Community nursing quality indicators for end-of-life care in England: Identification, preparation, and coordination

High-quality community nursing is essential to ensure that end-of-life care can be provided in community settings in line with patient preferences. This article examines the quality priorities commissioners sought to incentivise in end-of-life care, by reviewing a survey of Commissioning for Quality and Innovation (CQUIN) indicators for community nursing conducted in England in 2014-2015. Findings from the survey suggest that end-of-life care was not given a high priority with the CQUIN indicators for community nursing. Vigorous quality standards, including training and development, need to be in place to make sure that the potential of community nursing is being used to sensitively engage with people nearing the end of their lives and support them to plan their future care, if they so wish

Urgent care out of hours: A comparison of the experiences of older people and parents of young children in a semi-rural area

Older people and parents of young children are the most frequent users of out of hours care. However, their needs and expectations of care may be different. The aim of this study was to explore and compare the experiences and views of these two groups following the transfer of responsibility for out of hours services from General Practitioners (GPs) to a Primary Care Trust (PCT). Qualitative research using semi-structured interviews with 19 informants living in a geographically large, semi-rural PCT area in England served by 15 GP practices. Interviews were taped, transcribed and analysed using a thematic framework. Older people presented with more complex health problems than young children, and expressed more reluctance at calling the service. Both groups experienced similar access problems for using the primary care centre (PCC). Older people reported fewer difficulties obtaining a home visit, though experienced continuity problems when illness episodes lasted longer than one shift. Both groups questioned the ability of a doctor to diagnose accurately using only telephone assessment. Despite differences in presenting symptoms and attitudes to service use, older people and parents with young children experienced similar problems in accessing care at the PCC. Older people more frequently received home visits than parents with young children, and it may be that social context is not sufficiently taken into account when assessing need for a home visit. Practitioners should be aware that older people tend to minimise symptoms and should be cautious of relying on lay interpretations of illness when carrying out telephone assessments with this group. © 2007, Cambridge University Press. All rights reserved

GPs, nurses and pharmacists as prescribers in primary care: An exploration using the social identity approach

The social identity approach was used to explore the inter-professional relations of nurse prescribers, pharmacist prescribers and general practitioners (GPs) in primary care in the United Kingdom. We investigated the social identities of GPs, nurses and pharmacists as prescribers, the influence of social structure in practice settings and the implications for further development of nurse and pharmacist prescribing. Interviews were conducted with 21 GPs, nurse prescribers and pharmacist prescribers in primary care from the south of England. Five themes emerged including the ambiguous social identity of some nurse and pharmacist prescribers (‘a no man’s land’), constraining social structures (‘the doctor is king’), the content of GPs’ social identity (‘subtle prescribing’), the content of nurse and pharmacists’ social identity (‘more than just competent’) and context (‘engaging with each other’s identities’). At some GP practices there was a willingness to engage with the different social identities and reframe these within the organisational context of a GP surgery. At these sites, where social identities were respected and supported, the social identity approach offered insight into how the resulting teamwork could lead to a shared practice identity focused on multi-disciplinary working. This research provides evidence of how professional and organisational identities can be enhanced and supported. Further, there is the potential for an intervention using the social identify approach to improve patient care

Measuring quality in community nursing: A mixed methods study

AbstractBackgroundHigh-quality nursing care is crucial for patients with complex conditions and co-morbidities living at home, but such care is largely invisible to health planners and managers. Nursing care quality in acute settings is typically measured using a range of different quality measures; however, little is known about how service quality is measured in community nursing.ObjectiveTo establish which quality indicators are selected for community nursing; how these are selected and applied; and their usefulness to service users (patients and/or carers), commissioners and provider staff.DesignA mixed-methods study comprising three phases:1)A national survey of ‘Commissioning for Quality and Innovation’ indicators applied to community nursing care in 2014/2015. Data were analysed descriptively using SPSS 20.0.2)In-depth case study in five sites. Qualitative data were collected through observations, interviews, focus groups and documents. Thematic analysis was conducted using QSR NVivo 10.Findings from the first two phases were synthesised using a theoretical framework to examine how local and distal contexts affecting care provision impacted on selection and application of quality indicators for community nursing.3)Validity testing the findings and associated draft good practice guidance through a series of stakeholder engagement events held in venues across England.SettingThe national survey was conducted by telephone and e-mail. Each case study site comprised a Clinical Commissioning Group (CCG) and its associated provider of community nursing services.ParticipantsSurvey: 145 (68.7%) CCGs across England.Case study: NHS England national and regional quality leads (n=5); commissioners (n=19); provider managers (n=32); registered community nurses (n=45); adult patients (n=14) receiving care in their own homes and/or carers (n=7).FindingsA wide range of indicators was used nationally, with a major focus on organisational processes.Lack of nurse and service user involvement in indicator selection processes impacted negatively on their application and perceived usefulness. Indicator data collection was hampered by problematic IT software and connectivity and inter-organisational system incompatibility. Frontline staff considered indicators designed for acute settings inappropriate for use in community settings. Indicators did not reflect aspects of care such as time spent, kindness and respect, highly valued by frontline staff and service user participants.Workshop delegates (commissioners, provider managers, frontline staff and service users, n=242) endorsed the findings and draft good practice guidance.LimitationsOn-going service re-organisation during the study period affected access to participants in some sites. Limited available data precluded in-depth documentary analysis.ConclusionsCurrent quality indicators for community nursing are of limited use:Commissioners and provider managers should ensure that service users and frontline staff are involved in identifying and selecting indicators.Difficulties with connectivity and compatibility should be resolved before rolling new IT packages out into practice.Quality measures designed for acute settings should not be applied in community settings without modification.A mix of qualitative and quantitative methods should be used to determine service qualityFuture workResearch investigating appropriate modifications and associated costs of administering quality indicator schemes in integrated care settings.Funding detailsThe study was funded by the NIHR Health Service and Delivery Research programme

