Are Clinical Prediction Rules Used in Spinal Cord Injury Care? A Survey of Practice

Background

Accurate outcome prediction is desirable post spinal cord injury (SCI), reducing uncertainty for patients and supporting personalized treatments. Numerous attempts have been made to create clinical prediction rules that identify patients who are likely to recover function. It is unknown to what extent these rules are routinely used in clinical practice.

Objectives

To better understand knowledge of, and attitudes toward, clinical prediction rules amongst SCI clinicians in the United Kingdom.

Methods

An online survey was distributed via mailing lists of clinical special interest groups and relevant National Health Service Trusts. Respondents answered questions about their knowledge of existing clinical prediction rules and their general attitudes to using them. They also provided information about their level of experience with SCI patients.

Results

One hundred SCI clinicians completed the survey. The majority (71%) were unaware of clinical prediction rules for SCI; only 8% reported using them in clinical practice. Less experienced clinicians were less likely to be aware. Lack of familiarity with prediction rules was reported as being a barrier to their use. The importance of clinical expertise when making prognostic decisions was emphasized. All respondents reported interest in using clinical prediction rules in the future.

Conclusion

The results show widespread lack of awareness of clinical prediction rules amongst SCI clinicians in the United Kingdom. However, clinicians were positive about the potential for clinical prediction rules to support decision-making. More focus should be directed toward refining current rules and improving dissemination within the SCI community.

The early determinants of career choices for medical students following an obstetrics and gynaecology placement: Mixed methods study

OBJECTIVE

To explore the impact of attending a clinical placement in considering a career in obstetrics and gynaecology.

DESIGN

Mixed methods study.

SETTING

London Medical School.

POPULATION

Fifth year medical students attending a clinical placement in obstetrics and gynaecology.

METHODS

Between January 2021 and January 2022, questionnaires were used and semi-structured focus groups conducted, which were audio-recorded. Descriptive statistics were conducted and a framework analysis on transcribed focus groups.

MAIN OUTCOME MEASURE

The impact of the clinical placement on career choice.

RESULTS

Six main themes were identified from the analysis; three contributing to considering a career in obstetrics and gynaecology; pregnancy is not an illness, extraordinary experience of observing childbirth and variable specialty and three themes emerged contributing to not considering a career; lack of work-life balance, high stakes specialty and the emotional toll. Even at an undergraduate level, medical students exhibited concerns about the long-term feasibility of achieving work-life balance and avoiding professional burnout, which was partly attributed to the responsibility of looking after both the woman and their baby.

CONCLUSIONS

Obstetrics and gynaecology is perceived as an exciting and variable speciality by medical students. Students' experiences on the labour ward during a clinical placement appear to contribute to the consideration of a career in obstetrics and gynaecology. Students should be given opportunities to discuss their concerns about obstetrics, particularly over the potential psychological impact of adverse/traumatic birth events. It is crucial to provide a realistic introduction to obstetrics, to recruit enthusiastic junior doctors who will be resilient to the pressures of the speciality, to avoid burnout and minimise attrition rates.

'Is there something wrong with your voice?' A qualitative study of the voice concerns of people with laryngotracheal stenosis

BACKGROUND

Acquired laryngotracheal stenosis (LTS) is a rare condition that causes breathlessness and dyspnoea. Patients have reconstructive airway surgery to improve their breathing difficulties, but both LTS and the surgery can cause voice difficulties. The existing evidence base for management of voice difficulties for adults with LTS focuses on symptoms. There is limited information to provide clinical guidance for speech and language therapists (SLTs) and a limited understanding of the impact of voice changes on adults with LTS.

AIM

To investigate the lived experience of adults with laryngotracheal stenosis (LTS), who have had reconstructive surgery; here focussing on voice concerns with the aim of guiding clinical care for SLTs.

METHODS AND PROCEDURES

A phenomenological, qualitative study design was used. Focus groups and semi-structured interviews were completed with adults living with LTS who had had reconstructive surgery. Audio recordings were transcribed and inductive thematic analysis was used by the research team to identify themes and sub-themes.

