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IntroductionYoung people in contact with the youth justice system are more likely to present with complex ongoing needs than young people in the general population. To address this, the Framework for Integrated Care (SECURE STAIRS) is being implemented in the Children and Young People's Secure Estate: a ‘whole systems’ approach to support secure settings to develop trauma-informed and relationally based environments, supporting staff to provide consistent, therapeutic care. This paper aims to present the protocol for a national cohort study examining the impact and implementation of this cultural transformation programme.Methods and analysisA mixed-methods realist evaluation will be conducted. Data collection will take place between August 2018 and December 2020. Eighteen sites will collect routine service activity data and questionnaires completed by young people, parents/guardians and staff. Semi-structured interviews and non-participant observations will be conducted across five qualitative focus sites with young people and staff. An economic evaluation will examine value for money. The results will be triangulated at the analysis stage to gain an in-depth understanding of experiences.Ethics and disseminationEthical approval was granted by the Health Research Authority, Her Majesty’s Prison and Probation Service and UCL Ethics Committee. Findings will be disseminated via project reports, site feedback, peer-reviewed journal publications and conference presentations.

Parenteral opioids (intramuscular and intravenous drugs including patient-controlled analgesia) are used for pain relief in labour in many countries throughout the world. This review is an update of a review first published in 2010.To assess the effectiveness, safety and acceptability to women of different types, doses and modes of administration of parenteral opioid analgesia in labour. A second objective is to assess the effects of opioids in labour on the baby in terms of safety, condition at birth and early feeding.We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (11 May 2017) and reference lists of retrieved studies.We included randomised controlled trials examining the use of intramuscular or intravenous opioids (including patient-controlled analgesia) for women in labour. Cluster-randomised trials were also eligible for inclusion, although none were identified. We did not include quasi-randomised trials. We looked at studies comparing an opioid with another opioid, placebo, no treatment, other non-pharmacological interventions (transcutaneous electrical nerve stimulation (TENS)) or inhaled analgesia.Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the quality of each evidence synthesis using the GRADE approach.We included 70 studies that compared an opioid with placebo or no treatment, another opioid administered intramuscularly or intravenously or compared with TENS applied to the back. Sixty-one studies involving more than 8000 women contributed data to the review and these studies reported on 34 different comparisons; for many comparisons and outcomes only one study contributed data. All of the studies were conducted in hospital settings, on healthy women with uncomplicated pregnancies at 37 to 42 weeks' gestation. We excluded studies focusing on women with pre-eclampsia or pre-existing conditions or with a compromised fetus. Overall, the evidence was graded as low- or very low-quality regarding the analgesic effect of opioids and satisfaction with analgesia; evidence was downgraded because of study design limitations, and many of the studies were underpowered to detect differences between groups and so effect estimates were imprecise. Due to the large number of different comparisons, it was not possible to present GRADE findings for every comparison.For the comparison of intramuscular pethidine (50 mg/100 mg) versus placebo, no clear differences were found in maternal satisfaction with analgesia measured during labour (number of women satisfied or very satisfied after 30 minutes: 50 women; 1 trial; risk ratio (RR) 7.00, 95% confidence interval (CI) 0.38 to 128.87, very low-quality evidence), or number of women requesting an epidural (50 women; 1 trial; RR 0.50, 95% CI 0.14 to 1.78; very low-quality evidence). Pain scores (reduction in visual analogue scale (VAS) score of at least 40 mm: 50 women; 1 trial; RR 25, 95% CI 1.56 to 400, low-quality evidence) and pain measured in labour (women reporting pain relief to be "good" or "fair" within one hour of administration: 116 women; 1 trial; RR 1.75, 95% CI 1.24 to 2.47, low-quality evidence) were both reduced in the pethidine group, and fewer women requested any additional analgesia (50 women; 1 trial; RR 0.71, 95% CI 0.54 to 0.94, low-quality evidence).There was limited information on adverse effects and harm to women and babies. There were few results that clearly showed that one opioid was more effective than another. Overall, findings indicated that parenteral opioids provided some pain relief and moderate satisfaction with analgesia in labour. Opioid drugs were associated with maternal nausea, vomiting and drowsiness, although different opioid drugs were associated with different adverse effects. There was no clear evidence of adverse effects of opioids on the newborn. We did not have sufficient evidence to assess which opioid drug provided the best pain relief with the least adverse effects.Though most evidence is of low- or very-low quality, for healthy women with an uncomplicated pregnancy who are giving birth at 37 to 42 weeks, parenteral opioids appear to provide some relief from pain in labour but are associated with drowsiness, nausea, and vomiting in the woman. Effects on the newborn are unclear. Maternal satisfaction with opioid analgesia was largely unreported. The review needs to be examined alongside related Cochrane reviews. More research is needed to determine which analgesic intervention is most effective, and provides greatest satisfaction to women with acceptable adverse effects for mothers and their newborn.

