Using realist evaluation to assess primary healthcare teams’ responses to intimate partner violence in Spain

Objective: Few evaluations have assessed the factors triggering an adequate health care response to intimate partner violence. This article aimed to: 1) describe a realist evaluation carried out in Spain to ascertain why, how and under what circumstances primary health care teams respond to intimate partner violence, and 2) discuss the strengths and challenges of its application. Methods: We carried out a series of case studies in four steps. First, we developed an initial programme theory (PT1), based on interviews with managers. Second, we refined PT1 into PT2 by testing it in a primary healthcare team that was actively responding to violence. Third, we tested the refined PT2 by incorporating three other cases located in the same region. Qualitative and quantitative data were collected and thick descriptions were produced and analysed using a retroduction approach. Fourth, we analysed a total of 15 cases, and identified combinations of contextual factors and mechanisms that triggered an adequate response to violence by using qualitative comparative analysis. Results: There were several key mechanisms —the teams’ self-efficacy, perceived preparation, women-centred care—, and contextual factors —an enabling team environment and managerial style, the presence of motivated professionals, the use of the protocol and accumulated experience in primary health care—that should be considered to develop adequate primary health-care responses to violence. Conclusion: The full application of this realist evaluation was demanding, but also well suited to explore a complex intervention reflecting the situation in natural settings.

Opiniões sobre a visita de enfermagem em unidades de cirurgia: tradução, adaptação e validação de questionários

Enquadramento: Apesar da visita de enfermagem ou passagem de turno junto dos doentes garantir a continuidade dos cuidados de enfermagem, origina diversas questões éticas. Objetivos: Traduzir, adaptar e validar 2 questionários de colheita de dados sobre a visita de enfermagem em unidades cirúrgicas para a cultura portuguesa; identificar a opinião dos doentes e dos enfermeiros sobre a visita de enfermagem. Metodologia: Tradução, retroversão e adaptação dos questionários aplicados em 7 unidades cirúrgicas de um hospital central em Portugal de 22/08/2008 a 28/06/2009. A amostragem não probabilística acidental foi constituída por 137 enfermeiros e 96 doentes. Resultados: A visita de enfermagem promove a relação empática e de ajuda; a observação do doente e o planeamento de cuidados, no entanto é necessário clarificar o seu objetivo; incentivar à participação e ao envolvimento dos doentes; utilizar um discurso compreensível e garantir a privacidade da informação. Conclusão: Os questionários revelaram-se fidedignos e válidos na identificação das opiniões dos doentes e dos enfermeiros sobre a visita de enfermagem nas unidades de cirurgia em estudo.

Who owns the child in hospital? A preliminary discussion

Aim. To 'own' a person is considered an infringement of human rights, but we suggest that concepts of ownership influence interactions between parents and staff when a child is admitted to hospital. This paper aims to stimulate debate and contains an explanation of the exploration of the literature for research and discussion of ownership of the child. Method. A wide variety of library indexes, databases and populist media were examined although it was impossible to examine all literature which may have contained references to this topic, and, apart from databases which contained abstracts in English, we could not include literature written in any language other than English, Swedish, and Icelandic. Findings. We found no research that examines how concepts of ownership of a child affects communication between health professionals and parents and, ultimately, the delivery of health care. This paper begins discussion on the issues. Discussion. Historical literature shows that ownership of humans has been a part of many cultures, and parents were once considered to own their children. Ownership of another has legal connotations, for instance in guardianship struggles of children during marriage breakup and in ethical debates over surrogacy and products of assisted conception. Within health care, it becomes a contentious issue in transplantation of body parts, in discourse on autonomy and informed consent, and for religious groups who refuse blood transfusions. In health care, models such as family centred care and partnership in care depend on positive communication between parents and staff. If a hospital staff member feels that he/she owns a child for whom he/she is caring, then conflict between the staff member and the parents over who has the 'best interests of the child' at heart is possible. Conclusion. We encourage debate about concepts of who owns the hospitalized child - the parents or the staff? Should it be argued at all? Is the whole concept of ownership of another, be it adult or child, the ethical antithesis to modern beliefs about human rights? Comment on this issue is invited.

