Nurse led care

What's the difference between medical and nursing care? The answer is not straightforward, but shortages in the medical workforce mean that nurses are increasingly called on to undertake work that was previously done by doctors (such as undertaking surgery,1 prescribing drugs, performing triage in emergency departments), whereas shortages in the nursing workforce mean that healthcare assistants now do many tasks that nurses are trained to do. This fluidity in professional roles and competencies enables the health workforce to respond to need, but are outcomes for patients being improved? Do these benefits come at an additional cost, and if so, are they worth paying for

Acute care nurses' perceptions of barriers to using research information in clinical decision-making

Aim. To examine the barriers that nurses feel prevent them from using research in the decisions they make. Background. A sizeable research literature focusing on research utilization in nursing has developed over the past 20 years. However, this literature is characterized by a number of weaknesses: self-reported utilization behaviour; poor response rates and small, nonrandom sampling strategies. Design. Cross-case analysis involving anonymised qualitative interviews, observation, documentary audit and Q methodological modelling of shared subjectivities amongst nurses. The case sites were three large acute hospitals in the north of England. One hundred and eight nurses were interviewed, 61 of whom were also observed for a total of 180 h, and 122 nurses were involved in the Q modelling exercise (response rate of 64%). Results. Four perspectives were isolated that encompassed the characteristics associated with barriers to research use. These related to the individual, organization, nature of research information itself and environment. Nurses clustered around four main perspectives on the barriers to research use: (1) Problems in interpreting and using research products, which were seen as too complex, 'academic' and overly statistical; (2) Nurses who felt confident with research-based information perceived a lack of organizational support as a significant block; (3) Many nurses felt that researchers and research products lack clinical credibility and that they fail to offer the desired level of clinical direction; (4) Some nurses lacked the skills and, to a lesser degree, the motivation to use research themselves. These individuals liked research messages passed on to them by a third party and sought to foster others' involvement in research-based practice, rather than becoming directly involved themselves. Conclusions. Rejection of research knowledge is not a barrier to its application. Rather, the presentation and management of research knowledge in the workplace represent significant challenges for clinicians, policy-makers and the research community

The accessibility of research-based knowledge for nurses in United Kingdom acute care settings

Background. The successful dissemination of the results of the National Health Service (NHS) research and development strategy and the development of evidence based approaches to health care rely on clinicians having access to the best available evidence; evidence fit for the purpose of reducing the uncertainties associated with clinical decisions. Aim. To reveal the accessibility of those sources of information actually used by nurses, as well as those which they say they use. Design. Mixed method case site, using interview, observational, Q sort and documentary audit data in medical, surgical and coronary care units (CCUs) in three acute hospitals. Results. Three perspectives on accessibility were identified: (a) the humanist-in which human sources of information were the most accessible; (b) local information for local needs-in which locally produced resources were seen as the most accessible and (c) moving towards technology-in which information technology begins to be seen as accessible. Nurses' experience in a clinical specialty is positively associated with a perception that human sources such clinical nurse specialists, link nurses, doctors and experienced clinical colleagues are more accessible than text based sources. Clinical specialization is associated with different approaches to accessing research knowledge. Coronary care unit nurses were more likely perceive local guidelines, protocols and on-line databases as more accessible than their counterparts in general medical and surgical wards. Only a third of text-based resources available to nurses oil the wards had any explicit research base. These, and the remainder were Out of date (mean age of textbooks 11 years), and authorship hard to ascertain. Conclusion. A strategy to increase the use of research evidence by nurses should harness the influence of clinical nurse specialists, link nurses and those engaged in practice development. These roles Could act as 'conduits' through which research-based messages for practice, and information for clinical decision making, could flow. This role should be explored and enhanced

Four layer bandage compared with short stretch bandage for venous leg ulcers: systematic review and meta-analysis of randomised controlled trials with data from individual patients

