Dr Debbie Cooke

Objectives: To evaluate whether the additional information provided by minimally invasive glucose monitors results in improved glycaemic control in people with poorly controlled insulin-requiring diabetes, and to assess the acceptability and health economic impact of the devices. Design: A four-arm randomised controlled trial was undertaken. Setting: Participants were recruited from secondary care diabetes clinics in four hospitals in England. Participants: 404 people aged over 18 years with insulin-treated diabetes mellitus (types 1 or 2) for at least 6 months who were receiving two or more injections of insulin daily were eligible. Participants had to have had two glycosylated haemoglobin (HbA1c) values e 7.5% in the last 15 months. Interventions: Participants were randomised to one of four groups. Two groups received minimally invasive glucose monitoring devices [GlucoWatch Biographer or MiniMed Continuous Glucose Monitoring System (CGMS)]. These groups were compared with an attention control group (standard treatment with nurse feedback sessions at the same frequency as those in the device groups) and a standard control group (reflecting common practice in the clinical management of diabetes in the UK). Main outcome measures: Change in HbA1c from baseline to 3, 6, 12 and 18 months was the primary indicator of short- to long-term efficacy in this study. Perceived acceptability of the devices was assessed by use and a self-report questionnaire. A health economic analysis was also performed. Results: At 18 months all groups demonstrated a decline in HbA1c levels from baseline. Mean percentage changes in HbA1c were -1.4 for the GlucoWatch group, -4.2 for the CGMS group, -5.1 for the attention control group and -4.9 for the standard care control group. At 18 months the relative percentage reduction in HbA1c in each of the intervention arms was less than that in the standard care control group. In the intention to treat analysis no significant differences were found between any of the groups at any of the assessment times. There was no evidence that the additional information provided by the devices resulted in any change in the number or nature of treatment recommendations offered by the nurses. The health economics analysis indicated no advantage in the groups who received the devices; a lower cost and higher benefit were found for the attention control arm. Assessment of device use and acceptability indicated a decline in use of both devices, which was mo

Improving management of type 1 diabetes in the UK:
the Dose Adjustment For Normal Eating (DAFNE)
programme as a research test-bed. A mixed-method
analysis of the barriers to and facilitators of successful
diabetes self-management, a health economic analysis,
a cluster randomised controlled trial of different
models of delivery of an educational intervention and
the potential of insulin pumps and additional educator
input to improve outcomes.

To evaluate whether the additional information provided by minimally invasive glucose monitors results in improved glycaemic control in people with poorly controlled insulin-requiring diabetes, and to assess the acceptability and health economic impact of the devices.

Research demonstrates that patients have a poor understanding of glycosylated haemoglobin A1c (HbA1c) and that this impacts on effective diabetes self-management. This study attempted to replicate these findings in a UK outpatient sample of people with diabetes.

OBJECTIVETo determine whether improvements in glycemic control and diabetes-specific quality of life (QoL) scores reported in research studies for the type 1 diabetes structured education program Dose Adjustment for Normal Eating (DAFNE) are also found when the intervention is delivered within routine U.K. health care.RESEARCH DESIGN AND METHODSBefore and after evaluation of DAFNE to assess impact on glycemic control and QoL among 262 adults with type 1 diabetes.RESULTSThere were significant improvements in hemoglobin A(1c) from baseline to 6 and 12 months (from 9.1 to 8.6 and 8.8%, respectively) in a subgroup with suboptimal control. QoL was significantly improved by 3 months and maintained at both follow-up points.CONCLUSIONSLonger term improved glycemic control and QoL is achievable among adults with type 1 diabetes through delivery of structured education in routine care, albeit with smaller effect sizes than reported in trials.

Aims: Study aims were to (1) describe and compare the way diabetes structured education courses have evolved in the UK, (2) identify and agree components of course curricula perceived as core across courses and (3) identify and classify self-care behaviours in order to develop a questionnaire assessment tool. Methods: Structured education courses were selected through the Type 1 diabetes education network. Curricula from five courses were examined and nine educators from those courses were interviewed. Transcripts were analysed using framework analysis. Fourteen key stakeholders attended a consensus meeting, to identify and classify Type 1 diabetes self-care behaviours. Results: Eighty-three courses were identified. Components of course curricula perceived as core by all diabetes educators were: carbohydrate counting and insulin dose adjustment, hypoglycaemia management, group work, goal setting and empowerment, confidence and control. The broad areas of self-management behaviour identified at the consensus meeting were carbohydrate counting and awareness, insulin dose adjustment, self-monitoring of blood glucose, managing hypoglycaemia, managing equipment and injection sites; and accessing health care. Specific self-care behaviours within each area were identified. Conclusions: Planned future work will develop an updated questionnaire tool to access self-care behaviours. This will enable assessment of the effectiveness of existing structured education programmes at producing desired changes in behaviour. It will also help people with diabetes and their healthcare team identify areas where additional support is needed to initiate or maintain changes in behaviour. Provision of such support may improve glycaemia and reduce diabetes-related complications and severe hypoglycaemia. © 2013 Diabetes UK.

To determine whether continuous glucose information provided through use of either the GlucoWatch G2 Biographer or the MiniMed continuous glucose monitoring system (CGMS) results in improved glycated haemoglobin (HbA(1c)) for insulin-treated adults with diabetes mellitus, relative to an attention control and standard care group.

