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BackgroundImproving the quality and efficiency of healthcare is an international priority. A range of complex ward based quality initiatives have been developed over recent years, perhaps the most influential programme has been Productive Ward: Releasing Time to Care. The programme aims to improve work processes and team efficiency with the aim of ‘releasing time’, which would be used to increase time with patients ultimately improving patient care, although this does not form a specific part of the programme. This study aimed to address this and evaluate the impact using recent methodological advances in complex intervention evaluation design.MethodThe objective of this study was to assess the impact of an augmented version of The Productive Ward: Releasing Time to Care on staff and patient outcomes. The design was a naturalistic stepped-wedge trial. The setting included fifteen wards in two acute hospitals in a Scottish health board region. The intervention was the Productive Ward: Releasing Time to Care augmented with practice development transformational change methods that focused on staff caring behaviours, teamwork and patient feedback. The primary outcomes included nurses’ shared philosophy of care, nurse emotional exhaustion, and patient experience of nurse communication. Secondary outcomes covered additional key dimensions of staff and patient experience and outcomes and frequency of emergency admissions for same diagnosis within 6 months of discharge.ResultsWe recruited 691 patients, 177 nurses and 14 senior charge nurses. We found statistically significant improvements in two of the study’s three primary outcomes: patients’ experiences of nurse communication (Effect size=0.15, 95% CI; 0.05 to 0.24), and nurses’ shared philosophy of care (Effect size =0.42, 95% CI; 0.14 to 0.70). There were also significant improvements in secondary outcomes: patients’ overall rating of ward quality; nurses’ positive affect; and items relating to nursing team climate. We found no change in frequency of emergency admissions within six months of discharge.ConclusionsWe found evidence that the augmented version of The Productive Ward: Releasing Time to Care Intervention was successful in improving a number of dimensions of nurse experience and ward culture, in addition to improved patient experience and evaluations of the quality of care received. Despite these positive summary findings across all wards, intervention implementation appeared to vary between wards. By addressing the contextual factors, which may influence these variations, and tailoring some elements of the intervention, it is likely that greater improvements could be achieved.Trial registration numberUKCRN 14195.

Objective: The present study investigates whether nurses working for a national medical telephone helpline show evidence of "decision fatigue," as measured by a shift from effortful to easier and more conservative decisions as the time since their last rest break increases. Method: In an observational, repeated-measures study, data from approximately 4,000 calls to 150 nurses working for the Scottish NHS 24 medical helpline (37% of the national workforce) were modeled to determine whether the likelihood of a nurse's decision to refer a patient to another health professional the same day (the clinically safest but most conservative and resource inefficient decision) varied according to the number of calls taken/time elapsed since a nurse's last rest break and/or since the start of shift. Analyses used mixed-effect logistic regression. Results: For every consecutive call taken since last rest break, the odds of nurses making a conservative management decision (i.e., arranging for callers to see another health professional the same day) increased by 5.5% (p = .001, 95% confidence interval [CI: 2.2, 8.8]), an increase in odds of 20.5% per work hour (p < .001, 95% CI [9.1, 33.2]) or 49.0% (on average) from immediately after 1 break to immediately before the next. Decision-making was not significantly related to general or cumulative workload (calls or time elapsed since start of shift). Conclusions: Every consecutive decision that nurses make since their last break produces a predictable shift toward more conservative, and less resource-efficient, decisions. Theoretical models of cognitive fatigue can elucidate how and why this shift occurs, helping to identify potentially modifiable determinants of patient care.

Background. The development and transformation of nursing within professional tertiary education have exerted a great pressure and challenge upon nursing students. Stress experienced by nursing students is a common precursor of psychological distress and attrition. However, no scale is specifically used to evaluate the sources of stress experienced by nursing students in Mainland China. Aims and Objective. This study is aimed at testing and comparing the reliability and validity including sensitivity and specificity of two nursing students’ stress instruments, the Chinese version of Student Nurse Stress Index Scale (SNSI-CHI), and the Stressors in Student Nursing Scale (SINS-CN) in Chinese nursing students, and describing the stress status of nursing students in China. Methods. A cross-sectional survey was conducted in two nursing schools in Henan Province from August 2017 to January 2018. Data were collected by using a questionnaire comprising the Chinese version of SNSI (SNSI-CHI), the Chinese version of SINS (SINS-CN), and the Chinese Perceived Stress Scale (CPSS). Homogeneity and stability, content, construct and concurrent validity, and sensitivity and specificity were assessed. Results. The Cronbach’s alpha (α) of SNSI-CHI was 0.90, and the item-to-total correlations ranged from 0.35 to 0.66. The Cronbach’s α of SINS-CN was 0.93, and the item-to-total correlations ranged from 0.19 to 0.61. The findings of exploratory factor analysis (EFA) confirmed a good construct validity of SNSI-CHI and SINS-CN. The Pearson’s rank correlation coefficients, between total scores of SNSI-CHI and CPSS and SINS-CN and CPSS, were assessed to 0.38 ( P < 0.01 ) and 0.39 ( P < 0.01 ), respectively. Regarding the CPSS, as the criterion, the cut-points of SNSI-CHI and SINS-CN for the area under the receiver operator characteristic (ROC) curve were 0.77and 0.66, respectively. Conclusion. Both scales are valid and reliable for evaluating the source of stress of student nurses in China. Each has its own characteristics, but the SNSI-CHI demonstrated marginal advantage over the SINS-CN. The SNSI-CHI is short, is easily understood, and with clear dimension for the nursing students, and the SNSI-CHI is more acceptable for the users in China.

Background Infant moderate pressure massage is an effective evidence-based intervention that counters the consequences of prematurity and exposure to the Neonatal Intensive Care Unit (NICU) environment. This touch-based therapy reduces physiological stress and improves physical, cognitive and neurological development in stable preterm and low birth weight (LBW) infants. Currently, little is known about the barriers and facilitators that surround its implementation. Aims This study explored the cultural, organisational and contextual factors perceived by parents and healthcare professionals (HCPs) about the option of implementing infant massage in the Lebanese context. Methods A qualitative exploratory approach informed by Normalization Process Theory (NPT) was used; 22 parents and 38 HCPs were recruited from three university hospitals over seven-month period. COREQ guidelines were used to inform reporting and as a quality appraisal checklist. Framework approach was used for data analysis of the focus groups (seven with parents, six with HCPs) and non-participant observation. The four constructs of NPT guided data collection and analysis, interpretation of the findings and understanding of the implementation issues. Findings Four themes emerged: understanding infant massage; perception of massage benefits and risks; perceived barriers for engaging in the practice of massage, and strategies to facilitate future implementation. Participants were accepting of the massage concept. However, HCPs were concerned that workload and lack of time would make implementation difficult and interfere with daily care. Both groups highlighted parental fear and anxiety, entry to NICU, and space availability as main contextual and organizational implementation barriers. Communication, gradual implementation, encouragement and support were potential facilitators perceived by parents while adequate preparation, commitment, and establishing protocol and guidelines were the identified facilitators for HCPs. Conclusion Study findings provide important insights into the barriers and facilitators for the implementation of massage to assist in future evidence-based interventions within and beyond the Lebanese NICU context.

