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1.  Practice nursing: what do we know? 
doi:10.3399/bjgp15X683041
PMCID: PMC4275982  PMID: 25548295
2.  Evaluation of Diffuse Reflection Infrared Spectrometry for End-of-Shift Measurement of α-quartz in Coal Dust Samples 
The inhalation of toxic substances is a major threat to the health of miners, and dust containing respirable crystalline silica (α-quartz) is of particular concern, due to the recent rise in cases of coal workers’ pneumoconiosis and silicosis in some U.S. mining regions. Currently, there is no field-portable instrument that can measure airborne α-quartz and give miners timely feedback on their exposure. The U.S. National Institute for Occupational Safety and Health (NIOSH) is therefore conducting studies to investigate technologies capable of end-of-shift or real-time measurement of airborne quartz. The present study focuses on the potential application of Fourier transform infrared (FT-IR) spectrometry conducted in the diffuse reflection (DR) mode as a technique for measuring α-quartz in respirable mine dust. A DR accessory was used to analyze lab-generated respirable samples of Min-U-Sil 5 (which contains more than 90% α-quartz) and coal dust, at mass loadings in the ranges of 100–600 μg and 600–5300 μg, respectively. The dust samples were deposited onto three different types of filters, borosilicate fiberglass, nylon, and polyvinyl chloride (PVC). The reflectance, R, was calculated by the ratio of a blank filter and a filter with deposited mine dust. Results suggest that for coal and pure quartz dusts deposited on 37 mm PVC filters, measurements of −log R correlate linearly with known amounts of quartz on filters, with R2 values of approximately 0.99 and 0.94, respectively, for samples loaded up to ~4000 μg. Additional tests were conducted to measure quartz in coal dusts deposited onto the borosilicate fiberglass and nylon filter media used in the NIOSH-developed Personal Dust Monitor (PDM). The nylon filter was shown to be amenable to DR analysis, but quantification of quartz is more accurate when the filter is “free,” as opposed to being mounted in the PDM filter holder. The borosilicate fiberglass filters were shown to produce excessive interference, making quartz quantification impossible. It was concluded that, while the DR/FT-IR method is potentially useful for on-filter measurement of quartz in dust samples, the use of PVC filters produced the most accurate results.
doi:10.1080/15459624.2015.1011328
PMCID: PMC4681494  PMID: 25636081
coal dust; diffuse reflection spectrometry; silica; α-quartz
3.  Patient satisfaction and non-UK educated nurses: a cross-sectional observational study of English National Health Service Hospitals 
BMJ Open  2015;5(12):e009483.
Objectives
To examine whether patient satisfaction with nursing care in National Health Service (NHS) hospitals in England is associated with the proportion of non-UK educated nurses providing care.
Design
Cross-sectional analysis using data from the 2010 NHS Adult Inpatient Survey merged with data from nurse and hospital administrator surveys. Logistic regression models with corrections for clustering were used to determine whether the proportions of non-UK educated nurses were significantly related to patient satisfaction before and after taking account of other hospital, nursing and patient characteristics.
Setting
31 English NHS trusts.
Participants
12 506 patients 16 years of age and older with at least one overnight stay that completed a satisfaction survey; 2962 bedside care nurses who completed a nurse survey; and 31 NHS trusts.
Main outcome measure
Patient satisfaction.
Results
The percentage of non-UK educated nurses providing bedside hospital care, which ranged from 1% to 52% of nurses, was significantly associated with patient satisfaction. After controlling for potential confounding factors, each 10-point increase in the percentage of non-UK educated nurses diminished the odds of patients reporting good or excellent care by 12% (OR=0.88), and decreased the odds of patients agreeing that they always had confidence and trust in nurses by 13% (OR=0.87). Other indicators of patient satisfaction also revealed lower satisfaction in hospitals with higher percentages of non-UK educated nurses.
Conclusions
Use of non-UK educated nurses in English NHS hospitals is associated with lower patient satisfaction. Importing nurses from abroad to substitute for domestically educated nurses may negatively impact quality of care.
doi:10.1136/bmjopen-2015-009483
PMCID: PMC4680004  PMID: 26634400
4.  Evaluating the feasibility and effectiveness of a critical care discharge information pack for patients and their families: a pilot cluster randomised controlled trial 
BMJ Open  2015;5(11):e006852.
Objectives
To evaluate the feasibility and effectiveness of an information pack, based on self-regulation theory, designed to support patients and their families immediately before, during and after discharge from an intensive care unit (ICU).
Design and setting
Prospective assessor-blinded pilot cluster randomised controlled trial (RCT; in conjunction with a questionnaire survey of trial participants’ experience) in 2 ICUs in England.
Participants
Patients (+/− a family member) who had spent at least 72 h in an ICU, declared medically fit for discharge to a general ward.
Randomisation
Cluster randomisation (by day of discharge decision) was used to allocate participants to 1 of 3 study groups.
Intervention
A user-centred critical care discharge information pack (UCCDIP) containing 2 booklets; 1 for the patient (which included a personalised discharge summary) and 1 for the family, given prior to discharge to the ward.
