Rival bishops, rival cathedrals : the election of Cormac, archdeacon of Sodor, as bishop in 1331

Peer reviewedPublisher PD

An Exploration of the Role of Substance Misuse Nurses in Scotland

Executive Summary Background With the increase of drug misuse over the past two decades, the role of the Substance Misuse Nurse has increased dramatically. Research on the role of nurses working in this field is minimal and there is little known about what they do, what they think about their clients and their role, and how they approach treatment. A pilot study on substance misuse nurses in Grampian indicated that nurses may be key gatekeepers to specialist services and some nurses appeared to have an important role in clinical decision making. However, clinical decision making and other key aspects of nurse practice may vary across services in different geographical areas. This research was designed to gain a better understanding of the role of the substance misuse nurse in Scotland. Aims and Objectives The aim of this research was to describe and analyse the role of substance misuse nurses working with drug misusers in Scotland. The objectives were: • to identify the population of specialist nurses working directly in the management of illicit drug users in Scotland and gain baseline data on their demography, caseload, services provided and level of interaction with other health professionals; • to compare their attitudes to drug misusers with those of other health professionals; • to explore their beliefs about the effectiveness of different treatment options; • to examine their role in the initial client assessment and subsequent management; • to describe their interaction with the client; • to explore their relationship with other professionals. Methods Mixed quantitative and qualitative methods were used. The population of Substance Misuse Nurses and midwives working specifically with drug misusers across Scotland were identified and posted a comprehensive questionnaire. The questionnaire covered issues including qualifications, training, attitudes and beliefs about treatment and aspects of practice such as caseloads, services provided and relationships with other health and social professionals. Face-to-face interviews were conducted with a sub-sample of nurses including a range of gender, experience, and NHS areas. Interviews covered nurses’ assessment and decision making regarding treatment and relationships with other professionals. Observations of specialist nurse and client consultations allowed for some insight into the general structure of the consultation, the setting where the consultation took place and the roles of nurse and client in assessment and treatment planning. Characteristics of SMS nurses and services • A scoping exercise indentified 272 nurses. Of these 244 were sent a questionnaire (the remainder having left or being on sick leave). Of these, 79% responded. • Seventy percent (70%) were Grade G or above indicating a senior level workforce. • Most nurses were employed in substance misuse services (48%) or, similarly, drug and alcohol services (30%). • Formal training (university certificate/diploma) in substance misuse had been undertaken by 40% of nurses, induction training (i.e. at the start of employment) by 62% of nurses. • The median caseload was 38 clients. • The majority of consultations took place in clinical consultation rooms but this was not observed to influence the consultation. • Nurses reported that the average length of a consultation was 38 minutes. All of the observed consultations were scheduled for 30 minutes but half over-ran. Motivation, attitudes and beliefs • The challenging nature of working with drug misusers was a positive motivating factor for nurses working in this field. • Seventy-seven percent (77%) of nurses considered working with drug misusers to be rewarding, although 79% also considered that this population were not easy to deal with. Opinion was split about whether drug misusers could be manipulative in consultations. Initial assessment of clients • Waiting times for assessment were generally an issue of concern to nurses. • A detailed assessment was almost always conducted at the first consultation. • An SMR24 was almost always completed at the first consultation. • Interviews and observation of nurse-client consultations found that the approach to assessment seemed consistent across geographical areas. • Assessment included: brief physical examination, urine sampling, detailed exploration of drug use, exploration of physical problems, discussion of social and family support, housing and employment status and history of involvement in the criminal justice system. • Consultations were often brought to a close by discussing treatment expectations. • Initial assessment could take place over more than one appointment and several appointments could be required before a treatment plan was implemented. Making treatment decisions • Clients were actively encouraged to participate in treatment decisions. • Although 84% of nurses reported they were expected to follow a treatment protocol only 44% said they always did (for any treatment). • Eighty-six percent (86%) of nurses had seen the National Clinical Guidelines (DoH, 1999), and those who were interviewed felt that these provided a good framework for treatment, although they were perhaps lacking in detail. • Nurses reported that they often consulted widely with other health professionals but, most frequently, with the client, before making a treatment decision. • A third of nurses reported writing prescriptions for a doctor to sign. • Seventy percent (70%) of respondents felt nurses should be able write prescriptions but only if they were experienced nurses with appropriate training. Comparing beliefs of nurses with those of GPs and pharmacists Nurses were asked some questions which had been asked of GPs and pharmacists in previous national surveys conducted in 2000. This allowed for comparisons to be made: • When making treatment decisions nurses were less influenced than GPs by the attitude and behaviour of drug misusers. • When making treatment decisions nurses were more influenced than GPs by societal factors such as reducing the transmission of infectious disease. • Nurses were less likely than GPs to favour detoxification as a treatment approach, although 83% of nurses agreed that a community based detoxification programme was an effective tool for the treatment of drug misuse. • Nurses were more confident than GPs about their ability to successfully manage polydrug users. • Nurses and GPs were split in their beliefs about the effectiveness of dihydrocodeine. • Nurses believed more strongly than pharmacists that maintenance prescribing could stop the use of illicit drugs. • Fewer nurses than pharmacists believed that controlled drug dispensing should take place in central clinics rather than community pharmacies. Multidisciplinary working • Over half of nurses considered their relationship with pharmacists, GPs, health visitors/community nurses, hospital doctors and social workers to be good. • Opportunities to discuss services with local policy makers were considered insufficient. • Relationships with GPs seemed positive because nurses felt GPs valued their specialist