Uncovering the challenges of managing cachexia in advanced cancer: Preliminary results from semi-structured interviews with healthcare professionals in a regional cancer centre

Background: Cancer cachexia is a complex metabolic syndrome characterised by severe and progressive weight loss which is predominantly muscle mass. It is a devastating and distressing complication of advanced cancer with profound bio-psycho-social implications for patients and their families. At present there is no curative treatment for cachexiain advanced cancer therefore the most important healthcare response entails the minimisation of the psycho-social distress associated with it. However the literature suggests healthcare professionals’are missing opportunities to intervene and respond to the multi-dimensional needs of this population.

Objective:The objective of this study was to explore healthcare professionals’ response to cachexia in advanced cancer.

Methods: An interpretative qualitative approach was adopted in this study. A purposive sample of doctors, nurses, specialist nurses and dieticians were recruited from a regional cancer centre between November 2009 and November 2010. Data was collection was twofold: two multi-professional focus groups were conducted first to uncover the main themes and issues in cachexia management. This data then informed the interview schedule for the following 25 individual semi-structured interviews.

Results: Preliminary data analysis of the semi-structured interviews revealed distinct differences between disciplines in their perceptions of cancer cachexia which influenced their response to it in clinical practice. The commonality between disciplines, with the exception of palliative care, was a reliance on the biomedical approach to cancer cachexia management.

Discussion and Conclusions: Cancer cachexia is a complex and challenging syndrome which needs to be addressed from a holistic model of care to reflect the multi-dimensional needs of this patient group. The perspectives of those involved in care delivery is required in order to inform the development of interventions aimed at minimising the distress associated with this devastating syndrome.

Automatic decomposition and efficient semi-structured meshing of complex solids

In this paper, a novel approach to automatically sub-divide a complex geometry and apply an efficient mesh is presented. Following the identification and removal of thin-sheet regions from an arbitrary solid using the thick/thin decomposition approach developed by Robinson et al. [1], the technique here employs shape metrics generated using local sizing measures to identify long-slender regions within the thick body. A series of algorithms automatically partition the thick region into a non-manifold assembly of long-slender and complex sub-regions. A structured anisotropic mesh is applied to the thin-sheet and long-slender bodies, and the remaining complex bodies are filled with unstructured isotropic tetrahedra. The resulting semi-structured mesh possesses significantly fewer degrees of freedom than the equivalent unstructured mesh, demonstrating the effectiveness of the approach. The accuracy of the efficient meshes generated for a complex geometry is verified via a study that compares the results of a modal analysis with the results of an equivalent analysis on a dense tetrahedral mesh.

Clustering-based Query Routing in Cooperative Semi-structured Peer to Peer Networks

We consider the problem of resource selection in clustered Peer-to-Peer Information Retrieval (P2P IR) networks with cooperative peers. The clustered P2P IR framework presents a significant departure from general P2P IR architectures by employing clustering to ensure content coherence between resources at the resource selection layer, without disturbing document allocation. We propose that such a property could be leveraged in resource selection by adapting well-studied and popular inverted lists for centralized document retrieval. Accordingly, we propose the Inverted PeerCluster Index (IPI), an approach that adapts the inverted lists, in a straightforward manner, for resource selection in clustered P2P IR. IPI also encompasses a strikingly simple peer-specific scoring mechanism that exploits the said index for resource selection. Through an extensive empirical analysis on P2P IR testbeds, we establish that IPI competes well with the sophisticated state-of-the-art methods in virtually every parameter of interest for the resource selection task, in the context of clustered P2P IR.

Desperately Seeking Finance? The Demand for Finance by Women Owned and Led Businesses

The study reported here addresses some issues on gender, entrepreneurship and finance that have been identified as problematic in the literature. For example, much of the research to date is based on the assumption of entrepreneurship as male entrepreneurship; few studies have controlled for structural characteristics that may impact on the relationship between owner gender and a venture's ability to raise finance; and women are less likely than men to seek growth and external financing. Through the conduct of in-depth semi-structured interviews, an attempt has been made to give `voice' to women's intrinsically interesting experiences as the enactment of a situated practice, and not just in comparison with the assumed norm of male entrepreneurial activity. The findings suggest that when variables such as individual and firm characteristics are controlled for, generalizations found in the literature may not be supported. Further, the paper highlights that neither women entrepreneurs nor their businesses are homogeneous in nature and that greater heterogeneity in the study of female entrepreneurship in general, and access to finance in particular, is required.

