Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and a major predisposing risk factor for stroke. Current UK guidelines propose stroke-risk stratification of AF patients. Anticoagulation with warfarin is recommended for high risk patients, whereas treatment with aspirin alone is advised for those at low risk. The aim of this audit was to review practice at our institution and ascertain if guidelines on AF treatment were being followed.

A retrospective review of all patients diagnosed with non-valvular AF in June 2010 was undertaken. Patient records were reviewed to collect demographic and co-morbidity data relevant to stroke risk stratification. This was subsequently used to stratify patients according to stroke-risk using the CHADS2 scoring system. The use of anticoagulation and anti-platelet medication as well as any documented reasons for the omission of anticoagulation in high risk patients was noted.

The prevalence of non-valvular AF in our practice population was 1.5% (151/10,155); 70% (105/151) of AF patients were found to be at high risk of stroke; 36% (38/105) of high risk patients were not on anticoagulation and the majority (58%) of these patients had no clear reason documented for the omission of warfarin. Of the 15 patients at low risk of stroke, 12 (80%) were on warfarin. Seven (4.4%) of the 151 AF patients were on both warfarin and aspirin and six (4%) were on neither medication. The commonest documented reasons for omission of warfarin in the high risk group were dementia and a history of gastrointestinal bleeding.

The lack of documentation on withholding a proven beneficial treatment in high risk patients could potentially leave physicians open to medico-legal scrutiny. Maintaining low risk patients on anticoagulation may expose them to unnecessary risk. We recommend the use of automated audit tools designed to improve compliance with national guidelines.

To investigate the informed consent experiences of women with human immunodeficiency virus (HIV) and childhood trauma involved in a neurocognitive and neuroimaging study.

There is no previous research on the consent process for people with both HIV and childhood trauma, conditions that are syndemic in South Africa. Research on the consent process for each individual condition has shown that individuals with either of these conditions may be vulnerable research participants. This study aimed to investigate the opinions of the women involved in order to refine future consent processes and ensure that they are appropriate for this population.

A qualitative semi-structured interview was conducted with women from Khayelitsha township in South Africa involved in a cohort study on neurocognitive and neuroimaging outcomes in HIV and childhood trauma, who agreed to participate in an interview immediately following their final study appointment.

Aspects most frequently commented upon by participants during the interview were community recruitment, incentives for participation, quality of information provided, and misunderstandings and unexpected events. The overarching finding was that of therapeutic misconception; participants expected, and highlighted as incentives for participation, health benefits that were not part of the study. A minority of participants reported discomfort from questions concerning their traumatic experiences. Despite this, the consent process was well received and there was good understanding of confidentiality issues and the voluntariness of participation.

Full disclosure of true benefits from participation must be emphasised throughout the recruitment process. This is particularly important for participants with HIV who appear to participate because of perceived health incentives. Providing prior notification that questions about traumatic experiences will be asked may improve the experiences of participants. A generic but thoroughly conducted consent process is suitable in this population.

This paper is a report of part of a study that explored the ways in which health visitors manage uncertainty and anxiety when working with clients across cultures.

Internationally health care professionals are required to deliver a high standard of culturally appropriate care to increasingly diverse communities and yet problems persist. Research evidence informing cultural ‘competence’ is focused largely around student experience and consequently little is known about the day-to-day experiences of health professionals in diverse community settings. Anxiety and uncertainty are increasingly recognised as important emotions experienced by a variety of health care professionals when working across cultures and yet the ways in which anxiety and uncertainty is managed in practice is less well understood.

Grounded theory methodology was used and 21 semi-structured interviews were conducted with participating health visitors in the North East of England between May 2008 and September 2009. All participants described themselves as white.

This study identified three different positions adopted by the health visitors to manage uncertainty and anxiety in their work across cultures. Identified as, ‘Fixing a culture’, ‘Reworking the equality agenda’ and ‘Asserting the professional self’, these strategies identify the ways in which health visitors try to manage the uncertainty and anxiety they feel when working in diverse communities. All of these strategies attempt in different ways to negate cultural difference and to render culture as static and known.

Given that health professionals report anxiety and uncertainty when working across diverse community settings, identification of the strategies used by health visitors to manage that anxiety is important for both policy and practice. New strategies need to be developed to help health professionals to manage uncertainty and anxiety in ways that promote both cultural safe care and health equity.

The aim of this study was to describe district nurses’ (DNs’) experiences of their knowledge development in wound management when treating patients with different types of wounds at healthcare centers.

In primary healthcare, DNs are mainly responsible for wound management. Previous research has focused on DNs’ level of expertise regarding wound management, mostly based on quantitative studies. An unanswered question concerns DNs’ knowledge development in wound management. The present study therefore intends to broaden understanding and to provide deeper knowledge in regard to the DNs’ experiences of their knowledge development when treating patients with wounds.

A qualitative descriptive design was used. Subjects were a purposeful sample of 16 DNs from eight healthcare centers in a metropolitan area in Stockholm, Sweden. The study was conducted with qualitative interviews and qualitative content analysis was used to analyze the data.

