Small Caseload Research Articles

Fostering a "Feeling of Worth" Among Vulnerable HIV Populations: The Role of Linkage to Care Specialists.

To address barriers to adequate engagement in medical care among people living with HIV, Wisconsin's AIDS/HIV Program created a new position, the Linkage to Care (LTC) Specialist. Specialists provide intensive, short-term case management and patient navigation services for small caseloads of individuals at high risk of disengaging with medical care. Clients are eligible if they are newly diagnosed with HIV or new to medical care, recently released from incarceration, recently out of care, nonadherent to scheduled medical care visits, or have detectable viral load while in care. Interviews with 30 clients of Specialists were conducted to understand experiences with the program and medical care. Common themes included the ability of Specialists to navigate complex systems of care and support services, the unique role Specialists played in their clients' lives, and the challenges of transitioning out of the program. Although the primary goal of Specialists is to address barriers to medical care, they often adopted a holistic approach that also included housing, financial assistance, and other social determinants of health. Descriptions of the Specialist's role in implementation manuals focus on their functional roles and the services provided. However, clients often discussed the emotional support they received, especially for clients without strong social support networks. Many clients also desired an ongoing relationship with their Specialists even after discharge, but had been able to establish independence and self-efficacy. The LTC Specialists are resource-intensive considering their small caseloads, but fill an important gap in existing, often overtaxed case management systems.

The Troubled Families Programme and the Problems of Success

The Troubled Families Programme (TFP) is the latest example of a tradition of family intervention projects (FIPs) for which the evidence basis for success is ambiguous. However, research does suggest that features of such projects – for example, time and flexibility of FIP workers, afforded by relatively small caseloads – offer some benefits for service users. This article draws on an evaluation of a FIP delivered by a Unitary Authority as part of the wider TFP to consider such features and found similar benefits. The article frames the research in terms of the expansion of the TFP and the implications this may have for its practical successes. It concludes by underscoring that by extending the programme whilst reducing its funding the most recent round of the TFP threatens precisely the features previously identified as most advantageous.

Hypospadias surgery in England: Higher volume centres have lower complication rates

Hypospadias surgery has progressed steadily over recent years. There remains considerable variation in the operative management of boys with hypospadias in the UK, and it is therefore difficult to identify acceptable standards with regards to reoperation rates. To determine the frequency of reoperations and complications from all centres performing hypospadias surgery in England and to identify variables that influence outcome. All children undergoing NHS hypospadias surgery in England between 1999 and 2009 were identified using the Hospital Episode Statistics database. Patient demographics, centre type, and associated diagnostic (ICD-10) and treatment codes (OPCS4.6) were collected for both primary repairs and postoperative complications. Centres were classed as high volume if they performed an average of 20 or more operations a year. Operative complications were split into revisions (repeat repairs), repairs of urethral fistulae, repairs of meatal stenosis, or urethral stricture repairs. Statistical analysis included logistic regression, Spearman's correlation, and Mann-Whitney U for non-parametric data, with p<0.05 taken as significant. Data are presented as median (interquartile range) unless otherwise stated. children underwent a total of 23,962 operations at 75 centres in England during the study period. The median age at primary repair was 21 (15-38) months. The overall complication rate was 18.1%. The median complication rate for individual centres was 20.0% (13.9-27.4%) overall; 10.8% (4.7-15.9%) for revision procedures, 8.1% (5.5-11.7%) for urethral fistulae, 2.3% (1.1-3.7%) for meatal stenosis repairs, and 1.8% (0-2.8%) for urethral strictures. High volume centres had significantly lower complication rates than low volume centres (17.5% vs. 25%, p=0.01) (Figure), and this was proven to be an independent predictor of outcomes (p=0.01). Staged repairs were associated with more complications (p<0.001); however, patient age and centre type were not. Median time to repair of complication was 13 (8-22) months. This national population-based study used hospital episode statistics data. While accuracy is high and it has been validated for use in research, it has intrinsic limitations which affect our study. We are unable to fully account for the severity of hypospadias or the number of operating surgeons within institutions. This study has found a clear relationship between caseload volume and complications following hypospadias surgery. Furthermore, there is significant variability between centres in terms of their surgical outcomes. Taken together these results suggest that surgeons, particularly those in centres with small caseloads should assess their results against such benchmarks when evaluating the service they provide.

