In My Signals, health and social care staff and service users tell us what research is important to them and why they feel others need to know about it. Join the conversation on Twitter and tell us which Signals have interested, excited or surprised you, using #MySignals. You can find the latest NIHR Signals here.
In this collection, we asked three nurses of different levels of experience and specialities to tell us which Signals have interested them most and explain why they feel the findings are worth sharing.
Teresa Chinn MBE
Teresa Chinn MBE is a registered nurse of 20 years and a social media specialist. Teresa tweets, blogs and supports over 70 thousand nurses through the Twitter account @WeNurses. Teresa also maintains clinical practice through doing occasional bank work in a dementia care home. Teresa is a huge advocate for sharing, discussing and creating evidence and research through social media. She tweets as @AgencyNurse.
Carefully managed antibiotic use could halve antibiotic-resistant infections
“I was drawn to this Signal because of my work in care homes. I see so much antibiotic use in care homes, yet the antibiotic stewardship programmes that I encounter through my work on social media seem to be taking their time to filter through to everyone. I am not sure that antimicrobial resistance is well understood by both staff, residents and relatives in care homes, despite the NICE guidance recommendation that commissioners and healthcare providers should establish antibiotic stewardship across all care settings.
“Antimicrobial resistance is a global concern and something we need to get serious about before it’s too late. This Signal is something that not only will I be sharing across my social networks but also in my clinical workplace with the view to implementing an antibiotic stewardship programme.”
Nurses and pharmacists can prescribe as effectively as doctors
“I am very fortunate to do my clinical practice in a care home that has an outstanding rating from the Care Quality Commission and work with some excellent nurses and I often feel that they could be more autonomous in their practice. It seems to me that they could effectively reduce pressure on GPs by being able to prescribe medications.
“I was interested to see that the majority of studies in this review were of chronic disease management, as this fits in well with care homes. I was also pleased to read that patient outcomes after nurses or pharmacists prescribed medication, were similar to those for medical prescribing. This Signal gives the much needed evidence that can help us to drive forward new ways of working.”
Public health interventions may offer society a return on investment of £14 for each £1 spent
“This Signal caught my eye for very different reasons; I am currently working on a project with Public Health England, on their All Our Health framework, using social media to bring learning around the framework to healthcare professionals. Social media lends itself well to public health interventions, spreading messages, learning and discussion far and wide.
“The Signal interested me as the range of interventions mentioned (from vaccinations, road safety campaigns and taxation, to improved walking and cycling infrastructure, workplace obesity management, falls prevention, and smoking cessation) included some interventions that could be carried out via social media.
“Social media is a brilliantly cost effective way of reaching many people- if it is approached in the right way- so this got me thinking around the return on investment for public health interventions through social media versus traditional routes. The Signal doesn’t really mention routes of the interventions, and it is clear from the date range of the studies (1976 to 2015) that some of the studies would have taken place before the advent of social media. I feel that this is something that I need to read more about and will be looking at the full review and seeing if there is some methodology I can apply to social media interventions.
“I wholeheartedly believe that social media gives us a fantastic opportunity within public health and that this review could provide us with the evidence that this opportunity is worth taking.”
Rebecca Harper is a senior staff nurse working in intensive care with experience in general and cardiothoracic adult critical care. Rebecca has led quality improvement projects to identify and improve the nursing care of patients with delirium as well as several in medicines management and in promoting near miss reporting. She believes strongly in the value of clinical knowledge and research and the role of nurses as a safety critical profession. She tweets as @itsneverbecky.
Interventions that help and harm patients in the critical care unit
“This Signal attracted my attention because I immediately recognised some of the practices identified as causing harm to already critically unwell patients as interventions that I had been involved in carrying out, or that I had even suggested during ward rounds. Healthcare professionals in intensive care are faced with an abundance of new findings, expert opinions and guidance, this review really highlighted to me the importance, but also the challenge, of keeping our patients safe by challenging and updating practice. I have been sharing these findings, particularly with the nurses I mentor who are undertaking postgraduate critical care studies, in order to emphasise how fluid expert opinion and “best practice” can be. We would benefit greatly from a similar international study investigating why outdated or harmful practice persists, it may be daunting that our evidence to practice gap can be so vast, and exacerbated by constant waves of new literature, but increasing awareness among the professionals at the bed space will help to tackle this challenge.”
