Care Interface Research Articles

Training needs analysis of nurses caring for individuals an intellectual disability and or autism spectrum disorder in a forensic service

Purpose Examining the education and training needs of forensic nurses is paramount as services move from the older institutions to new care settings. The purpose of this study was to identify Irish Forensic nurses perceived deficits in their knowledge and skills to assist them to provide effective seamless care for individuals with an intellectual disability within their forensic mental health service, so that appropriate training could be provided. Design/methodology/approach Training needs analysis (TNA) procedures are used as a way of establishing the continuing processional development of staff, as they seek to identify the gaps between the knowledge and skills of an individual and the need for further training. A training needs tool developed by Hicks and Hennessy (2011) was used and completed by nurses working in an Irish forensic mental health service. A total of 140 surveys were circulated and 74 were completed (51 per cent response). Findings The top priority training needs identified were for additional training in research and audit and in the use of technology. Other self-identified training needs included additional training in behavioural management for challenging behaviour, understanding mental health and intellectual disability and dual diagnosis, training in enhancing communication skills and how to work with patients who have an intellectual disability patients specific training on autistic spectrum disorders and a guide and template for advance individual care planning and for caring for the physical health needs and promoting the physical health needs of these patients. Originality/value Despite there being a vast range of training issues identified, the majority of nurses appear to have a clear idea of their training needs to ensure the provision of seamless care for individuals with an intellectual disability within a forensic mental health setting. This TNA has identified the specific needs of nursing staff working at different positions across the interface of intellectual disability and forensic mental health care.

A Clínica Extensa na Interface entre a Universidade e a Atenção em Saúde

Resumo O presente ensaio pretende abordar a interface do trabalho entre a Universidade e a assistência à Saúde a partir da perspectiva da clínica ampliada em Psicanálise. Considerações teórico-metodológicas sobre a Clínica Extensa e o Narcisismo são os fundamentos de onde partiremos para abordar a especificidade da escuta psicanalítica no contexto institucional. Visamos demonstrar a experiência de acolhimento e acompanhamento de famílias e de díades mãe-bebê desde o início da gestação, incluindo condições críticas de internação em UTI-Neonatal. Faremos isso através da apresentação de uma proposta de dispositivos para a observação e a intervenção, a fim de discutir a necessidade de ampliação do trabalho do psicólogo para abordar a equipe multidisciplinar, considerando os fenômenos grupais que atravessam esse tipo de trabalho. Como conclusão, assinalamos a contribuição de uma escuta psicanalítica sobre a constituição do sujeito e a ética do desejo no contexto de uma lógica complexa em Psicologia da Saúde.

Implementation of a standardised annual anticoagulation specialist review in primary care.

An increasing number of patients are being prescribed direct oral anticoagulants (DOACs), while the patients who remain on warfarin are becoming more complex. There is currently a lack of a standardised anticoagulation review for patients in primary care, resulting in potentially preventable harm events. Our aim was to implement a new service, where a standardised review is carried out by a specialist multidisciplinary secondary care anticoagulation team. Overall, the implementation of a standardised review resulted in better optimisation of anticoagulation management for patients taking either a DOAC or a warfarin. Of the 172 eligible patients prescribed warfarin, 47 (27%) chose to switch a DOAC. The average time in therapeutic range for patients on warfarin before and after the pilot increased from 73.5% to 75%. Of 482 patients taking a DOAC, 35 (7%) were found to be on incorrect dose. In 32 (91%) of 35 patients, the dose was amended after notifying the patient's general practitioner. We also found a significant number of patients inappropriately prescribed concomitant medication such as antiplatelet or non-steroidal anti-inflammatory drugs, potentially putting the patients at an elevated risk of bleeding. While further research is needed; we believe the results of this pilot can be used to help build a case to influence the commissioning of anticoagulation services. Secondary care anticoagulation teams, like our own, may be well-placed to provide or support such services, by working across the primary care and secondary care interface to support our primary care colleagues.

