What aspects of intentional rounding work in hospital wards, for whom and in what circumstances? A realist evaluation protocol

INTRODUCTION: Intentional rounding (IR) is a structured process whereby nurses in hospitals carry out regular checks, usually hourly, with individual patients using a standardised protocol to address issues of positioning, pain, personal needs and placement of items. The widespread implementation of IR across the UK has been driven by the recommendations of the Francis Inquiry although empirical evidence of its effectiveness is poor. This paper presents a protocol of a multimethod study using a realist evaluation approach to investigate the impact and effectiveness of IR in hospital wards on the organisation, delivery and experience of care from the perspective of patients, their family members and staff. METHODS AND ANALYSIS: The study will be conducted in four phases. Phase 1: theory development using realist synthesis to generate hypotheses about what the mechanisms of IR may be, what particular groups may benefit most or least and what contextual factors might be important to its success or failure which will be tested in subsequent phases of the study. Phase 2: a national survey of all NHS acute trusts to explore how IR is implemented and supported across England. Phase 3: case studies to explore how IR is implemented 'on the ground', including individual interviews with patients, family members and staff, non-participant observation, retrieval of routinely collected patient outcomes and cost analysis. Phase 4: accumulative data analysis across the phases to scrutinise data for patterns of congruence and discordance and develop an overall evaluation of what aspects of IR work, for whom and in what circumstances. ETHICS AND DISSEMINATION: The study has been approved by NHS South East Coast-Surrey Research Ethics Committee. Findings will be published in a wide range of outputs targeted at key audiences, including patient and carer organisations, nursing staff and healthcare managers

Physician associates and GPs in primary care: a comparison.

BACKGROUND: Physician associates [PAs] (also known as physician assistants) are new to the NHS and there is little evidence concerning their contribution in general practice. AIM: This study aimed to compare outcomes and costs of same-day requested consultations by PAs with those of GPs. DESIGN AND SETTING: An observational study of 2086 patient records presenting at same-day appointments in 12 general practices in England. METHOD: PA consultations were compared with those of GPs. Primary outcome was re-consultation within 14 days for the same or linked problem. Secondary outcomes were processes of care. RESULTS: There were no significant differences in the rates of re-consultation (rate ratio 1.24, 95% confidence interval [CI] = 0.86 to 1.79, P = 0.25). There were no differences in rates of diagnostic tests ordered (1.08, 95% CI = 0.89 to 1.30, P = 0.44), referrals (0.95, 95% CI = 0.63 to 1.43, P = 0.80), prescriptions issued (1.16, 95% CI = 0.87 to 1.53, P = 0.31), or patient satisfaction (1.00, 95% CI = 0.42 to 2.36, P = 0.99). Records of initial consultations of 79.2% (n = 145) of PAs and 48.3% (n = 99) of GPs were judged appropriate by independent GPs (P<0.001). The adjusted average PA consultation was 5.8 minutes longer than the GP consultation (95% CI = 2.46 to 7.1; P<0.001); cost per consultation was GBP £6.22, (US$ 10.15) lower (95% CI = -7.61 to -2.46, P<0.001). CONCLUSION: The processes and outcomes of PA and GP consultations for same-day appointment patients are similar at a lower consultation cost. PAs offer a potentially acceptable and efficient addition to the general practice workforce

Intentional rounding in hospital wards to improve regular interaction and engagement between nurses and patients: a realist evaluation