Checklists are no substitute for experience in spotting patients who are deteriorating
“The nursing workforce is experiencing a protracted transformation, with pre-registration education under review as new entry routes and associate roles are added. The much needed move to an entirely degree educated profession allowed junior nurses, with less senior support, to quickly become expert in assessing and managing the deteriorating patient. I feel that this Signal is important in highlighting the risk of delegating central nursing responsibilities to less experienced practitioners.
“I was also very interested to read the suggestion that simulation training could be utilised to help nurses and teams use these track and trigger systems as changes to nurse education could see an increase in the utilisation of sim training. Nurses often talk of a “feeling” that something is “not right” about a patient’s condition, it is highlighted in this study that the conflict between this and normal clinical observations delays referrals. This “feeling” is really a complex subconscious expert use of clinical judgement and I think it was important that the conflict between this and track and trigger systems be highlighted and that protocols could actually incorporate this to support nurses.”
Transfusing blood close to its use-by date does not increase deaths in critically ill adults
“There have been several interesting but very early stage findings that suggest blood transfusions from those who are younger to those who are older may have potentially rejuvenating results. Critical care practice is often inundated with new fads and so I was very interested to read this Signal as it could go some way to dispelling the myths that evolve from these new ideas, as well as previous out-dated studies, that older blood could be harmful. Blood is an incredibly valuable resource, on a number of different levels, and so it is vital that we utilise it in the most effective and responsible way that we can. I would like to see national guidance mention the safety of transfusing older red blood cells more explicitly in order to help ensure this.”
Earplugs may reduce risk of confusion in patients while in intensive care
“I was immediately drawn to this Signal as a nurse working in intensive care who has led practice development projects aiming to tackle delirium. As well as being an incredibly frightening experience for patients and their relatives, delirium prolongs the length of time critical care patients are ventilated and the length of time that they stay in hospital for – putting them at risk of many other complications, as well as increasing healthcare costs. Not only this but delirium risks longer term cognitive impairment which can impact on patient’s lives, inhibiting return to usual social functioning and employment which has an impact on both the individual, communities and the wider economy. Prevention is always better, and cheaper, than cure. It is difficult, given the nature of intensive care, to create an environment allowing the usual day-night cycle which facilitates normal sleeping and so helps to reduce the risk of delirium, so it is great to have some evidence for a cheap intervention that nurses can utilise to help patients avoid a distressing and costly complication of critical illness. Although the evidence quality was mixed, it is clear that the use of earplugs stood out as a useful intervention and I will definitely be sharing this Signal with colleagues as a way of preventing delirium.”
Grace Van den Bergh
Grace Van den Bergh is a third year mental health nursing student at the University of the West of England. She tweets as @ge2vdb.
Talking therapy given by parents shows promise for childhood anxiety disorders
“This Signal stood out to me because, from my experience during clinical placements and echoed in the literature and personal accounts, the provision of talking therapies in the UK falls far short of the demand, including in children and young people’s services. There is no doubt that early intervention throughout the spectrum of ‘mental illness’ is correlated with improved outcomes, but with such high demand, many young people are left waiting for long periods, are forced to explore private options (if families are fortunate enough to afford this), or do not meet the criteria for support at all. In my experience, delayed treatment can sadly lead to crisis and potentially avoidable trauma for the young person and those around them.
“This Signal suggests that in teaching parents to deliver CBT (Cognitive Behavioural Therapy) to their child who is experiencing anxiety, similar outcomes are produced six months post intervention to that of the current practitioner-led solution-focused treatment, with around 70% considered ‘recovered’. This new approach could offer a more cost-effective option than current treatment, which, if implemented effectively, could equalize the current disparity between supply and demand.