COFFEE: control‐free noninvasive fetal chromosomal examination using maternal plasma DNA

The aim of this study is to develop an approach for analyzing plasma DNA sequencing data for noninvasive fetal chromosomal aneuploidy testing that does not require the comparison with control samples or a series of selected genomic regions. We developed the control-free noninvasive fetal chromosomal examination (COFFEE) algorithm by utilizing the size differences between the fetally derived and maternally derived DNA molecules in maternal plasma. We applied COFFEE on three datasets generated in different experimental settings. COFFEE showed 100% accuracy in trisomy 21 testing on these datasets. In contrast, samples analyzed using an existing control-based z-score method would introduce a false-positive result because of batch-to-batch variation, when the tested samples were analyzed using control samples from other batches. We believe that COFFEE is useful for enhancing the cost-effectiveness of noninvasive fetal chromosomal aneuploidy testing particularly in laboratories with small caseloads. Source code and testing datasets for COFFEE are available for download at http://www.cuhk.edu.hk/med/cpy/Research/COFFEE/. Control-free noninvasive fetal chromosomal examination is demonstrated to be a versatile data analysis approach and could enhance the application of noninvasive fetal chromosomal aneuploidy detection. © 2017 John Wiley & Sons, Ltd.

System Transformation Under the California Mental Health Services Act: Implementation of Full-Service Partnerships in L.A. County

The study evaluated the effect of California's Mental Health Services Act (MHSA) on the structure, volume, location, and patient centeredness of Los Angeles County public mental health services. This prospective mixed-methods study (2006-2013) was based in five Los Angeles County public mental health clinics, all with usual care and three with full-service partnerships (FSPs). FSPs are MHSA-funded programs designed to "do whatever it takes" to provide intensive, recovery-oriented, team-based, integrated services for clients with severe mental illness. FSPs were compared with usual care on outpatient services received (claims data) and on organizational climate, recovery orientation, and provider-client working alliance (surveys and semistructured interviews), with regression adjustment for client and provider characteristics. In the first year after admission, FSP clients (N=174) received significantly more outpatient services than did usual care clients (N=298) (5,238 versus 1,643 minutes, p<.001), and a larger proportion of these services were field based (22% versus 2%, p<.001). Compared with usual care clients, FSP clients reported more recovery-oriented services (p<.001) and a better provider-client working alliance (p=.01). Compared with usual care providers (N=130), FSP providers (N=42) reported more stress (p<.001) and lower morale (p<.001). Los Angeles County's public mental health system was able to transform service delivery in response to well-funded policy mandates. For providers, a structure emphasizing accountability and patient centeredness was associated with greater stress, despite smaller caseloads. For clients, service structure and volume created opportunities to build stronger provider-client relationships and address their needs and goals.

Intensive case management for severe mental illness.

Intensive case management for severe mental illness.

High volume is the key for improving in-hospital outcomes after radical prostatectomy: a total population analysis in Germany from 2006 to 2013.

Outcomes of radical prostatectomy are prone to publication bias, because most of the data originated from highly specialized centers. We assessed in-hospital outcomes of all radical prostatectomies in Germany from 2006 to 2013 focusing on caseload volume, surgical approach, and certification status. We analyzed the nationwide German hospital billing data covering 221,331 radical prostatectomies from 2006 to 2013. Outcomes were in-hospital mortality, surgical revision, and transfusion rates and the length of stay. Multivariate models described the impact of these factors. The yearly number of radical prostatectomies declined from 28,374 to 21,850. While shares of all other approaches decreased, shares for robot-assisted prostatectomy increased from 0.6 to 25.2%. Hospitals with ≥100 cases a year reported lower in-hospital mortality with 0.08 versus 0.17% for hospitals with <50 cases a year. On multivariate analysis, the odds for an individual death were doubled in hospitals with <50 cases a year. All other factors showed no significant impact on mortality. Concerning blood transfusion, the surgical approach was the strongest predictor with minimally invasive surgery (26% of the odds of conventional surgery) followed by caseload volume. Surgical revision was frequent in hospitals with lower rates of minimally invasive approaches (OR 1.6) and smaller caseloads (OR 1.4). Length of stay was reduced by 3days for caseloads ≥200 a year, 2days with minimally invasive approaches, and 1day in certified prostate cancer centers. Lacking clinical information is a major limitation. Annual caseload volume of hospitals is the most important factor for improved in-hospital outcomes.