Reframing translational research as transactional research:

Translational research (TR) is subject to increasing attention and demand in research and health policy in the Nordic countries as well as internationally. While clinician-scientists are often positioned as key actors in both policy and academic debates on TR, less is known about the clinician-scientists’ everyday work—their practices and commitments at the interface of academia and clinical health care. Drawing on the framework of arena analysis, developed in situational analysis, this article presents an empirical exploration of the everyday practices of clinician-scientists by extending research into a Danish hospital setting.
 The findings shed light on hospital-based translational research as constituted by clinician-scientists’ practical integration of and transactions across many different work practice arenas. This paper depicts these arenas and the complex of commitments and capabilities involved. The analysis converges with existing Science and Technology Studies approaches to translational research as mutually reconfiguring clinical and scientific practices. In addition, it adds to this debate by providing an empirical work practice account of hospital-based TR and by suggesting a conceptual reframing of translational research as transactional research.

Contribution of primary care organisation and specialist care provider to variation in GP referrals for suspected cancer: ecological analysis of national data

ObjectivesTo examine how much of the variation between general practices in referral rates and cancer detection rates is attributable to local health services rather than the practices or their populations.DesignEcological...

Entwicklung eines flexiblen Behandlungskonzepts für die neurologische Anschlussrehabilitation nach Schlaganfall (AOK-proReha Schlaganfall)

Objective of the studyThe aim was to develop an evidence-based treatment concept which describes a standard of performance for stroke patients in neurological follow-up rehabilitation, contracted by a statutory health insurance agency. MethodThe treatment concept was developed in several steps: a) first of all, a systematic literature search for guidelines was conducted and an online discussion forum was established, followed by b) formation of an expert group, as well as c) two expert workshops, two working groups and several written follow-up surveys. The implementation of the concept was scientifically accompanied by project team members from the eight pilot facilities selected. ResultsThe treatment concept in its current version provides eleven modules, ten of which refer to the rehabilitation itself and one to the interface of acute care and rehabilitation. An innovative feature of this treatment concept is that the often contradictory demands for standardization and flexibility of individual cases according to the patients’ needs are brought in line by freely selectable intensity standards. However, the commitment of a total minimum of therapy times is important. Since mid-March 2018, the treatment concept has been initially implemented in various pilot facilities occupied by the AOK Baden-Württemberg. ConclusionThe evidence-based and consensus-based concept is characterized by being individually and flexibly applicable to the individual patient. In this way, it meets the given demands and fulfils the requirements of a heterogeneous group of patients. It is intended to incorporate the treatment concept into the routine healthcare services offered by the AOK Baden-Württemberg. In addition, the treatment concept will be the basis for the development of performance-based remuneration.

Bridging the Behavioral Health Gap in Serious Illness Care: Challenges and Strategies for Workforce Development

Comorbidity with behavioral health conditions is highly prevalent among those experiencing serious medical illnesses and is associated with poor outcomes. Siloed provision of behavioral and physical healthcare has contributed to a workforce ill-equipped to address the often complex needs of these clinical populations. Trained specialist behavioral health providers are scarce and there are gaps in core behavioral health competencies among serious illness care providers. Core competency frameworks to close behavioral health training gaps in primary care exist, but these have not extended to some of the distinct skills and roles required in serious illness care settings. This paper seeks to address this issue by describing a common framework of training competencies across the full spectrum of clinical responsibility and behavioral health expertise for those working at the interface of behavioral health and serious illness care. The authors used a mixed-method approach to develop a model of behavioral health and serious illness care and to delineate seven core skill domains necessary for practitioners working at this interface. Existing opportunities for scaling-up the workforce as well as priority policy recommendation to address barriers to implementation are discussed.