OUTCOMES AND RESULTS

A total of 24 participants (five focus groups and two interviews) took part in the study before thematic saturation was identified in analysis. Three main themes were identified specific to the experience of living with LTS: the Medical, Physical and Emotional journey. All participants referenced voice difficulties as they related to each of these overall themes. Sub-themes directly related to voice included experience of surgery, information provision, staff expertise/complacency, symptoms, symptom management, identity, support networks, impact on life and living with a chronic condition.

CONCLUSIONS AND IMPLICATIONS

In this qualitative study participants have described the integral part voice difficulties play in their lived experience of LTS and reconstructive surgery. This is considered in the context of their clinical care and the need for individualised management and information provision throughout the course of their condition. The broader research literature relating to voice difficulties is explored with links made to people with LTS and recommendations made for future research into people living with LTS and dysphonia.

WHAT THIS PAPER ADDS

What is already known on this subject Adults with laryngotracheal stenosis (LTS) experience voice changes as a result of their condition, and the surgeries necessary as a treatment. These changes can lead to altered pitch, vocal fatigue, loss of pitch range and loss of volume control. Although there are known psychosocial implications both to living with a chronic condition and voice difficulties there has been no research exploring this in adults with LTS, and there is minimal clinical guidance for speech and language therapists (SLTs) working with these patients. What this paper adds to existing knowledge This research is the first study to explore the lived experience of adults with LTS who undergo reconstructive surgery, focusing on their voice concerns. This study demonstrates the multifactorial impacts of voice changes on all aspects of the lives of adults with LTS and the need for individualised information provision and clinical care to help support them. What are the potential or actual clinical implications of this work? Adults with LTS want expert SLTs to facilitate their care and support them throughout their LTS journey alongside other support networks. They want to be carefully prepared for reconstructive surgery and given clear information about symptoms and management of their voice difficulties. This has led to the reorganisation of the care pathway at our centre, and the introduction of a patient-led pretreatment session.

Issues faced by people with amputation(s) during lower limb prosthetic rehabilitation: A thematic analysis

BACKGROUND

Successful rehabilitation is essential to improve the physical and mental outcomes of people with lower limb amputation(s). Individuals have different goals and expectations of successful rehabilitation and experience issues that affect their quality of life.

OBJECTIVES

To determine factors affecting lower limb prosthetic rehabilitation from people with amputation(s), important for studies focusing on prosthetic and socket design and fitting because they provide context of need and user issues.

STUDY DESIGN

Thematic analysis of semistructured interviews.

METHODS

Ten people with amputation(s) were self-selected from a survey identifying factors affecting lower limb prosthetic rehabilitation. The telephone interviews were semistructured exploring the biggest impactors on and frustrations with rehabilitation and the socket. A thematic analysis was completed by following the undermentioned steps: familiarization, coding, generating themes, reviewing themes, defining and naming themes, and reporting.

RESULTS

Five distinct but interrelated themes were identified: External to Prosthesis, Body Impactors, Consequences of Ill-Fit, Prosthesis Irritants, and Work and Social Impact. Those living with amputation(s) mentioned prosthetic-related issues affecting their work and social life, including difficulties wearing their prosthesis all day, the socket's rigidity, and the ability to participate in hobbies.

CONCLUSIONS

The study provides new insights into the issues experienced during prosthetic rehabilitation, highlighting impacts beyond just physical health consequences. The study provides an evidence base for areas of the rehabilitation journey which could be improved to improve the quality of life of people with amputation(s).

Issues Faced by Prosthetists and Physiotherapists During Lower-Limb Prosthetic Rehabilitation: A Thematic Analysis

Successful prosthetic rehabilitation is essential to improve the physical and mental outcomes of people with lower-limb amputation. Evaluation of prosthetic services from a prosthesis user perspective have been published and commissioned by the national bodies, however, the perspectives of clinicians working with service users during rehabilitation have not to date been sought. We sought to determine factors impacting lower-limb prosthetic rehabilitation from a clinician's perspective to inform studies focusing on prosthetic and socket design and fitting. Six clinician (2 prosthetists, 4 physiotherapists) interviewees were self-selected from a survey exploring issues and frustrations during lower-limb prosthetic rehabilitation. Semi-structured interviews explored the impactors on and frustrations with rehabilitation and the prosthetic socket. A thematic analysis was subsequently conducted to identify themes in the responses. Five themes were identified: Service Disparity, Body Impactors, Consequences of Ill-Fit, Prosthesis Irritants, and Limitations of Practice. Each theme, though distinct, relates to the others either as a cause or consequence and should be viewed as such. Addressing the themes will have benefits beyond the issues addressed but also expand into the other themes. This study provides an insight into the clinician perspectives on lower-limb prosthetic rehabilitation, which has not been formally documented to date.