BACKGROUND: The government response to the care failures at the Mid Staffordshire NHS Foundation Trust led to the policy imperative of ‘regular interaction and engagement between nurses and patients’ (Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office; 2013. © Crown copyright 2013. Contains public sector information licensed under the Open Government Licence v3.0) in the NHS. The pressure on nursing to act resulted in the introduction of the US model, known as ‘intentional rounding’, into nursing practice. This is a timed, planned intervention that sets out to address fundamental elements of nursing care by means of a regular bedside ward round. OBJECTIVES: The study aims were to examine what it is about intentional rounding in hospital wards that works, for whom and in what circumstances. DESIGN: A multimethod study design was undertaken using realist evaluation methodology. The study was conducted in four phases: (1) theory development; (2) a national survey of all NHS acute trusts in England; (3) in-depth case studies of six wards, involving individual interviews, observations, retrieval of routinely collected ward outcome data and analysis of costs; and (4) synthesis of the study findings. SETTING: The study was conducted in acute NHS trusts in England. PARTICIPANTS: A total of 108 acute NHS trusts participated in the survey. Seventeen senior managers, 33 front-line nurses, 28 non-nursing professionals, 34 patients and 28 carers participated in individual interviews. Thirty-nine members of nursing staff were shadowed during their delivery of intentional rounding and the direct care received by 28 patients was observed. REVIEW METHODS: A realist synthesis was undertaken to identify eight context–mechanism–outcome configurations, which were tested and refined using evidence collected in subsequent research phases. RESULTS: The national survey showed that 97% of NHS trusts had implemented intentional rounding in some way. Data synthesis from survey, observation and interview findings showed that only two of the original eight mechanisms were partially activated (consistency and comprehensiveness, and accountability). The evidence for two mechanisms was inconclusive (visibility of nurses and anticipation); there was minimal evidence for one mechanism (multidisciplinary teamwork and communication) and no evidence for the remaining three (allocated time to care, nurse–patient relationships and communication, and patient empowerment). A total of 240 intentional rounds were observed within 188 hours of care delivery observation. Although 86% of all intentional rounding interactions were observed to be documented, fidelity to the original intervention [i.e. the Studer Group protocol (Studer Group. Best Practices: Sacred Heart Hospital, Pensacola, Florida. Hourly Rounding Supplement. Gulf Breeze, FL: Studer Group; 2007)] was generally low. LIMITATIONS: Intentional rounding was often difficult for researchers to observe, as it was rarely delivered as a discrete activity but instead undertaken alongside other nursing activities. Furthermore, a lack of findings about the influence of intentional rounding on patient outcomes in the safety thermometer data limits inferences on how mechanisms link to clinical outcomes for patients. CONCLUSIONS: The evidence from this study demonstrates that the effectiveness of intentional rounding, as currently implemented and adapted in England, is very weak and falls short of the theoretically informed mechanisms. There was ambivalence and concern expressed that intentional rounding oversimplifies nursing, privileges a transactional and prescriptive approach over relational nursing care, and prioritises accountability and risk management above individual responsive care. FUTURE WORK: It is suggested that the insights and messages from this study inform a national conversation about whether or not intentional rounding is the optimum intervention to support the delivery of fundamental nursing care to patients, or if the time is right to shape alternative solutions. FUNDING: The National Institute for Health Research Health Services and Delivery Research programme

Kualitas Hidup Pasien Diabetes Melitus Tipe 2 di Puskesmas Se Kota Kupang

Diabetes Mellitus is well known as a chronic disease which can lead to a decrease in quality of life in all domains. The study aims to explore the diabetic type 2 patient\u27s quality of life and find out the factors affecting in type 2 diabetic mellitus patients. The cross-sectional study design is used that included 65 patient with type 2 diabetes mellitus, in 11 public health centers of Kupang City. Data were collected by using Short Form Survey (SF-36) that assessed 8-scale health profile. Independent sample t-test is used to analyze the correlation between the factors affecting and the quality of life. the study showed that the QoL of DM patients decreased in all 8- health profile including physical functioning, social functioning, mental health, general health, pain, change in the role due to physical problems and emotional problems. The Study also showed there was a relationship between gender, duration of suffering from Diabetes mellitus, and complications to the quality of life. Male perceived a better quality of life than female

Ecological and physiological responses of arboreal mammals to urban habitat edges: A squirrel glider case study