© 2014 John Wiley & Sons Ltd.Aims and objectives: To explore patients' experiences of, views about and need for, social support after attending a structured education programme for type 1 diabetes. Background: Patients who attend structured education programmes attain short-term improvements in biomedical and quality-of-life measures but require support to sustain self-management principles over the longer term. Social support can influence patients' self-management practices; however, little is known about how programme graduates use other people's help. Design: This study was informed by the principles of grounded theory and involved concurrent data collection and analysis. Data were analysed using an inductive, thematic approach. Methods: In-depth interviews were undertaken postcourse, six and 12 months later, with 30 adult patients with type 1 diabetes recruited from Dose Adjustment for Normal Eating courses in the United Kingdom. Results: Patients' preferences for social support from other people ranged from wanting minimal involvement, to benefiting from auxiliary forms of assistance, to regular monitoring and policing. New self-management skills learnt on their courses prompted and facilitated patients to seek and obtain more social support. Support received/expected from parents varied according to when patients were diagnosed, but parents' use of outdated knowledge could act as a barrier to effective support. Support sought from others, including friends/colleagues, was informed by patients' domestic/employment circumstances. Conclusion: This study responds to calls for deeper understanding of the social context in which chronic illness self-management occurs. It highlights how patients can solicit and receive more social support from family members and friends after implementing self-care practices taught on education programmes. Relevance to clinical practice: Health professionals including diabetes specialist nurses and dietitians should explore: patients' access to and preferences for social support; how patients might be encouraged to capitalise on social support postcourse; and new ways to inform/educate people within patients' social networks.

Aim: To explore patients' experiences of using flexible intensive insulin therapy, a regimen requiring them to determine and adjust quick-acting and background/basal insulin doses and mealtime ratios. Methods: Repeat, in-depth interviews with 30 type 1 diabetes patients converted to flexible intensive insulin therapy recruited from Dose Adjustment for Normal Eating (DAFNE) courses in the UK. Results: While patients found determination of quick acting insulin doses relatively straightforward, many struggled, over time, to determine the correct mealtime ratios and adjust basal insulin doses independently. Reasons included: lack of confidence and poor analytical skills; deferential attitudes to health professionals; worries about hypoglycaemia; and, lack of record/diary keeping resulting in fixation on current readings and failure to spot patterns and problems. When health professional support was not sought and/or record keeping neglected, patients gradually developed over-reliance on corrective doses to attain blood glucose readings within target ranges. Conclusion: While patients are motivated to use flexible intensive insulin therapy, they expressed a need for on-going health professional input, particularly to support adjustment of background insulin doses and mealtime ratios. The need to sustain diary/record keeping should be emphasised to patients and provision of a dedicated glycaemic support service is recommended. © 2012 Elsevier Ireland Ltd. All rights reserved.

Purpose: This study reports an innovative theory-driven approach for developing filmed peer support for cancer self-management. Peer support conventionally includes empathetic interaction between people with shared experiences. This unique study considers how to authentically communicate peer empathy in a one-way film narrative.
Methods: We co-created a film based on phenomenological interviews with seven men who had volunteered to support other men by sharing their experiences of coping with prostate cancer. The film contributed to successful engagement with self-management. Interpretative Phenomenological Analysis of the interview data was conducted to explore the components of experiential empathy that the men had communicated.
Results: Four themes were identified illustrating what men wanted other men to know about coping with prostate cancer: Going into the unknown, it was difficult but I got through highlighted trauma and the importance of having a determined attitude; Only you can do it illustrated the triumph of their journey and of regaining control; I haven?t changed massively reflected the importance of a constant self; and Stay involved represented the overriding need to remain part of pre-cancer social environments.
Conclusions: We propose a construct framework of experiential empathy for men with prostate cancer: Resilience, Regaining Control, Continuity-of-Self and Social Connectedness. Filmed peer support that communicates these constructs will offer wide-ranging benefit to meet the needs of this group of men in both e-health and face-to-face self-management contexts. Further research could develop this theory-driven approach to filmed peer support for other cancer groups.

Aim: To explore whether, and why, patients change their food and eating practices following conversion to flexible intensive insulin therapy (FIIT), a regimen which requires quick acting insulin doses to be matched to the carbohydrate content of meals/snacks consumed. Methods: Repeat, in-depth interviews with 30 type 1 diabetes patients converted to FIIT recruited from Dose Adjustment for Normal Eating (DAFNE) courses in the UK. Data were analysed using an inductive, thematic approach. Results: Despite the potential of FIIT to enable greater dietary flexibility and freedom, most patients reported food and eating practices which were remarkably resistant to change. In some cases, FIIT adoption resulted in greater dietary rigidity over time. The opportunities FIIT presented for greater dietary freedom were counterbalanced by new challenges and burdens (e.g. having to simplify food choices to make carbohydrate estimation easier). Due to the emphasis FIIT places on carbohydrate counting, and patients' fears of hypos, low/no carbohydrate foodstuffs sometimes came to be seen as the healthiest or safest options. Conclusion: Concerns that FIIT may result in more excessive or unhealthy eating appear largely unfounded; however, consideration needs to be paid to the ways in which patients' conceptualisations of, and relationship with, food may change following FIIT conversion. © 2010 Elsevier Ireland Ltd.

Half of all bariatric surgical procedures are in women of childbearing age. Surgery may improve fertility yet exacerbate nutritional deficiencies, that may be disadvantageous to the fetus. A frequently encountered subgroup of obese women have type 2 diabetes. The health risks, to both mother and child, of diabetes in pregnancy are well described including 4.7× risk of stillbirth and 2× risk of congenital abnormality. What is not clear is whether bariatric surgery mitigates or complicates the health consequences of women with obesity and diabetes in pregnancy. In addition the influence of the type of surgery, the optimal interval between surgery and conception and evidence based preconception recommendations are unknown. This study complements wider research aiming to inform optimal management of this patient population. Obese diabetic women require clear guidance regarding pregnancy planning after surgery. This study will develop an understanding of the barriers and facilitators (psychological, behavioural, attitudinal and nutritional) to achieving effective pre-pregnancy health and care in women with type 2 diabetes who have undergone metabolic surgery. Currently women's perception of fertility issues and risks after bariatric surgery is unknown and thus a qualitative interpretive paradigm was chosen. Interviews with the target population will explore decision-making processes; experience regarding metabolic surgery and perceived pregnancy risk. Interviews with a broad range of health professionals involved in bariatric care will include rationale for selected surgical procedure and post surgery referral processes e.g. contraceptive care. This will advance understanding of how to provide targeted support and monitoring.

