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Background: Mesothelioma is a rare cancer without cure. Clinical guidelines recommend the timely provision of palliative/supportive care; however, a new study identified barriers to achieving this ambition. Objective: The study aimed to explore palliative care needs and the role of Mesothelioma Clinical Nurse Specialists (MCNSs); and to develop resources to address study findings. Methods: The mixed-methods study included a literature review, focus groups, interviews and surveys. Results: The study highlighted the important role of the MCNSs in palliative care and the need to: address disjointed care; improve support for families; and explain the benefits of palliative care for patients/families. A co-production approach developed an animation for patients/families to demystify palliative care and explain the benefits of early-stage engagement; and an infographic targeted at community and primary care professionals. Recommendations for community nursing practice are described.

Moral distress arises when a person is aware of the right course to take but is prevented from acting on it by institutional constraints. While this concept has been considered by nursing ethicists for many years, it has been particularly associated with the unprecedented healthcare conditions caused by the coronavirus disease 2019 (COVID-19) pandemic.To investigate the level of moral distress affecting advanced practice nurses (APNs) in the UK during the COVID-19 pandemic.This was a mixed-methods study in which a bespoke cross-sectional survey was sent to 243 APNs from across the UK who had been recruited to a broader longitudinal cohort study. The survey asked about their experiences, well-being and moral distress. Open-ended questions asked about their concerns regarding the health and well-being of their patients and colleagues.A total of 97 APNs completed the survey, yielding a 40% response rate. Levels of moral distress were significantly higher among APNs working in secondary care (P=0.026) compared with those working in primary care. All of the respondents expressed concerns about patients due to delayed care and about the mental well-being of their colleagues, particularly those who were redeployed to COVID-19 wards.The COVID-19 pandemic has caused moral and psychological distress for APNs. However, the type of distress and its direct causes varied among these practitioners. Tailored support is required to address moral distress and subsequently improve staff retention.

Aim: To explore higher education institution (HEI) perspectives on the development and implementation of trainee nursing associates (NAs) in the primary care workforce in England. Background: Current shortages of primary health care staff have led to innovative skill mix approaches in attempts to maintain safe and effective care. In England, a new level of nursing practice, NAs, was introduced and joined the workforce in 2019. This role was envisaged as a way of bridging the skills gap between health care assistants and registered nurses and as an alternative route into registered nursing. However, there is limited evidence on programme development and implementation of trainee NAs within primary care settings and HEI perspectives on this. Methods: This paper draws from a larger qualitative study of HEI perspectives on the trainee NA programme. Twenty-seven staff involved in training NAs, from five HEIs across England, were interviewed from June to September 2021. The interview schedule specifically included questions relating to primary care. Data relating to primary care were extracted and analysed using a combined framework and thematic analysis approach. Findings: Three themes were developed: ‘Understanding the trainee role and requirements’, ‘Trainee support in primary care’ and ‘Skills and scope of practice’. It is apparent that a more limited understanding of the NA programme requirements can lead to difficulties in accessing the right support for trainees in primary care. This can create challenges for trainees in gaining the required competencies and uncertainty in understanding what constitutes a safe scope of practice within the role for both employers and trainees. It might be anticipated that as this new programme becomes more embedded in primary care, a greater understanding will develop, support will improve and the nature and scope of this new level of practice will become clearer.