Performance Management in the UK Public Sector: addressing multiple stakeholder complexity

Purpose The aim of this paper is to explore the issues involved in developing and applying performance management approaches within a large UK public sector department using a multiple stakeholder perspective and an accompanying theoretical framework. Design/methodology/approach An initial short questionnaire was used to determine perceptions about the implementation and effectiveness of the new performance management system across the organisation. In total, 700 questionnaires were distributed. Running concurrently with an ethnographic approach, and informed by the questionnaire responses, was a series of semi-structured interviews and focus groups. Findings Staff at all levels had an understanding of the new system and perceived it as being beneficial. However, there were concerns that the approach was not continuously managed throughout the year and was in danger of becoming an annual event, rather than an ongoing process. Furthermore, the change process seemed to have advanced without corresponding changes to appraisal and reward and recognition systems. Thus, the business objectives were not aligned with motivating factors within the organisation. Research limitations/implications Additional research to test the validity and usefulness of the theoretical model, as discussed in this paper, would be beneficial. Practical implications The strategic integration of the stakeholder performance measures and scorecards was found to be essential to producing an overall stakeholder-driven strategy within the case study organisation. Originality/value This paper discusses in detail the approach adopted and the progress made by one large UK public sector organisation, as it attempts to develop better relationships with all of its stakeholders and hence improve its performance. This paper provides a concerted attempt to link theory with practice.

Towards a person-centred ‘culture’: the use of community development approaches in the Independent Youth Counselling Service in West Belfast

This paper is drawn from a qualitative study of clients, counsellors and the supervisors views of the value and impact of the Independent Youth Counselling Service (IYCS) in West Belfast. Data collection combined semi-structured interviews, focus groups and an open-ended questionnaire. The findings indicate the significance of factors above and beyond the person-centred counselling experience, in maximising the potential for growth and development for clients and counsellors. This holistic approach to counselling service provision employs a body of community development processes, which collectively combine to embed the counselling service in a complementary principled approach. This paper explores how these community development features bolster the counselling experience to promote a culture of person-centeredness, thereby increasing the empowerment of the client.

Implementing a resuscitation policy for patients at the end of life in an acute hospital setting: qualitative study

Objective : To explore attitudes and experiences of doctors and nurses regarding cardiopulmonary resuscitation for patients with end stage illness in an acute hospital. Design : Qualitative study; thematic analysis of two audio-taped focus groups and four semi-structured interviews. Setting : Acute district hospital, Northern Ireland. Participants : Seven nurses and nine doctors; varying nationality, gender and years of professional experience; involved in cardiopulmonary resuscitation decision-making. Results : Participants reported different interpretations of resuscitation policy and of what do not attempt to resuscitate (DNAR) decisions meant in relation to practical care for patients. This confusion in translating policy into practice contributed to communication difficulties in initiating, documenting and implementing cardiopulmonary resuscitation decisions. Participants were aware of how clinical conditions could change and reported uncertainty in determining end stage illness; they expressed fears of potential consequences of DNAR decisions for patients' care. The more disease-centred approach of doctors to patients' management, compared to nurses' more patient-centred approach, contributed to inter-professional conflict within teams. Doctors identified training needs in applying resuscitation policy and ethical principles in `real life' and nurses identified a need for ongoing professional support, which was perceived as being less available to junior doctors. Personal relationships between staff and patients, cultural reluctance to address sensitive issues and local community expectations of relatives being involved in decisions added to policy implementation difficulties. Conclusions : The findings indicate a need for ongoing staff support and training in applying resuscitation policy to decisions for patients with end stage illness in an acute hospital. They support suggestions that reviews of local resuscitation policy and of national guidelines should be undertaken with openness and honesty regarding the goals, opportunities and difficulties involved in trying to deliver good end of life care in local settings. Palliative Medicine 2007; 21 : 305—312 Key Words: do not attempt resuscitation (DNAR) • end stage illness • inter-professional • policy • resuscitation decisions

