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Background Immediate implant‐based breast reconstruction (IBBR) is the most commonly performed reconstructive procedure in the UK, but almost one in ten women experience implant loss and reconstructive failure after this technique. Little is known about how implant loss impacts on patients' quality of life. The first phase of the Loss of implant Breast Reconstruction (LiBRA) study aimed to use qualitative methods to explore women's experiences of implant loss and develop recommendations to improve care. Methods Semistructured interviews were conducted with a purposive sample of women who experienced implant loss after immediate IBBR, performed for malignancy or risk reduction across six centres. Interviews explored decision‐making regarding IBBR, and experiences of implant loss and support received. Thematic analysis was used to explore the qualitative interview data. Sampling, data collection and analysis were undertaken concurrently and iteratively until data saturation was achieved. Results Twenty‐four women were interviewed; 19 had surgery for malignancy and five for risk reduction. The median time between implant loss and interview was 42 (range 22–74) months. Ten women had undergone secondary reconstruction, two were awaiting surgery, and 12 had declined further reconstruction. Three key themes were identified: the need for accurate information about the risks and benefits of IBBR; the need for more information about ‘early‐warning’ signs of postoperative problems, to empower women to seek help; and better support following implant loss. Conclusion Implant loss is a devastating event for many women. Better preoperative information and support, along with holistic patient‐centred care when complications occur, may significantly improve the experience and outcome of care., Immediate implant‐based breast reconstruction is the most commonly performed reconstructive procedure worldwide after mastectomy for breast cancer, but up to one in ten women experience implant loss and reconstructive failure after this technique. This qualitative study explores the experiences of 24 women experiencing implant loss from six centres across the UK. It highlights the need for more balanced presentation of the risks and benefits of different techniques to inform decision‐making, the need for better information regarding the early signs of potential problems to empower women to seek help, and more support for patients experiencing this potentially devastating complication. Patients need better support

Background: Informal carers play an important role in the care of patients with mental illness. Little is known of the relationship experience of the patient and their informal carer (caring dyad) as the context for the intersection between physical and mental health.\ud Aim:This study aimed to explore the impact of comorbid cardiometabolic risk(CMR), metabolic syndrome (MetS) and related diseases and severe mental illness(SMI) on the caring dyad.\ud Design: Between October 2018 and March 2020, we conducted 11 indepth semistructured interviews across 6 adult caring dyads, interviewing each individual separately\ud Setting: Dyads were recruited within the United Kingdom; informal carers were nominated by the patient as a person who provided a significant amount of support.\ud Variable Being Studied: Participants were asked about the impacts of illness and caring on daily life.\ud Data Analysis: Data were analysed at the dyad level using thematic analysis,comparing and contrasting responses from each individual.\ud Results: Themes were identified: enhanced closeness, dissonance and balance within the caring dyad.\ud Discussion and Conclusions: This study uses a particular population of patients with comorbid CMR factors, MetS and related diseases and SMI and their informal carers to explore the relevance and utility of caring dyads as an analytical framework to inform practice and policy. Future interventions should consider factors impacting on dyadic relationships to formulate effective and sustainable dyadic care and treatment to improve health outcomes for both patients with SMI and their informal carers.\ud Patient/Public Involvement: In this study, patients and informal carers were participants. Topic guides were piloted with a patient and informal carer.

Wider networks of people are affected by a suicide death than originally thought, including those whose job-role brings them into contact with a death by suicide of another person. The impact of student suicide within United Kingdom (UK) Higher Education Institutions (HEIs) is unexplored and the experiences of staff members remain unknown. It is not known whether staff members have specific postvention needs following a student death by suicide. Any postvention support currently offered to staff members within UK HEIs lacks a context-specific evidence base. This study asked ‘How is a student suicide experienced by staff members within a UK HEI and what are the features of that experience?’ Staff members from diverse job-roles in two UK HEIs responded to a qualitative survey (n = 19) and participated in semi-structured interviews (n = 10). Data were transcribed and subjected to a constructivist grounded theory analysis. Participants’ experiences informed the development of a core category: ’Bearing witness’, which encompassed six further categories: ’Responding to a student suicide’; ’Experiencing a student suicide’; ’Needs and fears’; ’Experiences of support’; ’Human stories’; and ’Cultural stories’. The resulting grounded theory demonstrates how participants’ perceptions of impact are informed by their experiences of undertaking tasks following a student suicide within the community of their HEI. Processes of constructing perceptions of closeness to the student who died are evident amongst participants who did not know the student prior to their death. Tailored postvention support is required to respond to the range and complexity of HEI staff needs following a student death by suicide.

Background \ud Early referral forms a crucial part in early inflammatory/rheumatoid arthritis (EI/RA) recovery. Delayed decisions to refer can lead to severe incapacity and emotional distress for individuals and family and feelings of lost time. How patients with EI/RA experience early referral decisions in Primary Care is an under explored area and warrants further investigation. \ud Aim: To explore how patients newly diagnosed with EI/RA experienced their early contacts with Primary Care as they negotiated their journey through the referral process into secondary care. \ud Design and setting \ud Qualitative face to face interviews with newly diagnosed EI/RA patients \ud Methods: In-depth semi-structured interviews were conducted to explore patients’ experiences of referral from first symptoms to GP referral All participants were interviewed within two weeks of being diagnosed in Secondary Care. Data analysis was conducted using Interpretative Phenomenological Analysis (IPA). \ud Findings: All participants in this study described having experienced struggles with their navigation through Primary Care towards diagnosis and specialist EI/RA services. This struggle comprised 5 key elements: ‘Family persuasion, ‘Lack of continuity in care’, ‘Pushing for referral’, ‘Straining relationships’, ‘Lost time’. \ud Conclusion: The delays experienced by patients when attempting to reach an early referral decision in Primary Care cause frustration for those presenting with EI/RA, partly because they do not feel heard. There is a significant impact on patients and their families when referral to specialist care is delayed.