Peer tutoring in clinical communication teaching: the experience of 1st year students and their peer tutors

This article was migrated. The article was marked as recommended. This study explored the impact of peer tutoring in Clinical Communication teaching as it was expressed in the views of Year 1 students and their Peer Tutors at Imperial College London. Methods: a mixed methods approach was used combining questionnaires and focus groups. Quantitative findings were analysed using SPSS v23 and qualitative findings were analysed using Framework Methodology. Results: the findings suggest a very positive experience for both Year 1 students and their Peer Tutors with the former reporting feeling supported to practice and improve on their Clinical Communication Skills in a collaborative environment, being taught and learning from peers who would share their past educational experiences. No significant differences were found between students taught by Peer Tutors and those taught by Course Tutors. Peer Tutors on the other hand, reported an equally positive experience, which gave them an insight into teaching, improved their leadership and feedback skills, enhanced their confidence and helped them reflect on their own Clinical Communication skills. Conclusion: peer tutoring has many advantages as an educational method in medical education and Clinical Communication teaching and should be promoted in medical curricula.

Impact of wearable technology on psychosocial factors of osteoarthritis management: a qualitative study

OBJECTIVES

To identify the impact the use of wearable technology could have in patients with osteoarthritis in terms of communication with healthcare providers and patients' empowerment to manage their condition.

DESIGN

Qualitative study using focus groups with patients with osteoarthritis; data from patients' responses were analysed using Framework Methodology.

PARTICIPANTS

21 patients with knee osteoarthritis from the London area (age range 45-65 years) participated in a total of four focus groups. Recruitment continued until data saturation.

SETTING

The study was conducted in a university setting.

RESULTS

Patients' responses suggested a positive attitude on the impact wearable technology could have on the management of osteoarthritis. It was perceived that the use of wearable devices would benefit patients in terms of feeling in control of their condition, providing them with awareness of their progress, empowering in terms of self-management and improving communication with their clinician.

CONCLUSIONS

This paper suggests positive patient perspectives on the perceived benefits wearable technology could have on the management of osteoarthritis. The data that could be collected with the use of wearable technology could be beneficial both to patients and clinicians. The information obtained from this study suggests that introducing wearable technology into patient-centred care could enhance patient experience in the field of osteoarthritis and beyond.

A knee monitoring device and the preferences of patients living with osteoarthritis: a qualitative study

OBJECTIVES

To identify perspective of patients with osteoarthritis, in particular design requirements and mode of use, of wearable technology to support the rehabilitation pathway. This study is part of a user-centred design approach adopted to develop a rehabilitation tool for patients with osteoarthritis.

DESIGN

Qualitative study using a focus group approach; data management via a thematic analysis of patients' responses.

PARTICIPANTS

21 patients with osteoarthritis (age range 45-65 years) participated in 1 of the 4 focus groups. Recruitment continued until data saturation.

SETTING

The study was conducted in a university setting.

RESULTS

Main determinants of user acceptance of a wearable technology were appearance and comfort during use. Patients were supportive of the use of wearable technologies during rehabilitation and could recognise their benefit as monitors for their progress, incentives to adhere to exercise, and tools for more informed interaction with clinicians.

CONCLUSIONS

This paper should encourage adoption and development of wearable technology to support rehabilitation of patients with osteoarthritis. It is pivotal that technological development takes into account patients' views in that it should be small, light, discrete, not 'appear medical' or challenge the identity of the user. Derived data should be available to patients and clinicians. Furthermore, wearable technologies should be developed to operate in two modes: for exercise guidance and assessment only, and for unobtrusive everyday monitoring. The information obtained from this study should guide the design of new technologies and support their use in clinical practice.