knowledge. • Nurses had frequent contact with pharmacists and respected the difficulties of a pharmacist’s work. • Relationships with social services were variable. Some nurses felt undervalued by their social work colleagues, or felt there was a lack of joint planning for individual client care. • Nurses were clear about what circumstances should lead to a break in confidentiality between services and of how to go about this. • Integrated drug services were seen as potentially beneficial but there were specific concerns about the implications for clients of sharing information with other agencies and practical concerns about the size of joint assessment tools. Health and Safety at work • Sixty-four percent (64%) of nurses reported that they had been physically or verbally abused by clients, and half of those who had been subject to abuse felt current safety provision in their service was insufficient. Nurses in most areas said that the safety of staff was considered to be a high service priority, but there was evidence from interviews this was still lacking in some areas. • Greater use of personal alarms and alarms in consultation rooms, use of mobile phones, and specialised training were suggested as ways of improving safety. • Nurses said that the majority of their consultations take place in clinics/consultation rooms rather than clients’ homes. • The feeling was commonly expressed among interviewees that their work could be stressful, and this was seen as due to paperwork, excessive caseloads and working in isolation. Discussion of Findings This study provides baseline information which can be used to inform individual nurses, services, policy makers and researchers. Some individual nurses reading this report might find an element that is simply describing what they already know. This is inevitable but it is hoped individual nurses will still find interest in the views and practice of others within their profession. The value of this report is that it has quantified these findings on a national basis, providing robust data for workforce planning and needs assessment. It has not been possible to compare findings, and thus the practice of substance misuse nurses in Scotland, with other areas or countries because there is no comparable published work. It is also not possible to give guidelines or examples of ‘good practice’ as this would have involved data collection from clients and other professionals which was outwith this study’s remit. This study has found a reassuring consistence of practice across Scotland. Although many substance misuse nurses work in some degree of isolation there is an apparently high level of discussion and consultation with other service colleagues which provides support. The role of the nurse in the initial assessment and treatment plan is critical. Nevertheless, decisions regarding treatment plans were made largely between nurses and clients, with nurses making use of service protocols/guidelines. Some might question whether a nurse is the most appropriate person to undertake these tasks. Ability to conduct physical examination, some knowledge of pharmacology, mental health and psychology as well as an ability to explore the wider social context is required. On reflection a nurse, with mental health qualifications seems to have the most appropriate skills for this. There is a willingness by nurses to take on the role of prescribing albeit in a limited capacity, and only by very experienced nurses with appropriate training. Currently, a minority of nurses reported writing prescriptions to be signed by doctors, which is possible for doctors with handwriting exemptions. This raises issues about clinical governance. In signing the prescription a GP is still taking responsibility even though s/he may know little about the patient’s current condition. An important strand of a substance misuse nurse’s practice is ongoing support or counselling for clients. This raises issues about models of counselling followed and nurses’ competencies in doing this. The nature or model of counselling used by nurses was not explicitly covered in this research and further exploration of counselling would be an area for future research. Relationships with other professionals, were generally reported to be good. Nurses generally believed GPs valued their role. Comparison of attitudes of substance misuse nurses with earlier surveys of pharmacists and GPs indicates they are more positive in general and about treatment outcomes in particular. Nurses viewed the challenging aspect of working with drug misusers more positively than pharmacists and GPs. Nurses were less positive about their ability to influence policy. Currently substance misuse nurses have little input at policy level. At a local level, through Drug and Alcohol Action Teams (DAATs) this could improve the feeling of ownership towards service developments related to the Joint Future agenda. Service managers are currently the key link between nurses and DAATs. Perhaps a service nurse with more client contact should also attend to provide client feedback. At a national level greater nursing input into policy could give this specialist group a greater feeling of professional cohesion as well as keeping policy makers informed. Concerns about health and safety at work need to be considered at a national professional level as well as locally. Whether these issues should be addressed through the involvement of an organisation such as the Association of Nurses in Substance Abuse (ANSA) or an appointed individual is for discussion. Recommendations • All substance misuse nurses should receive induction training prior to commencing their post. Greater time should be protected to allow participation in training. • There should be further exploration of what models of counselling, if any, are followed to assess whether current training is adequate. • Appointment scheduling may need review as there was evidence that consultation time was routinely underestimated. Frequency of missed appointments needs to be considered at the same time. • Staffing of substance misuse nurses should be expanded in order to reduce: excessive caseloads; lengthy waiting lists; insufficient cover for holidays, training and absences; and occupational stress. • Nurses could be involved in GP training to share their experience of managing difficult cases such as poly-drug users and widen GPs perspective of the social benefits of drug misuse treatment. • Nurses should be kept aware of developments on integrated care for drug misusers. This would allow them to understand the principles behind integrated care and be aware of how their service fits into the overall plan. • Extending the role of senior substance misuse nurses to include the prescribing of controlled drugs should be considered. • A clearer job title should be given to nurses working in substance misuse so that they may be easily identified and representable at both DAAT and Scottish Executive level, e.g. Specialist Nurse in Substance Misuse. • Efforts should be made to improve substance misuse nurses’ opportunities to influence policy. • All substance misuse nurses should be provided with appropriate on going training, procedures and practices to allow them to carry out their work safely