Shared care pitfalls: high dose antipsychotic monitoring in the community

BackgroundShared care is an integral part of monitoring patients on high-dose antipsychotics (HDA). These off-label prescription medications used for treatment resistant schizophrenia carry significant risk of harm, including sudden death. The challenges of monitoring HDA prescriptions are complex in the community setting.AimIdentify pitfalls in community HDA prescribing and monitoring through an audit of a busy London adult psychosis service caseload.MethodTwo years on from an initial caseload audit and multidisciplinary team education programme, compliance on HDA monitoring forms was re-audited in greater depth. Correspondence between the community psychiatric team and each patient’s GP was reviewed, looking for evidence of shared care protocols. Results were combined with a literature search.ResultsNone of monitoring tests were adequately recorded. In 100% of cases windows for repeat ECG and observation monitoring had been missed. In 100% of cases blood tests had been carried out by the GP but this information was not documented appropriately. 0% of case records showed clear documentation of the shared care protocol from psychiatric team to GP.ConclusionHDA psychotic monitoring policies has been poor when audited at inpatient centres, however, these audits have led to improvements in guideline compliance. In this case, MDT education failed to lead to improvement. The primary–secondary care interface leaves GPs lacking certainty in their roles monitoring HDAs. Patients in the community are not always stable enough to have the insight or motivation to consistently engage with services. New strategies with a focus on shared care have been implemented to drive quality improvement.

Developing population health research priorities in Asian city state: Results from a multi-step participatory community engagement.

ObjectivesTo identify a broad range of research priorities to inform the studies seeking to improve population health outcomes based on the engagement of diverse stakeholders.MethodsA multi-step, participatory and mixed-methods approach was adopted to solicit and structure the investigative themes from diverse stakeholders. The priority setting exercise involved four key phases: (1) feedback from community leadership; (2) interim ranking survey and focus group discussions during the population health symposium; (3) individual in-depth interviews with stakeholders in the community; and (4) synthesis of the research priorities from the multistep process.ResultsDiverse stakeholders in Singapore, comprising community partnership leaders, health care and social service providers, users of population health services, patients and caregivers, participated in the research priority setting exercise. Initial 14 priorities were identified from six community leadership feedback, 42 survey responses, two focus groups (n = 16) and 95 in-depth interviews. The final integrated research agenda identified six priorities: empower residents and patients to take charge of their health; improve care transition and management through relationship building and communication; enhance health-social care interface; improve respite care services for long-term caregivers; develop primary care as a driving force for care integration; and capacity building for service providers. Selected research questions in each priority area were also generated to develop novel models of care, foster collaboration, implement optimal services and enhance understanding of the end users’ care needs.ConclusionsThis study illuminates that greater community engagement in research priority setting for population health can facilitate the formulation of evidence-based research agendas that matter to the care providers and service users in the community. The outcomes derived from this exercise will help focus researchers’ efforts through which meaningful gains can be made for population health.

The Patient-Held Active Record of Medication Status (PHARMS) study: a mixed-methods feasibility analysis.

Medication errors frequently occur as patients transition between hospital and the community, and may result in patient harm. Novel methods are required to address this issue. To assess the feasibility of introducing an electronic patient-held active record of medication status device (PHARMS) at the primary-secondary care interface at the time of hospital discharge. A mixed-methods study (non-randomised controlled intervention, and a process evaluation of qualitative interviews and non-participant observation) among patients >60 years in an urban hospital and general practices in Cork, Ireland. The number and clinical significance of errors were compared between discharge prescriptions of the intervention (issued with a PHARMS device) and control (usual care, handwritten discharge prescription) groups. Semi-structured interviews were conducted with patients, junior doctors, GPs, and IT professionals, in addition to direct observation of the implementation process. In all, 102 patients were included in the final analysis (intervention n = 41, control n = 61). Total error number was lower in the intervention group (median 1, interquartile range [IQR] 0-3) than in the control group (median 8, IQR (4-13.5, P<0.001), with the clinical significance score in the intervention group also being lower than the control group (median 2, IQR 0-4 versus median 11, IQR 5-20, P<0.001). The PHARMS device was found to be technically implementable using existing information technology infrastructure, and acceptable to all key stakeholders. The results suggest that using PHARMS devices within existing systems in general practice and hospitals is feasible and acceptable to both patients and doctors, and may reduce medication error.