Wake up, wake up! It's me! It's my life! patient narratives on person-centeredness in the integrated care context: a qualitative study

BACKGROUND

Person-centered care emphasizes a holistic, humanistic approach that puts patients first, at the center of medical care. Person-centeredness is also considered a core element of integrated care. Yet typologies of integrated care mainly describe how patients fit within integrated services, rather than how services fit into the patient's world. Patient-centeredness has been commonly defined through physician's behaviors aimed at delivering patient-centered care. Yet, it is unclear how 'person-centeredness' is realized in integrated care through the patient voice. We aimed to explore patient narratives of person-centeredness in the integrated care context.

METHODS

We conducted a phenomenological, qualitative study, including semi-structured interviews with 22 patients registered in the Northwest London Integrated Care Pilot. We incorporated Grounded Theory approach principles, including substantive open and selective coding, development of concepts and categories, and constant comparison.

RESULTS

We identified six themes representing core 'ingredients' of person-centeredness in the integrated care context: "Holism", "Naming", "Heed", "Compassion", "Continuity of care", and "Agency and Empowerment", all depicting patient expectations and assumptions on doctor and patient roles in integrated care. We bring examples showing that when these needs are met, patient experience of care is at its best. Yet many patients felt 'unseen' by their providers and the healthcare system. We describe how these six themes can portray a continuum between having own physical and emotional 'Space' to be 'seen' and heard vs. feeling 'translucent', 'unseen', and unheard. These two conflicting experiences raise questions about current typologies of the patient-physician relationship as a 'dyad', the meanings patients attributed to 'care', and the theoretical correspondence between 'person-centeredness' and 'integrated care'.

CONCLUSIONS

Person-centeredness is a crucial issue for patients in integrated care, yet it was variably achieved in the current pilot. Patients in the context of integrated care, as in other contexts, strive to have their own unique physical and emotional 'space' to be 'seen' and heard. Integrated care models can benefit from incorporating person-centeredness as a core element.

Motivation to study dental professions in one London Dental Institute

INTRODUCTION

While past research has explored dental students' motivation to study, there is limited understanding in the reasons behind career choice for hygienists/therapists and dental nurses. The aim of this study was to investigate simultaneously the views of students of dentistry, hygiene/therapy and dental nursing in King's College London and explore similarities or differences in career choice.

METHODS

All first-year students were invited to the questionnaire survey, exploring motivation to study using a 23-item instrument. Data were analysed using SPSS v18; statistical analysis included one-way analyses of variance and factor analysis.

RESULTS

The overall response rate to the study was 75% (n = 209). Ten out of 23 factors were considered important by more than 80% of respondents, with 'job security' (93.8%), 'desire to work with people' (88%) and 'degree leading to recognised job' (87.5%) being top three. Analysis suggested that 52% of the total variation in motivating influences was explained by four factors: 'features of the job' (26%), 'education/skills' (11%), 'public service' (8%) and 'careers-advising' (7%); at group level 'features of the job' were significantly more important for the direct entrants to dentistry (P = 0.001).

DISCUSSION

The findings suggest that across groups students were motivated to study by common influences reflecting altruistic, but also pragmatic and realistic motives, while 'features of the job' were more important for the direct entrants to dentistry.

Integrated care pilot in north-west London: a mixed methods evaluation

INTRODUCTION

This paper provides the results of a year-long evaluation of a large-scale integrated care pilot in north-west London. The pilot aimed to integrate care across primary, acute, community, mental health and social care for people with diabetes and/or those aged 75+ through care planning, multidisciplinary case reviews, information sharing and project management support.

METHODS

The evaluation team conducted qualitative studies of change at organisational, clinician and patient levels (using interviews, focus groups and a survey); and quantitative analysis of change in service use and patient-level clinical outcomes (using patient-level datasets and a matched control study).

RESULTS

The pilot had successfully engaged provider organisations, created a shared strategic vision and established governance structures. However, the engagement of clinicians was variable and there was no evidence to date of significant reductions in emergency admissions. There was some evidence of changes in care processes.

CONCLUSION

Although the pilot has demonstrated the beginnings of large-scale change, it remains in the early stages and faces significant challenges as it seeks to become sustainable for the longer term. It is critical that National Health Service managers and clinicians have realistic expectations of what can be achieved in a relatively short period of time.