<p><b>Objective:</b> To compare the effectiveness of two types of compression treatment (four layer bandage and short stretch bandage) in people with venous leg ulceration.</p> <p><b>Design:</b> Systematic review and meta-analysis of patient level data.</p> <p><b>Data:</b> sources Electronic databases (the Cochrane Central Register of Controlled Trials, the Cochrane Wounds Group Specialised Register, Medline, Embase, CINAHL, and National Research Register) and reference lists of retrieved articles searched to identify relevant trials and primary investigators. Primary investigators of eligible trials were invited to contribute raw data for re-analysis.</p> <p><b>Review:</b> methods Randomised controlled trials of four layer bandage compared with short stretch bandage in people with venous leg ulceration were eligible for inclusion. The primary outcome for the meta-analysis was time to healing. Cox proportional hazards models were run to compare the methods in terms of time to healing with adjustment for independent predictors of healing. Secondary outcomes included incidence and number of adverse events per patient.</p> <p><b>Results:</b> Seven eligible trials were identified (887 patients), and patient level data were retrieved for five (797 patients, 90% of known randomised patients). The four layer bandage was associated with significantly shorter time to healing: hazard ratio (95% confidence interval) from multifactorial model based on five trials was 1.31 (1.09 to 1.58), P=0.005. Larger ulcer area at baseline, more chronic ulceration, and previous ulceration were all independent predictors of delayed healing. Data from two trials showed no evidence of a difference in adverse event profiles between the two bandage types.</p> <p><b>Conclusions:</b> Venous leg ulcers in patients treated with four layer bandages heal faster, on average, than those of people treated with the short stretch bandage. Benefits were consistent across patients with differing prognostic profiles.</p&gt

Local electronic nematicity in the one-band Hubbard model

Nematicity is a well known property of liquid crystals and has been recently discussed in the context of strongly interacting electrons. An electronic nematic phase has been seen by many experiments in certain strongly correlated materials, in particular, in the pseudogap phase generic to many hole-doped cuprate superconductors. Recent measurements in high $T_c$ superconductors has shown even if the lattice is perfectly rotationally symmetric, the ground state can still have strongly nematic local properties. Our study of the two-dimensional Hubbard model provides strong support of the recent experimental results on local rotational $C_4$ symmetry breaking. The variational cluster approach is used here to show the possibility of an electronic nematic state and the proximity of the underlying symmetry-breaking ground state within the Hubbard model. We identify this nematic phase in the overdoped region and show that the local nematicity decreases with increasing electron filling. Our results also indicate that strong Coulomb interaction may drive the nematic phase into a phase similar to the stripe structure. The calculated spin (magnetic) correlation function in momentum space shows the effects resulting from real-space nematicity

What's the evidence that NICE guidance has been implemented? Results from a national evaluation using time series analysis, audit of patients' notes, and interviews

OBJECTIVES: To assess the extent and pattern of implementation of guidance issued by the National Institute for Clinical Excellence (NICE). DESIGN: Interrupted time series analysis, review of case notes, survey, and interviews. SETTING: Acute and primary care trusts in England and Wales. PARTICIPANTS: All primary care prescribing, hospital pharmacies; a random sample of 20 acute trusts, 17 mental health trusts, and 21 primary care trusts; and senior clinicians and managers from five acute trusts. MAIN OUTCOME MEASURES: Rates of prescribing and use of procedures and medical devices relative to evidence based guidance. RESULTS: 6308 usable patient audit forms were returned. Implementation of NICE guidance varied by trust and by topic. Prescribing of some taxanes for cancer (P <0.002) and orlistat for obesity (P <0.001) significantly increased in line with guidance. Prescribing of drugs for Alzheimer’s disease and prophylactic extraction of wisdom teeth showed trends consistent with, but not obviously a consequence of, the guidance. Prescribing practice often did not accord with the details of the guidance. No change was apparent in the use of hearing aids, hip prostheses, implantable cardioverter defibrillators, laparoscopic hernia repair, and laparoscopic colorectal cancer surgery after NICE guidance had been issued. CONCLUSIONS: Implementation of NICE guidance has been variable. Guidance seems more likely to be adopted when there is strong professional support, a stable and convincing evidence base, and no increased or unfunded costs, in organisations that have established good systems for tracking guidance implementation and where the professionals involved are not isolated. Guidance needs to be clear and reflect the clinical context