Structure and Content of Drug Monitoring Advices Included in Discharge Letters at Interfaces of Care: Exploratory Analysis Preceding Database Development.

BackgroundInadequate drug monitoring of drug therapy after hospital discharge facilitates adverse drug events and preventable hospital readmissions.ObjectiveThis study aimed to analyze the structure and content of drug monitoring advices of a representative sample of discharge letters as a basis for future electronic information systems.MethodsOn 2 days in November 2016, all discharge letters of 3 departments of a university hospital were extracted from the hospital information system. The frequency, content, and structure of drug monitoring advices in discharge letters were investigated and compared with the theoretical monitoring requirements expressed in the corresponding summaries of product characteristics (SmPC). The quality of the drug monitoring advices in the discharge letters was rated with the domains of an adapted systematic instructions for monitoring (SIM) score.ResultsIn total, 154 discharge letters were analyzed containing 1180 brands (240 active pharmaceutical substances), of which 50.42% (595/1180) could theoretically be amended with a monitoring advice according to the SmPC. In reality, 40 discharge letters (26.0%, 40/154) contained a total of 66 monitoring advices for 57 brands (4.83%, 57/1180), comprising 18 different monitoring parameters. Drug monitoring advices only addressed mean 1.9 (SD 0.8) of the 7 domains of the SIM score and frequently did not address reasons for monitoring (86%, 57/66), the timing of monitoring, that is, the start (76%, 50/66), the frequency (94%, 63/66), the stop (95%, 63/66), and how to react (83%, 55/66).ConclusionsDrug monitoring advices were mostly absent in discharge letters and a gold standard for appropriate drug monitoring advices was lacking. Hence, more effort should be put in the development of tools that facilitate easy presentation of clinically meaningful drug monitoring advices at the point of care.

Determinants of quality prostate cancer survivorship care across the primary and specialty care interface: Lessons from the Veterans Health Administration.

BackgroundWith over 3 million US prostate cancer survivors, ensuring high‐quality, coordinated cancer survivorship care is important. However, implementation of recommended team‐based cancer care has lagged, and determinants of quality care across primary and specialty care remain unclear. Guided by the theoretical domains framework (TDF), we explored multidisciplinary determinants of quality survivorship care in an integrated delivery system.MethodsWe conducted semistructured interviews with primary (4) and specialty (7) care providers across 6 Veterans Health Administration clinic sites. Using template analysis, we coded interview transcripts into the TDF, mapping statements to specific constructs within each domain. We assessed whether each construct was perceived a barrier or facilitator, examining results for both primary care providers (PCPs) and prostate cancer specialists.ResultsCancer specialists and PCPs identified 2 primary TDF domains impacting their prostate cancer survivorship care: Knowledge and Environmental context and resources. Both groups noted knowledge (about survivorship care) and procedural knowledge (about how to deliver survivorship care) as positive determinants or facilitators, whereas resources/material resources (to deliver survivorship care) was noted as a negative determinant or barrier to care. Additional domains more commonly referenced by cancer specialists included Social/professional role and identity and Goals, while PCPs reported the domain Beliefs about capabilities as relevant.ConclusionsWe used the TDF to identify several behavioral domains acting as determinants of high‐quality, team‐based prostate cancer survivorship care. These results can inform prostate cancer survivorship care plan content, and may guide tailored, multidisciplinary implementation strategies to improve survivorship care across the primary and specialty care interface.

Boosting the Oxygen Reduction Electrocatalytic Performance of Nonprecious Metal Nanocarbons via Triple Boundary Engineering Using Protic Ionic Liquids.

