Large angle transient dynamics (LATDYN) documentation. Post-processor manual

The post processor program was developed to view Large Angle Transient Dynamics (LATDYN) output data in predefined, predetermined formats. The post processor is used for plotting data, creating and maintaining a data base of plotting requests, comparing and manipulating data sets in the data base, and the preparing plots for documentation

Leveling transparency via situated intermediary learning objectives (SILOs)

When designers set out to create a mathematics learning activity, they have a fair sense of its objectives: students will understand a concept and master relevant procedural skills. In reform-oriented activities, students first engage in concrete situations, wherein they achieve situated, intermediary learning objectives (SILOs), and only then they rearticulate their solutions formally. We define SILOs as heuristics learners devise to accommodate contingencies in an evolving problem space, e.g., monitoring and repairing manipulable structures so that they model with fidelity a source situation. Students achieve SILOs through problem-solving with media, instructors orient toward SILOs via discursive solicitation, and designers articulate SILOs via analyzing implementation data. We describe the emergence of three SILOs in developing the activity Giant Steps for Algebra. Whereas the notion of SILOs emerged spontaneously as a framework to organize a system of practice, i.e. our collaborative design, it aligns with phenomenological theory of knowledge as instrumented action

How does the review process support adults in the first year post-stroke?

Background: Reducing stroke related mortality and morbidity is a Government priority. In 2007, the National Stroke Strategy recommended reviewing stroke survivors at six weeks, six months and annually thereafter but there is much variation in implementation and limited evaluation. While there is evidence of unmet need post-stroke there is little evidence to suggest that the review process ameliorates it. This study aimed to identify the purpose and outcomes of the review process from the perspective of patient, carer, provider and commissioner and to identify the mechanisms by which these were achieved. As many patients are still engaged in rehabilitation at six weeks post-stroke, a six-week review is of less significance than a six-month one by when services have usually withdrawn and patients report feeling abandoned. The annual review is not widely available and therefore this study concentrates on the six-month review. Method: A multiple case study approach underpinned by critical realism informed the research design and allowed in-depth exploration of the six-month review. Case studies draw on multiple sources of evidence to allow triangulation, develop convergent evidence and thus strengthen construct validity. Three sites in the South East Coast region were chosen for their different approaches set within the context of local policies and demographics. Data sources included interviews with patients, carers, providers who carried out reviews, service managers and commissioners; observations in clinical settings; and local policy and service documentation. This allowed multiple perspectives in order to explore the underlying mechanisms of the review. Patients were interviewed approximately six weeks post-discharge and again after their six-month review. Overall, 46 patients, 30 carers and 28 professionals were interviewed between December 2015 and October 2016. Twenty-nine reviews were observed. The age range of patients was 28-91 years and slightly more than half were male. Data analysis drew on three approaches selected for a particular strength: thematic analysis was chosen for its clear and succinct account of coding and epistemologically neutral stance (Braun and Clarke 2006); Yin's (2014) case study analysis provided helpful suggestions for theory development; and Bazeley's (2013) comprehensive text provided a model for analysis and theory development compatible with critical realism. Data was managed using Nvivo 11. Within each site, all data sources were coded in an iterative process to develop the coding framework and an understanding of site specific issues. Data was then explored across sites before building a typology of patients in order to develop a theoretical understanding of the review process that could be extended to a broader context. Findings: Six-month reviews carried out by stroke nurse specialists were found to be more medically orientated than those completed by a Stroke Association co-ordinator who focused on social issues. Reviewers regarded them as an opportunity to address unmet need but expressed different opinions as to what this encompassed. Managers and commissioners were mainly concerned with outcomes focused on (cost-) effectiveness. Patients' views were influenced by their experiences of the care pathway, orientation to rehabilitation and the nature of their relationships with clinicians during their rehabilitation. Those who reported a positive experience of care and took a proactive approach to rehabilitation were likely to self-manage their condition and find the review helpful. Their comments emphasised that they valued reassurance, information and advice. A second group was positive about rehabilitation but largely on their own terms and rejected advice from reviewers. Finally, a small number who did not find the review helpful had pre-existing long-term conditions and/or complex social circumstances. They were critical of services, did not trust reviewers or clinicians in general, and were focused on issues outside the remit of the review. Discussion: The medical and social paradigms which framed the review process each had their own strengths but some patients, particularly those with complex social circumstances and co-morbidities, needed elements of both within an individually tailored approach. There was a tension between the structure imposed by policy and the agency and wish of reviewers and patients to individualise the process. Encouraging self-management was a key aspect of the review but was limited by the nature of the intervention and gaps in community services. The review acted as a gateway to further services, for example clinical psychology, although such services were not always available. Recommendations: The six-month review needs to be embedded into the care pathway and strategies for secondary prevention reviewed and consolidated at each stage. Reviewers should be allowed the freedom to individualise the process on a needs-led basis rather than adhering to a rigid framework dictated by policy. The six-month review ought to relate back to therapy goals and forward to community services to encourage participation in valued activities, and community integration, which are the key goals of rehabilitation