Multidisciplinary strategies for the management of heart failure patients at high risk for admission - A systematic review of randomized trials

OBJECTIVES The aim of this study was to determine whether multidisciplinary strategies improve outcomes for heart failure (HF) patients. BACKGROUND Because the prognosis of HF remains poor despite pharmacotherapy, there is increasing interest in alternative models of care delivery for these patients. METHODS Randomized trials of multidisciplinary management programs in HF were identified by searching electronic databases and bibliographies and via contact with experts. RESULTS Twenty-nine trials (5,039 patients) were identified but were not pooled, because of considerable heterogeneity. A priori, we divided the interventions into homogeneous groups that were suitable for pooling. Strategies that incorporated follow-up by a specialized multidisciplinary team (either in a clinic or a non-clinic setting) reduced mortality (risk ratio [RR] 0.75, 95% confidence interval [CI] 0.59 to 0.96), HF hospitalizations (RR 0.74, 95% CI 0.63 to 0.87), and all-cause hospitalizations (RR 0.81, 95% CI 0.71 to 0.92). Programs that focused on enhancing patient self-care activities reduced HF hospitalizations (RR 0.66, 95% CI 0.52 to 0.83) and all-cause hospitalizations (RR 0.73, 95% CI 0.57 to 0.93) but had no effect on mortality (RR 1.14, 95% CI 0.67 to 1.94). Strategies that employed telephone contact and advised patients to attend their primary care physician in the event of deterioration reduced HF hospitalizations (RR 0.75, 95% CI 0.57 to 0.99) but not mortality (RR 0.91, 95% CI 0.67 to 1.29) or all-cause hospitalizations (RR 0.98, 95% CI 0.80 to 1.20). In 15 of 18 trials that evaluated cost, multidisciplinary strategies were cost-saving. CONCLUSIONS Multidisciplinary strategies for the management of patients with HF reduce HF hospitalizations. Those programs that involve specialized follow-up by a multidisciplinary team also reduce mortality and all-cause hospitalizations. (C) 2004 by the American College of Cardiology Foundation.

The WOMAC knee and hip osteoarthritis indices: Development, validation, globafization and influence on the development of the AUSCAN hand osteoarthritis indices

Clinical measurement in both clinical research and clinical practice requires tools and techniques that are valid, reliable and responsive. Patient-centred self-reported measures provide opportunity to evaluate consequences of osteoarthritis, that are important and relevant to patients with the condition. The WOMAC and AUSCAN Indices are health status measurement questionnaires that are valid, reliable and responsive, easy to complete, simple to score and available in multiple language forms and scaling formats. They provide opportunities to capture patient relevant information, relating to the impact of interventions, in clinical research and clinical practice environments. WOMAC data have also contributed to the development of proposed definitions for responder criteria and state-attainment criteria in osteoarthritis.

Family violence: Walking the tight rope between maternal alienation and child safety

Mothers are often alienated from their children when child abuse is suspected or confirmed, whether she is the primary abuser of the child or not. An abusive or violent partner often initiates the process of maternal alienation from children as a control mechanism. When the co-occurrence of maternal and child abuse is not recognised, nurses and health professionals risk further alienating a mother from her children, which can have detrimental effects in both the short and long term. Evidence shows that when mothers are supported and have the necessary resources there is a reduction in the violence and abuse she and her children experience; this occurs even in situations where the mother is the primary abuser of her children. The family-centred care philosophy, which is widely accepted as the best approach to nursing care for children and their families, creates tension for nurses caring for children who are the victims of abuse as this care generally occurs away from the context of the family. This fragmented approach to caring for abused children can inadvertently undermine the mother-child relationship and further contribute to maternal alienation. This paper discusses the complexity of family violence for nurses negotiating the 'tight rope' between the prime concern for the safety of children and further contributing to maternal alienation, within a New Zealand context. The premise that restoration of the mother-child relationship is paramount for the long-term wellbeing of both the children and the mother provides the basis for discussing implications for nursing practice.

Defining worthwhile and desired responses to treatment of chronic low back pain

Objective To describe patients' perceptions of minimum worthwhile and desired reductions in pain and disability upon commencing treatment for chronic low back pain. Design and Setting Descriptive study nested within a community-based randomized controlled trial on prolotherapy injections and exercises. Patients A total of 110 participants with chronic low back pain. Interventions Prior to treatment, participants were asked what minimum percentage reductions in pain and disability would make treatment worthwhile and what percentage reductions in pain and disability they desired with treatment. Outcome Measures. Minimum worthwhile reductions and desired reductions in pain and disability. Results. Median (inter-quartile range) minimum worthwhile reductions were 25% (20%, 50%) for pain and 35% (20%, 50%) for disability. This compared with desired reductions of 80% (60%, 100%) for pain and 80% (50%, 100%) for disability. The internal consistency between pain and disability responses was high (Spearman's coefficient of association of 0.81 and 0.87, respectively). A significant association existed between minimum worthwhile reductions and desired reductions, but no association was found between these two factors and patient age, gender, pain severity or duration, disability, anxiety, depression, response to treatment, or treatment satisfaction. Conclusions. Inquiring directly about patients' expectations of reductions in pain and in disability is important in establishing realistic treatment goals and setting benchmarks for success. There is a wide disparity between the reductions that they regard as minimum worthwhile and reductions that they hope to achieve. However, there is a high internal consistency between reductions in pain and disability that they expect.