Background: The nursing associate role was first deployed in England in 2019 to fill a perceived skills gap in the nursing workforce between healthcare assistants and registered nurses and to offer an alternative route into registered nursing. Initially, trainee nursing associates were predominantly based in hospital settings; however, more recently, there has been an increase in trainees based in primary care settings. Early research has focussed on experiences of the role across a range of settings, particularly secondary care; therefore, little is known about the experiences and unique support needs of trainees based in primary care. Aim: To explore the experiences and career development opportunities for trainee nursing associates based in primary care. Methods: This study used a qualitative exploratory design. Semi-structured interviews were undertaken with 11 trainee nursing associates based in primary care from across England. Data were collected between October and November 2021, transcribed and analysed thematically. Findings: Four key themes relating to primary care trainee experiences of training and development were identified. Firstly, nursing associate training provided a ‘valuable opportunity for career progression’. Trainees were frustrated by the ‘emphasis on secondary care’ in both academic content and placement portfolio requirements. They also experienced ‘inconsistency in support’ from their managers and assessors and noted a number of ‘constraints to their learning opportunities’, including the opportunity to progress to become registered nurses. Conclusion: This study raises important issues for trainee nursing associates, which may influence the recruitment and retention of the nursing associate workforce in primary care. Educators should consider adjustments to how the curriculum is delivered, including primary care skills and relevant assessments. Employers need to recognise the resource requirements for the programme, in relation to time and support, to avoid undue stress for trainees. Protected learning time should enable trainees to meet the required proficiencies.

Aims Advanced Nurse Practitioners (ANP) are well established within acute medical and Critical Care environments. The evolution of surgical ANPs have tended towards preoperative roles, such as anaesthesia or scrub, with few clinical roles involving the assessment of acute patients or inpatient care. The Royal College of Surgeons of England have recently recognised, by professional membership, the roles of non-medical members of the surgical team, such as ANPs and physician associates. This review explores the areas of impact of ANPs on the emergency General Surgery service provision to help develop the role of the modern surgical ANP. Methods A scoping literature review was performed to identify themes of ANP function and outcome. Search terms such as “Advanced Nurse Practitioners”, “Surgical Assessment Units” and “outcomes” were combined with Boolean operators to query PubMed, BNI, CINAHL, Google Scholar and HMIC databases. Studies in the last decade were included. Results We identified and screened 54 unique articles. 40 articles were reviewed for eligibility and 21 were included in this review. A thematic analysis identified the impact of ANPs on the process of care (such as assessment and treatment waiting times and patient satisfaction) and outcomes of care (readmission rates, length of stay and cost-effectiveness). Conclusion Research into the impact of ANPs are largely focused on objective outcome measures and within non-surgical specialties. Whilst this review demonstrates the positive aspects of ANP care on emergency care, we identify a paucity of evidence on patient-focused outcomes and the impact of ANPs on the patient journey within surgery.

Background: Studies have shown that understaffing may result in missed care, compromising patient outcomes. However, most of these studies have been conducted in secondary care, and there is a lack of similar evidence about the prevalence and type of missed care in community and primary care.\ud \ud \ud \ud Aim: To explore the prevalence of missed care in community and primary care settings, and to better understand its association with staffing levels.\ud \ud \ud \ud Method: A staffing survey was administered by the Royal College of Nursing to explore the working experiences of nurses from all settings across the UK. Respondents were asked questions about their latest shifts. For this study, the authors performed a secondary analysis of that data, focusing on the responses from primary and community care.\ud \ud \ud \ud Results: There were 3,009 responses to the survey from primary care, community care and care home nurses pertaining to the prevalence of understaffing, staffing levels and missed care. Analysis showed that, in primary care and the community, missed care was significantly more likely to occur on understaffed shifts (39%) compared to fully staffed shifts (23%).\ud \ud \ud \ud Conclusion: There is a high prevalence of understaffing in community nursing and instances of missed care are more likely to occur on understaffed shifts. Assessing appropriate staffing levels and skill mixes in community nursing is complex and current models tend to emphasise caseload numbers rather than workload. Local and national planning should focus on workload measures, incorporating a range of indicators that place safe and effective person-centred care at their core.