Background Individuals with severe mental illness, e.g. schizophrenia have up to a 20% shortened life expectancy compared to the general population. Cardiovascular disease, due to cardiometabolic risk and metabolic syndrome, accounts for most of this excess mortality. A scoping search revealed that there has not been a review of published studies on the role of pharmacy in relation to cardiometabolic risk, metabolic syndrome and related diseases (e.g. type 2 diabetes) in individuals with severe mental illness. Methods A mixed-methods systematic review was performed. Eleven databases were searched using a comprehensive search strategy to identify English-language studies where pharmacy was involved in an intervention for cardiometabolic risk, metabolic syndrome or related diseases in severe mental illness in any study setting from any country of origin. First, a mapping review was conducted. Then, implementation strategies used to implement the study intervention were classified using the Cochrane Effective Practice and Organisation of Care Taxonomy. Impact of the study intervention on the process (e.g. rate of diagnosis of metabolic syndrome) and clinical (e.g. diabetic control) outcomes were analysed where possible (statistical tests of significance obtained for quantitative outcome parameters reported). Quality assessment was undertaken using a modified Mixed Methods Appraisal Tool. Results A total of 33 studies were identified. Studies were heterogeneous for all characteristics. A total of 20 studies reported quantitative outcome data that allowed for detailed analysis of the impact of the study intervention. The relationship between the total number of implementation strategies used and impact on outcomes measured is unclear. Inclusion of face-to-face interaction in implementation of interventions appears to be important in having a statistically significantly positive impact on measured outcomes even when used on its own. Few studies included pharmacy staff in community or general practitioner practices (n = 2), clinical outcomes, follow up of individuals after implementation of interventions (n = 3). No studies included synthesis of qualitative data. Conclusions Our findings indicate that implementation strategies involving face-to-face interaction of pharmacists with other members of the multidisciplinary team can improve process outcomes when used as the sole strategy. Further work is needed on clinical outcomes (e.g. cardiovascular risk reduction), role of community pharmacy and qualitative studies. Systematic review registration PROSPERO CRD42018086411

In order to evaluate the extent and causes of pain during cardiac implantable electronic device (CIED) implantation in our hospital, a prospective audit over a 23-month period using a patient selfreporting questionnaire was undertaken. In total, 599 procedures were reported, 52.9% for de novo pacemaker implantation and 23.4% for high-energy devices (cardiac resynchronisation therapy defibrillator [CRT-D], implantable cardiac defibrillator [ICD], subcutaneous ICD). Overall, the median pain score was 2/10 (interquartile range 2–4). In total, 61.6% (367/599) reported no pain or mild pain (pain scores 0–3/10), 27.7% (165/599) reported moderate pain (pain score of 4–6/10) and 10.7% (64/599) reported severe pain (pain score of 7–10/10) during the procedure. Significant preimplant worry (odds ratio [OR] 2.13, 95% confidence interval [CI] 1.22 to 3.73) and higher lidocaine doses (OR 1.06, 95%CI 1.00 to 1.11) were associated with severe patient-reported pain. In conclusion, most patients underwent CIED implantation with minimum stress and maximum comfort. An important minority reported severe pain during the procedure. Optimising surgical technique and interventions targeted at reducing pre- and peri-implant worry, particularly in women, and especially in those receiving ICDs, warrants further investigation to reduce patient-reported pain during CIED implantation.

Extracellular matrix (ECM) proteins confer biomechanical properties, maintain cell phenotype and mediate tissue repair (via release of sequestered cytokines and proteases). In contrast to intracellular proteomes, where proteins are monitored and replaced over short time periods, many ECM proteins function for years (decades in humans) without replacement. The longevity of abundant ECM proteins, such as collagen I and elastin, leaves them vulnerable to damage accumulation and their host organs prone to chronic, age-related diseases. However, ECM protein fragmentation can potentially produce peptide cytokines (matrikines) which may exacerbate and/or ameliorate age- and disease-related ECM remodelling. In this review, we discuss ECM composition, function and degradation and highlight examples of endogenous matrikines. We then critically and comprehensively analyse published studies of matrix-derived peptides used as topical skin treatments, before considering the potential for improvements in the discovery and delivery of novel matrix-derived peptides to skin and internal organs. From this, we conclude that while the translational impact of matrix-derived peptide therapeutics is evident, the mechanisms of action of these peptides are poorly defined. Further, well-designed, multimodal studies are required.

