A qualitative study of advanced nurse practitioners’ use of physical assessment skills in the community: shifting skills across professional boundaries

Aim To explore multiple perspectives on the use of physical assessment skills by Advanced Nurse Practitioners in the UK Background Physical assessment skills practices are embedded in advanced nursing practice roles in the UK. There is little evidence on how these skills are used by Advanced Nurse Practitioners' on the community. Design Case study Methodology and methods. A qualitative interpretative single-embedded case study of 22 participants from South of England. A framework method analysed interview data collected by the researcher between March and August 2013. Participants included nurses, doctors, nurse educators and managers Findings Physical assessment skills education at Universities are part of a policy shift to develop a flexible workforce in the UK. Shared physical assessment practices are less to do with role substitution and more about preparing practitioners with skills that are fit for purpose. Competence capability and performance with physical assessment skills are an expectation of advanced nursing practice. Conclusions These skills are used successfully by community Advanced Nurse Practitioners to deliver a wide range of services in response to changing patient need. The introduction of physical assessment skills education to undergraduate professional preparation would create a firm foundation to develop these skills in post-graduate education. Relevance to clinical practice. • Physical assessment education prepares nurses with the clinical competencies to carry out healthcare reforms in the UK • Shared sets of clinical assessment competencies between disciplines have better outcomes for patients • Levels of assessment competence can depend on the professional attributes of individual practitioners • Unsupportive learning cultures can hinder professional development of advanced nursing practic

The chemistry of protoplanetary fragments formed via gravitational instabilities

In this paper, we model the chemical evolution of a 0.25 M$_{\odot}$ protoplanetary disc surrounding a 1 M$_{\odot}$ star that undergoes fragmentation due to self-gravity. We use Smoothed Particle Hydrodynamics including a radiative transfer scheme, along with time-dependent chemical evolution code to follow the composition of the disc and resulting fragments over approximately 4000 yrs. Initially, four quasi-stable fragments are formed, of which two are eventually disrupted by tidal torques in the disc. From the results of our chemical modelling, we identify species that are abundant in the fragments (e.g. H$_{\rm 2}$O, H$_{\rm 2}$S, HNO, N$_{\rm 2}$, NH$_{\rm 3}$, OCS, SO), species that are abundant in the spiral shocks within the disc (e.g. CO, CH$_{\rm 4}$, CN, CS, H$_{\rm 2}$CO), and species which are abundant in the circumfragmentary material (e.g. HCO$^{\rm +}$). Our models suggest that in some fragments it is plausible for grains to sediment to the core before releasing their volatiles into the planetary envelope, leading to changes in, e.g., the C/O ratio of the gas and ice components. We would therefore predict that the atmospheric composition of planets generated by gravitational instability should not necessarily follow the bulk chemical composition of the local disc material

Diel turbidity cycles in a headwater stream: evidence of nocturnal bioturbation?

Purpose: A small number of recent studies have linked daily cycles in stream turbidity to nocturnal bioturbation by aquatic fauna, principally crayfish, and demonstrated this process can significantly impact upon water quality under baseflow conditions. Adding to this limited body of research, we use high-resolution water quality monitoring data to investigate evidence of diel turbidity cycles in a lowland, headwater stream with a known signal crayfish (Pacifastacus leniusculus) population and explore a range of potential causal mechanisms. Materials and methods: Automatic bankside monitoring stations measured turbidity and other water quality parameters at 30-min resolution at three locations on the River Blackwater, Norfolk, UK during 2013. Specifically, we focused on two 20-day periods of baseflow conditions during January and April 2013 which displayed turbidity trends typical of winter and spring seasons, respectively. The turbidity time-series, which were smoothed with 6.5 hour Savitzky-Golay filters to highlight diel trends, were correlated against temperature, stage, dissolved oxygen and pH to assess the importance of abiotic influences on turbidity. Turbidity was also calibrated against suspended particulate matter (SPM) over a wide range of values via linear regression. Results and discussion: Pronounced diel turbidity cycles were found at two of the three sites under baseflow conditions during April. Spring night-time turbidity values consistently peaked between 21:00 and 04:00 with values increasing by ~10 nephelometric turbidity units (NTU) compared with the lowest recorded daytime values which occurred between 10:00 and 14:00. This translated into statistically significant increases in median midnight SPM concentration of up to 76% compared with midday, with night-time (18:00 – 05:30) SPM loads also up to 30% higher than that recorded during the daytime (06:00 – 17:30). Relating turbidity to other water quality parameters exhibiting diel cycles revealed there to be neither any correlation that might indicate a causal link, nor any obvious mechanistic connections to explain the temporal turbidity trends. Diel turbidity cycles were less prominent at all sites during the winter. Conclusions: Considering the seasonality and timing of elevated turbidity, visual observations of crayfish activity, and an absence of mechanistic connections with other water quality parameters, the results presented here are consistent with the hypothesis that nocturnal bioturbation is responsible for generating diel turbidity cycles under baseflow conditions in headwater streams. However, further research in a variety of fluvial environments is required to better assess the spatial extent, importance and causal mechanisms of this phenomenon

