• 20 Real talk - beyond advanced communication skills: outcomes of a residential workshop for palliative care doctors

      Whittaker, Becky; Watson, Sharan; Loughborough University, University of Derby (BMJ, 2019-03-19)
      Analysis of filmed data of patient consultations at a UK hospice provides the materials for ‘Real Talk’; a novel and flexible education intervention containing real-life film clips. Communication skills training is more likely to be effective in changing behaviours when it is experiential and interactive, being relevant to trainees’ practice. Methods Experienced palliative care doctors attended a three-day residential workshop in which they explored the Real Talk intervention in facilitated small groups. Discussions linked to the evidence relating to communication strategies, whilst reflective diaries and action planning provided opportunity for linking learning to their clinical and educator roles. The workshop was attended by 29 experienced palliative care doctors who completed a pre and post questionnaire we adapted from a validated tool. Pre-workshop questions asked for workshop expectations; 19 delegates identified all their expectations had been met, 10 did not indicate an answer. Narratives from the expanded answers noted the workshop had exceeded expectations and the ‘train the trainer’ approach was welcomed. Delegates identified the most effective aspects of learning included experiential small group work relating to the content of the Real Talk film clips, opportunity to critique underpinning evidence of how clinicians communicate in relation to conversations in end of life care and having an opportunity to reflect on learning and application to practice in a safe and stimulating environment. Engagement in, and feedback on, the workshop has provided a foundation on which to build our research in understanding complex communication and skills training. Providing interactive experiential learning, embedded in the emerging evidence base underpinning Real Talk, is crucial for clinicians seeking to explore complex communication skills with patients facing the end of life. Ensuring skilled facilitation, a safe environment and programme flexibility are crucial to the learning process.
    • 21 Real talk – a novel evidence-based, video-based communication skills training resource.

      Parry, Ruth; Whittaker, Becky; Pino, Marco; Watson, Sharan; Hamlyn, Sarah; Faull, Christina; University of Nottingham; Loughborough University; LOROS Hospice; DeMontfort University; et al. (BMJ Publishing Group Ltd., 2018-03-01)
      Background Much palliative care communication training draws on sparse evidence about practice. Yet training’s effectiveness depends on the strength of its underpinning evidence. An empirical, observational science of language and social interaction – ‘Conversation Analysis’ holds great promise because: it is generating copious evidence on communication, and healthcare–communication specifically; shows role–played interactions differ from authentic ones in fundamentally important ways; recent quantitative evaluations of interventions based on conversation analytic findings have shown effectiveness. Within a research and training development programme, we designed novel training resources – ‘Real Talk’ incorporating research findings and clips from video-recorded hospice consultations. We designed Real Talk to complement rather than replace existing resources. We report a preliminary evaluation of Real Talk’s strengths and weaknesses. Method Mixed-methods, qualitative evaluation entailing observations, interviews, and participant-completed feedback questionnaires. Results We collected data from 11 events, 10 trainers across England, and 150 trainees. Conclusions Trainees and trainers alike appreciated the video clips and their authentic nature. Observations and reports indicated Real Talk was particularly effective for encouraging participants to both emotionally engage with the nature of palliative care, and actively engage in discussion and overall learning about communication practices. Trainers used the video clips more than they did the research findings components; with a similar pattern seen in most trainees’ feedback. Our decision to design Real Talk for trainers to use without initial intensive training meant we could rapidly and widely distribute the resources and evaluate their use. However, this also meant heavy reliance on trainers’ existing facilitation skills, and on their allocation of adequate time to familiarise themselves with the materials. We argue that this is also why the research findings-based components were not put to full use by trainers. We are revising Real Talk and its delivery on the basis of our evaluation.
    • Acceptability of intrapartum ultrasound by mothers in an African population