You never stop learning as an Admiral Nurse.

What does your job involve? Admiral Nurses work with families affected by dementia, providing emotional support and practical advice. I lead a team of three, support them through management and supervision, allocate the busy caseload and oversee our ongoing evaluation work. I also carry a small clinical caseload and jointly work on some of our more complex cases with my team. As a nurse consultant, I also provide specialist input into service development locally.

Minimally Invasive Transanal Repair of Rectourethral Fistulas

BackgroundRectourethral fistulas (RUFs) represent an uncommon complication of pelvic surgery, especially radical prostatectomy. To date there is no standardised treatment for managing RUFs. This represents a challenge for surgeons, mainly because of the potential recurrence risk. ObjectiveTo describe our minimally invasive transanal repair (MITAR) of RUFs and to assess its safety and outcomes. Design, setting, and participantsWe retrospectively evaluated 12 patients who underwent MITAR of RUF at our centre from October 2008 to December 2014. Exclusion criteria were a fistula diameter greater than 1.5cm, sepsis, and/or faecaluria. Surgical procedureAfter fistula identification through cystoscopy and 5F-catheter positioning within the fistula, MITAR is performed using laparoscopic instruments introduced through Parks’ anal retractor. The fibrotic margins of the fistula are carefully dissected by a lozenge incision of the rectal wall, parallel to the rectal axis. Under the healthy flap of the rectal wall the urothelium is located and the fistulous tract is sutured with interrupted stitches. After a leakage test of the bladder, the rectal wall is sutured with interrupted stitches. Electrocoagulation is never used during this procedure. MeasurementsFistula closure, postoperative complications, and recurrence. Results and limitationsMedian follow-up was 21 (range, 12–74) mo. Median operative time was 58 (range, 50–70) min. Median hospital stay was 1.5 (range, 1–4) d. Early surgical complications occurred in one patient (8.3%). Recurrence did not occur in any of the cases. Limitations included retrospective analysis, small case load, and lack of experience with radiation-induced fustulas. ConclusionsMITAR is a safe, effective, and reproducible procedure. Its advantages are low morbidity and quick recovery, and no need for a colostomy. Patient summaryWe studied the treatment of rectourethral fistulas. Our technique, transanally performed using laparoscopic instruments, was found to be safe, feasible, and effective, with limited risk of complications.

Professional and practice characteristics associated with self-efficacy in assessment and intervention among social workers in aging

ABSTRACTThis study examined professional and practice characteristics associated with assessment and intervention self-efficacy among gerontological social workers in Ontario, Canada who participated in online surveys. Results from multivariate analyses indicated that higher client acuity, longer duration of practice experience, smaller caseloads, and a greater proportion of clients 85 and over were significantly associated with greater assessment self-efficacy. Greater client acuity and smaller caseloads were also significantly associated with greater intervention self-efficacy. Implications for education include the importance of providing practical experience with the oldest old and with clients with greater biopsychosocial complexity. Also recommended is the need for manageable caseloads, especially when older adults with complex needs are part of the practice milieu.

Ask the expert

John Chitty is co-director of a small animal and exotics practice in Hampshire, where he has a full avian, exotic, and small mammal caseload.

Interruptions in Search of a Purpose: Oral Argument in the Supreme Court, October Terms 1958-60 and 2010-12

