Conflicting priorities: evaluation of an intervention to improve nurse-parent relationships on a Tanzanian paediatric ward.

BACKGROUND: Patient, or parent/guardian, satisfaction with health care provision is important to health outcomes. Poor relationships with health workers, particularly with nursing staff, have been reported to reduce satisfaction with care in Africa. Participatory research approaches such as the Health Workers for Change initiative have been successful in improving provider-client relationships in various developing country settings, but have not yet been reported in the complex environment of hospital wards. We evaluated the HWC approach for improving the relationship between nurses and parents on a paediatric ward in a busy regional hospital in Tanzania. METHODS: The intervention consisted of six workshops, attended by 29 of 31 trained nurses and nurse attendants working on the paediatric ward. Parental satisfaction with nursing care was measured with 288 parents before and six weeks after the workshops, by means of an adapted Picker questionnaire. Two focus-group discussions were held with the workshop participants six months after the intervention. RESULTS: During the workshops, nurses demonstrated awareness of poor relationships between themselves and mothers. To tackle this, they proposed measures including weekly meetings to solve problems, maintain respect and increase cooperation, and representation to administrative forces to request better working conditions such as equipment, salaries and staff numbers. The results of the parent satisfaction questionnaire showed some improvement in responsiveness of nurses to client needs, but overall the mean percentage of parents reporting each of 20 problems was not statistically significantly different after the intervention, compared to before it (38.9% versus 41.2%). Post-workshop focus-group discussions with nursing staff suggested that nurses felt more empathic towards mothers and perceived an improvement in the relationship, but that this was hindered by persisting problems in their working environment, including poor relationships with other staff and a lack of response from hospital administration to their needs. CONCLUSION: The intended outcome of the intervention was not met. The priorities of the intervention--to improve nurse-parent relationships--did not match the priorities of the nursing staff. Development of awareness and empathy was not enough to provide care that was satisfactory to clients in the context of working conditions that were unsatisfactory to nurses

How Is Stress Reduced by a Workplace Mindfulness Intervention? A Qualitative Study Conceptualising Experiences of Change

Mindfulness-based interventions are effective as curative and preventative approaches to psychological health. However, the mechanisms by which outcomes are secured from such interventions when delivered in the workplace, and to a stressed workforce, are not well understood. The aim of the present study was to elicit and analyse accounts from past participants of a workplace mindfulness intervention in order to generate a preliminary model of how positive benefits appear to be secured. In-depth, semi-structured interviews were completed with 21 employees of a higher education institution who had completed an eight-week intervention based on Mindfulness-Based Stress Reduction, adapted for the workplace. Interviews invited participants to recount their experiences of the intervention and its impact, if any, on their work life. Aspects of the interview data that pertained to intervention experience and positive benefits were analysed using a version of grounded theory, leading to the generation of a provisional model of how positive change occurred. The model suggests that discrete, temporal experiences build on each other to generate multiple, positive benefits. As anticipated in mindfulness-based interventions, enhanced attentional capacity was important, but our provisional model also suggests that resonance, self-care, detection of stress markers, perceiving choice, recovering self-agency and upward spiralling may be central mechanisms that lead to positive outcomes. Understanding mechanisms of change may help support participant engagement and trust in work-based mindfulness programmes, and enhance participants’ ability to apply mindfulness in their work life

A programme to spread eGFR graph surveillance for the early identification, support and treatment of people with progressive chronic kidney disease (ASSIST-CKD): protocol for the stepped wedge implementation and evaluation of an intervention to reduce late presentation for renal replacement therapy

Background Patients who start renal replacement therapy (RRT) for End-Stage Kidney Disease (ESKD) without having had timely access to specialist renal services have poor outcomes. At one NHS Trust in England, a community-wide CKD management system has led to a decline in the incident rate of RRT and the lowest percentage of patients presenting within 90 days of starting RRT in the UK. We describe the protocol for a quality improvement project to scale up and evaluate this innovation. Methods The intervention is based upon an off-line database that integrates laboratory results from blood samples taken in all settings stored under different identifying labels relating to the same patient. Graphs of estimated glomerular filtration rate (eGFR) over time are generated for patients 65 years with an incoming eGFR <40 ml/min/1.73 m2. Graphs where kidney function is deteriorating are flagged by a laboratory scientist and details sent to the primary care doctor (GP) with a prompt that further action may be needed. We will evaluate the impact of implementing this intervention across a large population served by a number of UK renal centres using a mixed methods approach. We are following a stepped-wedge design. The order of implementation among participating centres will be randomly allocated. Implementation will proceed with unidirectional steps from control group to intervention group until all centres are generating graphs of eGFR over time. The primary outcome for the quantitative evaluation is the proportion of patients referred to specialist renal services within 90 days of commencing RRT, using data collected routinely by the UK Renal Registry. The qualitative evaluation will investigate facilitators and barriers to adoption and spread of the intervention. It will include: semi-structured interviews with laboratory staff, renal centre staff and service commissioners; an online survey of GPs receiving the intervention; and focus groups of primary care staff. Discussion Late presentation to nephrology for patients with ESKD is a source of potentially avoidable harm. This protocol describes a robust quantitative and qualitative evaluation of a quality improvement intervention to reduce late presentation and improve the outcomes for patients with ESKD