Primary outcome
Psychological well-being measured using Hospital Anxiety and Depression Scores (HADS), assessed at 5±1 days postunit discharge and 28 days/hospital discharge. Statistical significance (p≤0.05) was determined using χ2 and Kruskal-Wallis (H).
Results
158 patients were allocated to: intervention (UCCDIP; n=51), control 1: ad hoc verbal information (n=59), control 2: booklet published by ICUsteps (n=48). There were no statistically significant differences in the primary outcome. The a priori enrolment goal was not reached and attrition was high. Using HADS as a primary outcome measure, an estimated sample size of 286 is required to power a definitive trial.
Conclusions
Findings from this pilot RCT provide important preliminary data regarding the circumstances under which an intervention based on the principles of UCCDIP could be effective, and the sample size required to demonstrate this.
Trial registration number
Current Controlled Trials ISRCTN47262088; results.
doi:10.1136/bmjopen-2014-006852
PMCID: PMC4663421  PMID: 26614615
5.  Nursing consultations and control of diabetes in general practice: a retrospective observational study 
The British Journal of General Practice  2015;65(639):e642-e648.
Background
Diabetes affects around 3.6 million people in the UK. Previous research found that general practices employing more nurses delivered better diabetes care, but did not include data on individual patient characteristics or consultations received.
Aim
To examine whether the proportion of consultations with patients with diabetes provided by nurses in GP practices is associated with control of diabetes measured by levels of glycated haemoglobin (HbA1c).
Design and setting
A retrospective observational study using consultation records from 319 649 patients with diabetes from 471 UK general practices from 2002 to 2011.
Method
Hierarchical multilevel models to examine associations between proportion of consultations undertaken by nurses and attaining HbA1c targets over time, controlling for case-mix and practice level factors.
Results
The proportion of consultations with nurses has increased by 20% since 2002 but patients with diabetes made fewer consultations per year in 2011 compared with 2002 (11.6 versus 16.0). Glycaemic control has improved and was more uniformly achieved in 2011 than 2002. Practices in which nurses provide a higher proportion of consultations perform no differently to those where nurse input is lower (lowest versus highest nurse contact tertile odds ratio [OR] [confidence interval {95% CI}]: HbA1c ≤53 mmol/mol (7%) 2002, 1.04 [95% CI = 0.87 to 1.25] and 2011, 0.95 [95% CI = 0.87 to 1.03]; HbA1c ≤86 mmol/mol (10%) 2002, 0.97 [95% CI = 0.73 to 1.29] and 2011, 0.95 [95% CI = 0.86 to 1.04]).
Conclusion
Practices that primarily use GPs to deliver diabetes care could release significant resources with no adverse effect by switching their services towards nurse-led care.
doi:10.3399/bjgp15X686881
PMCID: PMC4582876  PMID: 26412840
diabetes mellitus; general practice; health workforce; nurses; nursing staff; primary health care
6.  Methodological considerations when translating “burnout”☆ 
Burnout research  2014;1(2):59-68.
No study has systematically examined how researchers address cross-cultural adaptation of burnout. We conducted an integrative review to examine how researchers had adapted the instruments to the different contexts. We reviewed the Content Validity Indexing scores for the Maslach Burnout Inventory-Human Services Survey from the 12-country comparative nursing workforce study, RN4CAST. In the integrative review, multiple issues related to translation were found in existing studies. In the cross-cultural instrument analysis, 7 out of 22 items on the instrument received an extremely low kappa score. Investigators may need to employ more rigorous cross-cultural adaptation methods when attempting to measure burnout.
doi:10.1016/j.burn.2014.07.001
PMCID: PMC4203660  PMID: 25343131
Europe; Nurses; Nursing; Burnout; Language translation; Content Validity Indexing; Human resources for health; Cross-cultural instrument adaptation
7.  Association of 12 h shifts and nurses’ job satisfaction, burnout and intention to leave: findings from a cross-sectional study of 12 European countries 
BMJ Open  2015;5(9):e008331.
Objectives
12 h shifts are becoming increasingly common for hospital nurses but there is concern that long shifts adversely affect nurses’ well-being, job satisfaction and intention to leave their job. The aim of this study is to examine the association between working long shifts and burnout, job dissatisfaction, dissatisfaction with work schedule flexibility and intention to leave current job among hospital nurses.
Methods
Cross-sectional survey of 31 627 registered nurses in 2170 general medical/surgical units within 488 hospitals across 12 European countries.
Results
Nurses working shifts of ≥12 h were more likely than nurses working shorter hours (≤8) to experience burnout, in terms of emotional exhaustion (adjusted OR (aOR)=1.26; 95% CI 1.09 to 1.46), depersonalisation (aOR=1.21; 95% CI 1.01 to 1.47) and low personal accomplishment (aOR=1.39; 95% CI 1.20 to 1.62). Nurses working shifts of ≥12 h were more likely to experience job dissatisfaction (aOR=1.40; 95% CI 1.20 to 1.62), dissatisfaction with work schedule flexibility (aOR=1.15; 95% CI 1.00 to 1.35) and report intention to leave their job due to dissatisfaction (aOR=1.29; 95% CI 1.12 to 1.48).