Objective\ud \ud Despite recent advances in research, malignant mesothelioma remains an incurable and devastating disease, typically bringing shock and emotional distress to patients and carers. Little research has addressed the psychological impact on either group. This scoping review examines the current state of evidence on the psychological effects of mesothelioma on patients and carers, and identifies areas for further research.\ud \ud \ud Methods\ud \ud We searched PubMed, PsychINFO, CINAHL, the Cochrane Library and Web of Science for English‐language peer‐reviewed research articles published 1981 to 2019 reporting studies focussing on the psychological effects of mesothelioma on patients and carers. Following data extraction and quality appraisal, reflexive thematic analysis was used to identify themes.\ud \ud \ud Results\ud \ud Seventeen articles met the inclusion criteria. Carers' experiences were generally amalgamated with patients'. Three themes were developed. The Passing of Time included the importance of timing of interventions; delays in the medical journey; awareness of different time‐phases in mesothelioma; and uncertainty/certainty. Dealing with Difficult Feelings reflected ubiquitous negative emotions, feelings about identity and states of being and associated coping strategies. Craving Good Communication covered issues related to sharing of information and to positive/negative aspects of communication.\ud \ud \ud Conclusions\ud \ud Though limited, the evidence indicates that mesothelioma, with its high symptom‐burden, incurability, rarity and asbestos‐related causation, leads to complex and inter‐relating psychological effects on patients and carers. These effects are both negative and positive. The sparse literature gives a partial picture and demonstrates an urgent need for more nuanced research. Studies exploring the experiences of specific groups are recommended, with particular attention required to carers.

Background Many reasons for missed appointments are given by people who inject drugs and it is suggested that one solution cannot solve this complex issue (Poll et al., 2017). Increasingly, nurses and other health professionals are expected to actively involve patients and service users in developing innovative, effective and accessible services. This project used co-production as the approach to address this challenge. Aims This paper describes how a co-production method was used to develop accessible nurse-led hepatitis C virus services for people who inject drugs. Methods Using research evidence from a study conducted by the lead author as a starting point, a series of co-production workshops were run using creative co-design methods to identify the barriers to engagement with clinics. Potential solutions were then co-produced. Results The solutions included myth-busting posters, peer-support, a mobile clinic van and the offer of incentives and enablers (travel costs or a reward for attendance). Conclusions The service-development project illustrates how, with the right methods, it is possible to successfully engage with hard-to-access groups to co-produce innovative solutions for an important clinical challenge.

Introduction & Background The delivery of clinical research and the Clinical Research Nurse (CRN) role is fundamental to the wider health agenda, yet both remain misunderstood outwith research teams. Methods A realist review was conducted to identify factors that influence how clinical research is perceived by healthcare professionals operating outside NHS clinical research teams. Keyword searches were undertaken across four healthcare databases including grey literature, with iterative snowball searching. Data were extracted from 42/387 sources. Coding generated 3664 extracts of text across 160 themes. Theories generated were presented as ‘If-Then’ statements. Results Thirteen theory statements described factors that may influence how clinical research is perceived by healthcare professionals operating outside clinical research teams across three contextual levels: • Micro: Individual characteristics/behaviours/CRN perceptions • Meso: Interpersonal relationships at the interface between CRN roles and healthcare delivery • Macro: Systemwide/infrastructural/cultural issues impacting clinical research delivery. Conclusion Factors at micro, meso and macro level contexts may influence how clinical research is perceived by healthcare professionals operating outside clinical research teams. This has the potential to affect the success of clinical research delivery. Meso level theories regarding the perceptions of healthcare professionals outwith research teams may provide insight. Empirical testing of one such theory is underway.

This study investigated, 'What is the perceived value of a PhD to doctoral and postdoctoral nurses in the UK?'Little is known about what happens to the careers of nurses who undertake a doctorate and whether they use these skills in the next career steps.Nurses (n = 47) with doctorates were recruited via professional networks and twitter (@NMAHP_DoctorateStudy). Qualitative responses from the nurses were analysed using thematic analysis.Three themes emerged from qualitative analysis: impact on career, utilization and value, and impact on self.This study provides one of the few insights into how doctoral trained nurses understand and experience the value and utility of their studies to themselves and others.Nurse managers can play a crucial role in generating a research-led culture within their clinical setting. This would include promoting an understanding of research as something directly related to patient benefit rather than an abstract, intellectual activity.