Aim: Young-people with psychosis have higher rates of obesity, premature cardiovascular disease and death compared to non-psychotic peers in the general population due to changes in metabolic regulation linked to antipsychotic medication and adverse health risk behaviors. The aim of this paper is to outline the development, implementation, and evaluation of a combined 12-week exercise and health behavior intervention delivered as part of an Early Intervention in Psychosis (EIP) routine service, within the UK. Methods: Participants (n=27) completed a 12-week combined intervention program, engaging in weekly, 90-minute sessions comprising a healthy behavior education session (45 minutes), followed by a facilitated exercise session (45 minutes). Anthropometric data from participants (n=26) were collected at baseline, 12 weeks, and 12 months post-intervention. Health behaviors and clinical measurements were assessed at baseline and 12 months. Results: Mean baseline data suggests participants were at an increased health risk on entry to the program, with elevated values in mean body mass index (BMI; 70% overweight/obese), waist circumference, resting heart rate, and triglycerides. Fifty percent reported smoking daily, 64% ate < 5 fruits/vegetables per day, and 52% of participants were prescribed highly obesogenic antipsychotic medications (i.e., Olanzapine). At 12 weeks and 12 months, no changes were observed in mean BMI, waist circumference or any other clinical variable (p > 0.05). At 12 months, participants reported a positive impact on health behaviors including improved diet, increased physical activity levels, and cessation of substance use (n=2), alcohol use (n=2), and smoking (n=4). Focus groups captured participant experiences, engagement with and satisfaction with the program, including challenges/barriers to program adherence. Conclusions: The 12-week exercise and health behaviors program supported participants to attenuate their physical health risk which was sustained at 12 months follow up. Self-reported positive health behavior changes are likely to have contributed to the prevention of excessive weight gain in this high-risk period. The evaluation was designed to have validity for a ’real world EIP setting’ and reflect the complexity of delivery amongst this participant group. Evaluation findings influenced subsequent commissioning of the physical health intervention as an ongoing element of routine EIP care within the participant site.

Background\ud A diagnosis of serious mental illness can impact on the whole family. Families informally provide significant amounts of care but are disproportionately at risk of carer burden when compared to those supporting people with other long-term conditions. Shared decision making (SDM) is an ethical model of health communication associated with positive health outcomes, however there has been little research to evaluate how routinely family are invited to participate in SDM, or what this looks like in practice. \ud Objective\ud This UK study aimed to better understand how the family caregivers of those diagnosed with SMI are currently involved in decision making, particularly decisions about treatment options including prescribed medication. Objectives were to:-\ud • Explore the extent to which family members wish to be involved in decisions about prescribed medication\ud • Determine how and when professionals engage family in these decisions \ud • Identify barriers and facilitators associated with the engagement of family in decisions about treatment. \ud Participants\ud Open-ended questions were sent to professionals and family members to elicit written responses. Qualitative responses were analysed thematically. \ud Results\ud Themes included the definition of involvement and ‘rules of engagement’. Staff members are gatekeepers for family involvement and the process is not democratic. Family and staff ascribe practical, rather than recovery-oriented roles to family, with preoccupation around notions of adherence. \ud Conclusions\ud Staff members need support, training and education to apply SDM. Time to exchange information is vital but practically difficult. Negotiated teams, comprising of staff, service users, family, peers as applicable, with ascribed roles and responsibilities could support SDM.

Recent research has highlighted that the number of people impacted by a death by suicide is far greater than previously estimated and includes wider networks beyond close family members. It is important to understand the ways in which suicide impacts different groups within these wider networks so that safe and appropriate postvention support can be developed and delivered. A systematic review in the form of a qualitative research synthesis was undertaken with the aim of addressing the question ‘what are the features of the experiences of workers in health, education or social care roles following the death by suicide of a client, patient, student or service user?’ The analysis developed three categories of themes, ‘Horror, shock and trauma’, ‘Scrutiny, judgement and blame’, and ‘Support, learning and living with’. The mechanisms of absolution and incrimination were perceived to impact upon practitioners’ experiences within social and cultural contexts. Practitioners need to feel prepared for the potential impacts of a suicide and should be offered targeted postvention support to help them in processing their responses and in developing narratives that enable continued safe practice. Postvention responses need to be contextualised socially, culturally and organisationally so that they are sensitive to individual need.

Adrenaline auto-injectors (AAIs) improve outcomes and reduce fatalities in patients with anaphylaxis, but many patients neither carry them nor know how to use them. Practitioner training in evidence-based strategies designed to increase patient adherence could improve the likelihood of AAI adherence, as well as increase confidence amongst practitioners to initiate discussions about practical and perceptual barriers to AAI adherence. This paper reports the development of a new practitioner training intervention, grounded in health psychology theory and evidence designed for practitioners in contact with patients with anaphylaxis to encourage adherence to AAIs. Potential implications for the design, implementation and evaluation of future practitioner training in strategies they can use to encourage anaphylaxis patients’ AAI adherence are discussed. Although designed for those working with anaphylaxis patients, this step-by-step process to encouraging adherence could be adapted for practitioners working with patients living with other long-term conditions.

Background: Clinicians draw on instructional approaches when training patients with anaphylaxis to use adrenaline auto-injectors, but patient use is poor. Psychological barriers to these behaviours exist but are not considered routinely when training patients to use auto-injectors. Health Psychology principles suggest exploring these factors with patients could improve their auto-injector use.\ud Objective: To evaluate the impact of a 90 - minute workshop training clinicians in strategies and techniques for exploring and responding to psychological barriers to auto-injector use with patients. Attendees’ knowledge, confidence and likelihood of using the strategies were expected to improve.\ud Methods: Impact was evaluated using a longitudinal mixed-method design. Twenty-nine clinicians (general and specialist nurses, general practitioners, pharmacists) supporting patients with anaphylaxis in UK hospitals and general practice attended. Self-rated knowledge, confidence and likelihood of using the strategies taught were evaluated online one week before, 1–3 and 6–8 weeks after the workshop. Clinicians were invited for telephone interview after attending to explore qualitatively the workshop impact. \ud Results: Chi-square analyses were significant in most cases (p

Anaphylaxis is a serious, rare condition increasing in prevalence. This study explored the psychological experience of adult-onset anaphylaxis from patient, family and staff perspectives. Semi-structured interviews were conducted with 12 participants. Two global themes emerged from thematic analysis: ‘controllability’ (‘an unknown and distressing experience’, ‘the importance of control over triggers’ and ‘responsibility but no control: the impact on others’) and ‘conflict’ (‘rejecting illness identity’, ‘minimisation of risk’, ‘accessing specialist care: running in slow motion’ and ‘patient-centred versus service-centred care’). Findings highlight the importance of perceived control and emphasise the presence of conflict in the experience of this complex, episodic condition.