Factors Influencing Trends in Opioid Prescribing for Older People: A Scoping Review

Aim: The review aimed to identify factors influencing opioid prescribing as regular pain-management medication for older people. Background: Chronic pain occurs in 45–85% of older people but appears to be under-recognised and undertreated. However, strong opiate prescribing is more prevalent in older people, increasing at the fastest rate in this age group. Method: This review included all study types, published 1990-2017, which focused on opioid prescribing for pain-management among older adults. Arksey and O’Malley’s (2005) framework was used to scope the literature. PubMed, EBSCO Host, the UK Drug Database and Google Scholar were searched. Data extraction, carried out by two researchers, included factors explaining opioid prescribing patterns and prescribing trends. Findings: 613 papers were identified and 53 were included in the final review consisting of 35 research papers, 10 opinion pieces and 8 grey literature sources. Factors associated with prescribing patterns were categorised according to whether they were patient-related, prescriber-driven or system driven. Patient factors included age, gender, race and cognition; prescriber factors included attitudes towards opioids and judgements about ‘normal’ pain; and policy/system factors related to the changing policy landscape over the last three decades, particularly in the USA. Conclusion: A large number of context-dependent factors appeared to influence opioid prescribing for chronic pain-management in older adults but the findings were inconsistent. There is a gap in the literature relating to the UK healthcare system; the prescriber and the patient perspective; and within the context of multi-morbidity and treatment burden

Proof of concept evaluation of a project using ‘conversations inviting change’ methodology to support the development of in-place systems leadership in local care hubs

This evaluation took place between March and August 2018 and was commissioned by the NHS Leadership Academy on behalf of Kent and Medway Sustainability and Transformation Plan (STP) and delivered by East Kent Community Education Provider Network (EK CEPN). The programme consisted of three development sessions carried out over two sites, or multi-professional teams known as hubs, clusters or primary care networks by an experienced facilitator using the model ‘conversations inviting change’. This model embodies a narrative approach that recognises the domains identified by the National Leadership Academy of individual effectiveness, relationships and connectivity, innovation and improvement, learning and capacity building (NHS Leadership Academy, 2017)

Evaluation of West Kent Clinical Commissioning Group Clinical Microsystems Programme for General Practice

This evaluation was commissioned by West Kent Clinical Commissioning Group (CCG) who have invested in training senior managers in the role of coach to facilitate implementation of the clinical microsystems programme developed by the Dartmouth Institute, USA (Nelson et al., 2008). The approach shows promise in improving quality within the NHS (Williams, Dickinson, Robinson, & Allen, 2009, p126) and accords with new ways of working identified in the General Practice Forward View (NHS England, 2016). To-date, nearly thirty general practices in West Kent have been involved in the programme carrying out a range of quality improvement programmes (Arnold & Kankam, 2017)

How unmet are unmet needs post-stroke? A policy analysis of the six-month review

Background: Stroke is the fourth largest cause of death in the UK and a leading cause of death and disability worldwide. Policy recommends reviewing patients at six-months post-stroke to identify unmet needs but lacks evidence of effectiveness. This study explored needs identified by patients, how they were addressed by the six-month review (6MR) and whether or not policy aspirations for the review were substantiated by the data. Methods: A multiple case study design underpinned by critical realism. Data sources included interviews with 46 patients and 28 professionals across three sites in the South East Coast of England. Patients’ interviews coincided with their reviews of which twenty-nine were observed. Thematic analysis of interviews, observations and policy documents was carried out within and across sites. Results: There were ‘hotspots’ in the care pathway where patients and carers felt particularly unsupported. Whilst these gaps exacerbated anxiety, they were neither universal nor ameliorated by review. Patients consistently identified unmet needs related to rehabilitation, information/education and support. Stroke nurse specialists focused on investigations, medication and liaising with general practitioners or consultants while the Stroke Association co-ordinator focused on sign-posting to other services and provision of generic information which not all respondents found helpful. The remit of review was more modest than that of policy aspirations. Conclusions: The review rests on two causal assumptions: that identifying unmet need will lead to its amelioration; and that provision of information will lead to behaviour change and self-management. While there was some evidence to support the former, there was almost none for the latter. The 6MR would benefit from a patient-led approach to its timing and format; a consistent and individualised approach to stroke education and self-management that is embedded across the care pathway; and targeting reviews should be considered