Aim: To describe the perceived role of nurses and other carers of people with multiple sclerosis from the perspective of different stakeholders (people with multiple sclerosis, non-specialist nurses, specialist nurses and other health care professionals). Background: Multiple sclerosis is one of the commonest causes of disability in young adults. People with multiple sclerosis require supportive care during the disease trajectory. The role of different health and social care providers has not been reported previously. Design, Survey, Method: Questionnaire data collected in 2002 during the first phase of scale development (health professionals n = 459; people with multiple sclerosis n = 65; total response rate 59·4%). The data were reanalysed to compare responses across sample groups. Results: There was consensus that neurologists and specialist nurses were the most appropriate professionals in the provision of specialist care with specialist nurses also being identified as key providers of emotional support. However, there were also significant differences in nominations reflecting the different perspectives of the stakeholder groups and a self-report bias. Each stakeholder group frequently emphasised their own perceived contribution to care. The different perspective of people with multiple sclerosis was also noteworthy with their greater emphasis on social care and lay support. Conclusions: The findings indicate a dissonance in the views of different stakeholders within the care system. The division of labour associated with nursing care requires further exploration. The contrasting paradigms of health care professionals and people with multiple sclerosis regarding models of disability were highlighted. Relevance to clinical practice: Multiple sclerosis, like other chronic illnesses, requires substantial nursing care. There is a growing number of specialist nurses in the workforce, however, little is known how their role interfaces with other nurses.

Aim. To develop and validate a learning needs assessment scale. Background. Learning needs analysis is a central component of continuing professional development but there is a lack of psychometrically developed learning needs assessment tools. Self-assessment questionnaires are emerging as a key method. The development of a learning needs analysis scale for multiple sclerosis specialist nurses is described. Design. A psychometric approach comprising the three phases of the development and testing of the scale are outlined. Method. Phase 1: Item identification using a literature review; postal survey of stakeholders (n = 320), 20 nurse interviews; four nurse focus groups; five telephone interviews with people with MS. Phase 2: Refinement of draft scale and establishing face and content validity testing using an expert panel. Phase 3: Testing of draft scale using data from a postal survey (n = 47 MS specialist nurses) to assess the feasibility and effectiveness of scale, internal consistency and construct validity. Test–retest reliability was assessed using data from 17 MS specialist nurse respondents to calculate intra-class correlation coefficients. Results. The data from the different study phases informed scale refinement. The validity and reliability of the scale was confirmed through testing. Conclusion. The study provides an example of how a robust learning needs assessment scale may be developed for a specialist area of nursing practice to be used in conjunction with more subjective approaches. Relevance to clinical practice. High quality nursing care depends upon a competent nursing workforce that engages in continuing professional development. This study provides an example of a psychometrically developed learning needs assessment scale to inform continuing professional development needs of nurses working in a specialist area of practice.

With national evidence on what women want from maternity services, and the benefits of continuity of carer schemes, this article describes the management, evaluation and results of a local project It is a triangulation of the significant and important results of three separate pieces of work undertaken as part of the evaluation of Stoke Mandeville Hospital NHS Trust's Changing Childbirth project.