Background Cardiac rehabilitationis effective in promoting physical/psychological recovery following acute coronary syndrome. Yet, rates of attendance at outpatient cardiac rehabilitation by eligible patients are low. Objectives This study examined the determinants of attendance at outpatient cardiac rehabilitation in acute coronary syndrome patients following discharge until cardiac rehabilitation commencement. Design A weekly electronic diary measured cardiac-related cognitions and mood and examined their relation to attendance at outpatient cardiac rehabilitation. Settings Three United Kingdom National Health Service secondary care settings in two Health Board areas in Scotland. Participants Acute coronary syndrome patients were recruited from March 2012 to June 2013 prior to hospital discharge. Of 488 eligible patients referred for cardiac rehabilitation, 214 consented. Methods Consecutive patients completed a pre-hospital discharge questionnaire targeting age, diagnosis, social class and smoking history. Acute coronary syndrome patients then completed a weekly electronic diary from the first week of discharge until the start of cardiac rehabilitation. Multilevel structural equation models estimated the effects of initial, i.e. baseline and rate of change in cardiac-related cognition and mood on attendance. Intention to attend cardiac rehabilitation was reflected, log transformed, reported thereafter as “do not intend”. The role of “do not intend” was explored as a mediator of the relationship between cardiac-related cognition and mood on attendance. Results 166 participants provided, on average, 5 weeks of diary entries before cardiac rehabilitation commenced. High intention (i.e. low “do not intend”) to attend CR and its rate of increase over time predicted attendance. Low negative emotional representation, high perceived necessity, high confidence in maintaining function, low negative affect, and high positive affect following discharge predicted attendance at cardiac rehabilitation. The rate of change in cardiac-related mood and these cognitions was not predictive. Baseline and rate of change in “do not intend” entirely mediated relationships between a) perceived necessity, b) negative affect and attendance at cardiac rehabilitation. Conclusions Negative affect in the first weeks following discharge represents the key challenge to a patient maintaining their intention to attend cardiac rehabilitation. Intervention to improve attendance should focus on improving intention to attend following discharge and during recovery by improving patient understanding of cardiac rehabilitation and reducing negative affect.

Aims and objectives To update and re-validate the Valuing Patients as Individuals Scale for use as a patient appraisal of received healthcare. Background Healthcare in the United Kingdom and beyond is required to deliver high quality, person-centred care that is clinically effective and safe. However, patient experience is not uniform, and complaints often focus on the way patients have been treated. Legislation in United Kingdom requires health services to gather and use patients' evaluations of care to improve services. Design This study uses scoping literature reviews, cognitive testing of questionnaire items with patient and healthcare staff focus groups, and exploratory factor analysis. Methods/Setting/Participants Data were collected from 790 participants across 34 wards in two acute hospitals in one National Health Service Health Board in Scotland from September 2011–February 2012. Ethics and Research and Development approval were obtained. Results Fifty six unique items identified through literature review were added to 72 original Valuing Patients as Individuals Scale items. Face validity interviews removed ambiguous or low relevance items leaving 88 items for administration to patients. Two hundred and ninety questionnaires were returned, representing 37% response rate, 71 were incomplete. Thus 219 complete data were used for Exploratory Factor Analysis with varimax orthogonal rotation. This revealed a 31 item, three factor solution, Care and Respect; Understanding and Engagement; Patient Concerns, with good reliability, concurrent and discriminant validity in terms of gender. A shortened 10 item measure based on the top 3 or 4 loading items on each scale was comparable. Relevance to clinical practice The short scale version is now being routinized in real-time evaluation of patient experience contributing to this United Kingdom, National Health Service setting meeting its policy and legislative requirements. What does this paper contribute to the wider global clinical community? •The updated Valuing Patients as Individuals Scale; •Is a reliable and valid measure specifically designed to capture the issues that matter most to people receiving secondary care. •Has been developed based upon current conceptualisations of person-centred care and the clinical practices required to deliver this. •May be used within service improvement work as a trigger to ensure person-centred care delivery.

Aims and objectives To explore what reasons do nonattenders and noncompleters give for their patterns of participation or nonparticipation in cardiac rehabilitation programmes and how future uptake could be enhanced. Background Cardiac rehabilitation is a cost-effective clinical intervention designed for adults with acute coronary syndrome. Despite evidence from meta-analyses demonstrating that cardiac rehabilitation programmes facilitate physical and psychological recovery from acute coronary syndrome, only 20–50% of eligible patients attend Phase III outpatient programmes. Design A qualitative study using thematic analysis. Method Within the context of a larger mixed-method study, acute coronary syndrome patients were recruited between 2012–2014 from three hospitals in Scotland. Of 214 patients who consented to enrol in the main study, a purposive subsample of 25 participants was recruited. Semi-structured interviews were conducted and analysed using thematic analysis. Results Three major influences of participation were identified: (1) personal factors, (2) programme factors and (3) practical factors. In addition, valuable suggestions for future programme modifications were provided. A significant barrier to attending cardiac rehabilitation programmes is that participants perceived themselves to be unsuitable for the programme alongside a lack of knowledge and/or misconceptions regarding cardiac rehabilitation. Conclusion The responses of nonattenders and noncompleters revealed misconceptions related to programme suitability, the intensity of exercise required and the purpose of a cardiac rehabilitation programme. As long as these misconceptions continue to persist in coronary syndrome patients, this will impact upon attendance. The lack of perceived need for cardiac rehabilitation stems from a poor understanding of the programme, especially among nonattenders and noncompleters and subsequently an inability to comprehend possible benefits. Relevance to clinical practice The knowledge of common misconceptions puts clinical nurses in a better position to identify and pro-actively address these erroneous assumptions in their patients in order to improve participation in cardiac rehabilitation.

One of the striking regularities of human behavior is that a prolonged physical, cognitive, or emotional activity leads to feelings of fatigue. Fatigue could be due to (1) depletion of a finite resource of physical and/or psychological energy or (2) changes in motivation, attention, and goal-directed effort (e.g. motivational control theory).To contrast predictions from these two views in a real-time study of subjective fatigue in nurses while working.One hundred nurses provided 1,453 assessments over two 12-hr shifts. Nurses rated fatigue, demand, control, and reward every 90 min. Physical energy expenditure was measured objectively using Actiheart. Hypotheses were tested using multilevel models to predict fatigue from (a) the accumulated values of physical energy expended, demand, control, and reward over the shift and (b) from distributed lag models of the same variables over the previous 90 min.Virtually all participants showed increasing fatigue over the work period. This increase was slightly greater when working overnight. Fatigue was not dependent on physical energy expended nor perceived work demands. However, it was related to perceived control over work and perceived reward associated with work.Findings provide little support for a resource depletion model; however, the finding that control and reward both predicted fatigue is consistent with a motivational account of fatigue.

Accessible summaryWhat is known on the subject? According to estimates more than half of adult mental health service users are parents, but their experiences are largely lacking from research literature. Parental mental illness can often be viewed from a risk perspective. Parents with mental illness and their families have unmet support needs. What this paper adds to existing knowledge? Parents with mental illness want acknowledgement that they can be able and responsible. Many parents adopt an expert by experience identity. Fathers can feel their parental role is not recognized and mothers express fears of being judged if they discuss their illness. What are the implications for practice? Adult mental health services need to recognize and support parental role of service users. Joint care planning and family oriented care should be promoted. Professionals should take advantage of the knowledge of these parents and they could be more actively engaged in service development. AbstractIntroduction Parental mental illness is often viewed from a risk perspective. Despite this, being a parent can be both valuable and motivating. Research literature lacks the perspective of mothers and fathers, who have experienced mental illness. Aim This study explores how parents with mental illness construct their identities as mothers and fathers and their experiences with health and social care services. Method Three focus groups with 19 participants were conducted in Finland and Scotland. Methods of discourse analysis have been used in to analyse the interview data. Results Adult service users want their parenting role recognized and supported. Parents have knowledge and skills which can be utilized and many have adopted an expert by experience identity. Discussion Being able to see oneself as a ‘good’ parent can be challenging but important. Parents may require support, but want to be included in the planning of their care. Services could make more use of the knowledge and skills parents and families have, and joint working could lessen parents’ anxieties. Implications for practice Mental health practitioners are in a key position in providing more family centred, resource focused care. Service user expertise should be acknowledged in clinical practice.