We tend to think of the Supreme Court as an institution that is unchanging. Nothing, of course, could be further from the truth. The Court has changed in important ways throughout its history. During the last few decades, the Court has experienced many significant changes: Congress has virtually eliminated the Court’s mandatory jurisdiction; the Court has reduced by almost half the number of cases in which it grants review; the number of law clerks has increased; the numbers of lower court cases and judges have increased substantially; the Court has shortened by half the amount of time normally allowed for oral argument; the length of the post-argument conference has reportedly shrunk; the exchanges in the Justices’ opinions have become more strident; and the Justices appear to relish a kind of celebrity that even their recent predecessors had shunned. Notwithstanding these changes, Judge John G. Roberts, Jr., suggested shortly before his appointment as Chief Justice that “one thing that has remained fairly constant [since 1980] has been the level of questioning” at oral argument. That conclusion was based on a comparison of two sets of cases that were argued in 1980 and 2003, respectively. Because the Justices have seemed to other observers to have become more assertive at oral argument in recent years, we decided to inquire further by comparing a set of cases from the recent past (October Terms 2010-12) with a set from a period (October Terms 1958-60) about twenty years before the start date of the Chief Justice’s study. Our empirical study, which provides two snapshots in time, combines quantitative and qualitative methods in an attempt to understand interactions among the Justices and between the Justices and counsel; how those interactions may now be different from those of a half-century ago; and the possible significance of those differences for our understanding of the Court’s role in our constitutional system.We found significant differences. In the older cases, the nature and shape of oral argument reflected what might be taken to be the traditional purposes of oral argument, but the more recent cases suggest a different dynamic. The Justices rarely allowed counsel to develop a coherent narrative, and they often used an advocate’s limited time to state their own views and to joke or argue with each other. The Justices seemed more personally invested in individual cases at the oral argument stage, perhaps because of larger staffs and smaller caseloads, among other factors, and they often acted as if oral argument were simply an opportunity for them to say what they would like to say about a case. It may be that they do so with a view toward convincing their colleagues, and that what was once a relatively less important aspect of oral argument has become its dominant purpose. It may also be the case, however, that the Justices recognize that their colleagues also may have thoroughly studied the case and made up their minds, so that oral argument seems to be a less important exercise. It may be that the Justices now hear oral argument only because they always have done so, and abandoning it would be difficult politically, but have no theorized, shared view of its current significance. In any event, the “new oral argument” is not about the lawyers, who may often seem to be props, bystanders, or straight-men in the well of the Court. Nor is it about the parties, whose interests are at stake, or about the public. Oral argument seems to be for the Justices, and only for the Justices – time to be used in whatever ways they may find appealing at the moment. Indeed, one might say that it seems to be “all about them.” But what the Court hopes to achieve through oral argument remains unclear.We suggest that oral argument still has a role to play in the process of Supreme Court adjudication and make some suggestions for how the value of oral argument might be enhanced.

Predictors of Clinical Outcome of Assertive Community Treatment (ACT) in a Rural Area in Denmark: An Observational Study with a Two-Year Follow-Up.

Assertive Community Treatment (ACT) is a multidisciplinary team approach to community care treatment, mainly characterised by small caseload and individualised care. The aim of the present study was to identify predictors of clinical outcome in ACT using an observational design. Three ACT Teams were established in The North Denmark Region to treat patients with severe mental illness. The patients were identified and followed in regional and national psychiatric registers, and in social and somatic case registers, 2years before and 2years after inclusion. The results showed that the use of psychiatric hospital services decreased significantly for the 240 included patients. Furthermore, the psychopharmacological profile was improved. No significant change occurred in the consumption of the somatic hospitals. Clinical outcome, defined as halving of admissions or bed days, was in a logistic analysis predicted by the patient's psychiatric use of inpatient service prior to inclusion in an ACT Team.

From deinstitutionalization to recovery-oriented assertive community treatment in Hong Kong: What we have achieved

This paper explored the effectiveness of Assertive Community Treatment (ACT) for severely ill mental patients during a period of rapid deinstitutionalization in Hong Kong. We employed a flanking historical control design. The treatment group comprised 70 participants with 3 or more admissions to psychiatric hospitals within the preceding 12 months, and received ACT. Two historical control groups (C1 and C2), each 70 participants, with similar inclusion criteria flanking the recruitment period of treatment group, were identified and received Treatment as Usual (TAU). Outcome data were measured at baseline, 6, 12 and 18 months of intervention. Readmission rates, bed-days, emergency room visits and days of missing medical appointments improved with time during the deinstitutionalization process, irrespective of treatment modality. In addition, ACT had superior effect in most of these outcome parameters, compared to the control groups. We reported that the current model of ACT, with a relatively small case load per case manager, round the clock services, multidisciplinary team approach, with psychiatrists integrated in the services and case managers responsible for health and social care, is an effective intervention for helping people with mental illness who pursue their chosen independent living in the community.