Background\ud Depression is common in the postnatal period and can lead to adverse effects on the infant and wider family, in addition to the morbidity for the mother. It is not clear whether antidepressants are effective for the prevention of postnatal depression and little is known about possible adverse effects for the mother and infant, particularly during breastfeeding. This is an update of a Cochrane Review last published in 2005.\ud \ud Objectives\ud To assess the effectiveness of antidepressant medication for the prevention of postnatal depression, in comparison with any other treatment, placebo or standard care.\ud \ud Search methods\ud We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR ‒ both Studies and References), CENTRAL (Wiley), MEDLINE (OVID), Embase (OVID), PsycINFO (OVID), on 13 February 2018. We also searched the World Health Organization (WHO) trials portal (ICTRP) and ClinicalTrials.gov on 13 February 2018 to identify any additional unpublished or ongoing studies.\ud \ud Selection criteria\ud Randomised controlled trials (RCTs) of initiation of antidepressants (alone or in combination with another treatment), compared with any other treatment, placebo or standard care for the prevention of postnatal depression among women who were either pregnant or had given birth in the previous six weeks and were not currently depressed at baseline.\ud \ud Data collection and analysis\ud We used standard methodological procedures expected by Cochrane. We requested missing information from investigators wherever possible and sought data to allow intention-to-treat analyses.\ud \ud Main results\ud Two trials including a total of 81 participants fulfilled the inclusion criteria for this review. All participants in both studies had a history of postnatal depression and were not taking antidepressant medication at baseline. Both trials were conducted by the same research group. Risk of bias was low or unclear in most domains for both studies. We were unable to perform a meta-analysis due to the small number of studies.\ud \ud One study compared nortriptyline with placebo and did not find any evidence that nortriptyline was effective in preventing postnatal depression. In this study, 23% (6/26) of women who took nortriptyline and 24% (6/25) of women who took placebo experienced postnatal depression (RR 0.96, 95% CI 0.36 to 2.59, very low quality evidence) in the first 17 weeks postpartum. One woman taking nortriptyline developed mania; and one side effect, constipation, was more common among women taking nortriptyline than those taking placebo.\ud \ud The second study compared sertraline with placebo. In this study, 7% (1/14) of women who took sertraline developed postnatal depression in the first 17 weeks postpartum compared with 50% (4/8) of women who took placebo. It is uncertain whether sertraline reduces the risk of postnatal depression (RR 0.14, 95% CI 0.02 to 1.07, very low quality evidence). One woman taking sertraline had a hypomanic episode. Two side effects (dizziness and drowsiness) were more common among women taking sertraline than women taking placebo.\ud \ud Conclusions are limited by the small number of studies, small sample sizes and incomplete outcome data due to study drop-out which may have led to bias in the results. We have assessed the certainty of the evidence as very low, based on the GRADE system. No data were available on secondary outcomes of interest including child development, the mother‒infant relationship, breastfeeding, maternal daily functioning, family relationships or maternal satisfaction.\ud \ud Authors' conclusions\ud Due to the limitations of the current evidence base, such as the low statistical power of the included studies, it is not possible to draw any clear conclusions about the effectiveness of antidepressants for the prevention of postnatal depression. It is striking that no new eligible trials have been completed in the period of over a decade since the last published version of this review. Larger trials are needed which include comparisons of antidepressant drugs with other prophylactic treatments (e.g. psychological interventions), and examine adverse effects for the fetus or infant. Future reviews in this area may benefit from broadening their focus to examine the effectiveness of antidepressants for the prevention of perinatal (i.e. antenatal or postnatal) depression, which could include studies comparing antidepressant discontinuation with continuation for the prevention of relapse of depression during pregnancy and the postnatal period.

WHAT IS KNOWN ON THE SUBJECT?: User involvement, when people who have accessed services become actively involved in aspects of mental health care, can sometimes be "tokenistic" and not well thought through. Users are often involved in their own care, and asked for feedback, but are less likely to be meaningfully involved in developing services and training staff. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: To implement meaningful involvement, it is important to know why some users choose to devote time to such activities. User representatives in this study, involved in a UK mental health service, wanted to help people in a similar position and give something back to those that helped them. As people started involvement activities, such as interviewing staff, they gained confidence and felt part of something that was making a difference. After being supported by staff to explore opportunities, representatives become more independent and some moved to different, sometimes salaried, roles. Some representatives did not feel valued or supported. Staff often controlled opportunities, and many users missed out on being involved. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Staff need to understand and receive training on involvement. The definition of involvement should be agreed by users and staff together, and outcomes of involvement activities must be fed-back to users on a regular basis. There should be dedicated involvement workers in services, to support individuals and integrate involvement into the system. It is important to consider how to make involvement accessible to more mental health service users. ABSTRACT: Introduction Despite guidance promoting user involvement, meaningful involvement continues to be debated within services. To effectively implement involvement, it is important to acknowledge why users devote time to such activities. Aim This study explores user representatives' experiences of involvement, including motivations and personal benefits. Method Thirteen user representatives involved in activities such as staff training and interviews were recruited from a UK National Health Service mental health Trust during 2015. Themes within semi-structured interviews were developed using constructivist grounded theory analysis. Memo-writing, process and focused coding, and core categories supported development of the conceptual framework of being a user representative. Findings Being a user representative was inextricably linked to wellness, yet staff governed opportunities. Making a difference to others and giving back were initial motivating factors. Experiences depended on feeling valued, and the theme of transition captured shifts in identity. Discussion User representatives reported increased confidence and well-being when supported by staff. However, involvement triggered mental health difficulties and identified the need for regular monitoring and reflection of involvement activities and practice. Implications for practice Services should consider coproduction, where users and staff agree together on involvement definitions. Dedicated involvement workers are crucial to supporting individual well-being and monitoring involvement.