The covid-19 global pandemic has impacted on nurses who have rapidly adapted to new ways of working, and experienced negative impacts due to over-stretched services. Two surveys captured the experiences of lung cancer and mesothelioma specialist nurses in the United Kingdom (UK) in 2020, but the impact of later stages of the pandemic was unknown. This study aimed to explore the impact of covid-19 on lung Cancer and mesothelioma nurses since January 2021, the second wave of the pandemic.An online cross-sectional survey with both open and closed questions explored the impact of covid-19 on ways of working and workload, quality of care, and health and wellbeing. The survey was open to UK based lung cancer and mesothelioma advanced or specialist nurses.85 nurses responded to the survey. The majority were Clinical Nurse Specialists, based in England. Respondents reported changes in ways of working due to redeployment, staff shortages, and home working. Widespread adoption of virtual working practices led to concerns of negative impacts. Perceived excessive workload impacted on care with two-thirds of the sample (57, 67%) reporting they had been unable to provide the same quality of care to patients. Impacts on nurses' health and wellbeing were reported with two-thirds of the sample (56, 66%) reporting a deterioration in emotional wellbeing and mental health. Coping mechanisms employed included online team support to share experiences and increased uptake of exercise; however, impacts on lifestyle and access to coping mechanisms varied.Nurses have stepped up to the challenges of the pandemic with teamwork and innovation, but pressure arising from the pandemic and high workloads led to negative impacts on wellbeing. The authors have provided recommendations to improve patient care and support the wellbeing of nurses, which will be key to a resilient workforce living with covid-19. Whilst this study focussed on lung cancer and mesothelioma specialists, the findings have wider implications for other cancer specialties.

Aim\ud \ud This article describes the development and implementation of a virtual consensus development project to address current challenges in adult nursing care in the UK.\ud \ud \ud Design\ud \ud This is a Consensus Development Project (CDP).\ud \ud \ud Methods\ud \ud The five stages of this CDP were: develop questions (informed by PPI representatives and a documentary review), generate evidence reviews, recruit and orient the lay panel, host consensus seminars, and consult with panel members and stakeholders.\ud \ud \ud Results\ud \ud To the best of our knowledge, a CDP has not previously been conducted in a UK nursing context, and this is the first of its kind to be hosted virtually. This article contributes a detailed outline of the consensus development methodology and constructive commentary to support future consensus development projects. Learning points include reflections on the impact of hosting this event virtually, the relationship between the project coordinator and chair, and the composition of the lay panel.

Background\ud \ud Cancer nurse specialists are advanced practitioners who offer continuity of care and expert support for people diagnosed with specific cancers. Health Education England's Cancer Workforce Plan prioritises expansion of cancer nurse specialist numbers by 2021 as part of the Cancer Taskforce Strategy for England.\ud \ud \ud \ud Objective\ud \ud To assess whether working practices of advanced practice specialist nurses are associated with clinical outcomes for people with lung cancer.\ud \ud \ud \ud Methods\ud \ud Adults with non-small cell lung cancer followed from 30 days post-diagnosis in English secondary care were obtained from the English National Lung Cancer Audit, 2007 to 2011. A national survey of lung cancer nurse specialists provided information on self-reported working practices. Mortality and unplanned admissions from 30 days to 12 months post diagnosis were respectively analysed using Cox and Poisson regression. Outcomes were assessed according to patients’ receipt of initial assessments by a lung cancer nurse specialist and according to trust-level reported working practices. Regression models were adjusted for individual sociodemographic and clinical characteristics, error adjusted for intracorrelations within regional cancer networks, and presented separately according to patients’ treatment pathways (surgery, chemotherapy, radiotherapy, or no anti-cancer therapy).\ud \ud \ud \ud Results\ud \ud Data for 108,115 people with lung cancer were analysed and associations with mortality and unplanned admissions were infrequent. Among people receiving only radiotherapy, however, the hazard for death was 17% lower among those who received an assessment by a lung cancer nurse specialist, compared with no assessment (hazard ratio = 0.83, 95% confidence interval 0.73–0.94; p = 0.003). The hazard was also lower among those receiving surgery (hazard ratio = 0.91, 0.84–0.99; p = 0.028). Among those receiving radiotherapy, nurse specialists’ reported confidence within multidisciplinary team settings was associated with a lower risk of death (hazard ratio = 0.88, 0.78–1.00; p = 0.049) and a lower rate of unplanned cancer-related admissions (incidence rate ratio = 0.83, 0.73–0.95; p = 0.007). Lung cancer nurse specialist assessments before/at diagnosis, were associated with a 5% lower rate of unplanned admissions, compared to when assessments occurred after diagnosis.\ud \ud \ud \ud Conclusion\ud \ud The contribution of nurse specialist working practices was occasionally associated with better outcomes for people with lung cancer. These were not limited to a single treatment pathway, but do indicate discrete relationships within pathways. Our study provides initial measures of overall lung cancer nurse specialist working practices at trusts, however, more detailed studies with longitudinal measurement of lung cancer nurse specialist-patient interaction are needed to better ascertain impacts on long-term patient outcomes. The findings highlight opportunities for potential improvement in effectiveness of service and care management.