Conclusions
Longer working hours for hospital nurses are associated with adverse outcomes for nurses. Some of these adverse outcomes, such as high burnout, may pose safety risks for patients as well as nurses.
doi:10.1136/bmjopen-2015-008331
PMCID: PMC4577950  PMID: 26359284
STATISTICS & RESEARCH METHODS
8.  Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study 
Lancet  2014;383(9931):1824-1830.
Summary
Background
Austerity measures and health-system redesign to minimise hospital expenditures risk adversely affecting patient outcomes. The RN4CAST study was designed to inform decision making about nursing, one of the largest components of hospital operating expenses. We aimed to assess whether differences in patient to nurse ratios and nurses’ educational qualifications in nine of the 12 RN4CAST countries with similar patient discharge data were associated with variation in hospital mortality after common surgical procedures.
Methods
For this observational study, we obtained discharge data for 422 730 patients aged 50 years or older who underwent common surgeries in 300 hospitals in nine European countries. Administrative data were coded with a standard protocol (variants of the ninth or tenth versions of the International Classification of Diseases) to estimate 30 day in-hospital mortality by use of risk adjustment measures including age, sex, admission type, 43 dummy variables suggesting surgery type, and 17 dummy variables suggesting comorbidities present at admission. Surveys of 26 516 nurses practising in study hospitals were used to measure nurse staffing and nurse education. We used generalised estimating equations to assess the effects of nursing factors on the likelihood of surgical patients dying within 30 days of admission, before and after adjusting for other hospital and patient characteristics.
Findings
An increase in a nurses’ workload by one patient increased the likelihood of an inpatient dying within 30 days of admission by 7% (odds ratio 1·068, 95% CI 1·031–1·106), and every 10% increase in bachelor’s degree nurses was associated with a decrease in this likelihood by 7% (0·929, 0·886–0·973). These associations imply that patients in hospitals in which 60% of nurses had bachelor’s degrees and nurses cared for an average of six patients would have almost 30% lower mortality than patients in hospitals in which only 30% of nurses had bachelor’s degrees and nurses cared for an average of eight patients.
Interpretation
Nurse staffing cuts to save money might adversely affect patient outcomes. An increased emphasis on bachelor’s education for nurses could reduce preventable hospital deaths.
Funding
European Union’s Seventh Framework Programme, National Institute of Nursing Research, National Institutes of Health, the Norwegian Nurses Organisation and the Norwegian Knowledge Centre for the Health Services, Swedish Association of Health Professionals, the regional agreement on medical training and clinical research between Stockholm County Council and Karolinska Institutet, Committee for Health and Caring Sciences and Strategic Research Program in Care Sciences at Karolinska Institutet, Spanish Ministry of Science and Innovation.
doi:10.1016/S0140-6736(13)62631-8
PMCID: PMC4035380  PMID: 24581683
9.  EXPERTS 1—experiences of long-term life-limiting conditions among patients and carers: protocol for a qualitative meta-synthesis and conceptual modelling study 
BMJ Open  2015;5(4):e007372.
Introduction
Increasing numbers of the population are living with long-term life-limiting conditions with a significant proportion characterised by multimorbidity. Patients with these conditions often experience high volumes of clinical interaction involving them, their caregivers and healthcare providers in complex patterns of organising, coordinating, negotiating and managing care. A better understanding of the sources of experienced complexity and multimorbidity, from the patient perspective is paramount to improve capacity and manage workload to promote improved experience of illness, more effective healthcare utilisation and improved healthcare outcomes. To better understand the sources of complexity we will undertake an evidence synthesis of qualitative studies of patient and informal carer experiences of three common long-term life-limiting conditions. We will investigate what is known about these diseases at different stages in disease progression, treatment regimens and places of care.
Method and analysis
We will include qualitative studies of patients’ and carers’ (aged >18) accounts of their experiences of healthcare provision in a range of settings and healthcare systems. We will conduct an extensive electronic database search of publications in English between 2000 and 2014. Results and discussions sections of the papers will be regarded as formal data using the constant comparison method of qualitative analysis. From the meta-synthesis results, we will build a conceptual model of mechanisms and processes that shape patients’ journeys towards end of life to suggest where in the patient journey new interventions to improve patient and carer experience can be developed and delivered. The study is being conducted between 1 December 2014 and 31 December 2015.
Ethics and dissemination
No human subjects or personal data are involved and no ethical issues are anticipated. An important element of dissemination is informing user communities about the practical implications of the work through workshops, meetings and social media. Scientific results will be published in peer reviewed journals and disseminated through conferences.
Trial registration number
PROSPERO CRD42014014547.
doi:10.1136/bmjopen-2014-007372
PMCID: PMC4390683  PMID: 25838511
chronic disease; multimorbidity; patient complexity; treatment burden; workload
10.  One size does not fit all: a qualitative content analysis of the importance of existing quality improvement capacity in the implementation of Releasing Time to Care: the Productive Ward™ in Saskatchewan, Canada 
Background
Releasing Time to Care: The Productive Ward™ (RTC) is a method for conducting continuous quality improvement (QI). The Saskatchewan Ministry of Health mandated its implementation in Saskatchewan, Canada between 2008 and 2012. Subsequently, a research team was developed to evaluate its impact on the nursing unit environment. We sought to explore the influence of the unit’s existing QI capacity on their ability to engage with RTC as a program for continuous QI.