Characteristic velocities of stripped-envelope core-collapse supernova cores

The velocity of the inner ejecta of stripped-envelope core-collapse supernovae (CC-SNe) is studied by means of an analysis of their nebular spectra. Stripped-envelope CC-SNe are the result of the explosion of bare cores of massive stars ($\geq 8$ M$_{\odot}$), and their late-time spectra are typically dominated by a strong [O {\sc i}] $\lambda\lambda$6300, 6363 emission line produced by the innermost, slow-moving ejecta which are not visible at earlier times as they are located below the photosphere. A characteristic velocity of the inner ejecta is obtained for a sample of 56 stripped-envelope CC-SNe of different spectral types (IIb, Ib, Ic) using direct measurements of the line width as well as spectral fitting. For most SNe, this value shows a small scatter around 4500 km s$^{-1}$. Observations ($< 100$ days) of stripped-envelope CC-SNe have revealed a subclass of very energetic SNe, termed broad-lined SNe (BL-SNe) or hypernovae, which are characterised by broad absorption lines in the early-time spectra, indicative of outer ejecta moving at very high velocity ($v \geq 0.1 c$). SNe identified as BL in the early phase show large variations of core velocities at late phases, with some having much higher and some having similar velocities with respect to regular CC-SNe. This might indicate asphericity of the inner ejecta of BL-SNe, a possibility we investigate using synthetic three-dimensional nebular spectra.Comment: 14 pages, 10 figures, MNRAS accepte