Super Weyl invariance: BPS equations from heterotic worldsheets

It is well-known that the beta functions on a string worldsheet correspond to the target space equations of motion, e.g. the Einstein equations. We show that the BPS equations, i.e. the conditions of vanishing supersymmetry variations of the space-time fermions, can be directly derived from the worldsheet. To this end we consider the RNS-formulation of the heterotic string with (2,0) supersymmetry, which describes a complex torsion target space that supports a holomorphic vector bundle. After a detailed account of its quantization and renormalization, we establish that the cancellation of the Weyl anomaly combined with (2,0) finiteness implies the heterotic BPS conditions: At the one loop level the geometry is required to be conformally balanced and the gauge background has to satisfy the Hermitean Yang-Mills equations.Comment: 1+31 pages LaTeX, 5 figures; final version, discussion relation Weyl invariance and (2,0) finiteness extended, typos correcte

Holography of a Composite Inflaton

We study the time evolution of a brane construction that is holographically dual to a strongly coupled gauge theory that dynamically breaks a global symmetry through the generation of an effective composite Higgs vev. The D3/D7 system with a background magnetic field or non-trivial gauge coupling (dilaton) profile displays the symmetry breaking. We study motion of the D7 brane in the background of the D3 branes. For small field inflation in the field theory the effective Higgs vev rolls from zero to the true vacuum value. We study what phenomenological dilaton profile generates the slow rolling needed, hence learning how the strongly coupled gauge theory's coupling must run. We note that evolution of our configuration in the holographic direction, representing the phyiscs of the strong interactions, can provide additional slowing of the roll time. Inflation seems to be favoured if the coupling changes by only a small amount or very gently. We speculate on how such a scenario could be realized away from N=4 gauge theory, for example, in a walking gauge theory.Comment: 13 pages, 12 figures; v2: Added reference

Neurological impact of emboli during adult cardiac surgery.

OBJECTIVES: This study draws on advances in Doppler ultrasound bubble sizing to investigate whether high volumes of macro-bubbles entering the brain during cardiac surgery increase the risk of new cerebral microbleeds (CMBs), ischemic MR lesions, or post-operative cognitive decline (POCD). METHODS: Transcranial Doppler (TCD) ultrasound recordings were analysed to estimate numbers of emboli and macrobubbles (>100 μm) entering the brain during cardiac surgery. Logistic regression was used to explore the hypothesis that emboli characteristics affect the incidence of new brain injuries identified through pre- and post-operative MRI and neuropsychological testing. RESULTS: TCD, MRI, and neuropsychological test data were compared between 28 valve and 18 CABG patients. Although valve patients received over twice as many emboli per procedure [median: 1995 vs. 859, p = .004], and seven times as many macro-bubbles [median: 218 vs. 28, p = .001], high volumes of macrobubbles were not found to be significantly associated with new CMBs, new ischaemic lesions, or POCD. The odds of acquiring new CMBs increased by approximately 5% [95% CI: 1 to 10%] for every embolus detected in the first minute after the release of the aortic cross-clamp (AxC). Logistic regression models also confirmed previous findings that cardiopulmonary bypass time and valve surgery were significant predictors for new CMBs (both p = .03). Logistic regression analysis estimated an increase in the odds of acquiring new CMBs of 6% [95% CI: 1 to 12%] for every minute of bypass time over 91 mins. CONCLUSIONS: This small study provides new information about the properties and numbers of bubbles entering the brain during surgery, but found no evidence to substantiate a direct link between large numbers of macrobubbles and adverse cognitive or MR outcome. Clinical Trial Registration URL - http://www.isrctn.com. Unique identifier: 66022965

A prospective cohort study assessing clinical referral management & workforce allocation within a UK regional medical genetics service

Abstract Ensuring patient access to genomic information in the face of increasing demand requires clinicians to develop innovative ways of working. This paper presents the first empirical prospective observational cohort study of UK multi-disciplinary genetic service delivery. It describes and explores collaborative working practices including the utilisation and role of clinical geneticists and non-medical genetic counsellors. Six hundred and fifty new patients referred to a regional genetics service were tracked through 850 clinical contacts until discharge. Referral decisions regarding allocation of lead health professional assigned to the case were monitored, including the use of initial clinical contact guidelines. Significant differences were found in the cases led by genetic counsellors and those led by clinical geneticists. Around a sixth, 16.8% (109/650) of referrals were dealt with by a letter back to the referrer or re-directed to another service provider and 14.8% (80/541) of the remaining patients chose not to schedule an appointment. Of the remaining 461 patients, genetic counsellors were allocated as lead health professional for 46.2% (213/461). A further 61 patients did not attend. Of those who did, 86% (345/400) were discharged after one or two appointments. Genetic counsellors contributed to 95% (784/825) of total patient contacts. They provided 93.7% (395/432) of initial contacts and 26.8% (106/395) of patients were discharged at that point. The information from this study informed a planned service re-design. More research is needed to assess the effectiveness and efficiency of different models of collaborative multi-disciplinary working within genetics services. Keywords (MeSH terms) Genetic Services, Genetic Counseling, Interdisciplinary Communication, Cohort Studies, Delivery of Healthcare, Referral and Consultation