Introduction The critical challenge of determining the correct level and skill-mix of nursing staff required to deliver safe and effective healthcare has become an international concern. It is recommended that evidence-based staffing decisions are central to the development of future workforce plans. Workforce planning in mental health and learning disability nursing is largely under-researched with few tools available to aid the development of evidence-based staffing levels in these environments. Aim It was the aim of this study to explore the experience of staff using the Safer Nursing Care Tool (SNCT) and the Mental Health and Learning Disability Workload Tool (MHLDWT) in mental health and learning disability environments. Method Following a 4-week trial period of both tools a survey was distributed via Qualtrics on-line survey software to staff members who used the tools during this time. Results The results of the survey revealed that the tools were considered a useful resource to aid staffing decisions; however specific criticisms were highlighted regarding their suitability to psychiatric intensive care units (PICU) and learning disability wards. Discussion This study highlights that further development of workload measurement tools is required to support the implementation of effective workforce planning strategies within mental health and learning disability services. Implications for Practice With increasing fiscal pressures the need to provide cost-effective care is paramount within NHS services. Evidence-based workforce planning is therefore necessary to ensure that appropriate levels of staff are determined. This is of particular importance within mental health and learning disability services due to the reduction in the number of available beds and an increasing focus on purposeful admission and discharge.

The impact of how knowledge can effect attitude change is important in order to understand the consequences for stigma. The relationship between increasing subject knowledge of mental health and attitude change was explored. The sample comprised 39 students (18 male and 21 female) from a university in the West Midlands. Participants’ level of knowledge and stigma were recorded through pre- and post-tests using the Mental Health Knowledge Schedule (MAKS), Community Attitudes toward the Mentally Ill (CAMI) and the Opinions about Mental Illness (OMI) scale. Information about mental illness was provided between conditions followed by a distractor task. Responses were calculated and combined to give an overall score. A sign test with continuity correction was used to see whether there was a difference in attitudes. The pre- and post-test conditions were scored. Results demonstrate a statistically significant median decrease in stigma in the post-test condition (p = 0.03). Therefore, this research provides support for the success of providing knowledge and information about mental illness in order to reduce stigma.

The file attached to this record is the author's final peer reviewed version. The Publisher's final version can be found by following the DOI link. It is increasingly acknowledged that service-user satisfaction and experience are fundamental to the achievement of high quality care delivery worldwide. Research in this area identifies a need to capture the experience of care providers, to expand methodological approaches beyond the survey instrument and to develop patient-centred approaches that include effective partnerships between professionals, patients and their carers or family members. Evidence highlights the coercive potential of admission in adult acute mental health, and the increased complexity associated with enhancing patient satisfaction and experience in these environments. This study aimed to explore the experiences of staff, service-users, and carers with admission in two adult acute inpatient mental health wards. A grounded theory (GT) approach was adopted such that theory was developed inductively through data collection and analysis. A total of twenty-two participants were interviewed, this included: 9 (40%) service-users, 10 (46%) members of staff and 3 (14%) carers. The substantive theory of admission produced was organised across three major categories, namely: a person-centred beginning; building relationships along the way and barriers to the service received. These interrelated factors determine the meaningfulness of the admission and have the power to hinder or facilitate improvement to a service-user’s wellbeing and their evaluation of being admitted to an inpatient mental health ward. The process of admission in an acute inpatient mental health environment can pre-determine satisfaction and experience with services. It is essential that person-centred ideals are maintained from the outset in order to maximise the quality of care received. This includes the implementation of strategies that facilitate involvement approaches and nurturing positive relationships to improve communication, concordance, shared decision-making and participation with care delivery.

Objective: This study aimed to elicit and explore the experiences of teenage mothers with postpartum depression focussing on their experiences of being a teenage mother; support needs and the potential for support and education to be delivered by healthcare workers, or peers. Background: Teenage mothers are three times more likely to get postnatal depression than older mothers and are at increased risk of poorer mental health for up to three years postpartum. Method: Fifteen first-time mothers aged 16–19, living in Stoke on Trent, UK, with an infant aged under one year and suffering from postpartum depression were interviewed. Qualitative data were analysed using thematic framework analysis to identify emergent patterns and themes. Results: Four key themes emerged: stigma and perceptions of being judged; social and professional support; knowledge and information; and barriers to utilising support. Conclusion: The results highlighted the stigma, both real and perceived, that teenage mothers experienced as ...

Overview The purpose of this module is to outline and discuss the opportunities for nurse prescribers working within multidisciplinary teams across a range of health services. There will be an introduction to the single competency framework for prescribing (National Prescribing Centre, 2012), accompanied by reflective activities to help you consider how to implement the framework into your prescribing practice. Multiple choice questions are provided for self-assessment to help you achieve the learning outcomes.