Protein folding rates correlate with heterogeneity of folding mechanism

By observing trends in the folding kinetics of experimental 2-state proteins at their transition midpoints, and by observing trends in the barrier heights of numerous simulations of coarse grained, C-alpha model, Go proteins, we show that folding rates correlate with the degree of heterogeneity in the formation of native contacts. Statistically significant correlations are observed between folding rates and measures of heterogeneity inherent in the native topology, as well as between rates and the variance in the distribution of either experimentally measured or simulated phi-values.Comment: 11 pages, 3 figures, 1 tabl

Photometry and spectroscopy of faint candidate spectrophotometric standard DA white dwarfs

We present precise photometry and spectroscopy for 23 candidate spectrophotometric standard white dwarfs. The selected stars are distributed in the Northern hemisphere and around the celestial equators and are all fainter than r ~ 16.5 mag. This network of stars, when established as standards, together with the three Hubble Space Telescope primary CALSPEC white dwarfs, will provide a set of spectrophotometric standards to directly calibrate data products to better than 1%. These new faint standard white dwarfs will have enough signal-to-noise ratio in future deep photometric surveys and facilities to be measured accurately while still avoiding saturation in such surveys. They will also fall within the dynamic range of large telescopes and their instruments for the foreseeable future. This paper discusses the provenance of the observational data for our candidate standard stars. The comparison with models, reconciliation with reddening, and the consequent derivation of the full spectral energy density distributions for each of them is reserved for a subsequent paper.Comment: 31 pages, 17 figures, 10 tables, ApJ in press (accepted on December 23rd, 2018

Cyclotron effective mass of 2D electron layer at GaAs/AlGaAs heterojunction subject to in-plane magnetic fields

We have found that Fermi contours of a two-dimensional electron gas at \rmGaAs/Al_xGa_{1-x}As interface deviate from a standard circular shape under the combined influence of an approximately triangular confining potential and the strong in-plane magnetic field. The distortion of a Fermi contour manifests itself through an increase of the electron effective cyclotron mass which has been measured by the cyclotron resonance in the far-infrared transmission spectra and by the thermal damping of Shubnikov-de Haas oscillations in tilted magnetic fields with an in-plane component up to 5 T. The observed increase of the cyclotron effective mass reaches almost 5 \% of its zero field value which is in good agreement with results of a self-consistent calculation.Comment: 4 pages, Revtex, figures can be obtained on request from [email protected]; to appear in Phys. Rev. B (in press). No changes, the corrupted submission replace

K Corrections For Type Ia Supernovae and a Test for Spatial Variation of the Hubble Constant

Cross-filter K corrections for a sample of "normal" Type Ia supernovae (SNe) have been calculated for a range of epochs. With appropriate filter choices, the combined statistical and systematic K correction dispersion of the full sample lies within 0.05 mag for redshifts z<0.7. This narrow dispersion of the calculated K correction allows the Type Ia to be used as a cosmological probe. We use the K corrections with observations of seven SNe at redshifts 0.3 < z <0.5 to bound the possible difference between the locally measured Hubble constant (H_L) and the true cosmological Hubble constant (H_0).Comment: 6 pages, 3 Postscript figures, uuencoded uses crckapb.sty and psfig.sty. To appear in Thermonuclear Supernovae (NATO ASI), eds. R. Canal, P. Ruiz-LaPuente, and J. Isern. Postscript version is also available at http://www-supernova.lbl.gov