Many women will experience complications in early pregnancy. The loss of a pregnancy can cause considerable emotional distress for women and their families, as well as physical morbidity that results in over 50 000 inpatient admissions in the UK annually.1 The mortality associated with ectopic pregnancy is decreasing but remains at an estimated 0.2 per 1000 ectopic pregnancies. Of the women who died during 2006–08, half were from minority ethnic groups—and so may have accessed care later or experienced difficulty in communication—and most deaths were associated with substandard care due to failure to consider ectopic pregnancy when presentation was atypical.2 Therefore, it is vital that healthcare professionals in all specialties are alert to the possibility of ectopic pregnancy in order to avoid missed opportunities for diagnosis. This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on the care for women with ectopic pregnancy and miscarriage.3 NICE recommendations are based on systematic reviews of the best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italics in square brackets. ### Support and information giving

Historically, nurses have made a significant contribution to the health of children. To date, few attempts have been made to conceptualize the nature of that contribution. This article describes a scoping exercise undertaken to provide a conceptual basis for examining the contribution of nurses to child health and child health services. Three approaches were utilized: strategic topic-focused literature reviews (asthma, cancer, disadvantaged families, minor ailments, school health, sick neonates, teenage pregnancy, children with complex needs, children in need of protection or looked-after, troubled schoolchildren), stakeholder conferences and an expert panel. The contribution of nurses to child health and child health services was found to be broad-ranging and diffuse. The contribution is expressed in four integrated dimensions: assessment, health promotion, clinical care and health care organization. The conceptual models detailed in the scoping exercise provide a platform for future inquiry.

This article summarises the most recent guidance from the National Institute for Health and Clinical Excellence (NICE) for healthcare professionals caring for women during labour and birth.1 It defines the care that women who are at low risk of complications in labour at term should expect to receive, and therefore it relates to most women giving birth in the United Kingdom. NICE recommendations are based on systematic reviews of the best available evidence. When minimal evidence is available, a range of consensus techniques is used to develop recommendations. In this summary, recommendations derived primarily from consensus techniques are indicated with an asterisk (*). ### General principles ### Place of birth

In England, rates of caesarean section have increased from 9% of births in 1980 to 24.8% in 2010.1 The indications for the procedure vary. Healthcare professionals have to provide evidence based information for women about the risks and benefits of both planned and unplanned caesarean section. To advise women appropriately they also need to be aware of specific indications for caesarean section, effective management to avoid unnecessary caesarean section and reduce morbidity from caesarean section, and birth after a caesarean section. This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on caesarean section.2 NICE recommendations are based on systematic reviews of the best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italics in square brackets. ### Possible reasons for caesarean section #### Breech presentation (existing recommendations) #### Morbidly adherent placenta Women found antenatally to have morbidly adherent placenta (an abnormal adherence of the placenta to the uterine wall) will be advised to have a caesarean section. #### Diagnosis of morbidly adherent placenta (new recommendation)

Bacterial meningitis and meningococcal septicaemia in children and young people are associated with considerable mortality and morbidity. Case fatality rates vary according to the causative organism and the age of the child or young person. In the United Kingdom they range from 2% to 11% and are especially high (about 10%) in neonates (children younger than 28 days). Survivors of bacterial meningitis and meningococcal septicaemia may experience serious long term morbidities (box 1). This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on the management of bacterial meningitis and meningococcal septicaemia in children and young people aged under 16 years in primary and secondary care.1 #### Box 1 Long term morbidities associated with bacterial meningitis and meningococcal septicaemia NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets. ### Symptoms and signs of bacterial meningitis and meningococcal septicaemia View this table: Symptoms and signs of bacterial meningitis and meningococcal septicaemia

Constipation is described as “the subjective complaint of passage of abnormally delayed or infrequent passage of dry, hardened faeces, often accompanied by straining and/or pain.”1 Constipation is common in childhood, is rarely life threatening, and therefore might be expected to have little effect on healthcare provision. The reality is somewhat different, however. Symptoms become chronic in more than a third of patients, causing great discomfort, and many children need medical treatment and nursing care.2 3 4 5 Lack of understanding about the condition, delayed diagnosis, and suboptimal treatment and support contribute to ongoing symptoms and multiple medical consultations.6 Social costs include children missing school, being excluded from peer group activities, and feeling that they cannot tell their friends about their condition. This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on the care and management of children and young people with idiopathic constipation.7 NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the experience and opinion of the Guideline Development Group (GDG) on what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets. ### Establishing the presence of constipation Establish whether constipation is present during history taking. Two or more of the following findings indicate constipation