      Wiafe, Yaw Amo; Whitehead, Bill; Venables, Heather; Dassah, Edward T; University of Derby; Kwame Nkrumah University of Science and Technology, Kumasi, Ghan (Springer, 2019-05-08)
      Intrapartum ultrasound is gaining high acceptance by many women as another method for assessing labour progression. Despite growing evidence of the effectiveness of ultrasound in labour, the acceptance of intrapartum ultrasound has not been previously investigated in black Africans. This study aimed to determine women’s acceptance of intrapartum ultrasound and their preference for transperineal ultrasound or digital vaginal examination (digital VE) in Ghana. An analytical cross-sectional study was conducted among mothers who had had both digital VE and transperineal ultrasound during labour in a tertiary hospital. Information about their sociodemographic characteristics, experience with, and preference for ultrasound or digital VE in labour using a pretested structured questionnaire was obtained. Their experiences were categorised as ‘tolerable, ‘quite uncomfortable’ or ‘very uncomfortable’. Categorical variables were compared using Fisher’s exact test. A p value < 0.05 was considered statistically significant. Altogether, 196 women were recruited into the study. The mean age of the women was 26.7 years (standard deviation, 4.6 years). Nearly half (47%) of the women had never delivered before. Significantly more women considered transperineal ultrasound to be more tolerable than digital VE (66% vs. 40%; p < 0.001). Almost all the women (97.5%) described their experience with transperineal ultrasound to be better than digital VE, and would choose transperineal ultrasound over digital VE in the future (98.5% vs. 1.5%; p < 0.001). The findings of this study are comparable to those of other related studies reported recently. This research confirms high acceptance of ultrasound in labour by mothers from different countries and across continents, implying that cultural differences do not influence women’s responses to and interest in intrapartum ultrasound. Most women found ultrasound in labour to be more tolerable than digital VE. Whenever possible, transperineal ultrasound should be provided as an alternative to digital VE during labour.
    • Acute renal failure in cirrhosis: Is it as bad as we think?

      Rye, Kara; Taylor, Nicholas; Li, Ka Kit; Mortimore, Gerri; Johnson, M.; Freeman, Jan G.; Derby City General Hospital (BMJ Publishing Group Ltd., 2007-04)
      Introduction: Acute renal failure (ARF) is associated with a mortality of 50–60% in critically ill patients admitted to the intensive care unit (ICU). Prerenal causes and acute tubular necrosis (ATN) account for more than 85% of cases and are potentially reversible. ARF frequently complicates cirrhosis, is often attributed to hepatorenal syndrome (HRS), which may preclude aggressive treatment with its mortality up to 90%. Aims & Methods: The aim of this study was to identify factors that may predispose to or precipitate ARF in cirrhosis, and determine outcome and mortality. A retrospective review of cirrhotic patients admitted with or developing renal impairment (defined as serum creatinine >130 μmol/l or oliguria <500 ml/24 h) from October 1999–April 2004. Patients with bleeding gastro-oesophageal varices were excluded. Demographic details, cause of ARF, potential early warning features, management and outcome were recorded. Results: Eighty patients, median age 52 years (25–84), 46 male, median MELD 26 (7–43). Alcohol was causal in 88.8%. ARF occurred in 41/80 (51.3%) on admission, or a median of 6 days after admission (1–34). Median serum creatinine at onset of renal impairment 172 μmol/l (60–589). An identifiable precipitant was found in 62/80 (77.5%) and were concurrent in 51%; nephrotoxic drugs 50%, sepsis 45% (culture positive 27/36), recent paracentesis (preceding month) 28.8%, fluid loss 26.3%, and spontaneous bacterial peritonitis 13.3%. HRS occurred in 17.5%. No parenchymal renal disease or obstructive uropathy was seen. 54% were hyponatraemic (serum sodium <130 μmol/l) at onset of ARF. ARF was heralded by a fall in median mean arterial pressure (MAP) of 14.1 mm Hg from admission (p<0.001, CI 6.8–19.7). 71.2% received volume expansion, 91.1% terlipressin, 79.7% salt poor albumin, 93.4% antibiotics, 7.5% MARS/renal support. MAP did not rise significantly 24 h after initiation of treatment (p = 0.56). 28 day mortality was 61%. HRS patients had higher MELD scores than non-HRS patients (30 v 25; p = 0.0152) but 28 day mortality was not significantly different (64.3% v 60.6% respectively, p = 0.797). Conclusion: ARF in cirrhosis is rarely due to HRS but is most commonly pre-renal in origin and multifactorial. Potential early warning features include hyponatraemia and a falling MAP. Current treatment regimes may not be aggressive enough to reverse renal hypoperfusion. Despite this mortality for our cirrhotic cohort was similar to non-cirrhotic patients admitted to ITU with ARF. Development of ARF in a cirrhotic patient should not preclude aggressive treatment.
    • Advanced liver training: where are the courses

      Mortimore, Gerri; University of Derby (2016-07-01)
    • Advanced nurse practitioners: the NHS England framework.

      Reynolds, Julie; Mortimore, Gerri; University of Derby (Mark Allen Group, 2018-03-02)
    • Alcohol- is it all that bad?

      Mortimore, Gerri; University of Derby (The Hypocratic Post, 2018-02-05)
      According to a YouGov poll, 3.1 million people in the UK planned to take part in Dry January this year and give up alcohol. With January now behind us, how many people will continue to abstain or cut back on their alcohol intake, and who will choose to hop back off the wagon? The answer to this question is very dependent on how much we drink or, in other words, the total amount of alcohol units we consume. Of course, many of us who regularly consume alcohol don’t really think about the units we drink unless we are contemplating driving. I think many people will be shocked to realise that they are drinking many more units than is recommended by the Department of Health.
    • Alcohol-use disorders: prevention.