BackgroundVascular services is changing rapidly, having emerged as a new specialty with its own training and specialised techniques. This has resulted in the need for reconfiguration of services to provide adequate specialist provision and accessible and equitable services.ObjectivesTo identify the effects of service configuration on practice, resource use and outcomes. To model potential changes in configuration. To identify and/or develop electronic data collection tools for collecting patient-reported outcome measures and other clinical information. To evaluate patient preferences for aspects of services other than health-related quality of life.DesignThis was a multiple methods study comprising multiple systematic literature reviews; the development of a new outcome measure for users of vascular services (the electronic Personal Assessment Questionnaire – Vascular) based on the reviews, qualitative studies and psychometric evaluation; a trade-off exercise to measure process utilities; Hospital Episode Statistics analysis; and the development of individual disease models and a metamodel of service configuration.SettingSpecialist vascular inpatient services in England.Data sourcesModelling and Hospital Episode Statistics analysis for all vascular inpatients in England from 2006 to 2018. Qualitative studies and electronic Personal Assessment Questionnaire – Vascular evaluation with vascular patients from the Sheffield area. The trade-off studies were based on a societal sample from across England.InterventionsThe data analysis, preference studies and modelling explored the effect of different potential arrangements for service provision on the resource use, workload and outcomes for all interventions in the three main areas of inpatient vascular treatment: peripheral arterial disease, abdominal aortic aneurysm and carotid artery disease. The electronic Personal Assessment Questionnaire – Vascular was evaluated as a potential tool for clinical data collection and outcome monitoring.Main outcome measuresSystematic reviews assessed quality and psychometric properties of published outcome measures for vascular disease and the relationship between volume and outcome in vascular services. The electronic Personal Assessment Questionnaire – Vascular development considered face and construct validity, test–retest reliability and responsiveness. Models were validated using case studies from previous reconfigurations and comparisons with Hospital Episode Statistics data. Preference studies resulted in estimates of process utilities for aneurysm treatment and for travelling distances to access services.ResultsSystematic reviews provided evidence of an association between increasing volume of activity and improved outcomes for peripheral arterial disease, abdominal aortic aneurysm and carotid artery disease. Reviews of existing patient-reported outcome measures did not identify suitable condition-specific tools for incorporation in the electronic Personal Assessment Questionnaire – Vascular. Reviews of qualitative evidence, primary qualitative studies and a Delphi exercise identified the issues to be incorporated into the electronic Personal Assessment Questionnaire – Vascular, resulting in a questionnaire with one generic and three disease-specific domains. After initial item reduction, the final version has 55 items in eight scales and has acceptable psychometric properties. The preference studies showed strong preference for endovascular abdominal aortic aneurysm treatment (willingness to trade up to 0.135 quality-adjusted life-years) and for local services (up to 0.631 quality-adjusted life-years). A simulation model with a web-based interface was developed, incorporating disease-specific models for abdominal aortic aneurysm, peripheral arterial disease and carotid artery disease. This predicts the effects of specified reconfigurations on workload, resource use, outcomes and cost-effectiveness. Initial exploration suggested that further reconfiguration of services in England to accomplish high-volume centres would result in improved outcomes, within the bounds of cost-effectiveness usually considered acceptable in the NHS.LimitationsThe major source of evidence to populate the models was Hospital Episode Statistics data, which have limitations owing to the complexity of the data, deficiencies in the coding systems and variations in coding practice. The studies were not able to address all of the potential barriers to change where vascular services are not compliant with current NHS recommendations.ConclusionsThere is evidence of potential for improvement in the clinical effectiveness and cost-effectiveness of vascular services through further centralisation of sites where major vascular procedures are undertaken. Preferences for local services are strong, and this may be addressed through more integrated services, with a range of services being provided more locally. The use of a web-based tool for the collection of clinical data and patient-reported outcome measures is feasible and can provide outcome data for clinical use and service evaluation.Future workFurther evaluation of the economic models in real-world situations where local vascular service reconfiguration is under consideration and of the barriers to change where vascular services do not meet NHS recommendations for service configuration is needed. Further work on the electronic Personal Assessment Questionnaire – Vascular is required to assess its acceptability and usefulness in clinical practice and to develop appropriate report formats for clinical use and service evaluation. Further studies to assess the implications of including non-health-related preferences for care processes, and location of services, in calculations of cost-effectiveness are required.Study registrationThis study is registered as PROSPERO CRD42016042570, CRD42016042573, CRD42016042574, CRD42016042576, CRD42016042575, CRD42014014850, CRD42015023877 and CRD42015024820.FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 9, No. 5. See the NIHR Journals Library website for further project information.

