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

Anatomical Specializations for Nocturnality in a Critically Endangered Parrot, the Kakapo (Strigops habroptilus)

The shift from a diurnal to nocturnal lifestyle in vertebrates is generally associated with either enhanced visual sensitivity or a decreased reliance on vision. Within birds, most studies have focused on differences in the visual system across all birds with respect to nocturnality-diurnality. The critically endangered Kakapo (Strigops habroptilus), a parrot endemic to New Zealand, is an example of a species that has evolved a nocturnal lifestyle in an otherwise diurnal lineage, but nothing is known about its' visual system. Here, we provide a detailed morphological analysis of the orbits, brain, eye, and retina of the Kakapo and comparisons with other birds. Morphometric analyses revealed that the Kakapo's orbits are significantly more convergent than other parrots, suggesting an increased binocular overlap in the visual field. The Kakapo exhibits an eye shape that is consistent with other nocturnal birds, including owls and nightjars, but is also within the range of the diurnal parrots. With respect to the brain, the Kakapo has a significantly smaller optic nerve and tectofugal visual pathway. Specifically, the optic tectum, nucleus rotundus and entopallium were significantly reduced in relative size compared to other parrots. There was no apparent reduction to the thalamofugal visual pathway. Finally, the retinal morphology of the Kakapo is similar to that of both diurnal and nocturnal birds, suggesting a retina that is specialised for a crepuscular niche. Overall, this suggests that the Kakapo has enhanced light sensitivity, poor visual acuity and a larger binocular field than other parrots. We conclude that the Kakapo possesses a visual system unlike that of either strictly nocturnal or diurnal birds and therefore does not adhere to the traditional view of the evolution of nocturnality in birds

The Rhaetian vertebrates of Chipping Sodbury, South Gloucestershire, UK, a comparative study

Microvertebrates are common in the basal bone bed of the Westbury Formation of England, documenting a fauna dominated by fishes that existed at the time of the Rhaetian Transgression, some 206 Myr ago. Two sites near Chipping Sodbury, south Gloucestershire, Barnhill Quarry and Chipping Sodbury railway cutting, show differing faunas. Top predators are the large bony fish Severnichthys and the shark Hybodus cloacinus, which preyed on smaller sharks such as Lissodus and Rhomphaiodon. These fishes in turn may have fed on a mixed diet of other fishes and invertebrates, and Lissodus was a shell crusher. Comparisons of these faunas with others described recently from the Bristol region, and from Devon, indicate remarkable faunal similarities in the Rhaetian basal Westbury Formation bone bed over a wide area, based on a variety of ecological statistics that document species diversities and relative abundances. Only the fauna from the Chipping Sodbury railway cutting differs significantly

Stochastic optimization application in molecular electronics

Molecular electronics is an exciting emerging technology in today's science involving interesting and challenging projects in a variety of interdisciplinary fields. There are dozens of proposed molecular electronic designs each with their advantages and disadvantages. The nanocell is our lowest level device which we believe trumps the major disadvantage inherit in most, if not all, other designs, that of the nanoscale construction of devices. As miniaturization continues into the nanoscale regime, the financial cost and the difficulty of engineering techniques to decreasing size are expected to increase sharply. The nanocell alleviates this problem by allowing molecules to self-assemble into random networks. These molecules are capable of retaining different conductive states. The challenge then is to program or reconfigure the molecular states of the nanocell post-fabrication. In essence, the nanocell idea is to shift the burden from fabrication to post-fabrication reconfiguration. We present in this thesis a description, simulations, and an analysis of a class of algorithms, called stochastic gradient descent, that may be useful in the post-fabrication programming phase