The Type IIn SN 1995G: Interaction with the CSM

We present the photometric and spectroscopic evolution of the type IIn SN 1995G in NGC 1643, on the basis of 4 years of optical and infrared observations. This supernova shows very flat optical light curves similar to SN 1988Z, with a slow decline rate at all times. The spectra are characterized by strong Balmer lines with multiple components in emission and with a P-Cygni absorption component blueshifted by only 700 km/s. This feature indicates the presence of a slowly expanding shell above the SN ejecta as in the case of SNe 1994aj and 1996L. As in other SNe IIn the slow luminosity decline cannot be explained only with a radioactive energy input and an additional source of energy is required, most likely that produced by the interaction between supernova ejecta and a pre--existent circumstellar medium. It was estimated that the shell material has a density n(H) >> 10^8 cm^-3, consistent with the absence of forbidden lines in the spectra. About 2 years after the burst the low velocity shell is largely overtaken by the SN ejecta and the luminosity drops at a faster rate.Comment: 14 pages, including 11 figures. Accepted by MNRA

The Emergence of the Infrared transient VVV-WIT-06

We report the discovery of an enigmatic large-amplitude (ΔKs> 10.5 mag) transient event in near-IR data obtained by the VISTA Variables in the Via Lactea (VVV) ESO Public Survey. The object (designated VVV-WIT-06) is located at R.A. = 17:07:18.917, decl. = -39:06:26.45 (J2000), corresponding to Galactic coordinates l = 347.14539, b = 0.88522. It exhibits a clear eruption, peaking at Ks = 9 mag during 2013 July and fading to Ks ~ 16.5 in 2017. Our late near-IR spectra show post-outburst emission lines, including some broad emission lines (upward of {FWHM} ~ 3000 k/s). We estimate a total extinction of A_V=10--15 mag in the surrounding field, and no progenitor was observed in ZYJHKs images obtained during 2010-2012 (down to Ks> 18.5 mag). Subsequent deep near-IR imaging and spectroscopy, in concert with the available multiband photometry, indicate that VVV-WIT-06 may be either: (I) the closest Type I SN observed in about 400 years, (II) an exotic high-amplitude nova that would extend the known realm of such objects, or (III) a stellar merger. In all of these cases, VVV-WIT-06 is a fascinating and curious astrophysical target under any of the scenarios considered.Peer reviewe

Implications For The Hubble Constant from the First Seven Supernovae at z >= 0.35

The Supernova Cosmology Project has discovered over twenty-eight supernovae (SNe) at 0.35 <z < 0.65 in an ongoing program that uses Type Ia SNe as high-redshift distance indicators. Here we present measurements of the ratio between the locally observed and global Hubble constants, H_0^L/H_0^G, based on the first 7 SNe of this high-redshift data set compared with 18 SNe at z <= 0.1 from the Calan/Tololo survey. If Omega_M <= 1, then light-curve-width corrected SN magnitudes yield H_0^L/H_0^G < 1.10 (95% confidence level) in both a Lambda=0 and a flat universe. The analysis using the SNe Ia as standard candles without a light-curve-width correction yields similar results. These results rule out the hypothesis that the discrepant ages of the Universe derived from globular clusters and recent measurements of the Hubble constant are attributable to a locally underdense bubble. Using the Cepheid-distance-calibrated absolute magnitudes for SNe Ia of Sandage (1996}, we can also measure the global Hubble constant, H_0^G. If Omega_M >= 0.2, we find that H_0^G < 70 km/s/Mpc in a Lambda=0 universe and H_0^G < 78 km/s/Mpc in a flat universe, correcting the distant and local SN apparent magnitudes for light curve width. Lower results for H_0^G are obtained if the magnitudes are not width corrected.Comment: 13 pages, 2 Postscript figures. Preprint also available at http://www-supernova.lbl.gov . To appear in ApJ Letter