Methods
We conducted interviews with staff from 8 nursing units and asked them to speak about their experience doing RTC. Using qualitative content analysis, and guided by the Organizing for Quality framework, we describe the existing QI capacity and impact of RTC on the unit environment.
Results
The results focus on 2 units chosen to highlight extreme variation in existing QI capacity. Unit B was characterized by a strong existing environment. RTC was implemented in an environment with a motivated manager and collaborative culture. Aided by the structural support provided by the organization, the QI capacity on this unit was strengthened through RTC. Staff recognized the potential of using the RTC processes to support QI work. Staff on unit E did not have the same experience with RTC. Like unit B, they had similar structural supports provided by their organization but they did not have the same existing cultural or political environment to facilitate the implementation of RTC. They did not have internal motivation and felt they were only doing RTC because they had to. Though they had some success with RTC activities, the staff did not have the same understanding of the methods that RTC could provide for continuous QI work.
Conclusions
RTC has the potential to be a strong tool for engaging units to do QI. This occurs best when RTC is implemented in a supporting environment. One size does not fit all and administrative bodies must consider the unique context of each environment prior to implementing large-scale QI projects. Use of an established framework, like Organizing for Quality, could highlight the distinctive supports needed in particular care environments to increase the likelihood of successful engagement.
Electronic supplementary material
The online version of this article (doi:10.1186/s12913-014-0642-x) contains supplementary material, which is available to authorized users.
doi:10.1186/s12913-014-0642-x
PMCID: PMC4279911  PMID: 25547227
Productive ward; Releasing time to care; Organizing for quality; Nursing; Qualitative methodology; Quality improvement capacity; Change mechanisms
11.  Assessing the Susceptibility of Transgenic Mice Overexpressing Deer Prion Protein to Bovine Spongiform Encephalopathy 
Journal of Virology  2014;88(3):1830-1833.
Several transgenic mouse models have been developed which facilitate the transmission of chronic wasting disease (CWD) of cervids and allow prion strain discrimination. The present study was designed to assess the susceptibility of the prototypic mouse line, Tg(CerPrP)1536+/−, to bovine spongiform encephalopathy (BSE) prions, which have the ability to overcome species barriers. Tg(CerPrP)1536+/− mice challenged with red deer-adapted BSE resulted in 90% to 100% attack rates, and BSE from cattle failed to transmit, indicating agent adaptation in the deer.
doi:10.1128/JVI.02762-13
PMCID: PMC3911610  PMID: 24257620
12.  Development of an early nurse led intervention to treat children referred to secondary paediatric care with constipation with or without soiling 
BMC Pediatrics  2013;13:193.
Background
Constipation is a common chronic childhood condition referred to secondary care. Effective treatment requires early intervention, prolonged medication to soften stools and behavioural support to achieve a regular habit of sitting on the toilet to pass a stool. The purpose of this audit and service development was to assess routine consultant paediatrician-led care against minimum standards and if appropriate to develop a nurse-led intervention. The new care package could then be tried out within general paediatric clinics in Glasgow as a service evaluation. NICE guideline (CG99) has a research recommendation to compare nurse-led care with routine consultant-led care.
Methods
Design was an audit then development of a nurse-led intervention followed by a service evaluation. Participants were children (age 0–13 years), referred by their General Practitioner (GP) to the Royal Hospital for Sick Children Glasgow, with constipation the main problem in the GP letter. The audit covered appointment waiting times, intervention provided, initial follow-up and parental satisfaction with routine consultant-led practice. The nurse-led intervention focused on self-help psychology practice with NICE guideline medical support. This was compared with routine consultant paediatrician care in a service evaluation.
Results
The audit found consultant-led care had long waiting times, delayed initial follow-up and variable intervention. The new nurse-led intervention is described in detail. The nurse-led intervention performed well compared with consultant-led care. Less ‘nurse-led’ children, 3/45 (7%), were still constipated passing less than 3 stools per week compared with 8/58 (14%) receiving consultant-led care. Less ‘nurse-led’ parents, 10/45 (22%), reported their child having pain passing stools in the previous week compared with consultant-led care, 26/58 (45%). The proportion of children, over 4 years, free from soiling accidents was similar, 15/23 (65%) in the nurse-led group and 18/29 (62%) with consultant-led care. Parental satisfaction was slightly better in the nurse-led group.
Conclusion
It is difficult to achieve minimum standards using routine consultant-led care for children referred by their GP with constipation. Nurse-led early intervention is feasible and has produced promising results in a service evaluation. An exploratory trial is planned to develop a teaching module, robust outcomes including costs and benefits, and methodology for a definitive trial recommended by NICE.
doi:10.1186/1471-2431-13-193
PMCID: PMC3870966  PMID: 24252503
Constipation; Child; Intervention studies; Psychological techniques; Medicine
13.  Atypical Scrapie Prions from Sheep and Lack of Disease in Transgenic Mice Overexpressing Human Prion Protein 
Emerging Infectious Diseases  2013;19(11):1731-1739.