Background Currently, relatively little is known regarding the sources and levels of stress experienced by nursing students in China. This is largely because there is no reliable and valid, culturally appropriate measure of student nurse’ stress. A culturally acceptable, Chinese Version of the Student Nurse Stress Index Scale (SNSI-CHI), with established reliability and validity, is needed to identify sources of stress in Chinese nursing students. Methods This validation study used a cross-sectional descriptive survey design. Stratified cluster random sampling was used to collect data from August 2017 to January, 2018 from 1100 nursing students in Henan Province, China. A demographic questionnaire, SNSI-CHI and Perceived Stress Scale (PSS-14) were administered. Exploratory and confirmatory factor analysis was carried out on two randomly selected samples (each N = 538) from the overall return. The content, construct, predictive and concurrent validity of the translated SNSI-CHI were examined. Results 1076 nursing students returned the survey (97.82% response rate). The average total score of SNSI-CHI was 58.455 ± 13.903. The internal consistency, test-retest reliability and content validity of the SNSI-CHI was excellent with a content validity index of 0.954. A four factor simple structure was revealed and confirmed using exploratory (explaining 75% of the variance) and confirmatory factor analysis (x2/df = 1.347, GFI = 0.956, AGFI = 0.945, RMR = 0.032, RMSEA = 0.025, NFI = 0.974, IFI = 0.993, TLI = 0.992, CFI = 0.993). This structure, i.e. academic load, clinical concerns, interface worries and personal problems compared well with the original SNSI. The SNSI-CHI totals and subscales showed good concurrent and predictive validity with the PSS-14 as comparator or criterion. A score of higher than 65 on the SNSI-CHI indicates high levels of perceived stress symptoms. Some 10.5% of respondents experience high levels of stressful demand. Sensitivity and specificity values of 71.7% and 75.1% respectively, demonstrated good predictive validity. Limitations This study sample was confined to the Henan Province, which may limit its generalizability. A larger and more diverse sample is needed in the future research. Conclusions The SNSI-CHI is both reliable and valid and culturally appropriate for use in China and its structure enables cross-cultural comparison.

Background The study objective was to investigate and synthesize available evidence relating to the psychological health of Emergency Dispatch Centre (EDC) operatives, and to identify key stressors experienced by EDC operatives. Methods Eight electronic databases (Embase, PubMed, Medline, CINAHL, PsycInfo, PsycArticles, The Psychology and Behavioural Sciences Collection, and Google Scholar) were searched. All study designs were included, and no date limits were set. Studies were included if they were published in English, and explored the psychological health of any EDC operatives, across fire, police, and emergency medical services. Studies were excluded if they related solely to other emergency workers, such as police officers or paramedics. Methodological quality of included studies was assessed using checklists adapted from the Critical Appraisal Skills Programme. A narrative synthesis was conducted, using thematic analysis. Results A total of 16 articles were included in the review. Two overarching themes were identified during the narrative synthesis: ‘Organisational and Operational Factors’ and ‘Interactions with Others’. Stressors identified included being exposed to traumatic calls, lacking control over high workload, and working in under-resourced and pressured environments. Lack of support from management and providing an emotionally demanding service were additional sources of stress. Peer support and social support from friends and family were helpful in managing work-related stress. Discussion EDC operatives experience stress as a result of their work, which appears to be related to negative psychological health outcomes. Future research should explore the long-term effects of this stress, and the potential for workplace interventions to alleviate the negative impacts on psychological health. PROSPERO Registration Number CRD42014010806.

Purpose Prostate cancer survivors are keen to engage as active partners in the management of their condition but have voiced a number of unmet support needs that make effective self-management problematic. Identifying self-management behaviours and evaluating how self-management changes over time may provide valuable insights into how men can be better supported to self-manage. Our systematic review aimed to identify the self-management behaviours for prostate cancer survivors and to evaluate whether these change over time. Methods Using the PRISMA statement we performed a systematic review of studies that identified the self-management behaviours of prostate cancer survivors. Databases searched included: DARE, CDSR, Medline, CINAHL, PsycINFO and ASSIA. Studies were classified by levels of evidence and quality assessment. Results 111 publications were retrieved from the search and 5 publications were included. Men performed a variety of self-management behaviours for psychological and physical problems. Only one study assessed changes in self-management behaviours over time and was limited to men treated by radiotherapy. Conclusion Despite the recent political drive for cancer survivors to self-manage, this review has demonstrated the evidence base is under-developed and a wide range of research is needed to address the unmet supportive care needs of prostate cancer survivors. Practically, this review has identified that Dodd’s Self-Care Log was found to have the strongest psychometric properties for additional research in this area.

Objective Men affected by prostate cancer can experience profound physical and psychological sequalae; and unmet support needs are prevalent in men affected by this disease. Social support has been linked to improved health-related quality of life (HRQoL) and coping strategies, but little is known about the relationship between social support, coping and HRQoL for prostate cancer survivors. This review aims to identify the mechanism through which social support influences the relationship between coping and HRQoL for prostate cancer survivors. Methods A literature review was conducted from the earliest date available to January 2013. Medline, CINAHL, PsycInfo, and ASSIA databases were searched using terms relevant to coping, social support and prostate cancer. Studies that explored the relationship between coping, social support and HRQoL were included. Results 175 studies were assessed for potential inclusion with 11 publications included in this review. Studies predominately reported main effects of perceived social support on HRQoL, and few studies assessed moderation and mediation effects of coping and social support on HRQoL. Perceived social support was frequently assessed, but few studies evaluated the effects of received social support or satisfaction with social support on HRQoL. Conclusions The evidence base is under-developed at present. Future research should use a multidimensional inventory of the social support constructs to examine how each of the constructs influences the relationship between coping and HRQoL over time. This may facilitate the development of appropriately targeted social support interventions that are theoretically driven to address the unmet support needs of prostate cancer survivors.

Abdul-Razak Abubakari,1 Martyn C Jones,2 William Lauder,3 Alison Kirk,4 John Anderson,5 Devasenan Devendra,6 Ebrahim K Naderali11School of Health Sciences, Liverpool Hope University, Hope Park, Liverpool, 2School of Nursing and Midwifery, University of Dundee, Dundee, 3School of Nursing and Midwifery and Health, University of Stirling, Stirling, 4Department of Sport, Culture and the Arts, University of Strathclyde, Glasgow, 5Homerton University Hospital NHS Trust, Homerton Row, London, 6West Hertfordshire Hosptials NHS Trust, Watford, UKObjectives: This study investigated ethnic differences in diabetes-specific knowledge, illness perceptions, self-management, and metabolic control among black-African, black-Caribbean,and white-British populations with type 2 diabetes. The study also examined associations between demographic/disease characteristics and diabetes-specific knowledge, illness perceptions, self-management, and metabolic control in each of the three ethnic groups.Design: Cross-sectionalSetting: Diabetes/retinal screening clinics in Hackney and Brent, London.Methods: Black-African, black-Caribbean and white-British populations with type 2 diabetes were asked to participate. Questionnaires measuring demographic/disease characteristics, diabetes-specific knowledge, self-management, and illness perceptions were used for data collection. Data for glycated hemoglobin (HbA1c) and microvascular complications were obtained from medical records. Ethnic differences in diabetes-related measures were estimated using analysis of variance/covariance. Multiple regression techniques were used to determine relationships between demographic/disease characteristics and measured diabetes-related outcomes.Results: Three hundred and fifty-nine patients participated in the study. White-British participants had high diabetes-specific knowledge compared to their black-African and black-Caribbean counterparts. Black-Africans reported better adherence to self-management recommendations than the other ethnic groups. Compared to the white-British patients, black-African and black-Caribbean participants perceived diabetes as a benign condition that could be cured. Educational status and treatment category were determinants of diabetes-specific knowledge in all three ethnic groups. However, different demographic/disease characteristics predicted adherence to self-management recommendations in each ethnic group.Conclusion: Clearly, there is disease (diabetes) knowledge-perception variation between different ethnic groups in the UK which may partly influence overall disease outcome. It is plausible to recommend screening, identifying, and dispelling misconceptions about diabetes among ethnic minority patients by health care professionals as well as emphasizing the importance of self-management in managing chronic diseases such as diabetes.Keywords: black-African, black-Caribbean, white-British, diabetes, illness perceptions, self-management

Nurses working for telephone-based medical helplines must maintain attentional focus while quickly and accurately processing information given by callers to make safe and appropriate treatment decisions. In this study, both higher levels of general occupational stress and elevated stress levels on particular shifts were associated with more frequent failures of attention, memory, and concentration in telephone nurses. Exposure to a stressful shift was also associated with a measurable increase in objectively assessed information-processing errors. Nurses who experienced more frequent cognitive failures at work made more conservative decisions, tending to refer patients on to other health professionals more often than other nurses. As stress is associated with cognitive performance decrements in telephone nursing, stress-reduction interventions could improve the quality and safety of care that callers to medical helplines receive.