Understandings of citizenship education in Northern Ireland and the Republic of Ireland: Public discourses among stakeholders in the public and private sectors

Internationally, citizenship education has come to the fore in the past decade. It may be particularly importantwithin the context of societies with a legacy of political conflict, such as Northern Ireland and the Republic of Ireland, where it is being implemented as part of the statutory curriculum. This article explores understandingsof citizenship education among stakeholders in the private and public sectors in Northern Ireland and the Republic of Ireland with the aim to compare these with curricular conceptualizations of citizenship inboth contexts. Semi-structured interviews were conducted in both societies involving non-governmentalorganizations, political parties, trade unions and the police. Results indicated that levels of awareness aboutcitizenship education varied substantially and understandings mainly reflected current theory and curriculumpractice in citizenship. Commonalities emerged as in both societies similar key concepts were identified whiledifferences transpired over issues relating to national identity and political conflict, which may raise questionsfor history and citizenship education in both societies.

The journey to concordance for patients with hypertension: a qualitative study in primary care

Objective: We aimed to explore, using qualitative methods, the perspectives of patients with hypertension on issues relating to concordance in prescribing.

Method: This study took place in NHS general practices in Northern Ireland. A purposeful sample of patients who had been prescribed anti-hypertensive medication for at least one year were invited to participate in focus groups or semi-structured interviews; data were analysed using constant comparison.

Main outcome measures: The perspectives of patients with hypertension on issues relating to concordance in prescribing.

Results: Twenty-five individuals participated in five focus groups; two participated in semi-structured interviews. Participants felt they could make valuable contributions to consultations regarding their management. They were prepared to negotiate with GPs regarding their medication, but most deferred to their doctor’s advice, perceiving doctors’ attitudes and time constraints as barriers to their greater involvement in concordant decision-making. They had concerns about taking anti-hypertensive drugs, were aware of lifestyle influences on hypertension and reported using personal strategies to facilitate adherence and reduce the need to take medication.

Conclusions: Participants indicated a willingness to be?involved in concordance in prescribing anti- hypertensive medication but needed health professionals to address their concerns and confusion about the nature of hypertension. These findings suggest that there is a need for doctors and other healthcare professionals with responsibility for prescribing to develop skills specifically to explore the beliefs and views underlying an individual’s medication use. Such skills may need to be developed through specific training programmes at both undergraduate and postgraduate level.

Peer-mentoring for first-time mothers from areas of socio-economic disadvantage: a qualitative study within a randomised controlled trial

Objective: To explore the difficulties experienced by lay-workers, women and health professionals involved in a peer-mentoring programme for first-time mothers living in socially disadvantaged areas. Design: Qualitative study; semi-structured interviews with lay-worker peer-mentoring programme participants at two separate stages of the programme (antenatal and postnatal). Setting: Community based. Participants: 11 women receiving peer-mentoring support (from first hospital antenatal visit to one year postnatal); 11 lay-workers; 2 research midwives. Results: Lay-workers had difficulty initiating contact with women and failure to establish contact affected their morale adversely. They felt that women understood their intended role poorly and attempted to develop relationships with them by sharing personal experiences and offering friendship; women who participated in the programme appreciated this. Developing a peer-mentor relationship was difficult if women lacked interest in the programme or in continuing contact. External influences on peer-mentoring uptake and delivery included family and friends who could prevent or encourage women’s participation and cause difficulties for the lay-worker both in delivering support and arranging follow-up. Lay-workers providing support to women from a different ethnic background experienced difficulties relating to both language and culture: these were perceived to affect peer-mentor relationships adversely. Major personal difficulties for lay-workers related to time constraints in reconciling mentoring requirements with demands of family and other work. Informing midwives of these difficulties helped identify solutions through training and ongoing professional support for the lay-workers. Conclusions: Lay-worker peer support is appreciated by first time mothers but difficulties in initiating contact, developing peer-mentor relationships and external influences such as family, ethnicity and time constraints are relevant to poor uptake and high staff turnover. In developing peer support programmes, awareness of potential difficulties and of how professional support can help resolve these should improve uptake and thus optimise the evaluations of their effectiveness.