      Mortimore, Gerri; University of Derby (National Institute for Health and Care Excellence (NICE), 2010-06)
    • Alcohol: is it all that bad?

      Mortimore, Gerri; University of Derby (University of Derby, 2018-02-01)
    • ‘Am I a student or a Health Care Assistant?’ A qualitative evaluation of a programme of pre-nursing care experience.

      Whiffin, Charlotte Jane; Baker, Denise; Henshaw, Lorraine; Nichols, Julia J.; Pyer, Michelle; University of Derby; University of Northampton; Senior Lecturer in Nursing; College of Health and Social Care; University of Derby; Head of Allied Health and Social Care; College of Health and Social Care; University of Derby; Head of Post-Graduate Health Care; College of Health and Social Care; University of Derby; et al. (Wiley, 2018-07-10)
      Aim To examine the experiences of pre‐nursing Health Care Assistants during a six‐month programme of pre‐nursing care experience. Background Care experience prior to commencing programmes of nurse education is broadly considered to be advantageous. However, it is not clear how formal care experience prior to nurse education has an impact on the values and behaviours of the aspirant nurse. Design A longitudinal prospective qualitative study using focus group discussions. Methods Data were collected from 23 pre‐nursing health care assistants during September 2013 ‐ February 2014. Three focus groups were held at the beginning, middle and end of the programme of care experience at each of the participating hospitals. A thematic analysis was used to analyse data sets from each hospital. Findings from each hospital were then compared to reach final themes. Results Five major themes were identified in the analysis of qualitative data: personal development; positioning of role in the healthcare team; support and supervision; perceived benefits; and advice and recommendations. These themes were underpinned by deep aspirations for better care and better nurses in the future. Conclusions Pre‐nursing care experience can positively prepare aspirant nurses for programmes of nurse education. The benefits identified were confirmation of aspiration (or otherwise) to pursue nursing; learning opportunities and aspiration to improve patient experience. Risks for the programme included poor supervision; role ambiguity or confusion; demotivation through a deteriorating view of nursing and poor treatment by others. The longer‐term impact on values and behaviours of this cohort requires further evaluation.
    • Another way for student exchanges: A Google + community for collaborative learning related to European public health issues

      Collins, Guy; Koning, Mirjam; van de Velde, Ellen; University of Derby; Rotterdam University (Consortium of Institutes of Higher Education in Health and Rehabilitation in Europe, 2016-04-14)
    • Applying best practice: the venesection clinics of the future

      Mortimore, Gerri; university of Derby (University of Derby, 2019-04-13)
      Discussed patient experiences of venesections and trying to get it right first time across venesection departments across the country.
    • Apprenticeships

      Baker, Denise; University of Derby (2018-11)
    • Are newly qualified nurses prepared for practice?

      Holmes, Dinah; Whitehead, Bill; University of Derby (EMAP, 2011-05)
      While many people find starting a new job stressful, the transition from student to newly qualified nurse comes with additional pressures, as being unprepared could harm patients.
    • Are we missing a trick? Why is occupational therapy not talking about the role and development of assistant practitioners?

      Biggam, Amanda; University of Derby (2019-06-17)
      The aim of this poster is to present a scoping of recent literature around the role of assistant practitioners within healthcare, and to present the argument that as a profession we need to be more proactive in developing the skills and knowledge of our support staff. Recently, there has been a drive to develop the nursing associate role to help fill the gap between healthcare support workers and registered nurses. Clear guidance on standards of proficiency have been developed; with the role being registered by the NMC aligning it with the nursing family (NMC, 2018). Within allied health professions, literature reviews highlight that Radiography have embraced the formal development of their support workers, with the Society of Radiographers producing a scope of practice (Johnson, 2012) and a clear career pathway from assistant practitioner to registered radiographer. Occupational therapy, however, does not appear in the recent literature to be researching the impact and benefits of the assistant practitioner role. This poster will allow consideration of the barriers and opportunities for a more defined role of assistant practitioners within occupational therapy. Evidence suggests that the formalisation of an occupational therapy based assistant practitioner, with a coherent training and development opportunities, ensures the success of this role (Wheeler, 2017). This poster will aim to generate discussion about how empowering existing staff to complete a foundation degree will not only recognise our existing workforce but will positively impact on our clients’ clinical outcomes.
    • Ascites: drainage and management.