Randomised, controlled trial of alternating pressure mattresses compared with alternating pressure overlays for the prevention of pressure ulcers : PRESSURE (pressure relieving support surfaces) trial

Objective To compare whether differences exist between alternating pressure overlays and alternating pressure mattresses in the development of new pressure ulcers, healing of existing pressure ulcers, and patient acceptability. Design Pragmatic, open, multicentre, randomised controlled trial. Setting 11 hospitals in six NHS trusts. Participants 1972 people admitted to hospital as acute or elective patients. Interventions Participants were randomised to an alternating pressure mattress (n = 982) of- an alternating pressure overlay (n = 990). Main outcome measures The proportion of participants developing a new pressure ulcer of grade 2 or worse; time to development of new pressure ulcers; proportions of participants developing a new ulcer within 30 days; healing of existing pressure ulcers; and patient acceptability Results Intention to treat analysis found no difference in the proportions of participants developing a new pressure ulcer of grade 2 or worse (10.7% overlay patients, 10.3% mattress patients; difference 0.4%, 95% confidence interval - 23% to 3.1%, P = 0.75). More overlay patients requested change owing to dissatisfaction (23.3%) than mattress patients (18.9%, P = 0.02). Conclusion No difference was found between alternating pressure mattresses and alternating pressure overlays in the proportion of people who develop a pressure ulcer

Differences in the potential for dementia prevention between major ethnic groups within one country: A cross sectional analysis of population attributable fraction of potentially modifiable risk factors in New Zealand

Background: Twelve potentially modifiable risk factors (less education, hypertension, obesity, alcohol, traumatic brain injury (TBI), hearing loss, smoking, depression, physical inactivity, social isolation, diabetes, air pollution) account for an estimated 40% of worldwide dementia cases. We aimed to calculate population attributable fractions (PAFs) for dementia for the four largest New Zealand ethnic groups (European, Māori, Asian, and Pacific peoples) to identify whether optimal dementia prevention targets differed by ethnicity. Methods: We calculated risk factor prevalence for 10 risk factors using the New Zealand Health Survey 2018/19 and published reports for hearing loss and TBI prevalences. We calculated the PAF for each risk factor using calculated prevalence and relative risk estimates from previous meta-analyses. To account for risk factor overlap, we calculated communality of risk factors and a weighted PAF. Findings: The weighted PAF for dementia was 47•7% overall in New Zealand, 47•6% for Europeans, 51•4% for Māori, 50•8% for Pacific peoples, and 40•8% for Asians. Highest PAFs for Europeans were hearing loss (8%) and social isolation (5•7%), and for Asians hearing loss (7•3%) and physical inactivity (5•5%). For Māori and Pacific peoples, highest PAFs were for obesity (7•3% and 8•9% respectively) and hearing loss (6•5% and 6•6%). Interpretation: New Zealand has higher dementia prevention potential than worldwide estimates with high prevalences of untreated hearing loss and obesity. The relative contribution of individual risk factors PAFs varies by ethnic group. Public health strategies for dementia prevention need to be tailored to these differences

Protease activity as a prognostic factor for wound healing in venous leg ulcers.