Aims Use of blood glucose targets is considered essential to help patients with Type1 diabetes achieve tight glycaemic control following structured education. To foster effective use of blood glucose targets, we explored patients' experiences and views of implementing clinically recommended blood glucose targets after attending a structured education programme promoting intensive insulin treatment. Methods Repeat, in-depth interviews with 30 patients with Type1 diabetes recruited from Dose Adjustment for Normal Eating (DAFNE) courses in the UK. Data were analysed using an inductive, thematic approach. Results Patients found use of blood glucose targets motivational. Targets enabled patients to identify problems with blood glucose control and prompted them to make insulin dose adjustments independently, or with assistance. However, patients tended to adapt or simplify targets over time to: make them more attainable and easy to remember; reduce risk of hypoglycaemia; and, mitigate feelings of failure when attempts to attain clinically defined targets were unsuccessful. Some patients were advised to use elevated targets to counter hypoglycaemia unawareness and required help from health professionals to determine when/if these should be reduced. Conclusions Although blood glucose targets are an important component of diabetes self-management, patients may adapt and personalize them over time, sometimes inadvertently, with a potentially detrimental impact on long-term glycaemic control. Blood glucose targets should be regularly revisited during clinical reviews and revised/new targets agreed to accommodate patients' concerns and difficulties. Other interventions may need to be considered to promote effective use of blood glucose targets. © 2012 The Authors. Diabetic Medicine © 2012 Diabetes UK.

OBJECTIVETo develop a linguistically and psychometrically validated U.K. English (U.K./Ireland) version of the Diabetes-Specific Quality-of-Life Scale (DSQOLS) for adults with type 1 diabetes.RESEARCH DESIGN AND METHODSWe conducted independent forward and backward translation of the validated German DSQOLS. An iterative interview study with health professionals (n = 3) and adults with type 1 diabetes (n = 8) established linguistic validity. The DSQOLS was included in three Dose Adjustment for Normal Eating (DAFNE) studies (total N = 1,071). Exploratory factor analysis (EFA) was undertaken to examine questionnaire structure. Concurrent and discriminant validity, internal consistency, and reliability were assessed.RESULTSEFA indicated a six-factor structure for the DSQOLS (social aspects, fear of hypoglycemia, dietary restrictions, physical complaints, anxiety about the future, and daily hassles). High internal consistency reliability was found for these factors and the weighted treatment satisfaction scale (± = 0.85-0.94). All subscales were moderately, positively correlated with the Audit of Diabetes-Dependent Quality-of-Life (ADDQoL) measure, demonstrating evidence of concurrent validity. Lower DSQOLS subscale scores [indicating impaired quality of life (QoL)] were associated with the presence of diabetes-related complications.CONCLUSIONSThe DSQOLS captures the impact of detailed aspects of modern type 1 diabetes management (e.g., carbohydrate counting and flexible insulin dose adjustment) that are now routine in many parts of the U.K. and Ireland. The U.K. English version of the DSQOLS offers a valuable tool for assessing the impact of treatment approaches on QoL in adults with type 1 diabetes.

BACKGROUND: Published research has demonstrated that the multiple mini-interview (MMI) is a reliable assessment instrument in medical and nursing student selection. There is a dearth of evidence specifically relating to the advancement and subsequent evaluation of MMIs in the context of student midwife selection. OBJECTIVES: To develop, pilot and examine the reliability of MMIs in pre-registration student midwife selection in a UK setting. DESIGN AND SETTING: DeVellis' framework for questionnaire development underpinned the generation of MMI scenarios. BSc (Hons) Midwifery Studies students at a Higher Education Institution in the UK volunteered to participate in 'mock' MMI circuits during the first week of their programme. RESULTS: An eight station model was piloted. Communication skills were rated at each station as a generic attribute. Station specific attributes assessed included: compassion and empathy; respect for difference and diversity; honesty and integrity; intellectual curiosity and reflective nature; advocacy; respect for privacy and dignity; team working and initiative; the role of the midwife and motivation to become a midwife. Participants' responses to scenario questions were rated on a 7 point scale. Cronbach's alpha scores measuring internal consistency ranged from 0.91 to 0.97 CONCLUSION: The systematic development of the MMI model and scenarios resulted in 'excellent' reliability across all stations. These findings endorse the MMI technique as a reliable alternative to the personal interview in informing final decisions in pre-registration student midwife selection.

© 2014 IEEE.Survey questionnaires are often heterogeneous because they contain both quantitative (numeric) and qualitative (text) responses, as well as missing values. While traditional, model-based methods are commonly used by clinicians, we deploy Self Organizing Maps (SOM) as a means to visualise the data. In a survey study aiming at understanding the self-care behaviour of 611 patients with Type-1 Diabetes, we show that SOM can be used to (1) identify co-morbidities; (2) to link self-care factors that are dependent on each other; and (3) to visualise individual patient profiles; In evaluation with clinicians and experts in Type-1 Diabetes, the knowledge and insights extracted using SOM correspond well to clinical expectation. Furthermore, the output of SOM in the form of a U-matrix is found to offer an interesting alternative means of visualising patient profiles instead of a usual tabular form.

Half of all bariatric surgical procedures are in women of childbearing age but it remains unclear whether surgery is suitable for women who subsequently conceive: specifically the relative risks and benefits of potential nutrient deficiencies versus weight reduction. We will present data collected from Clinical Practice Research Databases on the maternal and fetal outcomes of pregnancies complicated either by obesity or previous bariatric surgery (BS). Two groups, matched to obese controls for BMI pre-BS and post-BS (at the time of ante-natal booking) will be compared. In this way, the effect of BS on pregnancy outcomes may be examined, independent of its effect on weight. A sub-group of women with antecedent Type 2 diabetes (T2DM) will allow for investigation of the additional impact and persistence of this co-morbidity. This builds upon pilot data collected from a retrospective cohort of women (18-45years) undergoing laparoscopic roux-en-Y (RYGB) surgery over a 24-month period (n=218). After exclusions and loss to follow up, data from 111 patients were analysed; 81 (73%) had conceived prior to RYGB, 20 (18%) became pregnant post RYGB and a further 22 patients (20%) were trying to conceive at the time of data collection. Three women had T2DM which resolved post BS. A suggestion of greater miscarriage risk prior to surgery in this sub-group will be confirmed as more women are recruited. Pregnancy is a frequent desire/occurrence after BS. This database study will advance understanding of the maternal and fetal outcomes of such pregnancies and inform antenatal care.

