SummaryBackgroundStudies evaluating titration of antihypertensive medication using self-monitoring give contradictory findings and the precise place of telemonitoring over self-monitoring alone is unclear. The TASMINH4 trial aimed to assess the efficacy of self-monitored blood pressure, with or without telemonitoring, for antihypertensive titration in primary care, compared with usual care.MethodsThis study was a parallel randomised controlled trial done in 142 general practices in the UK, and included hypertensive patients older than 35 years, with blood pressure higher than 140/90 mm Hg, who were willing to self-monitor their blood pressure. Patients were randomly assigned (1:1:1) to self-monitoring blood pressure (self-montoring group), to self-monitoring blood pressure with telemonitoring (telemonitoring group), or to usual care (clinic blood pressure; usual care group). Randomisation was by a secure web-based system. Neither participants nor investigators were masked to group assignment. The primary outcome was clinic measured systolic blood pressure at 12 months from randomisation. Primary analysis was of available cases. The trial is registered with ISRCTN, number ISRCTN 83571366.Findings1182 participants were randomly assigned to the self-monitoring group (n=395), the telemonitoring group (n=393), or the usual care group (n=394), of whom 1003 (85%) were included in the primary analysis. After 12 months, systolic blood pressure was lower in both intervention groups compared with usual care (self-monitoring, 137·0 [SD 16·7] mm Hg and telemonitoring, 136·0 [16·1] mm Hg vs usual care, 140·4 [16·5]; adjusted mean differences vs usual care: self-monitoring alone, −3·5 mm Hg [95% CI −5·8 to −1·2]; telemonitoring, −4·7 mm Hg [–7·0 to −2·4]). No difference between the self-monitoring and telemonitoring groups was recorded (adjusted mean difference −1·2 mm Hg [95% CI −3·5 to 1·2]). Results were similar in sensitivity analyses including multiple imputation. Adverse events were similar between all three groups.InterpretationSelf-monitoring, with or without telemonitoring, when used by general practitioners to titrate antihypertensive medication in individuals with poorly controlled blood pressure, leads to significantly lower blood pressure than titration guided by clinic readings. With most general practitioners and many patients using self-monitoring, it could become the cornerstone of hypertension management in primary care.FundingNational Institute for Health Research via Programme Grant for Applied Health Research (RP-PG-1209-10051), Professorship to RJM (NIHR-RP-R2-12-015), Oxford Collaboration for Leadership in Applied Health Research and Care, and Omron Healthcare UK.

This article presents an empirical study of nurses' and patients' assessment of patients' pain following surgery. The study aimed to replicate and extend previous research which indicated that nurses tend to underestimate patients' pain. The independent variables were type of operation, patient gender, time since surgery and nurses' experience. Results confirmed that nurses give consistently lower pain ratings than patients. The prediction that nurses' pain ratings would be influenced by the type of operation was not confirmed. Not surprisingly, pain ratings were lower on day four than on day one. The data failed to confirm previous findings that the more junior the nurses the greater pain they infer in their patients. The main conclusion of this research is that nurses continue to underestimate the severity of pain suffered by patients postoperatively.

The first article in this two-part series (Vol 5(13): 778-84) presented an empirical study of nurses' and patients' pain following surgery. Results indicate that nurses give consistently lower pain ratings for patient's pain than do patients. The main implication of this research is that nurses continue to underestimate the severity of pain suffered by patients postoperatively. This article considers a second empirical study, the objectives of which were to determine which methods nurses use to assess and monitor pain relief and which factors influence their decision to give or withhold analgesia. Results reveal that while nurses claim to rely on patients' self-reports of pain, the most influential factors in the decision whether or not to give analgesia are the dosage, type and frequency of drug prescribed. The main reason for withholding analgesia is that the patient reacted adversely to the medication. Student nurses placed more emphasis than trained nurses on the timing and amount of analgesia given. Nurses had a good knowledge of pain assessment tools, although few had used them.

This two-part article presents psychological and social factors which affect pain perception and response and the implications of these for nursing practice. In this article, the complex interactions between neurophysiological and psychological factors are outlined and theories of pain perception and ways in which the pain experience can be modulated are presented. The role of psychological factors, attitudes, beliefs and expectations of both patient and practitioner, pain behaviours and ability to cope are discussed. In the second part, these are further elaborated with particular reference to the nurse-patient interaction. The use of psychological approaches to augment clinical practice, such as education, reduction of anxiety and improving coping ability, are suggested. Finally, the importance of communication skills in pain management is addressed.

There is growing consensus that healthcare assistants (HCAs) need access to professional training, education and support. The authors describe a short course designed to educate and support HCAs, focusing on the care of older people.