Public and animal health controls to limit human exposure to animal prions are focused on bovine spongiform encephalopathy (BSE), but other prion strains in ruminants may also have zoonotic potential. One example is atypical/Nor98 scrapie, which evaded statutory diagnostic methods worldwide until the early 2000s. To investigate whether sheep infected with scrapie prions could be another source of infection, we inoculated transgenic mice that overexpressed human prion protein with brain tissue from sheep with natural field cases of classical and atypical scrapie, sheep with experimental BSE, and cattle with BSE. We found that these mice were susceptible to BSE prions, but disease did not develop after prolonged postinoculation periods when mice were inoculated with classical or atypical scrapie prions. These data are consistent with the conclusion that prion disease is less likely to develop in humans after exposure to naturally occurring prions of sheep than after exposure to epizootic BSE prions of ruminants.
doi:10.3201/eid1911.121341
PMCID: PMC3837652  PMID: 24188521
Atypical scrapie; bovine spongiform encephalopathy; BSE; Nor98 scrapie; prions; prion disease; prion protein; scrapie; sheep BSE; transgenic mice; transmissible spongiform encephalopathy (TSE); variant Creutzfeldt-Jakob disease; vCJD
15.  Acupuncture for ‘frequent attenders’ with medically unexplained symptoms: a randomised controlled trial (CACTUS study) 
The British Journal of General Practice  2011;61(587):e295-e305.
Background
Medically unexplained physical symptoms (MUPS) are common and difficult to treat.
Aim
To investigate the effectiveness of adding five-element acupuncture to usual care in ‘frequent attenders’ with MUPS.
Design and setting
Randomised controlled trial in four London general practices.
Method
Participants were 80 adults with MUPS, consulting GPs ≥8 times/year. The intervention was individualised five-element acupuncture, ≥12 sessions, immediately (acupuncture group) and after 26 weeks (control group). The primary outcome was 26-week Measure Yourself Medical Outcome Profile (MYMOP); secondary outcomes were wellbeing (W-BQ12), EQ-5D, and GP consultation rate. Intention-to-treat analysis was used, adjusting for baseline outcomes.
Results
Participants (80% female, mean age 50 years, mixed ethnicity) had high health-resource use. Problems were 59% musculoskeletal; 65% >1 year duration. The 26-week questionnaire response rate was 89%. Compared to baseline, the mean 26-week MYMOP improved by 1.0 (95% confidence interval [CI] = 0.4 to 1.5) in the acupuncture group and 0.6 (95% CI = 0.3 to 0.9) in the control group (adjusted mean difference: acupuncture versus control –0.6 [95% CI = –1.1 to 0] P = 0.05). Other between-group adjusted mean differences were: W-BQ12 4.4 (95% CI = 1.6 to 7.2) P = 0.002; EQ-5D index 0.03 (95% CI = –0.11 to 0.16) P = 0.70; consultation rate ratio 0.90 (95% CI = 0.70 to 1.15) P = 0.4; and number of medications 0.56 (95% CI = 0.47 to 1.6) P = 0.28. All differences favoured the acupuncture group. Imputation for missing values reduced the MYMOP adjusted mean difference to –0.4 (95% CI = –0.9 to 0.1) P = 0.12. Improvements in MYMOP and W-BQ12 were maintained at 52 weeks.
Conclusion
The addition of 12 sessions of five-element acupuncture to usual care resulted in improved health status and wellbeing that was sustained for 12 months.
doi:10.3399/bjgp11X572689
PMCID: PMC3103692  PMID: 21801508
acupuncture; chronic disease; medically unexplained symptoms; primary care; randomised controlled trial
16.  Traditional acupuncture for people with medically unexplained symptoms: a longitudinal qualitative study of patients’ experiences 
The British Journal of General Practice  2011;61(587):e306-e315.
Background
People with medically unexplained physical symptoms (MUPS) are helped by interventions that combine physical and psychological explanations and treatment. Traditional acupuncture may offer such a perspective, but its use for these patients has not been investigated.
Aim
To ascertain how patients with MUPS perceive and experience five-element acupuncture treatment.
Design and setting
A longitudinal qualitative interview study, nested in a randomised controlled trial was carried out in four general practices in socioeconomically diverse areas of London.
Method
A purposive sample of 20 trial participants was interviewed twice, at the start and the end of 6 months of acupuncture treatment. Semi-structured interviews were transcribed, coded, and analysed thematically, summarising both across-case as themes and within-case individual vignettes.
Results
Acupuncture, initially accepted as ‘just another referral’ — one like many others that had been tried and proved unsuccessful — was valued for the amount of time allotted with a caring practitioner who listened and responded, as well as for the interactive and holistic nature of the sessions. These attributes encouraged many patients to take an active role in their treatment, including making cognitive or behavioural lifestyle changes. Interviewees cited a wide range of changes in their health that spanned physical, psychological, and social dimensions. These were largely positive and included an increase in physical and/or mental energy, as well as feelings of greater personal control, calmness, and relaxation. Three interviewees reported worsening health but did not ascribe this to acupuncture.