Background: Stroke care is becoming increasingly reliant on advanced nursing practice (ANP); however, little is known about these roles within the stroke specialty. Aims: To explore the current knowledge of advanced nursing practice in stroke services internationally, specifically, the conceptualisation of ANP and the rationale for its implementation. Methods: Arskey and O'Malley's scoping review methodology was employed, and six academic databases were used. Findings: Two key themes were identified; ‘role development’ and ‘four pillars of advanced practice’. The review identifies that ANP is implemented primarily to provide acute stroke care. Conclusions: Current research does not clarify the rationale for implementing these posts or how ANP is conceptualised. This review does identify that stroke ANP incorporates the four pillars of advanced practice (clinical, research, leadership and education) and was implemented to improve the quality of stroke care. Barriers and facilitators to implementation were also identified.

Aim To explore how the COVID‐19 pandemic affected nursing associate work, training and well‐being experiences. Design Cross‐sectional survey. Methods A survey of trainee and newly qualified nursing associates was completed in July 2020. Closed responses were analysed using descriptive statistics with inferential comparisons made between community and secondary care settings. Open questions were analysed thematically. Results Sixty‐four participants responded. Over half (53.2%) experienced an increased workload with 24.2% reporting extensions in their role. One third (32.3%) were redeployed, and a quarter (24.2%) did not feel safety concerns were adequately addressed when raised. Those working in the community reported significantly more concerns about staffing (p = .03), working overtime (p = .03), missed care (p = .02) and safety (p = .04). Despite this, many (75.8%) participants felt able to provide the same standards of care. Several spoke about enhanced teamwork, and the majority (96.8%) were not looking to leave their post.

Mesothelioma is a rare, life-limiting and aggressive cancer with a high symptom burden. This article explores the effect of the coronavirus disease 2019 (COVID-19) pandemic on the experiences of patients with mesothelioma and their carers. The charity Mesothelioma UK conducted a service evaluation that included two surveys – one with patients with mesothelioma and their carers, and the other with UK mesothelioma clinical nurse specialists – to explore the effects of the COVID-19 pandemic.\ud \ud \ud This article presents the results of these surveys, which suggest that patients with mesothelioma and their carers have been disproportionately affected by the COVID-19 pandemic in various areas. These include treatment and investigations, communication with healthcare teams, confusion concerning shielding, and the emotional and psychological burden of the pandemic. The authors include recommendations for practice to ensure patients and their families receive optimal treatment and support during the remainder of the pandemic.