“She makes me feel that I'm not alone”: Linkage to Care Specialists provide social support to people living with HIV

Wisconsin's Linkage to Care intervention incorporates elements of individually tailored patient navigation and case management designed to increase linkage and retention in HIV-related medical care. It is delivered by Linkage to Care Specialists in HIV medical clinics and community-based agencies. Researchers interviewed a diverse sample of clients to conduct preliminary evaluation of the pilot phase of this intervention. The participants' relationships with their Specialists emerged as a major unifying theme of the data. Comfortable and close relationships with Specialists served as motivation to adhere to medical care, mitigated negative feelings associated with HIV-related stigma, and resulted in increased comfort with medical care and positive health outcomes including engagement in care and undetectable viral load. As a result of the Specialists' support, many participants were reluctant to transition out of the Linkage to Care program. The positive effects demonstrated by Specialists are balanced against the costs of small caseloads that are potentially not feasible within traditional case management models. Future interventions to increase medical care engagement, among HIV+ individuals at risk of lack of engagement, should develop strategies to “personalize” the patient experiences within health care and psychosocial services delivery systems, as well as screening tools to triage clients into different levels of personal service provision intensity based on need and desire.

Reshaping diabetes care into the community to meet population needs

60 British Journal of Healthcare Management 2015 Vol 21 No 2 © 2 01 5 M A H ea lth ca re L td challenges, a primary care-led service meets a number of parallel agendas: • The emerging emphasis on personalisation and supported care planning as the NHS response to demographic pressure; with an ageing population, frailty and multiple morbidities predominating at a time of static income • The sheer volume of diabetes costs within capitation budgets for primary and community as payment structures are reformed • People with long-term condition want care closer to home where they spend 99% of their lives • Changes in the organisational framework and provider landscape of the NHS as outlined in the Five Year Forward View (NHS England, 2014b). Capacity and capability vary within primary care, but successful system change has to be owned—not just imposed from above—within a two-tothree year implementation program. Equally important is to get consensus support from those with diabetes embedded into strategic direction and implementation. Changes in primary care will need to be supported with training programmes, real time metrics, support from colleagues in specialist services, and the right incentives. Practices will need to agree to work within a quality improvement scheme as an alternative to a performance management culture. A primary care-led system will have to ensure that the 10% of people with diabetes who do need specialist secondary or tertiary care (i.e. pregnancy, insulin pumps, unstable type insulin dependent patient etc) have rapid access within an agreed budgeted framework. Specialist services will have much smaller caseloads, enabled by new contract specification to spend much of their time working with more difficult and complex cases. This ensures that skills (such as insulin conversion), reside in primary care. Other critical related services (especially foot care and retinal screening) must work within new pathways, developing a closer direct relationship with practice, including audit, peer review and training.

Barriers to implementation of case management for patients with dementia: a systematic mixed studies review.

Results of case management designed for patients with dementia and their caregivers in community-based primary health care (CBPHC) were inconsistent. Our objective was to identify the relationships between key outcomes of case management and barriers to implementation. We conducted a systematic mixed studies review (including quantitative and qualitative studies). Literature search was performed in MEDLINE, PsycINFO, Embase, and Cochrane Library (1995 up to August 2012). Case management intervention studies were used to assess clinical outcomes for patients, service use, caregiver outcomes, satisfaction, and cost-effectiveness. Qualitative studies were used to examine barriers to case management implementation. Patterns in the relationships between barriers to implementation and outcomes were identified using the configurational comparative method. The quality of studies was assessed using the Mixed Methods Appraisal Tool. Forty-three studies were selected (31 quantitative and 12 qualitative). Case management had a limited positive effect on behavioral symptoms of dementia and length of hospital stay for patients and on burden and depression for informal caregivers. Interventions that addressed a greater number of barriers to implementation resulted in increased number of positive outcomes. Results suggested that high-intensity case management was necessary and sufficient to produce positive clinical outcomes for patients and to optimize service use. Effective communication within the CBPHC team was necessary and sufficient for positive outcomes for caregivers. Clinicians and managers who implement case management in CBPHC should take into account high-intensity case management (small caseload, regular proactive patient follow-up, regular contact between case managers and family physicians) and effective communication between case managers and other CBPHC professionals and services.

