Debbie Carrick-Sen

What is perinatal well-being? A concept analysis and review of the literature

Objective: To conceptualise and review the literature pertaining to ‘perinatal well-being’. Background: Poor perinatal mental health can have detrimental consequences for women’s life-long health and the well-being of their children and family; however, the meaning of the term ‘perinatal well-being’ is unclear. This is an important concept to evaluate to better ascertain families requiring additional support; however, currently no validated assessment tool exists. In order to develop such a tool, it is necessary to first determine the meaning of this concept. Methods: The concept analysis framework of Walker and Avant was used. Electronic bibliographic databases were searched to find papers written in English and dated 1946–2012. These included: CINAHL, PubMed, Medline via OVID, Embase, PsycINFO, British Nursing Index, Web of Science, All EBM Reviews – Cochrane DSR, ACP Journal club, DARE and Global Health. From undertaking a detailed literature review the defining attributes were ascertained: model, borderline, related, contrary, invented and illegitimate cases were constructed. The antecedents and consequences were then identified and empirical referents determined. Results: The apparent attributes of ‘perinatal well-being’ are (a) the time period ranging from before and after childbirth; (b) multi-dimensional elements which include; physical, psychological, social, spiritual, economical and ecological; and (c) subjective cognitive and/or affective self-evaluation of life. Conclusion: ‘Perinatal well-being’ is a complex concept which involves self-evaluation of various inter-relating life dimensions during the perinatal period. Qualitative research to explore factors which effect self-evaluation is required to assist in the development of an effective assessment tool for use within clinical practice.

Effectiveness of cognitive behavioural therapy (CBT) interventions for anxiety in patients with chronic obstructive pulmonary disease (COPD) undertaken by respiratory nurses: the COPD CBT CARE study: (ISRCTN55206395)

BackgroundAnxiety and depression are common co-morbidities in patients with chronic obstructive pulmonary disease (COPD). Serious implications can result from psychological difficulties in COPD including reduced survival, lower quality of life, and reduced physical and social functioning, increased use of health care resources and are associated with unhealthy behaviours such as smoking. Cognitive behavioural therapy (CBT) is a psychological intervention which is recommended for the treatment of many mental health problems including anxiety and depression. Unfortunately access to trained CBT therapists is limited. The aim of this study is to test the hypothesis that CBT delivered by respiratory nurses is effective in the COPD population. In this paper the design of the Newcastle Chronic Obstructive Pulmonary Disease Cognitive Behavioural Therapy Study (Newcastle COPD CBT Care Study) is described.Methods/DesignThis is a prospective open randomised controlled trial comparing CBT with self-help leaflets. The primary outcome measure is the Hospital Anxiety & Depression Scale (HADS) – anxiety subscale. Secondary outcome measures include disease specific quality of life COPD Assessment Tool (CAT), generic quality of life (EQ5D) and HADS-depression subscale. Patients will be followed up at three, six and 12 months following randomisation.DiscussionThis is the first randomised controlled trial to evaluate the use of cognitive behavioural therapy undertaken by respiratory nurses. Recruitment has commenced and should be complete by February 2014.Trial registrationCurrent Controlled Trials, ISRCTN55206395

Preparation for parenthood: a concept analysis

Objective: This article reviewed the literature and critically analysed the concept of preparation for parenthood. The analysis is mainly of a discursive nature with some theoretical underpinnings. Background: Preparation for parenthood is a concept that is generally used within psychology, sociology and health professional practice especially midwifery, in terms of preparation for birth and parenthood sessions. However, parents often report feeling unprepared during this period. In order to ensure appropriate delivery of support and education during this time it is important to fully understand what preparation for parenthood really means by unravelling its component elements and understanding its contemporary relevance. Methods: A number of sources were searched using the keywords ‘preparation’ and ‘parenthood’. The concept analysis framework put forward by Walker and Avant was used to develop appropriate cases to further illustrate and explore meaning. Results: The literature search confirmed limited evidence with regards to an in-depth exploration of the concept and the separate elements that are related to each other. This investigation is the first of its kind considering the full range of meanings with regards to the concept and the contemporary evidence available. Law, gender, culture and spirituality all influence the concept and thus antecedents and consequences cannot always be applied to contexts which are fundamentally different. Conclusion: Preparation for parenthood is multi-faceted and changing, thus further research with regards to this concept is warranted. This analysis provides the groundwork for the development of measures that may be used within clinical practice.