Aims and objectives. To present the findings of a structured literature review that aimed to identify the influences on thehealth, safety and welfare of adults with learning disabilities in acute hospitals.Background. There is increasing evidence regarding the inadequacy of care for people with learning disabilities in acute caresettings. However, few studies have specifically addressed their health, safety and welfare in such contexts.Design. Four key electronic databases (Medline; PsycINFO; British Nursing Index and archive; Cumulative Index to Nursingand Allied Health Literature) were searched for relevant literature published between 2000 and 2011.Methods. Publications assessed as meeting the inclusion criteria were retrieved in full. Data were extracted regarding meth-ods used; primary aims of the study being reported; and key findings.Results. Of the 3505 papers identified in the initial search, eight met the inclusion criteria. Analysis revealed six areas ofinfluence on the health, safety and welfare of adults with learning disabilities in acute hospitals: care provision (meetinghealth and personal needs); communication; staff attitudes; staff knowledge; supporters; and carers (valuing their role);physical environment.Conclusions. We represent these six areas diagrammatically, as concentric rings. These influence on health, safety andwelfare form an inner (direct) layer and an outer (indirect) layer consisting of liaison services and education/training. Thisnew conceptualisation of influences as being multi-layered assists in the identification of similarly multi-layered improvementstrategies.Relevance to clinical practice. Adults with learning disabilities can exert their own influence on health, safety and welfareand should be supported to make decisions about their own care. More broadly they should be involved with policy devel-opment, nurse education and research. This can be achieved through inclusive approaches, for example, inviting people withlearning disabilities to input into nursing curricula or to engage in research as coinvestigators.Key words: acute care, health, intellectual disabilities, learning disabilities, literature review, nursing, safety, secondary care,welfare

Aim. To examine the effects of nursing tasks (including their physiological and psychological demands, and the moderating effects of reward and control) on distress and job performance in real time. Background. Nurses working in hospital settings report high levels of occupational stress. Stress in nurses has been linked to reduced physical and psychological health, reduced job satisfaction, increased sickness absence, increased staff turnover, and poorer job performance. In this study, we will investigate theoretical models of stress and use multiple methods, including realtime data collection, to assess the relationship between stress and differentnursing tasks in general medical and surgical ward nurses. Design. A real-time, repeated measures design. Methods. During 2011/2012, 100 nurses from a large general teaching hospital in Scotland will: (a) complete self-reports of mood; (b) have their heart rate and activity monitored over two shifts to obtain physiological indices of stress and energy expenditure; (c) provide perceptions of the determinants of stress in complex ward environments; and (d) describe their main activities. All measures will be taken repeatedly in real time over two working shifts. Discussion. Data obtained in this study will be analysed to examine the relationships between nursing tasks, self-reported and physiological measures of stress and to assess the effect of occupational stress on multiple work outcomes. The results will inform theoretical understanding of nurse stress and its determinants and suggest possible targets for intervention to reduce stress and associated harmful consequences.

Nurses are a stressed group and this may affect their health and work performance. The determinants of occupational stress in nurses and other occupational groups have almost invariably been examined in between subject studies. This study aimed to determine if the main determinants of occupation stress, i.e. demand, control, effort and reward, operate within nurses. A real time study using personal digital-assistant-based ecological momentary assessment to measure affect and its hypothesised determinants every 90 min in 254 nurses over three nursing shifts. The measures were negative affect, positive affect, demand/effort, control and reward. While the effects varied in magnitude between people, in general increased negative affect was predicted by high demand/effort, low control and low reward. Control and reward moderated the effects of demand/effort. High positive affect was predicted by high demand/effort, control and reward. The same factors are associated with variations in stress-related affect within nurses as between.

This paper outlines the qualitative findings of a recent multimethod study exploring the impact of nurses assuming leadership roles in delivering primary health care to detainees within police custody suites in Scotland. The full multimethod study was conducted within a framework of realistic evaluation with key findings indicating that the nurse-led model of service delivery offers positive outcomes for all key stakeholders. Findings from the qualitative component of the study showed that the quality of clinical care for detainees improved, policing concerns for detainee safety were mitigated, and forensic medical examiners were able to expand their specialist roles. Key supporting mechanisms in achieving these outcomes included generating collaborative practices, enacting clinical leadership, and providing a forensic nursing educational program to empower nurses to generate service provision and grow professional autonomy.

Background Stress in health care professionals may reflect both the work and appraisal of work and impacts on the individuals, their patients, colleagues and managers. Purpose The purpose of the present study is to examine physiological and psychological effects of stressors (tasks) and theory-based perceptions of work stressors within and between nurses in real time. Methods During two work shifts, 100 nurses rated experienced stress, affect, fatigue, theory-based measures of work stress and nursing tasks on electronic diaries every 90 min, whereas heart rate and activity were measured continuously. Results Heart rate was associated with both demand and effort. Experienced stress was related to demand, control, effort and reward. Effort and reward interacted as predicted (but only within people). Results were unchanged when allowance was made for work tasks. Conclusions Real-time appraisals were more important than actual tasks in predicting both psychological and physiological correlates of stress. At times when effort was high, perceived reward reduced stress. Electronic supplementary material The online version of this article (doi:10.1007/s12160-015-9746-8) contains supplementary material, which is available to authorized users.

Aim This research protocol describes and justifies a study to assess patients' cardiac-related beliefs (i.e. illness representations, knowledge/misconceptions, cardiac treatment beliefs), motivation and mood over time to predict non-attendance at a cardiac rehabilitation programme by measuring weekly/monthly changes in these key variables. Background Heart disease is the UK's leading cause of death. Evidence from meta-analyses suggests that cardiac rehabilitation facilitates recovery following acute cardiac events. However, 30–60% of patients do not attend cardiac rehabilitation. There is some evidence from questionnaire studies that a range of potentially modifiable psychological variables including patients' cardiac-related beliefs, motivation and mood may influence attendance. Design Mixed-methods. Methods In this study, during 2012–2013, electronic diary data will be gathered weekly/monthly from 240 patients with acute coronary syndrome from discharge from hospital until completion of the cardiac rehabilitation programme. This will identify changes and interactions between key variables over time and their power to predict non-attendance at cardiac rehabilitation. Data will be analysed to examine the relationship between patients' illness perceptions, cardiac treatment beliefs, knowledge/misconceptions, mood and non-attendance of the cardiac rehabilitation programme. The qualitative component (face-to-face interviews) seeks to explore why patients decide not to attend, not complete or complete the cardiac rehabilitation programme. Discussion The identification of robust predictors of (non-)attendance is important for the design and delivery of interventions aimed at optimizing cardiac rehabilitation uptake. Funding for the study was granted in February 2011 by the Scottish Government Chief Scientist Office (CZH/4/650).

farquharson b., allan j., johnston d., johnston m., choudhary c. & jones m. (2012) Stress amongst nurses working in a healthcare telephone-advice service: relationship with job satisfaction, intention to leave, sickness absence, and performance. Journal of Advanced Nursing68(7), 1624–1635. Abstract Aims. This paper is a report of a study, which assessed levels of stress amongst nurses working in a healthcare telephone-advice service. We explored whether stress related to performance, sickness absence, and intention to leave. Background. Nurses report high levels of stress, as do call-centre workers. The emergence of telephone health advice services means many nurses now work in call-centres, doing work that differs markedly from traditional nursing roles. Stress associated with these roles could have implications for nurses, patients, and service provision. Design. This paper reports cross-sectional survey results. The design of the overall study included longitudinal elements. Method. A comprehensive study of stress was conducted amongst nurses working for a telephone-advice service in Scotland (2008–2010). All nurse-advisors were approached by letter and invited to participate. A total of 152 participants (33%) completed a questionnaire including General Health Questionnaire-12, Work Family Conflict Questionnaire, Job Satisfaction Scale and a measure of intention to leave the telephone-advice service and rated the perceived stress of 2 working shifts. Nurses’ employers provided data on sickness absence and performance. Results. Overall levels of psychological distress were similar to those found amongst Scottish women generally. In multiple regression, work–family conflict was identified as a significant predictor of job satisfaction and intention to leave, and significantly related to sickness absence. There were significant correlations between General Health Questionnaire scores and perceived stress of shifts and some performance measures. Conclusions. Work–family conflict is a significant predictor of job satisfaction, intention to leave, and sickness absence amongst telephone helpline nurses. Minimizing the impact of nurses’ work on their home lives might reduce turnover and sickness absence.