PurposeThe aim of this paper is to ascertain the attitudes and experiences of psychiatrists, nurse prescribers, and service users with regard to the prescription of antipsychotic medication, the route of administration, and the extent of service users' involvement.Design/methodology/approachA total of 26 psychiatrists and 12 nurses agreed to be interviewed in phase one of this study, concerning general aspects of prescribing. In phase two, 11 of the psychiatrists and five nurses from the first cohort took part in follow‐up interviews that focused specifically on their most recent prescribing experiences. In phase 3 of the study, 18 service users (14 male and 4 female) were recruited, during which their experiences of having medication prescribed was explored.FindingsThis interview‐based survey found that though there was some agreement between the attitudes and perceptions of prescribers and service users, there were also some important differences including differences with respect to the purposes of prescribed medication, when to prescribe, and under what conditions depot medication produces optimal results. It is not always clear to service users as to why certain medicines were prescribed nor is the information provided always understood. A considerable amount of prescribing practice is based on assumptions.Originality/valueEven though medication (both oral and depot) has been shown to be useful in certain situations, nevertheless, the type of medication, dose and mode of administration continues to be idiosyncratic and inconsistent. This paper seeks to contribute to the debate by identifying in which pharmacological interventions for people with severe mental health problems could be improved.

Mental health nurses have been entitled to train to become independent prescribers since May 2006; although the number of trained nurse prescribers seems to have increased steadily, a significant number of them have not actually undertaken prescribing roles on completion of their training or have limited their practice to supplementary prescribing. In order to support existing independent prescribers and to assist those nurses who have trained but are yet to prescribe independently, a mental health trust has piloted the use of individual and team formularies. An evaluation of this project indicated that formularies were well received by existing independent prescribers and were seen as a helpful instrument to support newly qualified and supplementary prescribers in their bid to become independent. Formularies can clarify and formalize each prescriber's area of competence, thus setting clear boundaries, reducing uncertainty and enhancing prescribers' confidence and willingness to take on this new role. Formularies may also be used to enhance communication with service users and further develop shared decision making. Effective procedures need to be in place to ensure formularies are up to date and reflect local practice.

PurposeAs the beliefs people hold exert more influence over their behaviour than any other single factor, the purpose of this paper is to elicit those held by service users about being cared for in acute mental health settings.Design/methodology/approachData were collected by means of a semi‐structured, non‐standardised, 17‐item interview schedule from an opportunistic sample of 44 respondents (18 men and 26 women) following their admission over a nine‐month period.FindingsFindings suggest that those admitted to acute care settings harbour very different beliefs about what to expect, what is being offered and how it will affect them. While some respondents saw admission as an event simply to be endured, others saw it as a means of gaining relief, accessing better care and treatment as well as providing respite for their families. Whereas previous knowledge and experience of acute care did influence their beliefs, this was largely due to how they interpreted experiences rather than the experiences themselves. The data also suggest that service users can be assisted to reframe their beliefs by means of genuine, consistent and empathic relationships, thus putting services users in a position to derive maximum benefit from being admitted.Originality/valueRelatively little attention has been paid to the beliefs that service users have on entry to mental health services, in comparison to that paid to problem‐identification, care planning and intervention regimens. A starting point for any health care intervention, especially mental health care, should be the identification of the beliefs held by those about to embark on treatment programmes. This area deserves much more attention than it has been given hitherto.

The growing number of people worldwide with mental health problems is increasing and making intensive demands on existing services. Recent reorganizations of healthcare provision in the UK have focused predominantly on administrative efficiency, standardization and cost-effectiveness. Although little evidence exists that reorganizations, per se, directly result in improved health nationally, nevertheless, organizational change coupled with improved care provision can have a considerable impact on the mental health of people. It is known that service users want person-centred help with improving their confidence, autonomy and cognitive and social skills so as to be able to manage their lives within the social context in which they live. In this study, semi-structured interviews were used to explore service users' expectations and experiences of acute inpatient care and the early post-discharge period. While the social environment of the wards was seen by many as conducive to promoting safety and interpersonal relationships, others found the experience lacking in assisting them to resume their lives post discharge. If acute care is to become more than a mechanism for addressing and containing risk, better targeted interventions are required to help individuals find strategies that are transferable to the context of their 'real' lives. A number of factors that were identified by respondents in this study are identified and discussed.

Mental health nurses can now train to become independent prescribers as well as supplementary prescribers. Independent nurse prescribing can potentially help to reorganize mental health services, increase access to medicines and improve service user information, satisfaction and concordance. However, mental health nursing has been slow to undertake prescribing roles, and there has been little work conducted to look at where nurse prescribing is proving successful, and those areas where it is less so. This survey was designed to collect information from directors of nursing in mental health trusts about the numbers of mental health prescribers in England, gather views about prescribing in practice, and elicit intentions with regards to the development of nurse prescribing. In some Trusts, the number of mental health nurse prescribers has increased to the point where wider impacts on workforce, the configuration of teams and services are inevitable. Currently, the way that prescribing is used within different organizations, services and teams varies and it is unclear which setting is most appropriate for the different modes of prescribing. Future work should focus on the impact of mental health nurse prescribing on service delivery, as well as on service users, colleagues and nurses themselves.

The New Ways of Working Programme (NWW) supports the ongoing modernisation of the NHS by encouraging existing staff to evaluate their roles and responsibilities with a view to the full utilisation of skills across the workforce. Non-medical prescribing provides an example of workforce change and role development by which NWW can be critiqued.\ud The introduction of non-medical prescribing within mental healthcare has supported the development of new services, increased access to medicines, promoted a holistic model of care, and reduced the distance between medical and non medical colleagues. Nurse prescribers with access to organisational and team support have proved to be safe and confident prescribers. However, a large number of nurse prescribers working in mental health services have failed to utilise their roles in practice, highlighting concerns about how to inform team members, service users and carers, about new roles, how to utilise new roles without destabilising the team as a whole, and how to employ innovative measures to evaluate the impact of new roles in practice.\ud This article highlights and discusses these issues, and considers the current evidence surrounding the role of the nurse prescriber in mental health and learning disability care settings. The article also explores the role of healthcare professionals in supporting service users and carers to navigate through a modernised NHS.