The overall aim of this thesis was to investigate the influence of edges with varying adjacent urban land-use intensities (edge contrast) on arboreal mammal ecology and physiology, using the squirrel glider (Petaurus norfolcensis) as a case study. It addressed the issue of the impacts of urbanisation on biodiversity with a focus on edge effects. While some species may respond favourably to habitat changes near edges, many forest-dependent wildlife species are negatively affected, with this effect varying among species and intensity of the edge effects. Forest-dependent wildlife, including arboreal mammals, are particularly sensitive to forest-urban edges due to their highly specific habitat requirements and inability or reluctance to cross the urban matrix. Despite the increasing recognition of the effects of urban landscapes, studies investigating the impacts of different types of urban edges (e.g. major roads, minor roads and residential areas) are lacking. Much of the information gained from this research is novel for arboreal and gliding mammals, and indeed for forest-dependent wildlife. This information expands on the current scientific knowledge base and may be used as a reference point for future studies. Information on species’ responses to multiple edge types may also be employed by urban land managers and developers to guide effective and scientifically informed urban management. This includes restoration and development decisions and actions for the protection of native wildlife such as the squirrel glider. This study used a number of multidisciplinary methods to investigate the ecological and physiological responses of arboreal mammals to contrasting urban road and residential edges compared to forest fragment interiors. This problem was investigated using the squirrel glider in the fragmented urban landscape of southeast Queensland, Australia. Field based fauna surveys were conducted at twenty-eight sites in fourteen habitat patches. Fauna surveys used live trapping and were repeated seven times over a twelve-month period covering all four seasons from May 2007 until May 2008. Surveys provided information on squirrel glider site use, occupancy and relative abundance, while also enabling radio-collar attachment for assessments of home-ranges and movement, and the collection of biological samples for physiological stress hormone assessments. Habitat surveys were incorporated to provide information on resource and structural changes near edges, together with specific influences on glider abundance, home-ranges and stress. Analysis of variance was used to determine differences in habitat resources and structure in relation to glider site usage in forest fragment interiors compared to road (minor and major) and residential edge habitats (Chapter 2). A mixed effects modelling approach was used to quantify the importance of site-level habitat factors relative to edge contrast and habitat patch size on squirrel glider abundance (Chapter 3). In addition, analysis of variance was used to test for differences in glider age and sex in interior habitats compared to road and residential edges (Chapter 3). Two methods (fixed kernel and minimum convex polygon) were used to determine squirrel glider home-ranges to allow comparisons with other studies, and provide insight into the potential influence of urban edges on squirrel glider movement behaviours (Chapter 4). A linear mixed effects modelling approach clustered by patch was used to determine the influence of edge contrast on squirrel glider physiological stress relative to site-level habitat factors and intraspecific competition (Chapter 5). Forest fragment interiors contained a higher abundance of large trees and nest hollows, together with a greater floristic species richness providing more reliable seasonal foraging sources (nectar and pollen). A higher abundance of these resources may explain the increased likelihood of trapping squirrel gliders (trap success) in these sites. Edge contrast had a strong negative effect on the abundance of squirrel gliders but is conditional on the presence of low numbers of unreliable flowering overstorey trees and the availability of nest hollows at a site. Results also indicated that older male gliders prefer forest fragment interiors over road and residential edge habitats. Squirrel gliders living in interior habitats have larger home-ranges and core areas than individuals living at road and residential edges sites. In addition, squirrel gliders were found to regularly cross narrow roads up to 20 m wide and with a tree gap up to 15 m to access adjacent vegetation. Squirrel gliders were also recorded utilising trees in residential backyards for foraging. Edge contrast was found to have a strong positive effect on squirrel glider physiological stress, however as was the case with abundance, this was conditional on the availability of habitat features at a site, specifically nest hollows. This thesis makes an important contribution to the current understanding of the responses of a gliding marsupial and forest-dependent wildlife as a group, living near contrasting edges in urban landscapes. On the whole, forest fragment interiors contain higher quality habitat resources allowing squirrel gliders to maintain larger home-range areas and higher abundances, while providing a less stressful environment. Despite this, lower contrast edges, such as minor roads and residential edges, have the capacity to provide sufficient habitat resources (e.g. nest hollows) enabling these sites to support smaller numbers of squirrel gliders. In addition, the availability of these key resources and a decrease in contrast at these edges, reduces the severity of physiological stressors and increases the likely short-term survival of resident individuals. While the importance of forest interiors for conservation is obvious, based on either individual (physiological) or population (abundance) level indicators, this study provides little evidence to suggest that high contrast edges (e.g. major roads) offer any significant conservation value to squirrel gliders in urban landscapes. Conversely, the conservation value of low contrast edges containing key site-level resources should not be underestimated for forest-dependent wildlife, including arboreal and gliding mammals in fragmented urban landscapes