Aim: To explore patients' experiences of using flexible intensive insulin therapy, a regimen requiring them to determine and adjust quick-acting and background/basal insulin doses and mealtime ratios. Methods: Repeat, in-depth interviews with 30 type 1 diabetes patients converted to flexible intensive insulin therapy recruited from Dose Adjustment for Normal Eating (DAFNE) courses in the UK. Results: While patients found determination of quick acting insulin doses relatively straightforward, many struggled, over time, to determine the correct mealtime ratios and adjust basal insulin doses independently. Reasons included: lack of confidence and poor analytical skills; deferential attitudes to health professionals; worries about hypoglycaemia; and, lack of record/diary keeping resulting in fixation on current readings and failure to spot patterns and problems. When health professional support was not sought and/or record keeping neglected, patients gradually developed over-reliance on corrective doses to attain blood glucose readings within target ranges. Conclusion: While patients are motivated to use flexible intensive insulin therapy, they expressed a need for on-going health professional input, particularly to support adjustment of background insulin doses and mealtime ratios. The need to sustain diary/record keeping should be emphasised to patients and provision of a dedicated glycaemic support service is recommended. © 2012 Elsevier Ireland Ltd.

Background Conventional insulin therapy requires patients with Type1 diabetes to adhere to rigid dietary and insulin injection practices. Recent trends towards flexible intensive insulin therapy enable patients to match insulin to dietary intake and lifestyle; however, little work has examined patients' experiences of incorporating these practices into real-life contexts. This qualitative longitudinal study explored patients' experiences of using flexible intensive insulin therapy to help inform the development of effective long-term support. Methods Semi-structured interviews were conducted with 30 adult patients with Type1 diabetes following participation in a structured education programme on using flexible intensive insulin therapy, and 6 and 12months post-course. Longitudinal data analysis used an inductive, thematic approach. Results Patients consistently reported feeling committed to and wanting to sustain flexible intensive insulin therapy. This regimen was seen as a logical and effective method of self-management, as patients experienced improved blood glucose readings and/or reported feeling better. Implementing and sustaining flexible intensive insulin therapy was enhanced when patients had stable routines, with more challenges reported by those working irregular hours and during weekends/holidays. Some patients re-crafted their lives to make this approach work for them; for instance, by creating dietary routines or adjusting dietary choices. Conclusions Clinical data have shown that flexible intensive insulin therapy can lead to improvement in glycaemic control. This study, drawing on patients' perspectives, provides further endorsement for flexible intensive insulin therapy by demonstrating patients' liking of, and their motivation to sustain, this approach over time. To help patients implement and sustain flexible intensive insulin therapy, follow-up support should encourage them to identify routines to better integrate this regimen into their lives. © 2011 The Authors. Diabetic Medicine © 2011 Diabetes UK.

Aims and objectives: To explore patients' experiences of, views about and need for, social support after attending a structured education programme for type 1 diabetes. Background: Patients who attend structured education programmes attain short-term improvements in biomedical and quality-of-life measures but require support to sustain self-management principles over the longer term. Social support can influence patients' self-management practices; however, little is known about how programme graduates use other people's help. Design: This study was informed by the principles of grounded theory and involved concurrent data collection and analysis. Data were analysed using an inductive, thematic approach. Methods: In-depth interviews were undertaken postcourse, six and 12 months later, with 30 adult patients with type 1 diabetes recruited from Dose Adjustment for Normal Eating courses in the United Kingdom. Results: Patients' preferences for social support from other people ranged from wanting minimal involvement, to benefiting from auxiliary forms of assistance, to regular monitoring and policing. New self-management skills learnt on their courses prompted and facilitated patients to seek and obtain more social support. Support received/expected from parents varied according to when patients were diagnosed, but parents' use of outdated knowledge could act as a barrier to effective support. Support sought from others, including friends/colleagues, was informed by patients' domestic/employment circumstances. Conclusion: This study responds to calls for deeper understanding of the social context in which chronic illness self-management occurs. It highlights how patients can solicit and receive more social support from family members and friends after implementing self-care practices taught on education programmes. Relevance to clinical practice: Health professionals including diabetes specialist nurses and dietitians should explore: patients' access to and preferences for social support; how patients might be encouraged to capitalise on social support postcourse; and new ways to inform/educate people within patients' social networks. © 2014 John Wiley & Sons Ltd.

© 2014 Elsevier Ltd.Background: Published research has demonstrated that the multiple mini-interview (MMI) is a reliable assessment instrument in medical and nursing student selection. There is a dearth of evidence specifically relating to the advancement and subsequent evaluation of MMIs in the context of student midwife selection. Objectives: To develop, pilot and examine the reliability of MMIs in pre-registration student midwife selection in a UK setting. Design and setting: DeVellis' framework for questionnaire development underpinned the generation of MMI scenarios. BSc (Hons) Midwifery Studies students at a Higher Education Institution in the UK volunteered to participate in 'mock' MMI circuits during the first week of their programme. Results: An eight station model was piloted. Communication skills were rated at each station as a generic attribute. Station specific attributes assessed included: compassion and empathy; respect for difference and diversity; honesty and integrity; intellectual curiosity and reflective nature; advocacy; respect for privacy and dignity; team working and initiative; the role of the midwife and motivation to become a midwife. Participants' responses to scenario questions were rated on a 7 point scale. Cronbach's alpha scores measuring internal consistency ranged from 0.91 to 0.97. Conclusion: The systematic development of the MMI model and scenarios resulted in 'excellent' reliability across all stations. These findings endorse the MMI technique as a reliable alternative to the personal interview in informing final decisions in pre-registration student midwife selection.