ObjectiveThe aim of the study was to understand the experiences of advanced practice nurses (APNs) in the UK during the 2020 COVID-19 pandemic, particularly in relation to safety, shortages and retention.DesignA cross-sectional, mixed-methods survey.SettingAPNs in any UK setting.ParticipantsThe survey was sent to an existing UK-wide cohort of APNs. 124 APNs responded (51%).ResultsUK-based APNs in this study reported shortages of staff (51%) and personal protective equipment (PPE) (68%) during the first 3 months of the coronavirus outbreak. Almost half (47%) had considered leaving their job over the same 3 months. Despite difficulties, there were reports of positive changes to working practice that have enhanced care.ConclusionUK APNs report COVID-19-related shortages in staff and equipment across primary and secondary care and all regions of the UK. Shortages of PPE during a pandemic are known to be a factor in the development of mental health sequelae as well as a risk factor for increased turnover and retention issues. Half of APNs surveyed were considering a change in job. The UK risks a further crisis in staff morale and retention if this is not acknowledged and addressed. APNs also expressed concern about patients not receiving routine care as many specialties closed or reduced working during the crisis. However, there were also many examples of good practice, positive changes and innovation.

Aim\ud \ud To understand how advanced nurse practitioners use knowledge to inform their discharge decision‐making in the emergency department.\ud \ud \ud \ud Background\ud \ud Advanced nurse practitioner roles have developed globally in a wide range of healthcare settings, including the emergency department, over the past few years. The scope of practice and training vary widely between countries. Little is known about how they use clinical knowledge in the emergency department.\ud \ud \ud \ud Design\ud \ud An ethnographic study was undertaken in an emergency department in the North of England.\ud \ud \ud \ud Method\ud \ud Data were collected by observation (n = 5) and semi‐structured interviews (n = 13) between September 2016 and June 2017. Interview transcripts and field notes were coded using Quirkos software. Thematic analysis was used to identify key themes.\ud \ud \ud \ud Findings\ud \ud In boundary blurring with medicine, advanced nurse practitioners in the emergency department need to make timely, autonomous discharge decisions. Knowledge mobilization is messy and complex; however, shortcuts facilitate autonomous discharge decision‐making. More experienced advanced nurse practitioners rely less on shortcuts as they draw on experiential knowledge.\ud \ud \ud \ud Discussion\ud \ud Boundary blurring in the advanced nurse practitioner role in the emergency department, requires reliable knowledge shortcuts. Support from senior colleagues and accessible smartphone apps enable advanced nurse practitioners to efficiently make discharge decisions. This study adds to previous research on how knowledge is managed in boundary blurring.\ud \ud \ud \ud Conclusion\ud \ud Advanced nurse practitioners in the emergency department require timely access to relevant, up to date knowledge. This study has highlighted their preferred knowledge sources to inform discharge decision‐making. In boundary blurring, shortcuts enable ANPs to use knowledge efficiently to inform patient care in the emergency department.\ud \ud \ud \ud Impact\ud \ud The findings increase our understanding of how to equip advanced nurse practitioners with knowledge to facilitate clinical decision‐making. Clinical managers should provide mentorship and relevant up to date knowledge shortcuts to ensure efficient, evidence‐based discharge decision‐making.

Aims To examine and explore organisational and role conditions that promote or inhibit job satisfaction and workplace well‐being for advanced practice nurses. Background The advanced practice role is common across the world. Research shows it is well regarded by patients and improves patient outcomes, but there is little evidence about what the role is like for nurses. Methods A subsample of an existing cohort of advanced practice nurses were invited for interview. Twenty‐two nurses were interviewed over the phone. Interviews transcripts were analysed using thematic analysis. Results Four themes were derived from the data; ‘the advanced nurse role and professional identity’, ‘feeling exposed’, ‘support for the advancement of the role’ and ‘demonstrating impact’. Conclusion Nurses report considerable dissatisfaction with role identity and concerns relating to isolation on a daily basis, and these negatively affect well‐being. However, they also identified significant satisfaction with the role, particularly when well‐supported and able to recognize the unique contribution that they made to the lives of patients and to their organisations. Implications for nursing management Clear role definitions, provision of high‐quality clinical supervision and addressing issues of isolation are likely to improve the job satisfaction of advanced practice nurses.