Physician associates and GPs in primary care: a comparison

Physician associates [PAs] (also known as physician assistants) are new to the NHS and there is little evidence concerning their contribution in general practice. This study aimed to compare outcomes and costs of same-day requested consultations by PAs with those of GPs

Investigating the contribution of physician assistants to primary care in England: a mixed-methods study

Background: Primary health care is changing as it responds to demographic shifts, technological changes and fiscal constraints. This, and predicted pressures on medical and nursing workforces, raises questions about staffing configurations. Physician assistants (PAs) are mid-level practitioners, trained in a medical model over 2 years at postgraduate level to work under a supervising doctor. A small number of general practices in England have employed PAs. Objective: To investigate the contribution of PAs to the delivery of patient care in primary care services in England. Design: A mixed-methods study conducted at macro, meso and micro organisational levels in two phases: (1) a rapid review, a scoping survey of key national and regional informants, a policy review, and a survey of PAs and (2) comparative case studies in 12 general practices (six employing PAs). The latter incorporated clinical record reviews, a patient satisfaction survey, video observations of consultations and interviews with patients and professionals. Results: The rapid review found 49 published studies, mainly from the USA, which showed increased numbers of PAs in general practice settings but weak evidence for impact on processes and patient outcomes. The scoping survey found mainly positive or neutral views about PAs, but there was no mention of their role in workforce policy and planning documents. The survey of PAs in primary care (n = 16) found that they were mainly deployed to provide same-day appointments. The comparative case studies found that physician assistants were consulted by a wide range of patients, but these patients tended to be younger, with less medically acute or complex problems than those consulting general practitioners (GPs). Patients reported high levels of satisfaction with both PAs and GPs. The majority were willing or very willing to consult a PA again but wanted choice in which type of professional they consulted. There was no significant difference between PAs and GPs in the primary outcome of patient reconsultation for the same problem within 2 weeks, investigations/tests ordered, referrals to secondary care or prescriptions issued. GPs, blinded to the type of clinician, judged the documented activities in the initial consultation of patients who reconsulted for the same problem to be appropriate in 80% (n = 223) PA and 50% (n = 252) GP records. PAs were judged to be competent and safe from observed consultations. The average consultation with a physician assistant is significantly longer than that with a GP: 5.8 minutes for patients of average age for this sample (38 years). Costs per consultation were £34.36 for GPs and £28.14 for PAs. Costs could not be apportioned to GPs for interruptions, supervision or training of PAs.Conclusions: PAs were found to be acceptable, effective and efficient in complementing the work of GPs. PAs can provide a flexible addition to the primary care workforce. They offer another labour pool to consider in health professional workforce and education planning at local, regional and national levels. However, in order to maximise the contribution of PAs in primary care settings, consideration needs to be given to the appropriate level of regulation and the potential for authority to prescribe medicines. Future research is required to investigate the contribution of PAs to other first contact services as well as secondary services; the contribution and impact of all types of mid-level practitioners (including nurse practitioners) in first contact services; the factors and influences on general practitioner and practice manager decision-making as to staffing and skill mix; and the reliability and validity of classification systems for both primary care patients and their presenting condition and their consequences for health resource utilisation

Time-delayed influence of urban landscape change on the susceptibility of koalas to chlamydiosis

Infectious diseases are important in the dynamics of many wildlife populations, but there is limited understanding of how landscape change influences susceptibility to disease