Objective: Research demonstrates that patients have a poor understanding of glycosylated haemoglobin A1c (HbA1c) and that this impacts on effective diabetes self-management. This study attempted to replicate these findings in a UK outpatient sample of people with diabetes. Method: 83 participants were recruited and asked to fill in a questionnaire assessing their understanding of HbA1c, diabetes self-care behaviours and diabetes-specific self-efficacy in relation to carrying out these self-care behaviours. Results: Only 26.5% of the participants were classified as having a good understanding of HbA1c. Correlational and univariate analyses indicated that this level of understanding was related to demographic variables, HbA1c levels and certain aspects of self-care and self-efficacy. A series of multiple regressions found that understanding was a significant predictor of HbA1c levels. Conclusion: The majority of participants seemed to have a poor understanding of HbA1c and this was related to aspects of their diabetes management, self-efficacy and HbA1c levels. Practical implications: These findings provide support for the application of programmes and initiatives aimed at improving patients understanding of clinical disease markers. © 2009 Elsevier Ireland Ltd.twofold: first, to investigate the acceptability of two continuous glucose monitoring devices for people with diabetes; and second, to develop a valid questionnaire measure to assess the acceptability of continuous glucose monitoring devices.

Aims:? Despite improvements in insulin therapy, hypoglycaemia remains an inevitable part of life for many people with Type?1 diabetes. Little attention has been paid to how individuals self-treat hypoglycaemia and their likes and dislikes of clinically recommended treatments. We explored participants' experiences of self-treating hypoglycaemia after attending a structured education programme for people with Type?1 diabetes. Our aims were: to identify treatments that are acceptable to people with Type?1 diabetes; and to provide recommendations for promoting self-treatment in line with clinical guidelines. Methods:? Thirty adults with Type?1 diabetes were recruited from the Dose Adjustment for Normal Eating (DAFNE) programme in the UK. Study participants were interviewed post-course and 6 and 12?months later, enabling their experiences to be explored over time. Results:? Study participants described a poor knowledge of how to self-treat hypoglycaemia correctly pre-course. Post-course, individuals often struggled to adhere to clinically recommended guidelines because of: panic, disorientation, hunger sensations and consequent difficulties ingesting fixed quantities of fast-acting carbohydrate; use of sweets to manage hypoglycaemia; reversion to habituated practices when cognitive impairment as a result of hypoglycaemia supervened; difficulties ingesting dextrose tablets; and other people's anxieties about under-treatment. Conclusions:? Historical experiences of hypoglycaemia and habituated practices can influence present self-treatment approaches. Professionals need to be aware of the range of difficulties individuals may experience restricting themselves to fixed quantities of fast-acting carbohydrate to manage hypoglycaemia. There may be merit in developing a more acceptable range of treatments tailored to people's own preferences, circumstances and needs. © 2012 The Authors. Diabetic Medicine © 2012 Diabetes UK.

The purpose of this study was to examine self-management and educational interventions developed to support people with inflammatory bowel disease (IBD) and to identify which type of intervention seems to be most effective. The search was deliberately overinclusive to capture studies that evaluated educational and self-management interventions. The following databases were searched: MEDLINE, Embase, CINAHL, PsycINFO, the National Research Register, and Cochrane. Twenty-three studies were included. Thirteen of these were randomized controlled trials. The content of the interventions reviewed varied widely. As expected, it is the three studies that have explicitly labeled themselves as self-management interventions that have incorporated the greatest number of self-management techniques. Two of these studies reported the greatest number of improved outcomes in relation to symptom reporting, psychological well-being, and healthcare resource use. There is clearly a role for information in IBD, but this review supports research in other conditions that shows that education cannot be assumed to lead to improvements in health and well-being. Much of the research in this area focuses on education rather than self-management. Where self-management techniques have been applied, the findings tend to be more promising. Gastroenterology nurses (or in the United Kingdom, IBD specialist nurses) may be best placed to facilitate self-management in this group.

Aims: To examine predictors of quality of life gains among people with type 1 diabetes following the Dose Adjustment for Normal Eating (DAFNE) self-management training programme. Methods: Clinical and questionnaire data were collected from 437 patients from 6 hospital centres before, and 18 months post-DAFNE intervention. Glycated haemoglobin (HbA
), weight, height, and blood pressure levels were recorded by clinicians during clinic appointments. Questionnaires included the Diabetes-Specific Quality of Life Scale (DSQOLS), the Problem Areas in Diabetes Scale (PAID) and the Hospital Anxiety and Depression Scale (HADS). Basic demographics were recorded at baseline. Linear mixed models were fitted to identify predictors of change in quality of life at an 18 month follow-up assessment. Results: Patients with high levels of diabetes-related distress experienced greatest improvement in DSQOLS quality of life scores (p = 0.001). Patients with poor glycaemic control (higher levels of HbA
; p = 0.03) and those with high levels of anxiety (p = 0.001) experienced the greatest reductions in diabetes-related distress. Conclusions: Patients with higher baseline levels of anxiety, higher levels of diabetes-related distress and higher baseline levels of HbA
are most likely to experience quality of life gain from participation in self-management programmes such as DAFNE. © 2012 Elsevier Ireland Ltd. All rights reserved.

OBJECTIVES: Psychiatric morbidity among the physically ill is an important issue, particularly in the light of research documenting the difficulties in accurately diagnosing and effectively treating psychiatric disorders in this group. The objectives of this study were: (1) To compare psychiatric morbidity in 11 physical conditions and a healthy comparison group. (2) To compare psychiatric morbidity between respondents with one of the 11 illnesses to those with more than one physical illness. DESIGN: The sample was derived from the cross-sectional Household Survey of Psychiatric Morbidity. METHODS: Psychiatric morbidity (excluding psychosis) was assessed by interview using the revised Clinical Interview Schedule (CIS-R) and physical illness through self-report in 10,108 adults. RESULTS: Eight of the 11 illness groups were more likely to be classified as having psychiatric morbidity on the CIS-R than the physically healthy group. There were no differences in psychiatric morbidity between the different illness groups. The presence of more than one physical illness significantly increased the likelihood of psychiatric morbidity in 10 of the 11 groups. CONCLUSIONS: This study further supports the association between physical and psychiatric illness. Importantly, it suggests an increased likelihood of psychiatric morbidity in the presence of more than one physical condition.