      Mortimore, Gerri; University of Derby (2018-01-25)
      This presentation will look at the death rates from liver disease over the last 40 years as well as the causes. Signs and symptoms of decompensated liver disease will be discussed to include the causes and types of ascites. The manifestation of Spontaneous bacterial peritonitis (SBP) will also be discussed along with the treatment of SBP, large volume paracentesis; including it's associated complications and the importance of written consent for these procedures.
    • Attributes of Iranian new nurse preceptors: A phenomenological study

      Borimnejad, Leili; Valizadeh, Sousan; Rahmani, Azad; Whitehead, Bill; Shahbazi, Shahla; Iran University of Medical Sciences; Tabriz University of Medical Sciences; University of Derby (Elsevier, 2017-10-17)
      Preceptors should possess attributes which help them in successfully performing the demanding and challenging role in the preceptorship. This research utilises a qualitative hermeneutic phenomenological approach to explore the attributes of new nurse preceptors. Six preceptors of a teaching hospital in Northwest of Iran who were selected by means of purposive sampling. Data were collected during eight months from July 2014 to March 2015 through in-depth semi-structured personal interviews. Interviews were recorded and transcribed and then were analyzed with the interpretive approach using the Diekelmann's seven-stage method in the MAXQDA10 software environment. Findings included two main themes “feeling proud and honored” and “professionalism” with subthemes including empathy, being nonjudgmental, patience, and spirit of self-sacrifice. The spirit of self-sacrifice was a unique attribute revealed in this research. Preceptors possessed several important attributes which are usually stressed in the literature as selection criteria for preceptors. These attributes could be further drawn upon when selecting new preceptors. Preceptors are role models. Existence of the spirit of self-sacrifice among preceptors could contribute to transferring of such spirit to new nurses and future preceptors as well as to preceptors’ patience with challenges of their role. Effective preceptorship needs preceptors who possess specific professional and personal attributes. These attributes could be drawn upon more objectively in the process of selection, preparation and evaluation of preceptors by clinical and educational nursing managers.
    • Automonic dysfunction measured by baroreflex sensitivity is markedly abnormal in stable cirrhosis despite minimal systemic haemodynamic changes

      Rye, Kara; Mortimore, Gerri; Austin, Andrew; Freeman, Jan G.; University of Derby (BMJ Publishing Group Ltd., 2009)
      Baroreceptor sensitivity (BRS) is well recognised as a composite marker of the overall integrity of the autonomic nervous system, maintaining cardiovascular status both at rest and during physiological stress. Autonomic dysfunction occurs in 43–80% of cases of cirrhosis, affecting both sympathetic and parasympathetic branches. BRS impairment occurs independently of aetiology and correlates with disease severity and the hyperdynamic circulation. BRS has been studied extensively in advanced disease, especially pre-transplantation but less so in more compensated disease. Impaired BRS is associated with a 5-fold increase in mortality, independent of cirrhosis stage, yet can be improved by drugs and liver transplantation.
    • Automonic dysfunction measured by baroreflex sensitivity is markedly abnormal in stable cirrhosis despite minimal systemic haemodynamic changes