A review of instruments to measure health-related quality of life and well-being among pregnant women

Objective: To describe a rapid review of major health-related, electronic bibliographic databases, to identify pregnancy-specific measures of health-related quality of life and well-being. This paper details the range of available instruments, rather than aiming to critique their psychometric properties or indicate problem prevalence. Background: While many instruments are used to measure health and well-being in pregnant women, most are primarily designed for use with a generic population to quantify the presence and magnitude of problems. Few instruments are designed to measure well-being specifically with pregnant women. Methods: A comprehensive search was undertaken to retrieve studies reporting the use of pregnancy-specific instruments to measure health-related quality of life or well-being. The search was conducted on Medline, Cochrane Library and Social Sciences Citation Indexes. Results: 1938 papers were identified and checked for inclusion at title and abstract stage. Eighty-four full papers were obtained for review against inclusion criteria. Thirty-nine papers were selected for inclusion, covering 30 instruments available for use solely with pregnant women. Most of the studies were conducted in Scandinavia or the USA, involved low-risk women, were of cross-sectional design or longitudinal design with data collected across more than one trimester. Conclusion: Most instruments identified in this review were developed for use in non-pregnancy contexts. Those specifically designed for use during pregnancy were infrequently used, apart from the Wijma Delivery Expectancy Questionnaire and the Cambridge Worry Scale. We found limited activity in assessing and measuring the health and well-being of pregnant women to capture positive psychological pregnancy outcomes.

The co-existence of depression, anxiety and post-traumatic stress symptoms in the perinatal period: A systematic review.

OBJECTIVE to identify and appraise the current international evidence regarding the presence and prevalence of the co-existence of depression, anxiety and post-traumatic stress symptoms in the antenatal and post partum period. METHODS using a list of keywords, Medline, CINHAL, Cochrane Library, EMBASE, PsychINFO, Web of Science and the Index of Theses and Conference Proceedings (Jan 1960 - Jan 2015) were systematically searched. Experts in the field were contacted to locate papers that were in progress or in press. Reference lists from relevant review articles were searched. Inclusion criteria included full papers published in English reporting concurrent depression, anxiety and post-traumatic stress symptoms in pregnant and post partum women. A validated data extraction review tool was used. FINDINGS 3424 citations were identified. Three studies met the full inclusion criteria. All reported findings in the postnatal period. No antenatal studies were identified. The prevalence of triple co-morbidity was relatively low ranging from 2% to 3%. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE triple co-morbidity does occur, although the prevalence appears to be low. Due to the presentation of complex symptoms, women with triple co-morbidity are likely to be difficult to identify, diagnose and treat. Clinical staff should be aware of the potential of complex symptomatology.

Hyperemesis in Pregnancy Study: a pilot randomised controlled trial of midwife-led outpatient care

OBJECTIVE To assess the feasibility of implementing a complex intervention involving rapid intravenous rehydration and ongoing midwifery support as compared to routine in-patient care for women suffering from severe nausea and vomiting in pregnancy, (NVP)/hyperemesis gravidarum (HG). STUDY DESIGN 53 pregnant women attending the Maternity Assessment Unit (MAU), Newcastle upon Tyne NHS Foundation Trust, Newcastle, UK with moderate-severe NVP, (as determined by a Pregnancy Unique Quantification of Emesis and Vomiting [PUQE] score ≥nine), consented to participate in this pilot randomised controlled trial (RCT). Subsequently 27 were randomised to the intervention group, 26 to the control group. Women in the intervention group received rapid rehydration (three litres Hartmans solution over 6h) and symptom relief on the MAU followed by ongoing midwifery telephone support. The control group were admitted to the antenatal ward for routine in-patient care. Quality of life (QoL) determined by SF36.V2 score and PUQE score were measured 7 days following randomisation. Completion rates, readmission rate, length of hospital stay and pregnancy outcomes data were collected. RESULTS Groups were comparable at baseline. Questionnaire two return rate was disappointing, only 18 women in the control group (69%) and 13 women in the intervention groups (44%). Nonetheless there were no differences between groups on Day 7 in terms of QoL, mean PUQE score, satisfaction with care, obstetric and neonatal outcomes or readmission rates. However, total combined admission time was higher in the control group (94h versus 27h, p=0.001). CONCLUSIONS This study suggests that day-case management plus ongoing midwifery support may be an effective alternative for treating women with severe NVP/HG. A larger trial is needed to determine if this intervention affects womens QoL.

Twin parenthood: the midwife's role – a randomised controlled trial

To determine whether a midwife‐led intervention improved preparation for twin parenting and maternal psychosocial outcome.