The content analysis resulted in three categories and 11 sub-categories. The first category, ‘ongoing learning by experience,’ was based on experiences of learning alongside clinical practice. The second category ‘searching for information,’ consisted of various channels for obtaining information. The third category, ‘lacking organizational support,’ consisted of experiences related to the DNs’ work organization, which hindered their development in wound care knowledge.

The DNs experienced that they were in a constant state of learning and obtained their wound care knowledge to a great extent through practical work, from their colleagues as well as from various companies. A lack of organizational structures and support from staff management made it difficult for DNs to develop their knowledge and skills in wound management, which can lead to inadequate wound management.

Data on the uptake of clinical guidelines into practice are essential to guide and evaluate quality improvement interventions. Organizations responsible for service specification, monitoring and improvement need to consider the practicality of and trade-offs made in different data collection methods. We examined the feasibility of deriving and applying review criteria for clinical guidelines in English primary care.

We selected two sets of guidance, on osteoporosis and depression, and used a consensus process to derive review criteria. We manually extracted data on adherence to review criteria from patient records in 20 general practices from three NHS primary care trusts in northern England. We compared the relative utility of extracted data with that of routinely available data, summarizing feasibility using what we termed a Resource Ratio.

Of 53 proposed review criteria we assessed, 41 were judged clinically important, valid, relevant and measurable. Thirty-one could be assessed in 10% or more of sampled patients, whereas 15 could be readily extracted (resource ratio of 15 or less). Only eight met all desirable attributes for use as review criteria. Resource ratios correlated poorly with local stakeholders’ prior views on feasibility of data collection. We observed wide variations in compliance with review criteria, with notably low levels among self-care standards.

A minority of guideline recommendations were suitable for review criteria development, fewer still when using routinely available data. Local stakeholders tend to underestimate the actual resource requirements of data collection. Although improved design and use of clinical records may facilitate measurement of adherence to recommended practice, detailed assessments are still likely to rely upon some degree of manual data collection in the foreseeable future.

To synthesize information about management of end of life care in people with dementia using review papers.

There are increasing numbers of people being diagnosed with dementia worldwide, and the needs of people with dementia and their carers at the end of life may be different from those with other chronic diseases. By highlighting the challenges of palliative care in persons with dementia and the ways they are best managed, practitioners in primary care may be able to improve services for this group of people at the end of life.

A search of electronic databases of English language papers published in peer-reviewed journals, 2000–2011 inclusive was undertaken using broad terms related to palliative care and dementia. 6167 papers were identified. Titles and abstracts were read. Papers were included if they were literature reviews of palliative or end of life care for people with dementia/Parkinson's disease/Lewy body dementia/cognitive impairment/Alzheimer's disease or any other cognitive impairment, in any setting (hospital, care home, community) and covering people of all ages. Papers were excluded if they covered palliative care focusing on other conditions, or were about an aspect of dementia care and treatment not related to palliative care.

Our critical synthesis generated five main themes from this review of the reviews: (1) carers’ (family caregivers’) experiences; (2) person-centred care; (3) practice (including advance care planning, pain and comfort, nutrition, medical complications and minimizing the distress of behavioural symptoms); (4) system factors, including ethical dilemmas, decision making, information, and training; and (5) research priorities. There appears to be good evidence on the care and management of patients with dementia at the end of life which can be used to influence policy development and emerging specificity about research priorities in palliative care practice for people with dementia.

Consumer health organisations (CHOs), which operate outside the mainstream healthcare system with a specific focus on supporting people to self-manage their health conditions, have become widespread. Yet, there has been little systematic research into CHOs, including their perceived benefits and barriers, which encourage or deter their access by people with a variety of chronic health conditions.

This study explored the benefits of CHOs in self-management and also the barriers that inhibit their access, from the perspective of people with chronic conditions and their unpaid carers.

In-depth, semi-structured interviews were completed with 97 participants across four regions of Australia. The sample included a high representation of people from culturally and linguistically diverse backgrounds and Aboriginal and Torres Strait Islander people as well as non-indigenous Australians.

Three inter-related themes were identified that represented the benefits of involvement and participation in CHOs: knowledge and information, connection and support and experiential learning. However, limited access pathways emerged as a barrier that inhibited a person’s entry into CHOs. Furthermore, the person’s beliefs and experiences about their own health condition(s) also inhibited their continued participation in CHO programmes.

Although our findings confirm that CHOs are a valuable resource in alleviating the ‘work of being a patient’ for some people, there seems to be some barriers that prevent their full access and utilisation. Structured integration systems to increase the reliable delivery and accessibility of CHOs are needed to ensure that people who would benefit from accessing them can do so.

To explore practice teachers understanding of the process of professional education experienced by community nursing students.

This paper analyses the concepts of situated learning and communities of practice as an underpinning theoretical framework to understand the professional education of community nurses in practice settings. The paper also highlights the strengths and limitations of the community of practice theory as applied to professional education.