Conclusion
Many patients who were treated with five-element acupuncture perceived a range of positive effects and appeared to take on a more active role in consultations and self-care.
doi:10.3399/bjgp11X577972
PMCID: PMC3103693  PMID: 21801509
acupuncture therapy; frequent attenders; patient participation; primary care; qualitative research; unexplained symptoms
17.  Pharmaceutical Nanoparticles and the Mucin Biopolymer Barrier 
BioImpacts : BI  2012;2(4):173-174.
S U M M A R Y
Mucus in the gastrointestinal tract remains a tenacious barrier that restricts the passage of many orally administered compounds into the GIT’s epithelial layer and consequently into the systemic circulation. This results in significant decreases in the oral bioavailability of many therapeutic molecules. Nanoparticles offer an avenue to surpass this mucus barrier. They can be used as drug carriers to improve the bioavailability of many compounds that are restricted by mucus. Nanoparticles achieve penetration of the mucus barrier through a multitude of properties that they possess as their size, charge density, and surface functional groups which can all be tailored to achieve optimal penetration of the thick and fibrous mucus barrier. This article offers a quick review about the use of nanoparticles as drug carriers to increase mucus penetration in the gastro intestinal tract.
doi:10.5681/bi.2012.029
PMCID: PMC3648940  PMID: 23678457
Nanoparticles; Mucus; Mucin
18.  Nurse forecasting in Europe (RN4CAST): Rationale, design and methodology 
BMC Nursing  2011;10:6.
Background
Current human resources planning models in nursing are unreliable and ineffective as they consider volumes, but ignore effects on quality in patient care. The project RN4CAST aims innovative forecasting methods by addressing not only volumes, but quality of nursing staff as well as quality of patient care.
Methods/Design
A multi-country, multilevel cross-sectional design is used to obtain important unmeasured factors in forecasting models including how features of hospital work environments impact on nurse recruitment, retention and patient outcomes. In each of the 12 participating European countries, at least 30 general acute hospitals were sampled. Data are gathered via four data sources (nurse, patient and organizational surveys and via routinely collected hospital discharge data). All staff nurses of a random selection of medical and surgical units (at least 2 per hospital) were surveyed. The nurse survey has the purpose to measure the experiences of nurses on their job (e.g. job satisfaction, burnout) as well as to allow the creation of aggregated hospital level measures of staffing and working conditions. The patient survey is organized in a sub-sample of countries and hospitals using a one-day census approach to measure the patient experiences with medical and nursing care. In addition to conducting a patient survey, hospital discharge abstract datasets will be used to calculate additional patient outcomes like in-hospital mortality and failure-to-rescue. Via the organizational survey, information about the organizational profile (e.g. bed size, types of technology available, teaching status) is collected to control the analyses for institutional differences.
This information will be linked via common identifiers and the relationships between different aspects of the nursing work environment and patient and nurse outcomes will be studied by using multilevel regression type analyses. These results will be used to simulate the impact of changing different aspects of the nursing work environment on quality of care and satisfaction of the nursing workforce.
Discussion
RN4CAST is one of the largest nurse workforce studies ever conducted in Europe, will add to accuracy of forecasting models and generate new approaches to more effective management of nursing resources in Europe.
doi:10.1186/1472-6955-10-6
PMCID: PMC3108324  PMID: 21501487
19.  Nurse staffing and quality of care in UK general practice: cross-sectional study using routinely collected data 
Background
In many UK general practices, nurses have been used to deliver results against the indicators of the Quality and Outcomes Framework (QOF), a ‘pay for performance’ scheme.
Aim
To determine the association between the level of nurse staffing in general practice and the quality of clinical care as measured by the QOF.
Design of the study
Cross-sectional analysis of routine data.
Setting
English general practice in 2005/2006.
Method
QOF data from 7456 general practices were linked with a database of practice characteristics, nurse staffing data, and census-derived data on population characteristics and measures of population density. Multi-level modelling explored the relationship between QOF performance and the number of patients per full-time equivalent nurse. The outcome measures were achievement of quality of care for eight clinical domains as rated by the QOF, and reported achievement of 10 clinical outcome indicators derived from it.
Results
A high level of nurse staffing (fewer patients per full-time equivalent practice-employed nurse) was significantly associated with better performance in 4/8 clinical domains of the QOF (chronic obstructive pulmonary disease, coronary heart disease, diabetes, and hypertension, P = 0.004 to P<0.001) and in 4/10 clinical outcome indicators (diabetes: glycosylated haemoglobin [HbA1C] ≤7.4%, HbA1C ≤10% and total cholesterol ≤193 mg/dl; and stroke: total cholesterol ≤5 mmol/L, P = 0.0057 to P<0.001).