In the sociological tradition, markets are understood to be constituted of social relations: relations of trust, friendship, power and dependence, which have moral and emotional qualities. In this paper, we explore how people in energy poor households construct the energy market and its impact on energy policy. Drawing on secondary analysis of a large collection of qualitative interviews on the lived experience of energy poverty carried out from 2003 to 2018 (n = 197 interviews and 20 selected), and the results of an OFGEM quantitative survey on consumer engagement released in 2018, we document the experience of the energy poor as actors in the British retail energy market. We uncover a number of challenges and opportunities facing energy poor participants in the market: having access to good quality information about suppliers, energy tariffs and grants, and having the skills and resources to act on this is important, without these it can be difficult for people to take action. In explaining people’s engagement with the market, we draw on the concept of ‘socio-economic attachments’, showing how a supportive network of family and friends, and people’s trust of and resulting loyalty to their energy supplier mediate their engagement. These findings lead us to relational explanations of the retail energy market, with related policy recommendations: if we are to aim for people to act ‘rationally’, they will need support to navigate the market from intermediaries.

Sex-differences in incidence, rates and survival from malignant mesothelioma are well documented and often related to men’s greater exposure to asbestos, whilst women have a physiologically based higher survival rates. Findings show that early identification of patients with a good prognosis is key to appropriate management (1). The aim was to present early results from part of a wider study, the Gendered Experiences of Mesothelioma Study (GEMS), specifically considering sex and gender differences. We obtained anonymised, routinely collected data in the period from January 2016-December 2018, by a Mesothelioma UK-based charity (HASAG). We undertook an exploratory analysis using SPSS v.26 to compare sex-differences between time from symptom onset to diagnosis; immediate support available from next of kin, action in seeking legal advice, and occupation/ exposure. Results showed that there were more very young women ( 50≥ years) with mesothelioma than men 5% women vs. 0.5% men). For women, work-related exposure is often linked to the working environment rather than the direct handling of asbestos. Women were less likely to seek legal advice (60% vs 80% of men) and less likely to receive compensation. A survival analysis showed significant time difference between men and women from time of diagnosis to IIDB award (43 vs 47 (x²= 6.3, df1, p=0.01). The higher prevalence of mesothelioma cases in previously defined low-risk occupations suggest that a long-term low-level of exposure may be causing an increase in mesothelioma cases due to such type of exposure.

Objectives\ud \ud Continuing professional development is essential for healthcare professionals to maintain and acquire the necessary knowledge and skills to provide person centred, safe and effective care. This is particularly important in the rapidly changing healthcare context of the Covid-19 pandemic. Despite recognition of its importance in the United Kingdom, minimum required hours for re-registration, and related investment, have been small compared to other countries. The aim of this review is to understand the factors that optimise continuing professional development impact for learning, development and improvement in the workplace.\ud \ud \ud Design\ud \ud A rapid evidence review was undertaken using Arksey and O'Malley's (2005) framework; identifying a research question, developing a search strategy, extracting, collating and summarising the findings.\ud \ud \ud Review methods\ud \ud In addressing the question ‘What are the factors that enable or optimise CPD impact for learning, development and improvement in the workplace at the individual, team, organisation and system level?’ the British Nursing Index, the Cochrane Library, CINAHL, HTA database, King's Fund Library, and Medline databases were searched for key terms. A total of 3790 papers were retrieved and 39 were included.\ud \ud \ud Results\ud \ud Key factors to optimising the impact of nursing and inter-professional continuing development are; self-motivation, relevance to practice, preference for workplace learning, strong enabling leadership and a positive workplace culture. The findings reveal the interdependence of these important factors in optimising the impact of continuing professional development on person-centred care and outcomes.\ud \ud \ud Conclusion\ud \ud In the current, rapidly changing, healthcare context it is important for educators and managers to understand the factors that enhance the impact of continuing professional development. It is crucial that attention is given to addressing all of the optimising factors in this review to enhance impact. Future studies should seek to measure the value of continuing professional development for people experiencing care, nurses and the wider organisation.