For mental health nurses and service users to realize the benefits of non-medical prescribing, psychiatrists need to understand the remit of this role and be actively involved in influencing it. Although healthcare policy in the UK supports the expansion of non-medical prescribing, it requires much more for the successful implementation of such initiatives in practice. The aim of this survey was to explore the attitudes of all grades of psychiatrist working in two mental health trusts in the West Midlands to nurse prescribing. A specifically designed questionnaire was sent out to two groups of psychiatrists to assess their attitudes towards non-medical prescribing. Psychiatrists (n = 147) completed and returned a specifically designed questionnaire of their views. The more senior doctors appeared less concerned about nurse prescribing. Junior doctors expressed equivocation towards the role, suggesting that nurse prescribers be consistently supervised and have limited access to mental health drugs. The findings from this study have considerable implications for teams if junior doctors hold different views to their senior colleagues. Without the assistance of trusts in facilitating role change, the introduction of new roles could potentially heighten conflict between professions.

Aims The aim of this paper was to undertake a brief critical appraisal of evidence-based practice (EBP) as it is currently perceived in health care settings. Background The past two decades have seen EBP become increasingly important in health care planning, clinical thinking, and choice of treatments. It is based on scientific rationalism and adherents claim that decisions based on EBP are superior to those based on other approaches to care. Concerns are now being expressed that positivistic approaches to health care fail to take into account people’s preferences, their internal resources and their personal understandings of health and wellbeing. It has been argued that there may be multiple types of evidence, all of which have a part to play in the formulation and execution of health care. Methods After a literature search, this paper argues that whereas EBP may be useful in treating conditions that have a biological cause, it may be less helpful in understanding and treating conditions that have their origins in the social, psychological or spiritual domains. Results The nature, strengths and limitations of evidence-based practice is discussed in this paper. Nurses are encouraged to develop the critical skills of evaluating EBP in the lives and experiences of the people they care for. Conclusions Evidence-based practice has a part to play in improving the treatment provided for patients. Nonetheless, nurses should be aware of other kinds of evidence, and appreciate that any single approach to determining care, no matter how popular, is likely to lead to a service that does not truly meet the complex individual needs of patients. Implications for nursing management In order for evidence-based practice to be safe, the nursing workforce must be able to evaluate the strength and relevance of research findings, and be able to understand that there are different kinds of evidence which should be called upon in order to respond sensitively and appropriately to the preferences of patients. A responsive workforce embraces multiple ways of thinking, respects different paradigms of care, and is able to respond to and respect the forms of care people value and seek.

The introduction of supplementary prescribing formed part of an attempt to modernize the NHS, break down barriers across and within professions and enable patients to gain faster and easier access to medicines. Mental health nurses have been slower than other nursing specialities to take on the prescribing role. A number of reasons have been proposed for this including fears that the use of non-pharmacological interventions in mental health nursing could be marginalized. This focus group study set out to examine a group of mental health nurse prescribers working within a single organization and examine why some of these nurses put their prescribing role into practice and others did not. Findings suggest that organizations need to be clear about the scope and role specification of these prescribing roles. The availability and support of role models is important as the prescribing training course may generate, rather than abate, uncertainty about prescribing ability. In the absence of a critical mass of non-medical prescribers the prescribing initiative is being rolled out unevenly across teams, creating service inequities. Collaboration, particularly within teams, is vital for nurse prescribers to feel supported. Finally, to appreciate the true impact of the nurse prescribing role, any evaluation of benefits should be widened beyond the mere counting of scripts.

This qualitative study explores how recently qualified nurse prescribers describe, and rate, the safety of their prescribing. Internationally, the costs of drug errors are enormous and they can have serious implications for staff and patients. Nurses are now undertaking extended prescribing practice throughout the UK. Nurse prescribers work across different work settings and although safe prescribing is a priority in all of them, it is essential to ascertain the conditions that foster the highest levels of safety and how nurses can be supported in practice. Thirty-one nurses form the West Midlands area of England agreed to participate in an in-depth interview which sought to elicit their responses to various aspects of their prescribing work. They came from a variety of specialities and from hospital, community and general practice backgrounds. On completion of their training nurses were acutely aware of the responsibility that prescribing imposed on them. Although this awareness was thought to encourage caution and safety, it may also account for the fact that 26% of the nurses (n=8) had not prescribed since qualifying. Nurses felt that the multidisciplinary team had a vital role to play in supporting their prescribing practice as did collaborative working. It is concluded that those working in specialty areas that are less well-defined in terms of scope of practice (e.g. older adult nursing and learning disability) would benefit in particular from ongoing mentoring relationships with experienced prescribers and the development of individual formularies.

Even though the introduction of the role of the nurse prescriber promises improved access to medicines and increased flexibility in the workforce, the take-up of this role to date has been variable across the UK. This questionnaire-based study sought to compare the expectations of two distinct groups of nurses, one from a mental health and the other from a non-mental health background prior to becoming prescribers. Non-mental health nurses were of the opinion that being able to prescribe would increase efficiency and maximize resources, while mental health nurses saw prescribing primarily in terms of the benefits to clients--increased choice, improved access to care, better information about treatments and better quality of care.