The oxygen reduction reaction (ORR) in aqueous media plays a critical role in sustainable and clean energy technologies such as polymer electrolyte membrane and alkaline fuel cells. In this work, we present a new concept to improve the ORR performance by engineering the interface reaction at the electrocatalyst/electrolyte/oxygen triple-phase boundary using a protic and hydrophobic ionic liquid and demonstrate the wide and general applicability of this concept to several Pt-free catalysts. Two catalysts, Fe-N codoped and metal-free N-doped carbon electrocatalysts, are used as a proof of concept. The ionic liquid layer grafted at the nanocarbon surface creates a water-equilibrated secondary reaction medium with a higher O2 affinity toward oxygen adsorption, promoting the diffusion toward the catalytic active site, while its protic character provides sufficient H+/H3O+ conductivity, and the hydrophobic nature prevents the resulting reaction product water from accumulating and blocking the interface. Our strategy brings obvious improvements in the ORR performance in both acid and alkaline electrolytes, while the catalytic activity of FeNC-nanocarbon outperforms commercial Pt-C in alkaline electrolytes. We believe that this research will pave new routes toward the development of high-performance ORR catalysts free of noble metals via careful interface engineering at the triple point.

Haematology nurses' perspectives of their patients' places of care and death: A UK qualitative interview study.

PurposePatients with haematological malignancies are more likely to die in hospital, and less likely to access palliative care than people with other cancers, though the reasons for this are not well understood. The purpose of our study was to explore haematology nurses' perspectives of their patients’ places of care and death.MethodQualitative description, based on thematic content analysis. Eight haematology nurses working in secondary and tertiary hospital settings were purposively selected and interviewed. Transcriptions were coded and analysed for themes using a mainly inductive, cross-comparative approach.ResultsFive inter-related factors were identified as contributing to the likelihood of patients’ receiving end of life care/dying in hospital: the complex nature of haematological diseases and their treatment; close clinician-patient bonds; delays to end of life discussions; lack of integration between haematology and palliative care services; and barriers to death at home.ConclusionsHospital death is often determined by the characteristics of the cancer and type of treatment. Prognostication is complex across subtypes and hospital death perceived as unavoidable, and sometimes the preferred option. Earlier, frank conversations that focus on realistic outcomes, closer integration of palliative care and haematology services, better communication across the secondary/primary care interface, and an increase in out-of-hours nursing support could improve end of life care and facilitate death at home or in hospice, when preferred.

Plasma-assisted atomic layer deposition of nickel oxide as hole transport layer for hybrid perovskite solar cells

Careful interface design and engineering are “keys” to effectively implement a conformal 10 nm plasma-assisted atomic-layer-deposited NiO film as hole transport layer in a p–i–n perovskite solar cell architecture.

Integrated care: working at the interface of primary care and behavioural health. Dr L. Raney

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A categorisation of problems and solutions to improve patient referrals from primary to specialty care

BackgroundImproving access to specialty care has been identified as a critical issue in the delivery of health services, especially given an increasing burden of chronic disease. Identifying and addressing problems that impact access to specialty care for patients referred to speciality care for non-emergent procedures and how these deficiencies can be managed via health system delivery interventions is important to improve care for patients with chronic conditions. However, the primary-specialty care interface is complex and may be impacted by a variety of potential health services delivery deficiencies; with an equal range of interventions developed to correct them. Consequently, the literature is also diverse and difficult to navigate. We present a narrative review to identify existing literature, and provide a conceptual map that categorizes problems at the primary-specialty care interface with linkages to corresponding interventions aimed at ensuring that patient transitions across the primary-specialty care interface are necessary, appropriate, timely and well communicated.MethodsWe searched MEDLINE and EMBASE databases from January 1, 2005 until Dec 31, 2014, grey literature and reference lists to identify articles that report on interventions implemented to improve the primary-specialty care interface. Selected articles were categorized to describe: 1) the intervention context, including the deficiency addressed, and the objective of the intervention 2) intervention activities, and 3) intervention outcomes.ResultsWe identified 106 articles, producing four categories of health services delivery deficiencies based in: 1) clinical decision making; 2) information management; 3) the system level management of patient flows between primary and secondary care; and 4) quality-of-care monitoring. Interventions were divided into seven categories and fourteen sub-categories based on the deficiencies addressed and the intervention strategies used. Potential synergies and trade-offs among interventions are discussed. Little evidence exists regarding the synergistic and antagonistic interactions of alternative intervention strategies.ConclusionThe categorization acts as an aid in identifying why the primary-specialty care interface may be failing and which interventions may produce improvements. Overlap and interconnectedness between interventions creates potential synergies and conflicts among co-implemented interventions.