Background: Part of the multidisciplinary stroke unit team nurses report their role as complex and demanding. Aims: To explore stress of caring in nursing nurses'and its relationship with perception of the work environment and beliefs about stroke. Methods: This cross sectional study recruited a convenience sample of nursing staff from stroke units (n=44), 99% female; mean age 39 years (s.d. 9.6). The Stress of Caring Scale (SCS) and an adapted Illness Perception Questionnaire (IPQ-R: HP) were completed. The responses on the IPQ-R: HP were compared to stroke survivors (n=106) responses to the original IPQ-R completed in an earlier study. Results: Nurses' stress was positively correlated with perceptions of demand, strain and effort, and reward imbalance (PConclusions: Work environment and discrepancies between patients' and nurses’ beliefs may account for perceived stress and possibly impact on the nurse's role in rehabilitation.

Objectives Staff working in oncology report high levels of work-related stress. This arises partly from the nature of clinical work, including practitioner perceptions of high demand and low control or high effort and low reward. This comparative study investigated the correlates of work stress in a multidisciplinary group of staff and the associations between staff perceptions of the work environment, emotional distress, job satisfaction and work-based social support. Methods This questionnaire study combined quantitative and qualitative assessment in a cohort sample of multidisciplinary staff (N = 85) working in a cancer centre in North East Scotland. Ethical approval was granted by the local Research Ethics Committee. This paper reports on the quantitative element of the study, Results Response rate was 50.6% (N = 85). Older, female and nursing and support staff were more likely to participate. Support staff reported the lowest perceptions of control, job satisfaction and managerial support. Radiographers reported the highest levels of job satisfaction, co-worker and managerial support. Nurses perceived lower decision control and job satisfaction than allied health professionals or doctors. In general, perceptions of decisional control and reward were protective of job satisfaction, particularly when work demands were high. Co-worker support was associated with perceptions of reduced effort, greater reward and increased satisfaction. Managerial support was also associated with greater control beliefs. Overall, sickness absence exceeded the 5% rates seen in other National Health Service surveys, whereas turnover intention rates were similar. Conclusion The development and introduction of multilevel strategies to reduce demand, improve control and support perceptions are warranted, particularly for support staff. Copyright © 2011 John Wiley & Sons, Ltd.

Using Leventhal’s Common-sense self-regulation model, this study investigated associations between illness perceptions, self-management and metabolic-control outcomes for diabetes among European and African-origin patients with type 2 diabetes. Background. Compared to the general populations of their host countries, African-origin populations in the diaspora are disproportionately affected by diabetes and its microvascular complications. However, comparatively little is known about how African-origin patients with type 2 diabetes perceive about their condition and whether such perceptions influence their self-management behaviours. Design. Cross-sectional design. Methods. Participants were recruited from diabetes clinics in London. Illness perceptions and adherence to self-management recommendations were assessed using questionnaires and data for metabolic-control outcomes were obtained from patient records. Associations between variables were investigated using correlations and multiple-regression techniques. Data collection for the study was conducted between February and June 2008. Results. In all, 359 patients participated in the study. The results indicated that perceiving diabetes with severe consequences was associated with poor self-management in both African-origin (black-African and black-Caribbean) and European-origin (white-British) patients with type 2 diabetes. However, personal control perceptions were associated with better self-management in African-origin patients. In multivariate analysis, illness perceptions explained significant proportions of the variations in self-management behaviours in both European-origin and African-origin patients. Perceived personal control over diabetes was a main determinant of the variations in self-management among European and African-origin patients. Other dimensions of illness perceptions, including consequences and emotional representations contributed to variations in self-management among African-origin patients. After controlling for demographic/disease characteristics, self-management of diabetes did not predict any metabolic-control outcome for diabetes in any ethnic group. Conclusion. Illness perceptions are important determinants of self-management among African-origin patients.

jones mc, macgillivray s, kroll t, zohoor ar & connaghan j (2011) Journal of Nursing and Healthcare of Chronic Illness3, 174–185 A thematic analysis of the conceptualisation of self-care, self-management and self-management support in the long-term conditions management literature Aim. To conduct a thematic analysis of the conceptualisation of self-care in the chronic illness management literature. Background. The growing prevalence of chronic illness is an increasing challenge for health and social-care services that attempt to better support self-care and self-management. There is currently a lack of consensus about the meaning and usage of these terms in a rapidly expanding research and policy literature. This may hinder the service innovation based on such policy imperative and evidence. Methods. An iterative literature search was performed, across a wide variety of research databases, using the existing subject headings ‘self-care’ and ‘chronic disease’. Publications (1995–2008) were included if they had a primary focus on self-care or self-management of a long-term condition and provided some form of definition for these concepts. Publications were subject to systematic data extraction and subsequent thematic analysis. Results. The search resulted in 1469 publications, of which 247 were included. Publications represented a wide range of quantitative and qualitative designs focused on several long-term condition areas. Definitions of self-care (SC), self-management (SM) and self-management support (SMS) were multidimensional and varied as to who is involved, what is entailed and what is achieved. Whilst overlap exists, it is the nature of the networks involved (broad, focused or co-ordinated), the imperative for action (optional, unavoidable or essential), and the goals to be achieved (maintenance, coping or facilitation) that conceptually distinguish self-care, self-management and self-management support. Conclusions. Definitions of self-care, self-management and self-management support are complex and multidimensional. Key conceptual distinctions can be made between these terms suggesting that they can be applied with greater consistency and precision in practice, policy and research. Relevance to clinical practice. Future research must use these terms with greater precision to allow comparisons of the differential effectiveness of intervention programmes in long-term conditions.

Aims and objectives. To evaluate the impact and effectiveness of Flying Start NHS™ on the confidence, competence and career development of newly qualified practitioners. Background. The first year of practice as a registered nurse, midwife, or allied health professional is recognised as challenging. This paper presents the findings of a two-year evaluation of Flying Start NHS™, a web-based programme developed by NHS Education Scotland to support newly qualified health professionals during the transition from student to qualified practitioner. Design. Descriptive design with one to one and focus group interviews, plus a survey. Methods. The evaluation employed a multi-method approach including telephone interviews with Flying Start NHS™ leads/coordinators (n = 21) and mentors (n = 22) and focus groups with newly qualified practitioners (n = 95). An online survey was completed by 547 newly qualified practitioners. Results. A majority of newly qualified practitioners reported that Flying Start NHS™ had been useful in terms of clinical skills development and confidence. Those who were able to take protected time were more likely to complete the learning units and report that the support they received was good. Both newly qualified practitioners and mentors reported a lack of time. Newly qualified practitioners who took up posts in the community expressed greater satisfaction with the support received. Conclusions. NHS Boards should ensure that there is an ethos of support at all levels, as well as an understanding of the purpose of Flying Start NHS™ and what newly qualified practitioners require to do to complete it. The expectation that newly qualified practitioners will enrol on Flying Start NHS™ should be accompanied by an expectation that they will complete the programme in their first year, coupled with support to enable them to do so. Relevance to clinical practice. Undertaking Flying Start NHS™ in the first year of employment increases clinical skills development and confidence. Mentors require training and time to enable them to provide support.

