanding the importance of a particular form of knowledge which the health visitors referred to as 'intuitive awareness'.

Community nurses' perceptions of patient 'compliance' in wound care: a discourse analysis.

As part of an interview study of community nurses' perceptions of their work, 62 staff working within the district nursing service in one English National Health Service Trust (grades B-H) were asked to recount occasions when they had been involved in wound care and to discuss the ways in which working with patients who required such care could be either enhanced or made difficult. A large number of respondents expressed the view that non-compliance could pose serious problems for the management of wounds. Data relating to compliance are presented here and are interpreted in the light of discourse analysis, an approach which permits the researcher to focus on the meanings underlying the communications of research participants and to interpret those meanings in the light of social and cultural mores and influences. The authors found that non-compliance could be explained by nurses in a number of different ways. These ranged from passive resistance, which could be due to ignorance or lack of motivation, through overt refusal, to deliberate interference in order to prolong treatment. It also seeks to outline some of the factors that appear to motivate the nurses' desire to achieve compliance.

Wound care in the community setting: clinical decision making in context.

Sixty-two community nurses in northern England of grades B and D to H were interviewed by a team of four researchers. The interviews were semi-structured, and were tape-recorded, fully transcribed and content analysed. They were conducted as part of a larger study, the aim of which was to examine community nurses' perceptions of quality in nursing care. One of the main themes the work focused on was decision-making as an element of quality. Data relating to wound care were considered from the perspective of the insights they offered into clinical decision-making. Data were interpreted in the light of a literature review in which a distinction had been made between theories which represented clinical decision-making as a linear or staged process and those which represented it as intuitive. Within the former category, three sub-categories were suggested: theorists could be divided into 'pragmatists', 'systematisers' and those who advocated 'diagnostic reasoning'. The interpretation of the data suggested that the clinical decisions made by community nurses in the area of wound care appeared largely intuitive, yet were also closely related to 'diagnostic reasoning'. They were furthermore based on a range of sources of information and justified by a number of different types of rationale.

The importance of 'knowing the patient': community nurses' constructions of quality in providing palliative care.

This paper reports findings from a study conducted in one community health care trust where 62 members of the district nursing team (grades B-H) were interviewed. An adaptation of the critical incident technique was used to determine factors which contributed or detracted from high quality care for a number of key areas including palliative care. The centrality of knowing the patient and his/her family emerged as an essential antecedent to the provision of high quality palliative care. Factors enabling the formation of positive relationships were given prominence in descriptions of ideal care. Strategies used to achieve this included establishing early contact with the patient and family, ensuring continuity of care, spending time with the patient and providing more than the physical aspects of care. The characteristics described by the community nurses are similar to those advocated in 'new nursing' which identifies the uniqueness of patient needs, and where the nurse-patient relationship is objectified as the vehicle through which therapeutic nursing can be delivered. The link with 'new nursing' emerges at an interesting time for community nurses. The past decade has seen many changes in the way that community nursing services are configured. The work of the district nursing service has been redefined, making the ideals of new nursing, for example holism, less achievable than they were a decade ago. This study reiterates the view that palliative care is one aspect of district nursing work that is universally valued as it lends itself to being an exemplar of excellence in terms of the potential for realizing the ideals of nursing practice. This is of increasing importance in the context of changes that militate against this ideal.

Primary care services received during terminal illness.

The World Health Organization (1990) provides guidelines on what constitutes effective palliative care. However, it remains unclear whether people with a terminal illness living in their own homes have access to the services they need. This article reports on a study carried out in the United Kingdom on the views of people with a terminal illness (n = 15), their lay carers (n = 10) and bereaved carers (n = 19). Participants were asked about the primary care services they had received and their views on both helpful and unhelpful aspects of service provision. All terminally ill people in the study (except one) had cancer, which raises questions about access to palliative care services for non-cancer populations. Participants had contact primarily with district nurses, general practitioners and Macmillan nurses (specialist nurses). Few other services were received. A number of important issues arose from the data, indicating that lay carers in particular were not always receiving the information and support they needed in order to be effective caregivers.

Skills competency in nurse education: nurse managers' perceptions of diploma level preparation.

This paper reports on part of a national study conducted between 1994 and 1996, the overall aim of which was to examine the 'fitness for purpose' of the Project 2000 nursing education reforms. The study used multiple methods of data collection, including an individual and group interview study of nurse managers (n = 132) and a national survey of Project 2000 diplomates and traditionally prepared registered nurses (n = 5417). Findings in relation to the managers' expectations and experiences of diplomates are presented. This includes views on the level of skills achievement and skills acquisition of diploma level education. The qualities of the diplomates are discussed and this includes those areas where the skills of the diplomates are felt to achieve what is required of the role. Also included is an exploration of those skills which the managers felt fell short of expectations. Managers raised the long-standing concerns of clinical skills and competencies and discussed these in relation to the changing health care environment and the relative roles of other health care workers. The conclusions highlight the need to identify what could be seen as the 'core skills' required of a registered nurse and the need to explore the environment in which the diplomate takes up first appointment.