BACKGROUND: Venous leg ulcers (VLUs) are a common type of complex wound that have a negative impact on people's lives and incur high costs for health services and society. It has been suggested that prolonged high levels of protease activity in the later stages of the healing of chronic wounds may be associated with delayed healing. Protease modulating treatments have been developed which seek to modulate protease activity and thereby promote healing in chronic wounds. OBJECTIVES: To determine whether protease activity is an independent prognostic factor for the healing of venous leg ulcers. SEARCH METHODS: In February 2018, we searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Ovid Embase and CINAHL. SELECTION CRITERIA: We included prospective and retrospective longitudinal studies with any follow-up period that recruited people with VLUs and investigated whether protease activity in wound fluid was associated with future healing of VLUs. We included randomised controlled trials (RCTs) analysed as cohort studies, provided interventions were taken into account in the analysis, and case-control studies if there were no available cohort studies. We also included prediction model studies provided they reported separately associations of individual prognostic factors (protease activity) with healing. Studies of any type of protease or combination of proteases were eligible, including proteases from bacteria, and the prognostic factor could be examined as a continuous or categorical variable; any cut-off point was permitted. The primary outcomes were time to healing (survival analysis) and the proportion of people with ulcers completely healed; the secondary outcome was change in ulcer size/rate of wound closure. We extracted unadjusted (simple) and adjusted (multivariable) associations between the prognostic factor and healing. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion at each stage, and undertook data extraction, assessment of risk of bias and GRADE assessment. We collected association statistics where available. No study reported adjusted analyses: instead we collected unadjusted results or calculated association measures from raw data. We calculated risk ratios when both outcome and prognostic factor were dichotomous variables. When the prognostic factor was reported as continuous data and healing outcomes were dichotomous, we either performed regression analysis or analysed the impact of healing on protease levels, analysing as the standardised mean difference. When both prognostic factor and outcome were continuous data, we reported correlation coefficients or calculated them from individual participant data.We displayed all results on forest plots to give an overall visual representation. We planned to conduct meta-analyses where this was appropriate, otherwise we summarised narratively. MAIN RESULTS: We included 19 studies comprising 21 cohorts involving 646 participants. Only 11 studies (13 cohorts, 522 participants) had data available for analysis. Of these, five were prospective cohort studies, four were RCTs and two had a type of case-control design. Follow-up time ranged from four to 36 weeks. Studies covered 10 different matrix metalloproteases (MMPs) and two serine proteases (human neutrophil elastase and urokinase-type plasminogen activators). Two studies recorded complete healing as an outcome; other studies recorded partial healing measures. There was clinical and methodological heterogeneity across studies; for example, in the definition of healing, the type of protease and its measurement, the distribution of active and bound protease species, the types of treatment and the reporting of results. Therefore, meta-analysis was not performed. No study had conducted multivariable analyses and all included evidence was of very low certainty because of the lack of adjustment for confounders, the high risk of bias for all studies except one, imprecision around the measures of association and inconsistency in the direction of association. Collectively the research indicated complete uncertainty as to the association between protease activity and VLU healing. AUTHORS' CONCLUSIONS: This review identified very low validity evidence regarding any association between protease activity and VLU healing and there is complete uncertainty regarding the relationship. The review offers information for both future research and systematic review methodology

Interaction effects and quantum phase transitions in topological insulators

We study strong correlation effects in topological insulators via the Lanczos algorithm, which we utilize to calculate the exact many-particle ground-state wave function and its topological properties. We analyze the simple, noninteracting Haldane model on a honeycomb lattice with known topological properties and demonstrate that these properties are already evident in small clusters. Next, we consider interacting fermions by introducing repulsive nearest-neighbor interactions. A first-order quantum phase transition was discovered at finite interaction strength between the topological band insulator and a topologically trivial Mott insulating phase by use of the fidelity metric and the charge-density-wave structure factor. We construct the phase diagram at $T = 0$ as a function of the interaction strength and the complex phase for the next-nearest-neighbor hoppings. Finally, we consider the Haldane model with interacting hard-core bosons, where no evidence for a topological phase is observed. An important general conclusion of our work is that despite the intrinsic nonlocality of topological phases their key topological properties manifest themselves already in small systems and therefore can be studied numerically via exact diagonalization and observed experimentally, e.g., with trapped ions and cold atoms in optical lattices.Comment: 13 pages, 12 figures. Published versio