Conclusion
Practices that employ more nurses perform better in a number of clinical domains measured by the QOF. This improved performance includes better intermediate clinical outcomes, suggesting real patient benefit may be associated with using nurses to deliver care to meet QOF targets.
doi:10.3399/bjgp10X482086
PMCID: PMC2801804  PMID: 20040166
cross-sectional studies; family practice; health care; incentive; nursing staff; personnel staffing and scheduling; physician incentive plans; quality indicators; quality of health care; reimbursement
20.  Hospital admissions for asthma, diabetes and COPD: is there an association with practice nurse staffing? A cross sectional study using routinely collected data 
Background
Delivering good quality primary care for patients with chronic conditions has the potential to reduce non-elective hospital admissions. Practice nurse staffing levels in England have been linked to attainment of general practice performance targets for some chronic conditions. The aim of this study was to examine whether practice nurse staffing level is similarly associated with non-elective hospital admissions in three clinical areas: asthma, Chronic Obstructive Pulmonary Disease (COPD) and diabetes.
Methods
This observational study used cross sectional analysis of routinely collected data. Hospital admissions data for the period 2005-2006 (for asthma, COPD and diabetes) were linked with a database of practice characteristics, nurse staffing data and data on population characteristics for the same period. Statistical modelling explored the relationship between non-elective hospital admission rates for the three conditions and the list size per full time equivalent (FTE) practice nurse.
Results
Higher practice nurse staffing levels were significantly associated with lower rates of admission for asthma (p < 0.001) and COPD (p < 0.001). A similar association was seen for patients with two or more admissions (p < 0.05 for asthma and p < 0.001 for COPD). For diabetes, higher practice nurse staffing level was significantly associated with higher admission rates (p < 0.05), but this association was not significant in case of patients with two or more admissions. Across all models, increasing deprivation was associated with higher admission rates for all conditions.
Conclusions
The inconsistent relationship between nurse staffing and patient outcomes across the different conditions and the fact that for diabetes the relationship between staffing and outcomes was in a different direction from the association between staffing and care quality, highlights the need to avoid making a simple causal interpretation of these findings and reduces the possible confidence in such conclusions. There is a need for more research into the organisation and delivery of diabetes care services in general practice, preferably using patient level data; in order to better understand the impact of the different staffing configurations on patient outcomes.
doi:10.1186/1472-6963-10-276
PMCID: PMC2955649  PMID: 20858245
21.  Determinants of knowledge gain in evidence-based medicine short courses: an international assessment 
Open Medicine  2010;4(1):e3-e10.
Background
Health care professionals worldwide attend courses and workshops to learn evidence-based medicine (EBM), but evidence regarding the impact of these educational interventions is conflicting and of low methodologic quality and lacks generalizability. Furthermore, little is known about determinants of success. We sought to measure the effect of EBM short courses and workshops on knowledge and to identify course and learner characteristics associated with knowledge acquisition.
Methods
Health care professionals with varying expertise in EBM participated in an international, multicentre before–after study. The intervention consisted of short courses and workshops on EBM offered in diverse settings, formats and intensities. The primary outcome measure was the score on the Berlin Questionnaire, a validated instrument measuring EBM knowledge that the participants completed before and after the course.
Results
A total of 15 centres participated in the study and 420 learners from North America and Europe completed the study. The baseline score across courses was 7.49 points (range 3.97–10.42 points) out of a possible 15 points. The average increase in score was 1.40 points (95% confidence interval 0.48–2.31 points), which corresponded with an effect size of 0.44 standard deviation units. Greater improvement in scores was associated (in order of greatest to least magnitude) with active participation required of the learners, a separate statistics session, fewer topics, less teaching time, fewer learners per tutor, larger overall course size and smaller group size. Clinicians and learners involved in medical publishing improved their score more than other types of learners; administrators and public health professionals improved their score less. Learners who perceived themselves to have an advanced knowledge of EBM and had prior experience as an EBM tutor also showed greater improvement than those who did not.
Interpretation
EBM course organizers who wish to optimize knowledge gain should require learners to actively participate in the course and should consider focusing on a small number of topics, giving particular attention to statistical concepts.
PMCID: PMC3116678  PMID: 21686291
22.  Is satisfaction a direct predictor of nursing turnover? Modelling the relationship between satisfaction, expressed intention and behaviour in a longitudinal cohort study 
Background
The theory of planned behaviour states that attitudinal variables (e.g. job satisfaction) only have an indirect effect on retention whereas intentions have a direct effect. This study uses secondary data from a longitudinal cohort of newly qualified nurses to test for the direct and indirect effects of job satisfaction (client care, staffing, development, relationships, education, work-life interface, resources, pay) and intentions to nurse on working as a nurse during the 3 years after qualification.
Methods
A national sample (England) of newly qualified (1997/98) nurses (n = 3669) were surveyed at 6 months, 18 months and 3 years. ANOVA and MANOVA were used for comparison of mean job satisfaction scores between groups; intentions to nurse (very likely, likely vs. unlikely, very unlikely and unable to say at this stage); working (or not working as a nurse) at each time-point. Indirect and direct effects were tested using structural equation and logistic regression models.