      Rye, Kara; Mortimore, Gerri; Austin, Andrew; Freeman, Jan G.; Derby City General Hospital (BMJ Publishing Group Ltd., 2009-04)
      Introduction: Baroreceptor sensitivity (BRS) is well recognised as a composite marker of the overall integrity of the autonomic nervous system, maintaining cardiovascular status both at rest and during physiological stress. Autonomic dysfunction occurs in 43–80% of cases of cirrhosis, affecting both sympathetic and parasympathetic branches. BRS impairment occurs independently of aetiology and correlates with disease severity and the hyperdynamic circulation. BRS has been studied extensively in advanced disease, especially pre-transplantation but less so in more compensated disease. Impaired BRS is associated with a 5-fold increase in mortality, independent of cirrhosis stage, yet can be improved by drugs and liver transplantation. Aims and Methods: The aim of this study was to determine the prevalence of BRS abnormalities in a stable population of cirrhotics. We studied 16 cirrhotic patients with stable disease for >6 months. Systemic haemodynamics and BRS were assessed non-invasively in the supine position on two different days using the Finometer® (TNO instruments, Amsterdam). Data were downloaded to a PC-based analysis program (Beatscope®). Spontaneous BRS was assessed using software studying the relationship between inter-beat variability and beat-to-beat changes in systolic blood pressure. Portal pressure was assessed by measurement of the hepatic venous pressure gradient (HVPG). Results: Median age 47 (30 to 67) years, 63% male, median Child–Pugh (CP) score 6 and MELD 11. 94% alcoholic aetiology, 69% abstinent. 9/16 (56%) concomitant spironolactone. Median haemodynamic data as follows: systolic BP 147 (115 to 169) mm Hg, diastolic BP 82 (65 to 103) mm Hg, MAP 104 (87 to 131) mm Hg, HR 89 (54 to 117) bpm, SV 89 (36 to 164) ml, CO 7.0 (3.5 to 12.0) lpm, PVR 0.98 (0.45 to 2.14) MU, HVPG 18 (7 to 25) mm Hg. 12/16 (75%) had abnormal BRS (normal 8 to 10 ms/mm Hg) with median BRS 3.38 (1.14 to 11.19) ms/mm Hg. Sequential BRS readings were not significantly different (3.38 vs 3.98 ms/mm Hg, p = 0.87). Systemic haemodynamics were not significantly different in patients with impaired BRS compared with those with normal BRS. BRS did not correlate with disease severity (CP A 2.96 vs CP B 3.80 ms/mm Hg, p = 1.0), systemic haemodynamics, serum sodium or variceal size. There was a significant negative correlation between BRS and HVPG (r = −0.523, p = 0.045). Conclusion: Autonomic function as assessed by BRS is frequently abnormal in stable cirrhotic patients. Abnormalities of BRS are not associated with marked haemodynamic changes, suggesting that it is predominantly the vagal aspect that is impaired in stable disease. Abnormalities of BRS are associated with HVPG which may suggest that portal pressure itself plays a pivotal role in its causation. The significance of impaired BRS in this stable group needs to be determined by assessing long-term outcome.
    • Autonomic dysfunction measured by baroreflex sensitivity in markedly abnormal in stable cirrhosis despite minimal haemodynamic changes.

      Rye, Kara; Mortimore, Gerri; Austin, Andrew; Freeman, Jan G.; University of Derby; Derby Hospitals NHS Foundation Trust (British Association for the Study of Liver (BASL), 2008)
      Introduction: Autonomic dysfunction occurs in 43-80% of cases of cirrhosis, but is usually asymptomatic. The baroreflex arc is an important component of the autonomic nervous system main- taining cardiovascular status both at rest and during physio- logical stress. Baroreceptor sensitivity (BRS) is impaired in cirrhosis and correlates with disease severity. It has been stud- ied extensively in advanced disease, especially pre-transplan- tation, where impairment of BRS correlates with the presence of ascites, encephalopathy, and the hyperdynamic circulation. Impaired BRS is associated with a five-fold increase in mortal- ity predominantly from sepsis and variceal bleeding, inde- pendent of the stage of liver disease. Manipulation by ACE inhibitors, aldosterone antagonists and liver transplantation all improve BRS. The aim of this study was to determine the preva- lence of BRS abnormalities in a stable population with well compensated disease. Methods: We studied 11 stable cirrhotic patients. Spontaneous BRS was assessed in the supine position on two different days using software studying the relationship between inter-beat variability and beat-to-beat changes in sys- tolic blood pressure. Systemic haemodynamics (heart rate (HR), mean arterial pressure (MAP), cardiac output (CO), stroke vol- ume (SV), peripheral vascular resistance (PVR)) were assessed non-invasively using the Finometer®. Portal pressure was assessed by measurement of the hepatic venous pressure gra- dient (HVPG). Results: Median age 46 (30-67) years, 64% male, median Child-Pugh (CP) score 6 and MELD 11. Median haemodynamic data as follows: systolic BP 147 (115-169) mmHg, diastolic BP 82 (73-103) mmHg, MAP 103 (87-131) mmHg, HR 90 (63-110) bpm, SV 87 (38-141) ml, CO 8.0 (3.5-10.1) lpm, PVR 0.96 (0.64-2.14) MU, HVPG 18 (12-26)mmHg. 9/11 (82%) had abnormal BRS (normal 8- 10ms/mmHg) with median BRS 2.58 (1.14-9.46) ms/mmHg. Sequential BRS readings were not significantly different (2.58 vs 3.26 ms/mmHg, p=0.8). BRS did not correlate with disease severity (CP A 2.58 vs CP B 3.80 ms/mmHg, p=0.9), systemic haemodynamics, HVPG or serum sodium. Systemic haemody- namics were not significantly different in patients with impaired BRS compared to those with normal BRS. Conclusions: Auto- nomic function as assessed by BRS is markedly abnormal in sta- ble well compensated cirrhosis. Abnormalities are not specific to advanced disease as previously thought and in our group are not associated with marked hyperdynamic changes. Our data suggest that it is predominantly the vagal aspect that is impaired in well compensated disease. The long-term outcome of these patients needs to be assessed.