Students' knowledge of and attitudes towards primary health care.

The aims of this study were to assess nursing students' knowledge of and attitudes towards primary health care using a newly developed Canadian instrument, the Primary Health Care Questionnaire (PHCQ). The instrument was refined for use in the UK prior to collecting data from 427 students in degree, Project 2000, health visitor and district nursing courses. Findings indicate that students in all programmes surveyed have been exposed to the concepts of primary health care. Students have acquired knowledge about primary health care and, generally, positive attitudes to the concepts. Significant differences were found between several student groups on both the knowledge and attitude measures. Although further psychometric evaluation of this new measure is recommended, the PHCQ shows promise as a valuable measure for use in assessing the move toward an increased emphasis on primary health care concepts in nursing education.

Nurse-patient relationships: the context of nurse prescribing.

Nurse prescribing was initiated in the United Kingdom in October 1994 in eight demonstration sites. The evaluation of this extension to the community nurses' role explored both economic and qualitative benefits to patients, carers, nurses and other health care professionals. In this paper the impact of nurse prescribing on patients is explored. Benefits experienced by patients are described along with the difficulties encountered. The patients' views regarding nurses as prescribers are also explored. Data were collected by means of interviews with patients/carers, the focus of which was to evaluate changes associated with nurse prescribing. Patients raised a number of issues associated with their relationship with nurses. Patients valued nurses for both their accessibility and approachability, which led them to discuss health issues which would not otherwise have been brought to the attention of the general practitioner. The arguments which support the incorporation of these qualities into an expanded nursing role are presented.

Decision making: the context of nurse prescribing.

From October 1994 qualified district nurses and health visitors from eight demonstration sites in England have been able to prescribe from a limited list of formulary items. Data collected from nurses formed only one part of the evaluation of nurse prescribing. These data highlighted a number of areas where prescribing nurses were faced with difficult decisions. A number of authors have considered how both doctors and nurses make decisions, and the factors which may influence the decision making process. With reference to the literature this paper focuses on the findings related to decision making in the context of nurse prescribing.

The implications of Project 2000 and the formation of links with higher education for the professional and academic needs of nurse teachers in the United Kingdom.

A national study was conducted between 1991 and 1994 to explore and describe the changing role of the nurse teacher following the introduction of Project 2000 pre-registration nursing courses. Multiple methods were used to collect data from a wide variety of respondents (nurse teachers, midwife teachers, clinical nurses, health service managers and higher education lecturers). This paper presents the findings relating to the impact of Project 2000 and the move into higher education on the continuing educational needs of nurse teachers. Views on college strategies for staff development, the changing nature of teachers' academic and professional development needs and the problems of the conflicting demands experienced are reported. The research highlights the need for clinical credibility to be clearly defined in relation to nurse teachers and for educational institutions to place more emphasis on teachers' clinical development if the rhetoric of policy is to become a reality.

Research and the configuration of nursing services.

This paper is concerned with the way in which nursing research has influenced changes in the organization of nursing services, particularly the shift from so-called traditional nursing to new nursing. To this end published research and professional literature are selectively reviewed. The case is made to support the view that change in nursing has been driven forward by the evangelical zeal of opinion leaders rather than evidence. It is suggested that holistic care as embodied in new nursing is no longer affordable. Market pressures have precipitated a revisiting of the task basis of nursing. An effective anchor would have been a solid body of research evidence pointing up the value new nursing may have. Regrettably not enough research was done prior to the diffusion of new nursing. What was done was not always adequate, and what was adequate was not effectively deployed by nurse leaders. Nursing is the largest workforce in the NHS and has attracted a great deal of policy interest. It is suggested that it will become increasingly important for nursing to be more strategic, and develop its own professionally driven research agenda. The future of the nursing profession in uncertain. It is clear that evidence-based practice is centre stage, and there is a need for nursing to re-negotiate its professional boundaries and to develop intellectual partnerships in order to move the knowledge base of practice forward.

The clinical role of nurse teachers within a Project 2000 course framework.

This paper reports on part of a national study that was conducted over a 3-year period (1991-1994). The overall aim of the study was to explore the changing role of the nurse teacher. Multiple methods of data collection were used, including a modified Delphi survey, a case study and telephone interviews. The sample included a wide variety of respondents (nurse teachers, midwife teachers, clinical nurses, health service managers and higher education lecturers). Findings in relation to the clinical role of the nurse teacher within a Project 2000 course framework are presented. This includes the nature of the clinical role, views on linking theory and practice, and potential barriers to the nurse teacher's clinical role. The future role of nurse teachers within the clinical area is discussed and this includes suggestions for the ways in which a nurse teacher's clinical commitment could be facilitated. Issues relating to the role of lecturer/practitioner are also highlighted.