“Thinking critically, the effectiveness of parent delivered CBT is likely to be dependent on the parent-child relationship or home environment, with the development of a childhood anxiety disorder strongly correlated to having an anxious parent or traumatic experiences in the family home (e.g. divorce or bereavement). Questions that come to mind include the assumption that the parent may be confident in delivery or the child may be comfortable in being parent-led, with confidentiality already a contentious issue in children’s services.
“It would be interesting to explore the longer-term benefits of parent-led interventions and whether this increased understanding of CBT within families may be beneficial to wider family networks. It would be interesting, too, to explore this intervention in more deprived or minority communities to determine whether efficacy would be similar.”
Supported employment helps people with severe mental illness to obtain work
“The benefits of meaningful activity are well documented in recovery literature, including employment, which can have the power to build confidence and self-esteem, create a sense of purpose, improve quality of life and provide connection with others. Although not all service users may be in a position to consider employment, it has been suggested that as few as 5.7% of people in the care of secondary mental health services were in paid positions in 2014. This Signal stood out to me for this reason, exploring the best ways to support individuals to seek, obtain and maintain paid work.
“This review seeks to determine which interventions are most effective. Outcomes suggest that ‘supported’ and ‘augmented supported’ employment initiatives were the most successful, which can be defined as rapid and intensive support in searching for and maintaining employment, supplemented with other interventions such as social or cognitive skills based training. Although these findings are promising, the authors suggest that the quality of evidence reviewed was moderate to low. Considering the known benefits of employment, it therefore seems fundamental that vocational interventions should be explored further in favour of more reliable and definitive findings. It seems that augmented support, with the combination of skills training and consistent long-term coaching, would most improve outcomes. However, it’s important that intervention efficacy is balanced with cost effectiveness and I am concerned that this would prevent its introduction.
“Employment is a contentious issue. Recent initiatives have seen the joining up of healthcare services with strategies put forward by the Department of Work and Pensions, including the introduction of Employment Advisors in Improving Access to Psychological Therapies (IAPT) services. Although employment support and treatment are not enforced, the nature of psychological and welfare services working towards the same goal makes some people uncomfortable. It is important to also consider the quality of employment available, which this Signal does not do. Surely individuals with mental illness, like the wider population, deserve meaningful, stimulating opportunities that they enjoy and offer progression, which unfortunately is not always the case.”
Metformin shows early promise for controlling clozapine-related weight gain
“Clozapine is an antipsychotic medication prescribed to ‘treatment resistant’ individuals diagnosed with Schizophrenia who are unresponsive to two other medications. It is largely considered the gold standard in psychopharmacology, but as Mental Health Nurses, we are challenged with supporting individuals to balance the benefits of symptom management and the associated side effects of such treatment. Newer generation antipsychotics (although largely avoiding the extrapyramidal side effects of older generation alternatives) do increase the risk of weight gain in individuals, which in turn is associated with physical health problems like diabetes and cardio-metabolic disease.
“The impact of weight gain is not just physical, this is something I have become acutely aware of during my nursing education. Following illness or diagnosis, it is not uncommon for individuals to struggle with their identity, and recovery literature confirms that it is not truly possible to return fully to the premorbid person and life must instead be lived in spite of symptoms and limitations. This can be difficult to accept and, in my experience, can be impacted by the physical, psychological and emotional impact of side effects like weight gain.
“As demonstrated in personal accounts and the literature, significant weight gain induced by pharmacological treatment can lead individuals to consider ceasing treatment (with or without professional support), and is a predictor of relapse. It is therefore promising that alternative initiatives to control weight gain are being explored, like the supplementary prescription of Metformin. Although current initiatives prioritise supporting individuals to make lifestyle changes including diet and exercise, negative symptoms like low motivation are difficult to overcome and can make achieving these changes long-term really challenging. This Signal therefore adds a promising new perspective, and in future I hope we are able to offer more choice to the individuals we work with to manage the unwanted effects of medication.
“This Signal suggests that Metformin may be considered if other lifestyle interventions have first proven unsuccessful. Considering that the most significant weight gain often happens in the first 6 months of commencing Clozapine, could prescribing the drug earlier in the treatment limit the myriad of side-effects and help to accelerate recovery.”
Produced by the University of Southampton on behalf of NIHR through the NIHR Dissemination Centre