Aggressive behaviour in the high-secure forensic setting: the perceptions of patients

Twenty-seven patients undergoing treatment in a high-secure forensic facility participated in focus group interviews to elicit their perceptions of (1) the factors leading to aggressive behaviour; and (2) strategies to reduce the risk of such behaviour. The focus group interviews were audiotaped, transcribed and analysed using content analysis. The participants identified that a combination of patient, staff and environmental factors contributed to violence in the study wards. The cause of aggressive behaviour centred around five major themes: the environment; empty days; staff interactions; medication issues; and patient-centred factors. Potential strategies identified by patients to reduce aggressive behaviour included: early intervention; the provision of meaningful activities to reduce boredom; separation of acutely disturbed patients; improved staff attitudes; implementation of effective justice procedures; and a patient advocate to mediate during times of conflict. Findings suggested that social and organizational factors need to be addressed to change the punitive subculture inherent in forensic psychiatric facilities, and to ensure a balance between security and effective therapy.

Description and preliminary results from a structured specialist behavioural weight management group intervention:Specialist Lifestyle Management (SLiM) programme

Background -  Specialist Lifestyle Management (SLiM) is a structured patient education and self-management group weight management programme. Each session is run monthly over a 6-month period providing a less intensive long-term approach. The groups are patient-centred incorporating educational, motivational, behavioural and cognitive elements. The theoretical background, programme structure and preliminary results of SLiM are presented. Subjects/methods - The study was a pragmatic service evaluation of obese patients with a body mass index (BMI) ≥35 kg/m2 with comorbidity or ≥40 kg/m2 without comorbidity referred to a specialist weight management service in the West Midlands, UK. 828 patients were enrolled within SLiM over a 48-month period. Trained facilitators delivered the programme. Preliminary anonymised data were analysed using the intention-to-treat principle. The primary outcome measure was weight loss at 3 and 6 months with comparisons between completers and non-completers performed. The last observation carried forward was used for missing data. Results - Of the 828 enrolled within SLiM, 464 completed the programme (56%). The mean baseline weight was 135 kg (BMI=49.1 kg/m2) with 87.2% of patients having a BMI≥40 kg/m2 and 12.4% with BMI≥60 kg/m2. The mean weight change of all patients enrolled was −4.1 kg (95% CI −3.6 to −4.6 kg, p=0.0001) at the end of SLiM, with completers (n=464) achieving −5.5 kg (95% CI −4.2 to −6.2 kg, p=0.0001) and non-completers achieving −2.3 kg (p=0.0001). The majority (78.6%) who attended the 6-month programme achieved weight loss with 32.3% achieving a ≥5% weight loss. Conclusions - The SLiM programme is an effective group intervention for the management of severe and complex obesity.

Help-seeking for medically unexplained hearing difficulties:a qualitative study

Aims - Up to 10% of audiology patients report diffi culties hearing speech in noise even though clinical investigation reveals normal hearing thresholds, in other words, no evidence of physical pathology. The diagnostic category applied to these patients is known as King-Kopetzky Syndrome (KKS). This study aimed to gather descriptions of patients' experiences of the clinical encounter involving their KKS diagnosis and analyse the themes of help-seeking, as part of a larger study into the process of coping with medically unexplained hearing diffi culties. Method - A qualitative approach was employed, comprising unstructured interviews in the homes of 25 patients who had attended audiology services (and received a diagnosis of KKS) in Bath and Cardiff. Thematic analysis of transcripts was undertaken, infl uenced by grounded theory techniques. Findings - Informants characterized the clinical encounter as either negative or positive. Negative consultations were those in which patients' illness claims were dismissed and as such not validated. Positive encounters were typifi ed by the provision of meaningful information that reconciled clinical information with the patients' experiences of hearing loss. Conclusion - Successful management of medically unexplained illnesses requires the adoption of a patient-centred approach, rather than focusing on the absence of observable pathology

The role of shared decision-making in audiologic rehabilitation

Shared decision-making (SDM), a component of patient-centered care, is the process in which the clinician and patient both participate in decision-making about treatment; information is shared between the parties and both agree with the decision. Shared decision-making is appropriate for health care conditions in which there is more than one evidence-based treatment or management option that have different benefits and risks. The patient's involvement ensures that the decisions regarding treatment are sensitive to the patient's values and preferences. Audiologic rehabilitation requires substantial behavior changes on the part of patients and includes benefits to their communication as well as compromises and potential risks. This article identifies the importance of shared decision-making in audiologic rehabilitation and the changes required to implement it effectively.