The aim of this trial was to evaluate the Angina Plan (AP), a cognitive-behavioral nurse-facilitated self-help intervention against standard care (SC). A randomized controlled trial of 218 patients hospitalized with angina assessed participants predischarge and 6 months later. Data were collected during a structured interview using validated questionnaires, self-report, and physiological measurement to assess between group changes in mood, knowledge and misconceptions, cardiovascular risk, symptoms, quality of life, and health service utilization. The intention-to-treat (ITT) analysis found no reliable effects on anxiety and depression at 6 months. AP participants reported increased knowledge, less misconceptions, reduced body mass index (BMI), an increase in self-reported exercise, less functional limitation, and improvements in general health perceptions and social and leisure activities compared to those receiving SC. Sensitivity analysis excluding participants with high baseline depression revealed a statistical significant reduction in depression levels in AP compared to the SC participants. Analysis excluding participants receiving cardiac surgery or angioplasty removed the ITT effects on physical limitation, self-reported exercise and general health perceptions and the improvements seen in social and leisure activities, while adaptive effects on knowledge, misconceptions and BMI remained and between-group changes in depression approached significance. Initiating the AP in a secondary care setting for patients with new and existing angina produces similar benefits to those reported in newly diagnosed primary care patients. Further evaluation is required to examine the extent of observed effects in the longer term.

Background: Recovery from critical illness can be prolonged and can result in a number of significant short- and long-term psychological consequences. These may be associated with the patient's perception of the intensive care experience. Aim: The aims of the study were to assess patients' perceptions of their intensive care unit (ICU) experience and the effect of these on anxiety, depression and post-traumatic stress up to 6 months after discharge. Method: One hundred and three participants were recruited from six ICUs from one Critical Care Network in the United Kingdom. A prospective, longitudinal study was designed to assess anxiety, depression, post-traumatic stress symptomatology and patients' perceptions of their intensive care experience. Data were collected on three occasions: after intensive care discharge and before hospital discharge, and 2 months and 6 months later. Measures included the impact of events scale, hospital anxiety and depression scale and intensive care experience questionnaire. Results: Anxiety, depression, avoidance and intrusion scores did not significantly reduce over time. At hospital discharge there was a significant association between patients' perceptions of their intensive care experience and anxiety, depression, avoidance and intrusion scores at hospital discharge. Conclusion: Standardised assessment of an intensive care experience is important. It provides information about the patient experience which can inform care practice within ICU, following discharge to the ward and, in the longer term, rehabilitation.

Title. Stress in telephone helpline nurses: research protocol for a study of theoretical determinants, physiological aspects and behavioural consequences. Aim. This is a report of a research protocol to assess level, determinants and consequences of stress in NHS-24 telephone helpline nurses. Background. Nurses working in traditional hospital settings report high levels of occupational stress. Many nurses now work in call centres, environments with their own inherent stressors. Stress in nurses has been linked to reduced physical and psychological health, reduced job satisfaction, increased sickness absence and turnover, and poorer job performance. In this study, we will use multiple methods, including real time data collection to assess stress in telephone helpline nurses. Design. During 2008/09, NHS-24 nurses will (a) report general stress and call-bycall stress over two working shifts, (b) complete measures of theoretical determinants of occupational stress (demand, control, effort and reward), (c) have their concentration and attention tested before and after two shifts, (d) have their heart rate monitored over two shifts, (e) report job satisfaction, absenteeism and intended turnover and (f) allow the research team to retrieve related call data and performance indicators. Relationships between the variables will be assessed using regression and multi-level modelling. Discussion. Data will be analysed to examine the relationships between reported stress, physiological aspects of stress, call type, workplace attributes, cognitive performance, job satisfaction and absenteeism. The analysis will test models of occupational stress and assess the effects of stress on multiple work outcomes. The results will inform theoretical understanding of nurse stress, its determinants and possible methods of management. The practical challenges of conducting such a comprehensive study in a clinical environment are discussed.

Summary Objective To determine the prevalence and distribution of, and trends in, physical inactivity and diabetes in adult West African populations. Design Systematic review and meta-analysis. Methods Literature searches were conducted using four electronic databases. Journal hand searches and examination of citations of relevant articles were also undertaken. To be included, studies had to be population based, use clearly defined criteria for measuring diabetes and physical inactivity, present data that allowed calculation of the prevalence of diabetes or physical inactivity, and sample adult participants. Studies retrieved were appraised critically. Meta-analysis was performed using the DerSimonian-Laird random effect model. Results Twenty-one reports were retrieved for diabetes and 15 reports were retrieved for physical in/activity. Most studies (10 for diabetes and six for physical activity) were conducted solely among urban populations. The prevalence of diabetes in West Africa was approximately 4.0% [95% confidence interval (CI) 2.0–9.0] in urban adults and 2.6% (95%CI 1.5–4.4) in rural adults, and was similar in men and women [prevalence ratio (PR) 1.36, 95%CI 0.96–1.92]. Cumulative time trend analyses suggested an increase in the prevalence of diabetes among adults in urban West Africa, from approximately 3.0% (95%CI 1.0–7.0) to 4.0% (95%CI 2.0–9.0) in the past 10 years. The prevalence of inactivity in West Africa was 13% (95%CI 9.0–18.0). An association was found between physical inactivity and being older (≥50 years) (PR 1.82, 95%CI 1.36–2.44), female gender (PR 1.62, 95%CI 1.41–1.87) and urban residence (PR 2.04, 95%CI 1.58–2.63). Conclusions Diabetes and physical inactivity are important public health issues in urban West Africa, with similar prevalences to wealthy industrialized countries. There is an urgent need for policy makers, politicians and health promotion experts to put measures in place to encourage active lifestyles and control diabetes in urban West Africa.

This poster session discusses the prevalence and distribution of physical inactivity among adult West African populations.

To identify whether providing a new information leaflet for parents regarding the management of a febrile convulsion was more effective in comparison with standard leaflets. Although information leaflets are frequently recommended within healthcare, their quality is often poor. Furthermore, the evidence regarding the effectiveness of leaflets is inconsistent. Few studies have evaluated the effects of providing leaflets that have been developed to improve their quality. Within the specialty of paediatrics, parents are often unprepared regarding the management of febrile convulsion at home and the provision of supplementary leaflets is recommended, despite limited evidence regarding the effectiveness of this approach. There is also limited evidence regarding whether improving the quality of these leaflets leads to better outcomes, e.g. increasing parents’ behavioural knowledge. Double-blind randomized controlled trial. One hundred and twenty-six parents of children hospitalized due to benign febrile convulsion were recruited (May 2000–February 2002). Seventy-one parents were randomized to receive the standard care (control leaflet) and 55 parents received the intervention (new leaflet). Data were collected from parents on discharge immediately prior to receiving the intervention and 7–14 days following the intervention via telephone interview. Parents who received the new leaflet found this to be more reassuring and easier to understand than parents who received the control leaflet. No differences between groups were identified regarding the primary outcome, i.e. behavioural knowledge and most of the secondary outcomes, e.g. perceived confidence, state anxiety and satisfaction with the leaflet. Although this study provides modest support for the effectiveness of providing high-quality leaflets, further research is required to determine the best methods for optimizing the effectiveness of leaflets provided at hospital discharge. The quality of leaflets may influence some outcomes, e.g. understanding and reassurance with the written information provided; however, additional strategies to inform parents may be necessary.

In this paper we explore how aspects of the social world may be linked to mental health and psychiatric morbidity and propose that conditions should be created which allow individuals and communities greater opportunities for self-care and self-management. Specifically the focus is on social connections, disability and homelessness and work stress. There is a clear policy direction pursued by many national governments and international organizations such as the World Bank to build healthy communities. The environment as it relates to health and well-being can be thought of in terms of physical and social dimensions. We will argue that self-care and self-management at both the individual and the community level, in partnership with economic and health policies, are necessary to effectively address social determinants. It will also be suggested that although many in the profession will make the usual refrain that this has little relevance to mental health nurses, the opposite may be the case as mental health nurses have an important, albeit ill-defined, role to play in tackling social determinants.