748 Robot assisted radical prostatectomy and pelvic lymph node dissection in a centre with small case load: Functional results at follow-up of 5 years

748 Robot assisted radical prostatectomy and pelvic lymph node dissection in a centre with small case load: Functional results at follow-up of 5 years

The Practice of Reintegrative Shaming in Mental Health Court

Scholars and practitioners have renewed their interest in recognizing and designing restorative justice programs. Although these programs often provide successful outcomes, we know relatively little about why they work. Reintegrative shaming theory provides a lens by which to explain successful outcomes. This study uses over three years of direct observations to examine the practice of reintegrative shaming in a mental health court (MHC). We organize our findings around four primary components of reintegrative shaming outlined by Makkai and Braithwaite: respectful disapproval, disapproving the behavior rather than the individual, rejecting deviance as a master status, and ceremonial decertifications of deviance. Our data demonstrate that reintegrative shaming in MHC is largely accomplished through interactions with the judge, although the unique organization of the MHC, including their small caseloads, use of separate dockets, and pre-court team meetings, advance the court’s use of reintegrative shaming.

Reflecting on the meaning of true nursing quality

It is not uncommon to look back over our lives and recognise the important roles various people may have played. As part of my nurse education I had several work placements across the county to gain valuable nursing experience and a critical element to my learning. During that time I came into contact with nurses of varying levels of ability and grades. Two nurses have had a significant impact on me as I felt they demonstrated the polar opposites of what I perceived to be nursing qualities. Spouse (1996) argues that the most important feature of a work placement is the quality of the student–mentor relationship, a viewpoint with which I heartily agree. One of the first mentors during my nursing education quickly made me feel disillusioned and dissatisfied due to his poor attendance, unprofessional attitude and low application to work duties. His consistently vocal negativity towards mental health nursing had a depressing and demoralising effect upon me, particularly as I had only just taken my first steps into the world of nursing. Darling (1985) describes those mentors who abdicate their responsibility as ‘dumpers’. She referred to these mentors with whom we have negative relationships as ‘toxic mentors’ due to the detrimental effect they have on the mentee. I did not wish to be viewed negatively or to cause conflict with my mentor and therefore felt unable to voice my concerns either with the mentor or the team manager; unfortunately during this period my guidance tutor was absent on sick leave. With hindsight I managed the situation poorly by avoiding what I perceived as potential conflict rather than dealing with the issue proactively. Similarly to most nursing students I took action after completing the placement (Gray and Smith, 2000). Since this was not my first mentoring experience, I was left with a bitter after taste about the ethics and standards within mental health nursing and questioned whether I had made the right career choice. Pearcy and Elliott (2004) found that traumatic placement experiences have been cited as one of the reasons given by students for noncompletion of pre-registration courses. The second nurse was a team manager of a community mental health team. I had previous knowledge of the team and admired the strength of the team’s ethos of inclusiveness. I observed with interest the interaction between the team manager, his staff and service users. He was unstinting in his compassion, care and warmth towards others with an expert knowledge of his field. He showed a genuine interest in the person, whether it was a team member or service user. As a consequence he appeared to inspire the affection, admiration and respect of those around him. I reflected upon his qualities and skills with the aim of understanding what I could learn and take away from my observations to integrate into my own nursing practice. The team manager held a small caseload but due to the nature of the team remained familiar with all service users. He continually went beyond the call of duty, resulting in his nomination by service users for a local trust award. Daily morning meetings were held where open communication was encouraged with each member of staff, students included, able to voice an opinion without fear of criticism. This increased a feeling of being valued, where every person’s opinion counted. Being valued was further emphasised by the team manager giving praise, either publicly during a team meeting or privately on a one-to-one basis. I have observed the positive effect this had on staff. Doran et al (2004) contend the provision of support, encouragement and constructive feedback, taking a genuine and considerate interest in staff are instrumental in increasing cooperation and teamwork. Emotional intelligence demands selfawareness and an ability to be warm and empathetic within interpersonal relationships (Hurley, 2008). While admiring the team manager’s qualities and skills, human beings are unique and complex, and therefore individual. While I recognise the importance of how he manages situations, staff and service users, I need to ensure that I remain genuine and ‘true’ to myself, adapting my personal style rather than attempting to produce a carbon copy. Hurley (2008) outlines the importance of the use of ‘authentic self ’ within interpersonal relationships, necessitating congruence between actions, verbal and non-verbal communication. Taylor (2010) remarks on the ‘ordinariness’ of the nurse–patient relationship and the connectedness of being human. By ‘living authentically—of not living outside myself behind a veneer or a mask’ (Taylor, 2010) the connections of being human can enhance the quality of the providing and receiving of care, the holistic underpinnings to nursing practice. BJN