In the UK, nurse prescribing training is delivered within a Higher Education Institution (HEI). Although prescribing courses are regularly evaluated by individual HEIs and associated commissioning bodies, there has been little focus on the perspective of the lecturers who provide the training. The aim of this paper is to explore nurse lecturers' experiences of delivering nurse prescribing courses and their views on how well they prepare nurses for the prescribing role. Eight members of lecturing staff (7 female and 1 male) from four HEIs across the West Midlands participated in one-to-one, semi-structured interviews to discuss their experiences of prescribing training. Key issues to emerge were the selection criteria for acceptance onto prescribing courses; the diverse skills, experience and background of the nurses accepted; the addition of supplementary prescribing to independent prescribing courses, and the problems of providing pharmacology input into courses. Feedback from students and lecturers is vital to ensure the quality of training. The study recommends that selection criteria for prescribing training courses should receive further attention. Providing more material for potential students prior to their embarking on training would help applicants understand better what is involved and ultimately improve implementation of nurse prescribing in practice.

Aims and objectives. To outline the development and content of a ‘top-up’ neuropharmacology module for mental health nurse prescribers and consider how much pharmacology training is required to ensure effective mental health prescribing practice. Background. Debate about the content of prescribing training courses has persisted within the United Kingdom since the mid-1980s. In early 2003 supplementary prescribing was introduced and gave mental health nurses the opportunity to become prescribers. The challenge of the nurse prescribing curriculum for universities is that they have only a short time to provide nurses from a range of backgrounds with enough knowledge to ensure that they meet agreed levels of competency for safe prescribing. There is growing concern within mental health care that the prescribing of medication in mental health services falls short of what would be deemed good practice. Over the past two decades, nurse training has increasingly adopted a psychosocial approach to nursing care raising concerns that, although nurses attending prescribing training may be able to communicate effectively with service users, they may lack the basic knowledge of biology and pharmacology to make effective decisions about medication. Methods. Following the completion of a general nurse prescribing course, mental health nurses who attended were asked to identify their specific needs during the evaluation phase. Although they had covered basic pharmacological principles in their training, they stated that they needed more specific information about drugs used in mental health; particularly how to select appropriate drug treatments for mental health conditions. This paper describes how the nurses were involved in the design of a specific module which would enable them to transfer their theoretical leaning to practice and in so doing increase their confidence in their new roles. Results. The findings of this study suggest that the understanding and confidence of mental health nurse prescribers about the drugs they prescribe coupled with the information they provide to service users can be improved as a result of specific educational support. It would appear that adopting a prescribing dimension to one's role requires nurses to revisit a number of skills that are integral to the work of the mental health nurse, e.g. good communication, establishing empathy, listening to what clients say, responding to what is required and involving clients in their own care. Conclusion. Mental health nurses from one particular Trust in the West Midlands were provided with a ‘top-up’ course in neuropharmacology and, although they found this challenging, ultimately they found this to be helpful. As nurse prescribing is ‘rolled out’ to other nursing specialities it is important that local Trusts and Workforce Development Directorates maintain a dialogue about nurse prescriber training to ensure that nurse prescribers receive the appropriate time and support for their ongoing Continued Professional Development. Relevance to clinical practice. As increasing numbers of nurses from different specialities qualify as nurse prescribers it is vital that they are supported by their employing organizations and given the opportunity to maintain their competency and confidence in their prescribing practice.

Aims. This paper reports a study to elicit background data from recently qualified nurse prescribers and explore aspects of their work. Background. Nurse prescribing has been introduced quite recently in the United Kingdom. Although a certain amount of information is available about the characteristics of nurse prescribers, relatively little is known about their professional backgrounds, their reasons for choosing to become nurse prescribers and their perceptions of their emerging role. More information is needed to inform the selection, education and support of nurse prescribers. Method. All nurses who undertook a nurse prescribing course in one university in the West Midlands during 2003–2004 were invited to participate in the study. A 40-item questionnaire was used to gather data on demographics, expectations of nurse prescribing, personal and professional development and perceived education needs. Findings. Respondents considered that, despite initial problems, the nurse prescribing initiative would ultimately prove to be a cornerstone of improved service delivery for service users. The majority of nurses were already heavily involved in prescribing ‘by proxy’ and the course merely formalized what they were currently doing. Potentially, prescribing could advance the professional development of nurses, improve communication between professionals and patients, and make the experience of patients more beneficial. However, some concerns were expressed about how supportive the current climate in health care could be, given the multiple demands on time and energy required by so many other innovations. Conclusions. Respondents appeared balanced in their perceptions of this innovation and what it could realistically achieve. They were not indifferent to the many short and long-term problems that need to be resolved before it can be claimed to have become embedded in practice. The success of non-medical prescribing may depend on organizational support, coupled with a robust continuing professional development strategy for all nurse prescribers.

This systematic review assessed the success of randomized controlled trials of preventative interventions for postnatal depression (PND). Outcomes examined were estimates of PND prevalence. Methodological quality was determined through the examination of key components individually with independent data extraction by all three authors. Data sources included Medline, PsycINFO, Sociofile, CINAHL, COPAC, EMBASE, Cochrane library; hand searches and a newsletter requests for unpublished trials to the Marcé Society and Postpartum Support International. Twenty-one RCTs were included in this review. Nine of these trials demonstrated short-term preventative success (seven psychological and supportive interventions, one unpublished antidepressant trial and a calcium carbonate trial) but none provided any evidence of long-term success. Furthermore, the results of three of the psychological intervention trials should be viewed with caution due to a lack of methodological rigour. There is a need for future research into the prevention of PND to be tightly designed and maybe include an exploration of the experience of postnatal depression for multiparous women.