Developing a complex educational–behavioural intervention:the TREAT intervention for patients with atrial fibrillation

This article describes the theoretical and pragmatic development of a patient-centred intervention for patients with atrial fibrillation (AF). Theoretical models (Common Sense Model, Necessity-Concerns Framework), clinical frameworks, and AF patient feedback contributed to the design of a one-off hour-long behaviour-change intervention package. Intervention materials consisted of a DVD, educational booklet, diary and worksheet, which were patient-centred and easy to administer. The intervention was evaluated within a randomised controlled trial. Several “active theoretical ingredients” were identified (for e.g., where patients believed their medication was less harmful they spent more time within the therapeutic range (TTR), with general harm scores predicting TTR at 6 months). Allowing for social comparison and adopting behaviour change techniques enabled accurate patient understanding of their condition and medication. The process of developing the intervention using theory-derived content and evaluation tools allowed a greater understanding of the mechanisms by which this intervention was successful. Alleviating concerns about treatment medication by educating patients can help to improve adherence. This process of intervention development could be adopted for a range of chronic illnesses and treatments. Critical elements should include the use of: (1) clinical guidelines; (2) appropriate theoretical models; (3) patient input; and (4) appropriate evaluation tools.

Empowerment through education : enhancing quality of life of clients on anticoagulant therapy

This particular study was a sub-study of an on-going investigation by Porter and Kazcaraba (1994) at the Veterans Administration Medical Center in Miami. While the Porter and Kazcaraba study utilizes multiple measures to determine the impact of nurse patient collaborative care on quality of life of cardiovascular patients receiving anticoagulant therapy, this study sought to find whether health education could empower similar clients to improve their quality of life. A health education program based on Freire's belief that shared collective knowledge empowers individuals to improve their lives and their community and Porter's nurse patient collaborative care model was used. Findings on a sample of thirty-eight subjects revealed strong correlations between self-esteem and life satisfaction as well as a trend towards increased power post-treatment. No group comparisons were made at posttest because the sample size was too small for meaningful statistical analysis.

The knowledge, attitudes and beliefs of patients and their healthcare professionals around oral dosage form modification: a systematic review of the qualitative literature

Objectives: The objective of this systematic review was to synthesize the available qualitative evidence on the knowledge, attitudes and beliefs of adult patients, healthcare professionals and carers about oral dosage form modification. Design: A systematic review and synthesis of qualitative studies was undertaken, utilising the thematic synthesis approach. Data sources: The following databases were searched from inception to September 2015: PubMed, Medline (EBSCO), EMBASE, CINAHL, PsycINFO, Web of Science, ProQuest Databases, Scopus, Turning Research Into Practice (TRIP), Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Database of Systematic Reviews (CDSR). Citation tracking and searching the references lists of included studies was also undertaken. Grey literature was searched using the OpenGrey database, internet searching and personal knowledge. An updated search was undertaken in June 2016. Review methods: Studies meeting the following criteria were eligible for inclusion; (i) used qualitative data collection and analysis methods; (ii) full-text was available in English; (iii) included adult patients who require oral dosage forms to be modified to meet their needs or; (iv) carers or healthcare professionals of patients who require oral dosage forms to be modified. Two reviewers independently appraised the quality of the included studies using the Critical Appraisal Skills Programme Checklist. A thematic synthesis was conducted and analytical themes were generated. Results: Of 5455 records screened, seven studies were eligible for inclusion; three involved healthcare professionals and the remaining four studies involved patients. Four analytical themes emerged from the thematic synthesis: (i) patient-centred individuality and variability; (ii) communication; (iii) knowledge and uncertainty and; (iv) complexity. The variability of individual patient’s requirements, poor communication practices and lack of knowledge about oral dosage form modification, when combined with the complex and multi-faceted healthcare environment complicate decision making regarding oral dosage form modification and administration. Conclusions: This systematic review has highlighted the key factors influencing the knowledge, attitudes and beliefs of patients and healthcare professionals about oral dosage form modifications. The findings suggest that in order to optimise oral medicine modification practices the needs of individual patients should be routinely and systematically assessed and decision-making should be supported by evidence based recommendations with multidisciplinary input. Further research is needed to optimise oral dosage form modification practices and the factors identified in this review should be considered in the development of future interventions.