Measuring the impact of nurses and nursing: the core values

healthcare values. However, it is difficult to argue for evidence-based practice and the value of nursing if we are not creating the evidence on which to base our practice. Patients feel that relational aspects of nursing are very important: the approach of the nurse is the most important factor in securing a good experience for patients, enabling them to be ‘treated as a human being not a case’ with compassion, respect, empathy and by staff who are ‘interested in YOU’ (Maben and Griffiths, 2008: 7). We work in a health service where numbers matter and the measurable is influential. The lack of evidence on important aspects of nursing care has contributed to a largely reductionist debate about staffing levels and numbers of nurses needed on a shift in acute care. The focus is on maintaining the minimum nurse staffing needed to prevent harm, rather than what nurse staffing is needed to deliver excellence and individualised patient-centred care that encompasses our nursing values. Current staffing in acute care (and likely other settings) leaves many tasks undone (Ball et al, 2013), with the tasks essential for safety prioritised and ‘relationship’ aspects of nursing neglected. ‘Comfort/talk to patients’ was felt to have been left undone by 53% of nurses in acute care across Europe (UK: 66%) on their last shift because of insufficient time, with educating patients reported as not done by 41% (UK: 52%) (Ball et al, 2013; Ausserhofer et al, 2014). These are surely key elements of the nursing role? But without evidence of a measurable difference made to patients, it is difficult to argue our case in a metrics-obsessed resource-constrained health service. Lack of time to perform what nurses have been trained to do and indeed what they came into nursing for and want to do, leaves many feeling frustrated, stressed and burnt out. They feel they cannot reliably deliver care of the standard to which they aspire (Heinen et al, 2013). Nurses are being counted as a homogenous commodity to be provided in a numbers game that hospitals are obliged to report on, with little debate on quality rather than quantity; we are reduced to the minimum acceptable for safety rather than enough for excellence in care. Unless we can capture nursing’s unique contribution to positive aspects of care, such as compassion and dignity, we will be in a weak position to argue for the importance of enabling nurses to deliver care as they wish to. In the last issue of BJN (Deaton et al, 2014) we discussed the need for knowledge and evidence in nursing. However, there is a problem with definitions and outcome measures that demonstrate the value of the nursing contribution to patient care. While work has started to define ‘nurse-sensitive indicators’ (Griffiths et al, 2008) these focus on measuring what we can quantify: patient numbers, waits and length of stay, falls, pressure ulcers and infections. These are obviously very important, but our inability to articulate the value of nursing in relational aspects of care means that we are often focusing on preventing harms rather than doing good. When nurses are asked what is important to them, they vote overwhelmingly for personcentred care rather than more easily measured metrics (McCance et al, 2011). There has been little research trying to capture the value of nursing in terms of our core values and nursing’s unique contribution to patient care. Indeed, it is not clear that we even agree what constitute our core nursing values: are they the 6 Cs (Care, Compassion, Competence, Communication, Courage and Commitment); kindness, respect and dignity as in the new draft Nursing and Midwifery Council (NMC) code; or the NHS Constitution multidisciplinary values (respect, dignity, compassion, getting the basics right every time, improving lives and patient involvement)? It is a pity that these high-level values are not aligned. Many values are poorly defined and we are lacking a consensus on how to improve or measure them. Although academics have conducted concept analyses on some, practical operational definitions and agreement on what behaviours demonstrate the values are few. Indeed, they are maybe easier to identify if they are absent than present. For instance, dignity has been much talked about, with numerous recommendations, but attempts to measure it, or interventions with measurable outcomes, are lacking. We simply do not have evidence on what works (and just as importantly what does not work). There is a similar lack of evidence on interventions related to most of our other values. Does it matter that we cannot measure many of the core elements and values in nursing practice? Most are likely to be difficult to measure directly, but can be observed from behaviours. They are multi-factorial and require multidisciplinary behaviours. Additionally, nursing should not be the sole custodian of Measuring the impact of nurses and nursing: the core values

S4 A randomised controlled trial (rct) of cognitive behavioural therapy (cbt) for patients with chronic obstructive pulmonary disease