A qualitative grounded theory study was undertaken involving interviews with 30 community nurse practice teachers.

Emerging from the data were the central components of Lave and Wenger's theory of communities of practice. The practice teachers appeared to use these components including legitimate peripheral participation, sponsorship and journeying to good effect in facilitating the development of community nurse students. The paper extends Lave and Wenger's community of practice phenomenon and identifies how communities are (re)produced over time. The development of professional practitioners over a lengthy period of time within supportive communities of practice where one person with expertise in professional education sponsors the student and takes responsibility for their journey was perceived by practice teachers to be an important and appropriate approach. An approach that was found by practice teachers to transform the student's professional identity, enabling them to undertake a complex multifaceted role using a holistic, problem solving and participative style with clients and communities. It is also an approach that was hypothesised to allow the profession itself to (re)produce in a way that supports continuity but also promotes changes in practice.

In a primary health-care centre (PHCC) situated in a segregated area with low socio-economic status, ‘primary care triage’ has increased efficiency and accessibility. In the primary-care triage, the nurse sorts the patient to the appropriate PHCC profession according to described symptoms.

The aim of this study was to examine the patients’ experience of being triaged directly to a psychologist for assessment.

Interviews were conducted with 20 patients and then analysed using qualitative content analysis.

The results show that patients contacting the PHCC for mental health issues often are active agents with their own intent to see a psychologist, not a doctor, as a first-hand choice when contacting the PHCC. Seeking help for mental health issues is described as a sensitive issue that demands building up strength before contacting. The quick access to the preferred health-care professional is appreciated. The nurse was perceived as a caring facilitator rather than a decision maker. It is the patient's wish rather than the symptoms that directs the sorting. The patients’ expectations when meeting the psychologist were wide and diverse. The structured assessment sometimes collided and sometimes united with these expectations, yielding different outcome satisfaction. The results could be seen in line with the present goal to increase patients’ choice in the health-care system. The improved accessibility to the psychologist seems to meet community expectations. The results also indicate a need for providing more prior information about the assessment and potential outcomes.

Lymphoedema secondary to cancer is a relatively neglected and under-researched condition. Few studies report people's experiences of care and treatment provision when living with the condition. Current practice focuses on the physical treatment yet psychosocial needs often remain unmet. A previous study examining the patient perspective identified the theme of being ‘abandoned by medicine’. Perceived lack of support may result in a delayed adaptation and acceptance of this long-term condition and can significantly impact on psychological well-being. We explore this emerging theme alongside others in order to provide a guide to action for improvements for patient benefit.

The central aim was to explore women's views of their care and treatment following a diagnosis with lymphoedema secondary to cancer. This forms part of a larger study aimed at assessing appropriate screening tools to measure psychosocial distress.

A mixed-methods approach was used for the main study. Here we report the qualitative component, derived from in-depth semi-structured interviews conducted in the homes of the participants (n = 14) and focus group discussions (n = 15). In addition, qualitative comments from questionnaire data from a large-scale postal survey are included (n = 104).

Participants identified considerable deficiencies in health care workers’ knowledge and awareness of lymphoedema, which subsequently impacted on the patients’ needs for information, support and understanding. Access to appropriate treatment was patchy and problems were identified with the process of obtaining compression garments, massage and other sources of help. Although lymphoedema is a long-term disfiguring condition, and much is known about how this impacts on patients’ emotional well-being, little attention was paid by health professionals to potential psychosocial consequences. In essence women had to become experts of their own condition and cope as best as they could. We provide recommendations to improve service delivery and address these unmet needs.

Sickness absence is a complex phenomenon affected by aspects other than disease. One important factor that can affect sick leave is the individual’s experience of healthcare encounters. It is therefore essential to consider the quality of the encounter with health professionals and its impact on the patient’s rehabilitation and return to work.

The aim was to explore how sick-listed patients in Sweden perceive their contact with healthcare professionals in primary healthcare and to analyse what they view as crucial components for returning to work.

A qualitative approach was used. Data were collected by semi-structured telephonic interviews with patients who were or had been on sick leave. The transcribed interview text was analysed according to qualitative content analysis.

The analysis revealed two themes that highlight important areas for persons on sick leave in their healthcare encounters. The theme ‘Trust in the relationship’ contains categories describing the patients’ feelings of participation, and of being believed, confirmed, and listened to, and also dedication on the part of healthcare providers. Healthcare encounters that were characterised by professionalism, knowledge, continuity, and a holistic approach seemed to create trust. The theme ‘Structure and balance’ contains the participants’ views on important factors that could support the return-to-work process. All participants stated the importance of follow-up and a plan for rehabilitation. Sick leave itself can make a person passive, and participants in this study asked for support to balance activity, exercise, and work demands, which could facilitate their return to work.

Healthcare professionals can facilitate sick-listed persons’ rehabilitation back to work by providing a clear structure in the process and support in occupational balance. The healthcare encounters must build on a mutual trust.