Background: Bariatric surgery is becoming more common among
women of fertile age to manage obesity. The number of pregnancies
following bariatric surgery is, therefore, likely to rise. The standard
oral glucose tolerance test (OGTT) may lead to dizziness, sweating and
collapse in people after some types of bariatric surgery.
Aims: In view of this potential pitfall in the diagnosis of gestational
diabetes mellitus (GDM) after bariatric surgery, the authors surveyed
midwifery units to establish current practice for the screening and
diagnosis of GDM in women who have had bariatric surgery.
Methods: Out of 164 English obstetric units, 120 email surveys were
sent to a network of lead diabetes midwives in units across England.
A reminder email was sent 4 weeks later.
Findings: Twenty-seven (22.5%) responses were received. Five
respondents (26%) had specific policies in place to manage pregnancies
after bariatric surgery. A wide variety of approaches to GDM screening
and diagnosis were used in women with a history of bariatric surgery.
The OGTT was the most widely used test after bariatric surgery.
Conclusions: There is a need for national clinical guidelines to be
developed for the diagnosis of GDM after bariatric surgery.

We assessed temporal trends in diabetes prevalence and key diabetes risk factors (obesity, physical activity, smoking) over 5 years in a nationally representative sample.

Background

The neuropsychological consequences of exposure to environmental hypobaric hypoxia (EHH) remain unclear. We thus investigated them in a large group of healthy volunteers who trekked to Mount Everest base camp (5,300 m).

Methods

A neuropsychological (NP) test battery assessing memory, language, attention, and executive function was administered to 198 participants (age 44.5±13.7 years; 60% male). These were studied at baseline (sea level), 3,500 m (Namche Bazaar), 5,300 m (Everest Base Camp) and on return to 1,300 m (Kathmandu) (attrition rate 23.7%). A comparable control group (n = 25; age 44.5±14.1 years; 60% male) for comparison with trekkers was tested at/or near sea level over an equivalent timeframe so as to account for learning effects associated with repeat testing. The Reliable Change Index (RCI) was used to calculate changes in cognition and neuropsychological function during and after exposure to EHH relative to controls.

Results

Overall, attention, verbal ability and executive function declined in those exposed to EHH when the performance of the control group was taken into account (RCI .05 to -.95) with decline persisting at descent. Memory and psychomotor function showed decline at highest ascent only (RCI -.08 to -.56). However, there was inter-individual variability in response: whilst NP performance declined in most, this improved in some trekkers. Cognitive decline was greater amongst older people (r = .42; p

Conclusions

After correcting for learning effects, attention, verbal abilities and executive functioning declined with exposure to EHH. There was considerable individual variability in the response of brain function to sustained hypoxia with some participants not showing any effects of hypoxia. This might have implications for those facing sustained hypoxia as a result of any disease.

Stroke is a leading cause of mortality and disability across the globe. Emergency Medical Services assess and transport a large number of these patients in the prehospital setting. Guidelines for UK ambulance services recommend recording a 12-lead electrocardiogram in the prehospital environment, providing this does not add to significant delay in transporting the patient to hospital; however, this recommendation is not based on any evidence.A systematic review was conducted to search and synthesise the literature surrounding the use of prehospital electrocardiograms in acute stroke patients, focusing on the prevalence of abnormalities and their association with prognosis and outcome. Online databases, references from selected articles and hand searches were made to identify eligible studies. Two authors independently reviewed the studies to ensure eligibility criteria were met. Main outcomes were presence of abnormality on electrocardiogram, mortality and disability. No studies set in the prehospital environment were found by the search; therefore the eligibility criteria were widened to include hospital-based studies. A total of 18 studies were subsequently included in the review.Although the prevalence of electrocardiogram abnormalities appears common in hospitalised patients, their prognostic impact on mortality, disability and other adverse outcomes is conflicting amongst the literature. There is a lack of research surrounding the use of prehospital electrocardiogram in acute stroke patients.Future studies should be based in the prehospital environment and should investigate whether undertaking an electrocardiogram in the prehospital setting affects clinical management decisions or has an association with mortality or morbidity.

Background: As more men survive a diagnosis of prostate cancer, alternative models of follow-up care that address men?s enduring unmet needs and are economical to deliver are needed. This paper describes the protocol for an ongoing evaluation of a nurse-led supported self-management and remote surveillance programme implemented within the secondary care setting.

Methods/design: The evaluation is taking place within a real clinical setting, comparing the outcomes of men enrolled in the Programme with the outcomes of a pre-service change cohort of men, using a repeated measures design. Men are followed up at four and eight months post recruitment on a number of outcomes, including quality of life, unmet need, psychological wellbeing and activation for self-management. An embedded health economic analysis and qualitative evaluation of implementation processes are being undertaken.

Discussion: The evaluation will provide important information regarding the effectiveness, cost effectiveness and implementation of an integrated supported self-management follow-up care pathway within secondary care.

Purpose: This study reports an innovative theory-driven approach for developing filmed peer support for cancer self-management. Peer support conventionally includes empathetic interaction between people with shared experiences. This unique study considers how to authentically communicate peer empathy in a one-way film narrative. Methods: We co-created a film based on phenomenological interviews with seven men who had volunteered to support other men by sharing their experiences of coping with prostate cancer. The film contributed to successful engagement with self-management. Interpretative Phenomenological Analysis of the interview data was conducted to explore the components of experiential empathy that the men had communicated. Results: Four themes were identified illustrating what men wanted other men to know about coping with prostate cancer: Going into the unknown, it was difficult but I got through highlighted trauma and the importance of having a determined attitude; Only you can do it illustrated the triumph of their journey and of regaining control; I haven?t changed massively reflected the importance of a constant self; and Stay involved represented the overriding need to remain part of pre-cancer social environments. Conclusions: We propose a construct framework of experiential empathy for men with prostate cancer: Resilience, Regaining Control, Continuity-of-Self and Social Connectedness. Filmed peer support that communicates these constructs will offer wide-ranging benefit to meet the needs of this group of men in both e-health and face-to-face self-management contexts. Further research could develop this theory-driven approach to filmed peer support for other cancer groups.