Objectives to establish the reported practice of pelvic floor exercises and stress urinary incontinence after delivery. Design a longitudinal study using a postnatal postal questionnaire. Participants 257 women in the North-East of Scotland were sent questionnaires between June and December 2000, 6–12 months after delivery (previously recruited and interviewed during the last trimester of pregnancy). One hundred and sixty-three women responded (63.4%). Findings more women reported the practice of pelvic floor exercises after delivery than during pregnancy: 134 (83.2%) compared with 123 (76.4%). Six to 12 months after delivery, 96 (60%) women said that they were still doing the exercises. A third of respondents (n=54, 33.1%) reported stress incontinence at some time since having the baby. Of those reporting incontinence at the time of questionnaire completion, six (19.3%) said the incontinence was moderate or severe, whereas eight (34.7%) reported incontinence once a week or more. Women who had an operative vaginal delivery (forceps or ventouse delivery) were more likely to report the practice of pelvic floor exercises than those having a spontaneous vaginal delivery. No significant difference was found in reported rates of stress incontinence between women who had different modes of delivery. The practice of pelvic floor exercises daily or more often during pregnancy was associated with less reported postnatal incontinence compared with less frequent practice. Key conclusions self-reported rates of practice of pelvic floor exercises increased from pregnancy to the immediate postnatal period and subsequently declined. A third of women reported the symptoms of stress incontinence after delivery. Daily or more frequent practice of the exercises during pregnancy may be required in order to prevent postnatal incontinence (although further research is required to confirm this finding). Implications for practice midwives should continue to encourage regular and frequent practice of pelvic floor exercises in the postnatal period and beyond. They also need to ask about symptoms of stress incontinence and refer as necessary.

People with profound intellectual disabilities rarely experience a physically active lifestyle, and their long-term physical inactivity likely contributes to poor health. The authors developed and implemented a pilot exercise program for persons with a profound intellectual disability and conducted a study to evaluate the effort. The development of mobility, independent movement, and posture profiles resulted in a 16-week needs-led exercise program based on “rebound therapy,” with additional exercises, including active and passive exercise, walking, swimming, hydrotherapy, and team games. Study participants undertook 3–5 additional periods of low-impact exercise per week, providing moderate to low levels of activity judged in terms of energy costs. The program was evaluated using physiological measures (resting pulse, systolic and diastolic blood pressure, weight, height, body mass index, seizure activity, activity levels), counts of challenging behaviors, and by indices of quality of life and alertness outcomes. Participation in the exercise program was associated with decreases of frequency of challenging behaviors and increases in quality of life (freedom scores) and alertness. The authors concluded that barriers to the development and implementation of ongoing exercise programs in continuing care settings can be overcome by trained and motivated care staff.

Aims The aims of this paper were (1) to raise awareness of the issues in questionnaire development and subsequent psychometric evaluation, and (2) to provide strategies to enable nurse researchers to design and develop their own measure and evaluate the quality of existing nursing measures. Background The number of questionnaires developed by nurses has increased in recent years. While the rigour applied to the questionnaire development process may be improving, we know that nurses are still not generally adept at the psychometric evaluation of new measures. This paper explores the process by which a reliable and valid questionnaire can be developed. Methods We critically evaluate the theoretical and methodological issues associated with questionnaire design and development and present a series of heuristic decision-making strategies at each stage of such development. The range of available scales is presented and we discuss strategies to enable item generation and development. The importance of stating a priori the number of factors expected in a prototypic measure is emphasized. Issues of reliability and validity are explored using item analysis and exploratory factor analysis and illustrated using examples from recent nursing research literature. Conclusion Questionnaire design and development must be supported by a logical, systematic and structured approach. To aid this process we present a framework that supports this and suggest strategies to demonstrate the reliability and validity of the new and developing measure. Relevance to clinical practice In developing the evidence base of nursing practice using this method of data collection, it is vital that questionnaire design incorporates preplanned methods to establish reliability and validity. Failure to develop a questionnaire sufficiently may lead to difficulty interpreting results, and this may impact upon clinical or educational practice. This paper presents a critical evaluation of the questionnaire design and development process and demonstrates good practice at each stage of this process.

Purpose Unmet support needs are prevalent in men affected by prostate cancer. Moreover, little is known about the optimal type of social support, or its mechanism effect between coping and emotional outcome in men affected by this disease to identify areas for clinical intervention. This study aimed to empirically test the propositions of social support theory in "real time" within individual men living with and beyond prostate cancer. Methods Purposeful sub-sample from a larger prospective longitudinal study of prostate cancer survivors, took part in real time data collection using mobile technology. Self-reports were collected for 31 days prompted by an audio alarm 3 times per day (a total of 93 data entries) for each of the 12 case studies. Electronic data were analysed using time series analysis. Results Majority of response rates were >90%. Men reported a lack of satisfaction with their support over time. Testing the propositions of social support theory "within individuals" over time demonstrated different results for main effect, moderation and mediation pathways that linked coping and social support to emotional outcome. For two men, negative effects of social support were identified. For six men the propositions of social support theory did not hold considering their within-person data. Conclusion This innovative study is one of the first, to demonstrate the acceptability of e-health technology in an ageing population of men affected by prostate cancer. Collectively, the case series provided mixed support for the propositions of social support theory, and demonstrates that "one size does not fit all".

Loneliness can be defined as perceived social isolation and appears to be a relatively common experience in adults. It carries a significant health risk and has been associated with heart disease, depression and poor recovery after coronary heart surgery. The mechanisms that link loneliness and morbidity are unclear but one of the mechanisms may be through poor health beliefs and behaviours. The aims of this cross-sectional survey of 1289 adults were to investigate differences in health behaviours (smoking, overweight, BMI, sedentary, attitudes towards physical activity) in lonely and non-lonely groups. Lonely individuals were more likely to be smokers and more likely to be overweight - obese. The lonely group had higher body mass index scores controlling for age, annual income, gender, employment and marital status. Logistic regression revealed no differences in sedentary lifestyles. Lonely individuals were significantly less likely to believe it was desirable for them to lose weight by walking for recreation, leisure or transportation. The findings provide support for an association between health behaviours, loneliness and excess morbidity reported in previous studies.

Much research into work-related stress is based on retrospective self-reports, whereas records made at the time could be more valuable. In this study the primary components of two models of work stress, Karasek's demand-control (DC) model and Siegrist's effort-reward imbalance (ERI), were assessed in trained nurses using ambulatory diaries and traditional questionnaire methods. The diaries were entered on small hand-held computers and the method used has been termed ecological momentary assessment (EMA), in which recordings are made in real time in the working environment. The participants were 36 nurses who completed standardized questionnaires evaluating ERI, strain (from DC model), and, over three shifts, computerized behavioural diaries that measured effort-demand, control, reward, and stress every 90 minutes on average, enabling determination of strain and ERI repeatedly in the work situation. A total of 674 observations were recorded. Using multilevel linear modelling, it was found that the...

Few studies have examined the role of managerial support in the adaptation of entrants to healthcare. The purpose of this study was to identify the job characteristic and role-related variables that mediate the effects of managerial support and personality on the mental and physical health and sickness absence in two independent groups of new recruits to a healthcare organization. Entrants to a healthcare environment (student nurses) were surveyed 25 weeks after entry. Latent variables represented neuroticism, demand, control, role clarity and affective outcome variables in a simplified version of the Michigan model of work stress (House, 1981). This study used a two-stage approach to structural equation modelling, exploring hypothesized structural models on an initial data set (N=195) prior to confirmation on an independent replication data set (N=239) using multi-sample methods. Finally the confirmed model of choice was evaluated using the combined data (N=434). Emotional distress reported at 6 months w...