A well-conserved Plasmodium falciparum var gene shows an unusual stage-specific transcript pattern

The var multicopy gene family encodes Plasmodium falciparum erythrocyte membrane protein 1 (PfEMP1) variant antigens, which, through their ability to adhere to a variety of host receptors, are thought to be important virulence factors. The predominant expression of a single cytoadherent PfEMP1 type on an infected red blood cell, and the switching between different PfEMP1 types to evade host protective antibody responses, are processes thought to be controlled at the transcriptional level. Contradictory data have been published on the timing of var gene transcription. Reverse transcription-polymerase chain reaction (RT-PCR) data suggested that transcription of the predominant var gene occurs in the later (pigmented trophozoite) stages, whereas Northern blot data indicated such transcripts only in early (ring) stages. We investigated this discrepancy by Northern blot, with probes covering a diverse var gene repertoire. We confirm that almost all var transcript types were detected only in ring stages. However, one type, the well-conserved varCSA transcript, was present constitutively in different laboratory parasites and does not appear to undergo antigenic variation. Although varCSA has been shown to encode a chondroitin sulphate A (CSA)-binding PfEMP1, we find that the presence of full-length varCSA transcripts does not correlate with the CSA-binding phenotype

Archaeobotany in Australia and New Guinea: practice, potential and prospects

Archaeobotany is the study of plant remains from archaeological contexts. Despite Australasian research being at the forefront of several methodological innovations over the last three decades, archaebotany is now a relatively peripheral concern to most archaeological projects in Australia and New Guinea. In this paper, many practicing archaeobotanists working in these regions argue for a more central role for archaeobotany in standard archaeological practice. An overview of archaeobotanical techniques and applications is presented, the potential for archaeobotany to address key historical research questions is indicated, and initiatives designed to promote archaeobotany and improve current practices are outlined

Archaeobotany in Australia and New Guinea: practice, potential and prospects

Archaeobotany is the study of plant remains from archaeological contexts. Despite Australasian research being at the forefront of several methodological innovations over the last three decades, archaebotany is now a relatively peripheral concern to most archaeological projects in Australia and New Guinea. In this paper, many practicing archaeobotanists working in these regions argue for a more central role for archaeobotany in standard archaeological practice. An overview of archaeobotanical techniques and applications is presented, the potential for archaeobotany to address key historical research questions is indicated, and initiatives designed to promote archaeobotany and improve current practices are outlined

How do they measure up? Differences in stakeholder perceptions of quality measures used in English community nursing

© The Author(s) 2019. Objectives: To establish how quality indicators used in English community nursing are selected and applied, and their perceived usefulness to service users, commissioners and service providers. Methods: A qualitative multi-site case study was conducted with five commissioning organizations and their service providers. Participants included commissioners, provider organization managers, nurses and service users. Results: Indicator selection and application often entail complex processes influenced by wider health system and cross-organizational factors. All participants felt that current indicators, while useful for accountability and management purposes, fail to reflect the true quality of community nursing care and may sometimes indirectly compromise care. Conclusions: Valuable resources may be better used for comprehensive system redesign, to ensure that patient, carer and nurse priorities are given equivalence with those of other stakeholders

Antigenic Variation in Plasmodium falciparum Malaria Involves a Highly Structured Switching Pattern

Many pathogenic bacteria, fungi, and protozoa achieve chronic infection through an immune evasion strategy known as antigenic variation. In the human malaria parasite Plasmodium falciparum, this involves transcriptional switching among members of the var gene family, causing parasites with different antigenic and phenotypic characteristics to appear at different times within a population. Here we use a genome-wide approach to explore this process in vitro within a set of cloned parasite populations. Our analyses reveal a non-random, highly structured switch pathway where an initially dominant transcript switches via a set of switch-intermediates either to a new dominant transcript, or back to the original. We show that this specific pathway can arise through an evolutionary conflict in which the pathogen has to optimise between safeguarding its limited antigenic repertoire and remaining capable of establishing infections in non-naïve individuals. Our results thus demonstrate a crucial role for structured switching during the early phases of infections and provide a unifying theory of antigenic variation in P. falciparum malaria as a balanced process of parasite-intrinsic switching and immune-mediated selection