Background

Self-management interventions have become increasingly popular in the management of long term health conditions; however, little is known about their impact on psychological well-being in people with Multiple Sclerosis (MS).

Purpose

To examine the effectiveness of self-management interventions on improving depression, anxiety and health related quality of life in people with MS.

Method

A structured literature search was conducted for the years 2000 to 2016. The review process followed the PRISMA guidelines, and is registered with PROSPERO (no. CRD42016033925).

Results

The review identified 10 RCT trials that fulfilled selection criteria and quality appraisal. Self-management interventions improved health-related quality of life in 6 out of 7 studies, with some evidence of improvement in depression and anxiety symptoms.

Conclusion

Although the results are promising more robust evaluation is required in order to determine the effectiveness of self-management interventions on depression, anxiety and quality of life in people with MS. Evaluation of the data was impeded by a number of methodological issues including incomplete content and delivery information for the intervention and the exclusion of participants representing the disease spectrum. Recommendations are made for service development and research quality improvement.

Background: Universities in the United Kingdom (UK) are required to incorporate values based recruitment (VBR) into their healthcare student selection processes. This reflects an international drive to strengthen the quality of healthcare service provision. This paper presents novel findings in relation to the reliability and predictive validity of multiple mini interviews (MMIs); one approach to VBR widely being employed by universities.

Objectives: To examine the reliability (internal consistency) and predictive validity of MMIs using end of Year One practice outcomes of under-graduate pre-registration adult, child, mental health nursing, midwifery and paramedic practice students.

Design: Cross-discipline evaluation study. Setting: One university in the United Kingdom.

Participants: Data were collected in two streams: applicants to A) The September 2014 and 2015 Midwifery Studies programmes; B) September 2015 adult; Child and Mental Health Nursing and Paramedic Practice programmes. Fifty-seven midwifery students commenced their programme in 2014 and 69 in 2015; 47 and 54 agreed to participate and completed Year One respectively. 333 healthcare students commenced their programmes in September 2015. Of these, 281 agreed to participate and completed their first year (180 adult, 33 child and 34 mental health nursing and 34 paramedic practice students).

Methods: Stream A featured a seven station four-minute model with one interviewer at each station and in Stream B a six station model was employed. Cronbach?s alpha was used to assess MMI station internal consistency and Pearson?s moment correlation co-efficient to explore associations between participants? admission MMI score and end of Year one clinical practice outcomes (OSCE and mentor grading).

Results:

Stream A: Significant correlations are reported between midwifery applicant?s MMI scores and end of Year One practice outcomes. A multivariate linear regression model demonstrated that MMI score significantly predicted end of Year One practice outcomes controlling for age and academic entry level: coefficients 0.195 (p = 0.002) and 0.116 (p = 0.002) for OSCE and mentor grading respectively. In Stream B no significant correlations were found between MMI score and practice outcomes measured by mentor grading.

Internal consistency for each MMI station was ?excellent? with values ranging from 0.966?0.974 across Streams A and B.

Conclusion: This novel, cross-discipline study shows that MMIs are reliable VBR tools which have predictive validity when a seven station model is used. These data are important given the current international use of different MMI models in healthcare student selection processes.

Aim: This study was undertaken to explore the over-representation of black and minority ethnic (BME) staff in the disciplinary process in a National Health Service (NHS) Mental Health Trust.

Background: The Trust where this study was undertaken recognised there was a disproportional representation of BME staff involved in the disciplinary process. No reasons were given by the Trust for why this phenomenon existed. The over-representation of individuals from BME groups in NHS disciplinary hearings was raised as a topic for investigation by Parliament in 2008. Seminal work by Archibong and Darr (2010) has explored reasons for this over-representation. Ethnographic methodologies have not been used previously to develop our understanding of this area.
Methods: Critical and focused ethnography were used to observe a disciplinary hearing and gain the perspectives of employees directly involved in the disciplinary process in a single trust. To examine the culture of the Trust, data were collected through fieldwork, participant observation, semi-structured interviews, journal/diary and secondary data. Thematic analysis devised by Braun and Clarke (2006) was used to analyse the data collected.

Findings: Negative perceptions towards BME staff, particularly ?black African? nurses and healthcare assistants were uncovered. Tensions and rivalries within and between BME staff were also found.
Disciplinary investigations were not always based on facts and not all the findings were presented. Investigating officers and the chair of the panel were not always given training to undertake their roles. In some cases, BME personnel were intentionally selected onto the disciplinary panel to avoid accusations of racism, particularly when BME employees were likely to be dismissed. Disparity of the sanctions imposed for similar cases were reported. There was a perception that BME staff were not articulate and treated more harshly than their white counterparts. Equality and diversity initiatives also remain on the periphery.
The disaggregation and reconfiguration of services had some bearing on the performance of staff. Line management and clinical supervision was underutilised. Some managers who confronted BME employees were accused of ?racism? and had grievances taken out against them.

Conclusion: Disciplinary processes involving BME staff cannot be discussed in isolation. Key factors, such as the impact of disaggregation and the reconfiguration of the Trust at a time of continuous change in the NHS, the employment of BME staff as well as the disciplinary process itself, need to be considered together. The discussion also needs to shift from the polarised division between ?black and white? staff and focus on the differences and tensions within and among BME staff.

Background

Alternative models of cancer follow-up care are needed to ameliorate pressure on services and better
meet survivors? long-term needs. This paper reports an evaluation of a service improvement initiative for the followup
care of prostate cancer patients based on remote monitoring and supported self-management.