Results
Intentions expressed at 6 months to nurse at 18 months were associated with higher scores on pay and relationships, and intentions at 3 years were associated with higher scores on care, development, relationships, work-life interface, resources, pay respectively. Intentions expressed at 18 months to nurse at 3 years were associated with higher scores on development, relationships, education and work-life interface. Associations with actual nursing were fewer. Those working as a nurse had higher satisfaction scores for development (18 months) and relationships (3 years). Regression models found significant associations between the pay and staffing factors and intentions expressed at 6 months to nurse at 18 months, and between pay and intentions to nurse at 3 years. Many of the associations between intentions and working as a nurse were significant. Development was the only job satisfaction factor significantly associated with working as a nurse and just at 18 months.
Conclusion
Results partially support the theory of planned behaviour. Intentions expressed by nurses are stronger predictors of working as a nurse than job satisfaction. Retention strategies should focus on identifying nurses showing early signs of departure with emphasis on developmental aspects, mentoring and support.
doi:10.1186/1478-4491-6-22
PMCID: PMC2600630  PMID: 18976478
23.  A Japanese version of the Perceived Stress Scale: cross-cultural translation and equivalence assessment 
BMC Psychiatry  2008;8:85.
Background
This paper describes the development of a Japanese version of the Perceived Stress Scale (PSS), and examines the equivalence between the original and translated version. The PSS is one of the few instruments to measure a global level of perceived stress, and has been widely used in a range of clinical and research settings. The PSS has already been translated into several languages, but there is no validated Japanese version.
Methods
A forward-backward procedure was implemented. Multiple forward and backward translations were produced, and a panel of reviewers verified conceptual and semantic equivalence between the source and final versions. Non-professional translators who were not brought up in bilingual families were used in order to enhance representativeness of language in the target populations. The PSS was administered to 222 native English speakers and the Japanese version (PSS-J) to 1320 native Japanese speakers.
Results
Factor analysis showed similar factor loadings of the items and satisfactory factorial agreement between the PSS and PSS-J. Cronbach's alpha coefficient was high for both versions and for each factor.
Conclusion
It is concluded that the PSS and PSS-J are substantially equivalent and suited for use in comparative cross-cultural studies.
doi:10.1186/1471-244X-8-85
PMCID: PMC2569029  PMID: 18826581
24.  Job satisfaction trends during nurses' early career 
BMC Nursing  2008;7:7.
Background
Job satisfaction is an important component of nurses' lives that can impact on patient safety, productivity and performance, quality of care, retention and turnover, commitment to the organisation and the profession. Little is known about job satisfaction in early career and how it varies for different groups of nurses. This paper investigates how the components of job satisfaction vary during early career in newly qualified UK nurses.
Methods
Nurses were sampled using a combined census and multi-stage approach (n = 3962). Data were collected by questionnaire at 6 months, 18 months and 3 years after qualification between 1998 and 2001. Scores were calculated for seven job satisfaction components and a single item that measured satisfaction with pay. Scores were compared longitudinally and between nursing speciality (general, children's, mental health) using a mixed model approach.
Results
No single pattern across time emerged. Trends varied by branch and job satisfaction component. Rank order of job satisfaction components, from high to low scores, was very similar for adult and child branch nurses and different for mental health. Nurses were least satisfied with pay and most satisfied with relationships at 6 and 18 months and with resources (adult and child) and relationships (mental health) at 3 years. Trends were typically upwards for adult branch nurses, varied for children's nurses and downwards for mental health nurses.
Conclusion
The impact of time on job satisfaction in early career is highly dependent on specialism. Different contexts, settings and organisational settings lead to varying experiences. Future research should focus on understanding the relationships between job characteristics and the components of job satisfaction rather than job satisfaction as a unitary construct. Research that further investigates the benefits of a formal one year preceptorship or probationary period is needed.
doi:10.1186/1472-6955-7-7
PMCID: PMC2435528  PMID: 18534023
25.  Translation and equivalence assessment for a Japanese version of the modified Parental Nurturance Scale: a comparative study 
Background
This paper reports on the modification of the Parental Nurturance Scale (PNS), translation of the modified version (PNSM) from English to Japanese, and equivalence assessment between the PNSM and the translated version (PNSM-J). The PNS was modified so as to enable its use in nurturance studies where the prime source of nurturance might vary between respondents.
Method
It was translated into Japanese through the forward-backward translation procedure. With attempting to enhance representativeness of language in the target populations, translators used were married couples that consisted of a native English speaker and a native Japanese speaker. Multiple translations were produced and used to make a single Japanese version. A panel of reviewers identified problems in conceptual and semantic equivalence between the original and the translated versions. The Japanese version was altered accordingly with reference to alternate Japanese forms from the original English to Japanese translations. The altered translation was again re-translated into English and problematic differences were checked. This forward-backward process was repeated until satisfactory agreement was attained. The PNSM was administered to 222 native English speakers and the PNSM-J to 1320 native Japanese speakers.
Results
Factor analysis and target rotation revealed a nearly identical factor structure and factor loadings of the items of the PNSM and PNSM-J between the different cultural groups. High Cronbach's alpha coefficient supported the reliability of the test scores on both versions.
Conclusion
The equivalence between the two scales was supported. It is suggested that the PNSM and PNSM-J are suitable tools for comparative cross-cultural studies.
doi:10.1186/1751-0759-1-4
PMCID: PMC1805774  PMID: 17371574

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