Background Anxiety and depression are common co-morbidities in COPD. We conducted a RCT comparing CBT delivered by respiratory nurses (RNs) and self-help leaflets in 279 patients with COPD and anxiety. The CBT intervention delivered by RNs achieved clinical and statistical improvements for anxiety, depression and improving quality of life.1 RNs with dual physical and psychological skills are rare. However there is an appetite for RNs to be trained to identify and treat psychological difficulties experienced by respiratory patients using CBT.2 Aims To evaluate the effectiveness of The Lung Manual Intervention used in The Newcastle COPD CBT Care study1 on patient outcomes when delivered by nurses who completed 3 day foundation training compared to advanced post-graduate education in CBT. Methods Following an educational course, four respiratory nurses delivered The Lung Manual Intervention.1 Four nurses were randomly allocated patients and delivered CBT. Nurses with Diploma training delivered CBT to 83 patients; foundation level delivered 32. CBT sessions were audio-recorded to explore delivery of the intervention in practice. The recordings were then assessed fidelity of intervention delivery by an independent CBT therapist. Unpaired t-tests were used to compare mean anxiety scores and at baseline and three months. Results The nurses competency was rated highly by an independent CBT therapist. The mean number of CBT sessions was 4 and this was similar for all nurses. Table 1 summarises the outcome from nurses delivering The Lung Manual CBT intervention. Conclusion Brief education in CBT was effective in improving patient symptoms of anxiety at three months. RNs with dual skills in physical and psychological well being may be an appropriate model to provide holistic care for patients with COPD. References Heslop-Marshall K, Stenton C, Newton J, Carrick-Sen D, Baker C, Burns G, De Soyza A. A RCT of CBT delivered by respiratory nurses to reduce anxiety in COPD`. ERJ 2016;48:OA289. doi:10.1183/13993003.congress-2016.OA289 Heslop-Marshall K, Knighting K, Pilkington M, Kelly C. A UK survey on the experiences and views of Respiratory Nurses (RNs) on their role in delivering Cognitive Behavioural Therapy (CBT) for patients with Chronic Obstructive Pulmonary Disease (COPD)2017. In press. Abstract S4 Table 1 Summary of outcome from RNs delivering the lung manual intervention based on level of training Level of Training Number of patients/(percent) Mean HADS-Anxiety/SD at baseline Mean HADS-Anxiety at Three months Mean Difference at threemonths p-value (95% CI) Diploma level 83 (72) 12.3 (3.11) 8.93 (4.36) 3.37 <0.001 2.43–4.34 Foundation level 32 (28) 12.2 (3.26) 8.8 (4.92) 3.41 <0.001 2.05–4.76

M24 Prevalence of anxiety and patient characteristics from a randomised controlled trial (RCT) to identify if cognitive behavioural therapy (CBT) by respiratory nurses reduces anxiety in COPD

Introduction Anxiety and depression are common co-morbidities in COPD. Anxiety is associated with increased breathlessness, lower levels of self-efficacy, impaired health status, poorer treatment outcomes and reduced survival, increased risk of hospitalisation, longer in-patient stay, readmissions and unhealthy behaviours such as smoking and lack of exercise. The aim of this abstract is to present prevalence data, engagement and baseline patient characteristics from the largest RCT on CBT in COPD. Study design A multicentre RCT with follow up at 3, 6 and 12 months (ISCRCTN55206395). Outcome measures include mean HADS-A (anxiety) and HADS-D (depression) score,1 EuroQol -5D Questionnaire,2 COPD Clinical Assessment Tool3 and admission prevention at three, six and 12 months post intervention. Approach 1,518 patients were screened for symptoms of anxiety using the Hospital Anxiety and Depression Scale (HADS). Two thirds, 705 (59%) patients scored ≥8 for anxiety and were approached. Intervention Up to 6 CBT sessions provided by one of four respiratory nurses were offered. Self-help leaflets on anxiety and depression were provided as standard care. Usual care Self- help leaflets only. Results 42% of eligible patients consented to take part. Groups were well matched at baseline (Table 1) with no correlation between FEV1 and anxiety. A median of 4 CBT sessions (range 2–6) was delivered. Retention was high: 85% at 3 months and 72% at 6 months.Abstract M24 Table 1 Baseline characteristics CBT Group (n = 139) Control Group (n = 140) p-value (95% CI) Mean (SD) Mean (SD) Age 66 67 66.5 Gender Male 61 (44) 67 (48) 128 (46) Female 78 (56) 73 (52) 151 (54) Severity of COPD Mild 16 (11) 13 (9) 29 (10) Moderate 44 (32) 47 (34) 91 (33) Severe 50 (36) 49 (35) 99 (35) Very Severe 29 (21) 31 (22) 60 (22) Educational Level No educational qualifications 100 (75) 103 (77) 203 (73) HADS-Anxiety Score 12.3 (3.19) 12.0 (2.94) 0.47 (-0.456–0.988) HADS-Depression Score 9.4 (4.01) 9.0 (3.68) 0.34 (-0.470–1.347) CAT (Health Status) 28.2 (6.45) 28.7 (5.99) 0.52 (-1.944–0.990) EQ5D 0.41 (0.29) 0.41 (0.30) 0.95 (-0.07–0.07) Married or Co-habiting 68 (49) 63p (45) 132 (47) Current smoker 39 (28) 40 (29) 79 (28) Mean pack years 46 49 47 BMI 26 27 26.5 Conclusion The prevalence of anxiety and depression is high in patients with COPD and screening is therefore recommended. Affected patients were willing to engage in CBT in this large study. Results from 3, 6 and 12 months data will be will be available in November 2015 and will be reported. Results will include the cost effectiveness of CBT in COPD delivered by respiratory nurses. Funding NIHR fellowship. References 1 Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983;67(6):361–370 2 EQ-5D. www.euroqol.org/about-eq5d/how-to-use-eq-5d.html. Accessed 11.4.2015 3 Jone PW, Harding G, Berry P, Wiklund I, Chen WH, Kline LN. Development and first validation of the COPD Assessment Test. Eur Respir J. 2009;34(3):648–654