Methods:

This multi-centred, historically controlled study compared patient reported outcomes of men
experiencing the new Programme with men experiencing a traditional clinic appointment model of follow-up care,
who were recruited in the period immediately prior to the introduction of the Programme. Data were collected by
self-completed questionnaires, with follow up measurement at four and eight months post-baseline. The primary
outcome was men?s unmet survivorship needs, measured by the Cancer Survivors? Unmet Needs Survey. Secondary
outcomes included cancer specific quality of life, psychological wellbeing and satisfaction with care. The analysis
was intention to treat. Regression analyses were conducted for outcomes at each time point separately, controlling
for pre-defined clinical and demographic variables. All outcome analyses are presented in the paper. Costs were
compared between the two groups.
Results: Six hundred and twenty-seven men (61%) were consented to take part in the study (293 in the
Programme and 334 in the comparator group.) Regarding the primary measure of unmet survivorship needs, 25 of
26 comparisons favoured the Programme, of which 4 were statistically significant. For the secondary measures of
activation for self-management, quality of life, psychological well-being and lifestyle, 20 of 32 comparisons favoured
the Programme and 3 were statistically significant. There were 22 items on the satisfaction with care questionnaire
and 13 were statistically significant. Per participant costs (British pounds, 2015) in the 8 month follow up period
were slightly lower in the programme than in the comparator group (£289 versus £327). The Programme was
acceptable to patients.

Conclusion:

The Programme is shown to be broadly comparable to traditional follow-up care in all respects,
adding to evidence of the viability of such models.

Evidence-based practice (EBP) and Shared decision-making (SDM) are changing the nature of healthcare decisions. Evidence-based practice is a systematic approach of critical importance to medical practice intended to optimise decision-making by emphasising the value and use of evidence from scientific resources. Shared decision-making involves treating patients as partners, involving them in decision-making, and enlisting their sense of responsibility for their care while respecting their individual values and concerns. This study is theoretically driven by a curiosity of understanding the link between evidence-based practice, shared decision-making and patient-centred communication in order to achieve optimal care. It is broadly accepted that healthcare decisions require the integration of both research evidence and individual preferences. In the last decades, SDM has been hailed as the new paradigm for the doctor-patient relationship by health institutions and policy makers. However, the meaning and practical implications of such a new paradigm have been difficult to ascertain. To date, the need to consider patients as active partners in healthcare decision-making is growing. Yet, there has been little discussion resolving the potential conflict between promoting patient participation in decision-making regarding their health and the reliant on evidenced-based options. The thesis original contribution to knowledge is to fill these knowledge gaps by exploring the views and experiences of both users and providers of diabetes care about patient involvement in decision-making.
This research, using interviews, aims to develop a greater understanding of patients and doctors experience of communicating treatment and management during medical encounters, in light of the need for a more person-centred approach in decision-making to enhance quality of patient care and improve outcomes. Forty-six semi-structured interviews were conducted with doctors and patients with Type 2 Diabetes from one of the government hospitals in Eastern Province, Saudi Arabia. Data were analysed with the aid of NVivo using thematic analysis. Evidence suggests that people living with diabetes in Saudi Arabia seem to value opportunities to be involved in everyday decision-making about their care. How these opportunities are created, understood, supported and sustained in healthcare settings remains to be determined. In this study, most of the doctors reported that involving patients into decision-making was challenging because most patients did not feel they had sufficient knowledge and confidence to do so; however, many patients reported that they did want to engage in decisions about their health but did not feel actively listened to, respected, and empowered to do so. Both groups of participants identified contrasting expectations and perceptions regarding communication within the doctor-patient relationship. The findings of this study demonstrate the need for doctors to collaboratively pursue opportunities to ensure that person-centred interactions are more consistently evident in practice. The study not only adds to what is known about the benefits of patient participation, but also provides robust evidence for policy makers and practitioners arguing for the benefits of this.
Keywords: Evidence-based practice, shared decision-making, type 2 diabetes, patients? preferences and participation, self-management.

Background:

In England, a Values Based Recruitment (VBR) policy intends to ensure that healthcare students? individual values align with the values of the National Health Service (NHS) Constitution. However, students? values may become compromised with increased clinical experience, due to, for instance, distress, negative role models and hidden curricula.

Aim:

To explore potential differences in values between first, second, and third year students of adult nursing, in order to theorise whether and how such students? values may change over the duration of their programme, upon exposure to clinical practice environments.

Objectives:

1. To develop an instrument (Situational Judgement Test, SJT) that assesses students? congruence with the NHS Constitution values, and whether these are prioritised.

2. To establish whether the values (assessed using the SJT) of students with differing levels of experience (years one, two, and three ? particularly clinical practice experience) vary.

3. To generate insights into the considerations and reflections that students have regarding SJT items, and determine whether these vary between the different year groups.

4. To verify and gain a deeper understanding of these findings in the context of students? (practice) learning, as well as input for recommendations, through adult nursing Practice Liaison Tutors within the university.

Methods:

This research was granted a Favourable Ethical Opinion by the University of Surrey Ethics Committee. An SJT was developed (objective 1), and reliability and validity were determined with a pilot sample of 47 volunteers. Subsequently, first (n=13), second (n=15) and third (n=9) year students (total N=37) completed the SJT and participated in discussion sessions (objectives 2 and 3). Analysis took place using inferential statistics and thematic methods. Afterwards, six tutors were presented with the findings and interviewed (objective 4).

Findings:

SJT scores were highest in year one and lowest in year three (significant difference between first and third year group, F=7.28, p=.002). First year students expressed idealism. Second and third year students, however, experienced organisational hierarchy and difficulty speaking up against poor practice on their placements, at times de-prioritising the NHS Constitution values in response. Tutors could relate to these findings and suggested strategies to support students.

Discussion:

Despite the VBR policy, students? congruence with the NHS Constitution values may become compromised with increased clinical experience. Recommendations are made for education and placement organisations to prepare students for clinical practice, address hierarchy, and provide a safe and ethical learning environment.