The effectiveness of a stress management intervention designed to reduce affective distress in 79 student nurses who previously reported significant distress, was evaluated by comparing stress management with wait-list control. The intervention had reliable, positive effects on affective outcomes including General Health Questionnaire-30, State and Trait Anxiety Inventory, Beck Depression Inventory, and a measure of domestic satisfaction. The intervention also led to an increase in Direct Coping use. State Anxiety immediately preceding two important examinations, i.e. at 3 and 18 month follow-up, was lower for students receiving stress management. However, no effect was detected on sickness, absence and examination performance following this intervention. Stress management delivered in groups reduces affective distress and increases adaptive coping use in both clinical and academic settings.

The socio-ecological model of work stress (Schaefer & Moos 1993b) specifies the direct and indirect impact of the work environment on both staff and patient outcomes. Adopting this perspective, a critical review of the impact of the health-care setting on trained nurse and patient outcomes was carried out systematically using 94 studies identified for inclusion. Evidence was found of the validity of elements of the socio-ecological model of work stress to detail the direct and indirect influences on work-related distress in trained nurses. However, several direct and reciprocal relationships contained within the model were not supported, and complex interactional effects were apparent which were not predicted by Schaefer and Moos (1993b). In addition, key elements of the model await systematic research, i.e. the impact of the health-care system on patient outcomes. A nurse-specific extension of the socio-ecological model is presented in response. This amended model of work stress will enable the planning of evidence-based organizational strategies to alter problematic work climates faced by nurses, and provides a framework for the design of future research to maximize the quality of patient care provided by practitioners working in demanding health-care environments.

Levels of affective distress, sources of stress and coping strategies reported by first-year student nurses in Tayside, Scotland, were measured using the General Health Questionnaire (30-item version), the Beck & Srivastava Stress Inventory (BSSI) and a modified 'Ways of Coping Questionnaire'. Screening showed that, around the time of an initial series of hospital placements, 50.5% of students in cohort 1 (n = 109, week 40) and 67.9% of students in cohort 2 (n = 111, week 24) suffered significant affective distress. This exceeds levels reported in published studies of degree nursing students, fourth-year medical students, and the general female population. Distressed students reported the same sources of stress as the non-distressed students, but suffered them more intensely. Many BSSI items were seen as common sources of stress; however, the frequency with which an item was reported to be stressful was not related to whether scores on that item predicted overall distress. In both cohorts, the use of direct coping was associated with lower levels of distress, and with lower total stress scores on the BSSI. The use of fantasy and hostility was associated with high levels of distress and stress, in both groups. This screens of 220 first-year student nurses suggests that there is a problem with student distress around an initial series of general/surgical and psycho-social ward placements. The possible determinants of this distress and complex, and it is unlikely that presenting information alone will be sufficient to reduce this distress.

Aim: This study examined if self-efficacy in managing chronic obstructive pulmonary disease is associated with better mood, less breathlessness and fewer exacerbations; what helps or hinders patients in managing their chronic obstructive pulmonary disease (COPD); and patients’ suggestions to improve the self-management support they receive. Background: COPD is the fifth leading cause of death in the UK, and it has been suggested that supporting self-efficacy and self-management could improve patient outcomes and reduce demands for NHS resources. Methods: An exploratory, descriptive survey involving the collection of both quantitative and semistructured qualitative data was chosen. Participants were randomly selected from four GP practices across the north east of Scotland. Results: Higher levels of self-efficacy were associated with lower levels of breathlessness, lower levels of anxiety and lower levels of depression in COPD patients. There was no association between high self-efficacy and exacerbation rates. Conclusion: Increasing self-efficacy and reducing anxiety and depression in patients living with COPD are important focus points for self-management support.

Aim To explore the frequency of different nursing tasks in medical and surgical wards. Background: The time nurses spend on direct patient care is important for both patients and nurses. However, little is known about the time nurses spend on various nursing tasks. Methods: A real-time, repeated measures design conducted amongst 67 (n = 39 medical, n = 28 surgical) UK hospital nurses. Between September 2011 and August 2012 participants completed an electronic diary version of a classification of nursing tasks (WOMBAT) during shifts. Results: A total of 961 real-time measures of nursing task were obtained. Direct patient care [median = 37.5%, interquartile range = 27.8], indirect care (median = 11.1%, interquartile range = 19.4) and medication (median = 11.1%, interquartile range = 18.8) were most commonly reported. Participants were interrupted in 62% of entries (interquartile range = 35), reported adequate time in 78% (interquartile range = 31) and adequate resources in 89% (interquartile range = 36). Ward-related tasks were significantly more frequent on medical wards than surgical wards but otherwise there were no significant differences. Conclusions: Nurses spend the highest proportion of time in direct patient care and majority of this on core nursing activities. Interruptions to tasks are common. Nurses tend to report adequate time/resources. The frequency of nursing tasks is similar in medical and surgical wards. Implications for nursing management: Nurse managers should review the level of interruptions to nurses’ work and ensure appropriate levels of supervision.

Aims and objectives To examine the effect of nurse mood in the worst event of shift (negative affect, positive affect), receipt of work-based support from managers and colleagues, colleague and patient involvement on perceived quality of care delivery. Background While the effect of the work environment on nurse mood is well documented, little is known about the effects of the worst event of shift on the quality of care delivered by nurses. Design This behavioural diary study employed a within-subject and between-subject designs incorporating both cross-sectional and longitudinal elements. Methods One hundred and seventy-one nurses in four large district general hospitals in England completed end-of-shift computerised behavioural diaries over three shifts to explore the effects of the worst clinical incident of shift. Diaries measured negative affect, positive affect, colleague involvement, receipt of work-based support and perceived quality of care delivery. Analysis used multilevel modelling (mlwin 2.19; Centre for Multi-level Modelling, University of Bristol, Bristol, UK). Results High levels of negative affect and low levels of positive affect reported in the worst clinical incident of shift were associated with reduced perceived quality of care delivery. Receipt of managerial support and its interaction with negative affect had no relationship with perceived quality of care delivery. Perceived quality of care delivery deteriorated the most when the nurse reported a combination of high negative affect and no receipt of colleague support in the worst clinical incident of shift. Perceived quality of care delivery was also particularly influenced when the nurse reported low positive affect and colleague actions contributed to the problem. Conclusions Receipt of colleague support is particularly salient in protecting perceived quality of care delivery, especially if the nurse also reports high levels of negative affect in the worst event of shift. Relevance to clinical practice The effect of work-based support on care delivery is complex and requires further investigation.

Background The Revised Illness Perception Questionnaire (IPQ-R) has been used extensively to measure illness perceptions of several patient populations. However, the instrument was developed using participants of mainly European-origin. The reliability and validity of the IPQ-R may therefore need to be established before use among populations of different ethnic and cultural origins. Objectives This study investigated the factor structure and internal consistency reliability of the IPQ-R in African-origin patients with type 2 diabetes. Methods In this cross-sectional study, 221 adults of African descent with type 2 diabetes completed the IPQ-R. Participants were recruited from patients attending diabetes and retinal screening clinics in the London boroughs of Brent and Hackney. Confirmatory Factor Analysis based on the covariance matrix was used to determine factorial validity for the Timeline-acute/chronic, Consequences, Personal control, Treatment control, Illness coherence, Timeline-cyclical, Emotional representation and three causal subscales of the IPQ-R. Composite internal consistency reliability for individual subscales was determined using Cronbach's alpha coefficients. Results After eliminating three items and re-specifying six error covariances associated with large standardised residuals and low factor loadings, the hypothesised model adequately explained the covariance of African and Caribbean patients' responses to items of the IPQ-R. Also, composite reliability coefficients of all measured subscales were acceptable and inter-correlations between subscales were in line with those reported from other population groups. Conclusions The findings in this study suggest that although the IPQ-R may be valid and reliable across cultures, investigators may need to modify (e.g. by rewording) some of its items taking into account any linguistic origins of their populations of study. Further evaluation of the IPQ-R (including the identity subscale) in larger samples of African-origin populations is also recommended.