Care home managers' views of dental services for older people living in nursing and residential homes in inner city London

OBJECTIVE

To investigate care home managers' views on the provision of dental care (current and future; urgent, check-up and follow-up) for their residents, barriers to care and the impact of policy changes, by type of home (nursing vs residential), with a view to informing the planning and provision of care.

BASIC RESEARCH DESIGN

A cross sectional postal questionnaire survey and follow-up semi-structured interviews.

SETTING

Care homes in South East London. PARTCIPANTS: All care home managers in three south east London boroughs.

RESULTS

A 72% response rate (n=152) was achieved, 140 of which were designated as nursing and/or residential homes (92%). Almost all managers reported that the care homes had arrangements in place for residents to access some elements of dental care (99%, n=148). Reported barriers to care included residents' fear of treatment (53%), patients' limited mobility (45%) and waiting times for services (42%). Limited mobility (p=0.01) and transport issues (p=0.01) were more significant barriers for nursing homes, whereas fear (p=0.02) was more significant for residential homes. Access to a range of dental services and modes of service delivery were requested for the future; most notable were the demands for domiciliary services to be available to nursing homes and for residential homes to access local general dental practitioners to meet the needs of their residents.

CONCLUSIONS

Managers report having arrangements in place for residents to access dental services; however, there was a clear view that future arrangements should be more appropriate to the needs and vulnerabilities of their residents.

Career choice, pathways and continuing professional development of dental nurses at one institution

OBJECTIVE

To explore the career pathways and continuing professional development of dental nurses employed at one institution relative to the scope of practice.

METHOD

A questionnaire exploring career pathways and continuing professional development of dental nurses was compiled and delivered to clinical departments. Responses were entered onto SPSS v17 for analysis.

RESULTS

Ninety-eight percent (n = 64) of available nurses responded to the questionnaire survey. Eighty percent (n = 51) of the dental nurses were aged between 25 and 44 years, and 95% (n = 61) were female. The ethnicity of the workforce varied; 58% (n = 37) were White and this consequently constituted the largest ethnic group in the workforce. The dental nurses reported that they chose their profession for a wide variety of reasons, the most common one being the opportunity to progress in the dental sector. Before commencing training 38% (n = 24) were aware of their options for progression; this increased subsequent to training with between 55% (n = 35) and 66% (n = 42), depending on the option, stating that they were aware of their options for progression. Eighty-three percent (n = 53) were trained in an additional skill and all of those who were not (n = 11) stated that they would like this training. Conscious sedation was the most frequently possessed additional skill and radiography was the additional skill in which the highest proportion would like to be trained. Personal satisfaction was the most significant factor affecting the willingness of the workforce to pursue career progression.

CONCLUSION

The findings suggest that amongst dental nurses employed in one institution there is evidence that the majority benefit from continuing professional development opportunities, possess additional skills and are motivated to further their skills and progress in their careers.

Personality profile of students entering dentistry, hygiene/therapy and dental nursing at one London dental institute

INTRODUCTION

King's College London Dental Institute (KCLDI) is the largest school in the UK, training dental professionals: Dentists, Hygienists/Therapists and Dental Nurses. Although previous work has examined dental students, there is a dearth of studies on the personality profile of students of hygiene/therapy and dental nursing.

OBJECTIVE

To investigate the personality profile of students studying dentistry, hygiene/therapy and dental nursing at KCLDI, by programme, sex and ethnicity.

METHODS AND MATERIALS

All entrants into dentistry, hygiene/therapy and dental nursing at KCLDI were invited to participate in the study. A self report questionnaire including the brief version of the Five-Factor Model and personal details was administered to the 218 recruited students in groups and under supervised conditions.

RESULTS

  One-way ANOVA on data from 148 questionnaires revealed significant differences; the medical graduate entrants to dentistry appeared to have a more extraverted profile than hygiene/therapy entrants (P<0.04). The graduate entrants to dentistry were more open to experiences than the direct entrants (P<0.03) and the dental nursing trainees (P<0.03). The medical graduate entrants also appeared more open to experiences than the dental nursing trainees; the latter also appeared to have a more sensitive profile compared to the medical entry students (P<0.03). No differences were found between groups in agreeableness and conscientiousness.

CONCLUSIONS

The findings suggest the presence of personality differences between entrants to dentistry, hygiene/therapy and dental nursing. The implications of these findings are discussed.