Spitzer Reveals Evidence of Molecular Absorption in the Atmosphere of the Hot Neptune LTT 9779b

Non-rocky sub-Jovian exoplanets in high-irradiation environments are rare. LTT 9779b, also known as Transiting Exoplanet Survey Satellite (TESS) object of interest (TOI) 193.01, is one of the few such planets discovered to date, and the first example of an ultrahot Neptune. The planet's bulk density indicates that it has a substantial atmosphere, so to investigate its atmospheric composition and shed further light on its origin, we obtained Spitzer InfraRed Array Camera secondary eclipse observations of LTT 9779b at 3.6 and 4.5 μm. We combined the Spitzer observations with a measurement of the secondary eclipse in the TESS bandpass. The resulting secondary eclipse spectrum strongly prefers a model that includes CO absorption over a blackbody spectrum, incidentally making LTT 9779b the first TESS exoplanet (and the first ultrahot Neptune) with evidence of a spectral feature in its atmosphere. We did not find evidence of a thermal inversion, at odds with expectations based on the atmospheres of similarly irradiated hot Jupiters. We also report a nominal dayside brightness temperature of 2305 ± 141 K (based on the 3.6 μm secondary eclipse measurement), and we constrained the planet's orbital eccentricity to e < 0.01 at the 99.7% confidence level. Together with our analysis of LTT 9779b's thermal phase curves reported in a companion paper, our results set the stage for similar investigations of a larger sample of exoplanets discovered in the hot-Neptune desert, investigations that are key to uncovering the origin of this population

Spitzer Reveals Evidence of Molecular Absorption in the Atmosphere of the Hot Neptune LTT 9979b

Non-rocky sub-jovian exoplanets in high irradiation environments are rare. LTT 9979b, also known as TESS Object of Interest (TOI) 193.01, is one of the few such planets discovered to date, and the first example of an ultra-hot Neptune. The planet's bulk density indicates that it has a substantial atmosphere, so to investigate its atmospheric composition and shed further light on its origin, we obtained {\it Spitzer} IRAC secondary eclipse observations of LTT 9979b at 3.6 and 4.5 $\mu$m. We combined the {\it Spitzer} observations with a measurement of the secondary eclipse in the {\it TESS} bandpass. The resulting secondary eclipse spectrum strongly prefers a model that includes CO absorption over a blackbody spectrum, incidentally making LTT 9979b the first {\it TESS} exoplanet (and the first ultra-hot Neptune) with evidence of a spectral feature in its atmosphere. We did not find evidence of a thermal inversion, at odds with expectations based on the atmospheres of similarly-irradiated hot Jupiters. We also report a nominal dayside brightness temperature of 2305 $\pm$ 141 K (based on the 3.6 $\mu$m secondary eclipse measurement), and we constrained the planet's orbital eccentricity to $e < 0.01$ at the 99.7 \% confidence level. Together with our analysis of LTT 9979b's thermal phase curves reported in a companion paper, our results set the stage for similar investigations of a larger sample of exoplanets discovered in the hot Neptune desert, investigations which are key to uncovering the origin of this population.Comment: 12 pages, 5 figures; accepted to ApJ Letter

Association of Accelerometry-Measured Physical Activity and Cardiovascular Events in Mobility-Limited Older Adults: The LIFE (Lifestyle Interventions and Independence for Elders) Study.

BACKGROUND:Data are sparse regarding the value of physical activity (PA) surveillance among older adults-particularly among those with mobility limitations. The objective of this study was to examine longitudinal associations between objectively measured daily PA and the incidence of cardiovascular events among older adults in the LIFE (Lifestyle Interventions and Independence for Elders) study. METHODS AND RESULTS:Cardiovascular events were adjudicated based on medical records review, and cardiovascular risk factors were controlled for in the analysis. Home-based activity data were collected by hip-worn accelerometers at baseline and at 6, 12, and 24&nbsp;months postrandomization to either a physical activity or health education intervention. LIFE study participants (n=1590; age 78.9±5.2 [SD] years; 67.2% women) at baseline had an 11% lower incidence of experiencing a subsequent cardiovascular event per 500&nbsp;steps taken per day based on activity data (hazard ratio, 0.89; 95% confidence interval, 0.84-0.96; P=0.001). At baseline, every 30&nbsp;minutes spent performing activities ≥500&nbsp;counts per minute (hazard ratio, 0.75; confidence interval, 0.65-0.89 [P=0.001]) were also associated with a lower incidence of cardiovascular events. Throughout follow-up (6, 12, and 24&nbsp;months), both the number of steps per day (per 500&nbsp;steps; hazard ratio, 0.90, confidence interval, 0.85-0.96 [P=0.001]) and duration of activity ≥500&nbsp;counts per minute (per 30&nbsp;minutes; hazard ratio, 0.76; confidence interval, 0.63-0.90 [P=0.002]) were significantly associated with lower cardiovascular event rates. CONCLUSIONS:Objective measurements of physical activity via accelerometry were associated with cardiovascular events among older adults with limited mobility (summary score &gt;10 on the Short Physical Performance Battery) both using baseline and longitudinal data. CLINICAL TRIAL REGISTRATION:URL: http://www.clinicaltrials.gov. Unique identifier: NCT01072500