Interface modification to enhance electron extraction by deposition of a ZnMgO buffer on SnO2-coated FTO in CdTe solar cells

Achieving high open-circuit voltage (Voc) for CdTe thin film solar cells is challenging. We report that a ZnMgO (ZMO) buffer can improve Voc and the performance of CdTe solar cells when deposited on the tin oxide (SnO2 or TO) coated fluorine-doped tin oxide (FTO) substrates. The TO/ZMO bilayer buffer brings a better energy band matching at the front contact of CdTe thin film solar cells, which can reduce interface carrier recombination and facilitate electron extraction. Our best-performing CdTe solar cell using the TO/ZMO bilayer buffer has achieved a power conversion efficiency of 16.76%, with an open-circuit voltage of 838.75 mV, a short-circuit current density of 27.32 mA cm−2, and a fill factor of 73.14%, much higher than those of devices based on TO buffer. Our results suggest that a careful interface modification of front contact layers provides a simple and effective route to further improving the performance of CdTe solar cells with a higher Voc.

Lost in translation? Paradigm conflict at the primary-secondary care interface.

Historically, primary care (community and family) medicine has often been viewed as lower status than secondary care (hospital) practice. Current evidence suggests this pattern continues to impact medical practice and education. Medical education has however, yet to fully reflect this power dynamic, with undergraduate training in many institutions maintaining the hegemonic position of secondary care as the prime context for learning. In this paper, we present primary and secondary care as conflicting paradigms of medical practice. Using a sociocultural lens drawing on Figured Worlds theory, implications for medical education are explored. We outline the two paradigms as having distinct epistemologies, identities and practices. Tensions at the primary-secondary care interface can, from a sociocultural perspective, be seen to impact developing identity and day-to-day clinical practice issues such as patient safety. We offer possibilities for engaging with paradigm conflict in meaningful ways and suggest potential changes for future educational policy and practice.

Patient-centred access to health care: a framework analysis of the care interface for frail older adults

BackgroundThe objective of this study was to explore the issues surrounding access to health and social care services for frail older adults with Polish stakeholders, including healthy and frail/pre-frail older adults, health care providers, social care providers, and caregivers, in order to determine their views and perspectives on the current system and to present suggestions for the future development of a more accessible and person-centred health and social care system.MethodsFocus groups were used to gather qualitative data from stakeholders. Data were analysed using framework analysis according to five dimensions of accessibility to care: approachability, acceptability, availability and accommodation, affordability and appropriateness.ResultsGenerally services were approachable and acceptable, but unavailable. Poor availability related to high staff turnover, staff shortages and a lack of trained personnel. There were problems of long waiting times for specialist care and rehabilitation services, and geographically remote clinics. Critically, there were shortages of long-term inpatient care places, social care workers and caregivers. The cost of treatments created barriers to care and inequities in the system. Participants described a lack of integration between health and social care systems with differing priorities and disconnected budgets. They described an acute medical system that was inappropriate for patients with complex needs, alongside a low functioning social care system, where bureaucratisation caused delays in providing services to the vulnerable. An integrated system with a care coordinator to improve connections between services and patients was suggested.ConclusionsThere is an immediate need to improve access to health and social care systems for pre-frail and frail patients, as well as their caregivers. Health and social care services need to be integrated to reduce bureaucracy and increase the timeliness of treatment and care.