"Horses for Courses" Comment on "Translating Evidence Into Healthcare Policy and Practice: Single Versus Multi-Faceted Implementation Strategies – Is There a Simple Answer to a Complex Question?"

This commentary considers the vexed question of whether or not we should be spending time and resources on using multifaceted interventions to undertake implementation of evidence in healthcare. A review of systematic reviews has suggested that simple interventions may be just as effective as those taking a multifaceted approach. Taking cognisance of the Promoting Action on Research Implementation in Health Services (PARIHS) framework this commentary takes account of the evidence, context and facilitation factors in undertaking implementation. It concludes that a ‘horses for courses’ approach is necessary meaning that the specific implementation approach should be selected to fit the implementation task in hand whether it be a single or multifaceted approach and reviewed on an individual basis

Time, fear and transformation: Student nurses' experiences of doing a practicum (quality improvement project) in practice

Background  Improving and sustaining quality in healthcare continues to be a global challenge, resulting in the necessity of developing quality improvement (QI) skills and knowledge to use in practice. This paper reports student nurses' experiences of conducting a quality improvement project (Practicum) as a compulsory assessment whilst on clinical placement areas across Scotland.  Methods  Telephone and face-to-face interviews (n=18) were conducted using a semi-structured interview schedule. Discussions were transcribed verbatim and data were analysed thematically. Data were extracted from Practicum assignments (n=50).  Results  Three key themes emerged from the analysis: 1) Time; students highlighted the necessity of time in practice areas to acclimatise, socialise and conduct the Practicum. Timing of the Practicum within the curriculum was also important. 2) Fear; was experienced by many students at the perceived enormity of the assignment, the bravery needed to attempt to change practice and the adjustment to a unique type of assignment. 3) Transformation; students shared their shifted perceptions on completing a Practicum, including a sense of achievement and acknowledgement of key improvement skills for the future.  Conclusions   Student nurses need to be stretched beyond their comfort zones to rise to the challenge of the Practicum, whilst ensuring adequate support mechanisms are in place from a range of sources

“Horses for Courses” Comment on “Translating Evidence Into Healthcare Policy and Practice: Single Versus Multi-Faceted Implementation Strategies – Is There a Simple Answer to a Complex Question?”

This commentary considers the vexed question of whether or not we should be spending time and resources on using multifaceted interventions to undertake implementation of evidence in healthcare. A review of systematic reviews has suggested that simple interventions may be just as effective as those taking a multifaceted approach. Taking cognisance of the Promoting Action on Research Implementation in Health Services (PARIHS) framework this commentary takes account of the evidence, context and facilitation factors in undertaking implementation. It concludes that a ‘horses for courses’ approach is necessary meaning that the specific implementation approach should be selected to fit the implementation task in hand whether it be a single or multifaceted approach and reviewed on an individual basi

Physical Electronics

Contains reports on three research projects

PROPEL: implementation of an evidence based pelvic floor muscle training intervention for women with pelvic organ prolapse: a realist evaluation and outcomes study protocol

Abstract Background Pelvic Organ Prolapse (POP) is estimated to affect 41%–50% of women aged over 40. Findings from the multi-centre randomised controlled “Pelvic Organ Prolapse PhysiotherapY” (POPPY) trial showed that individualised pelvic floor muscle training (PFMT) was effective in reducing symptoms of prolapse, improved quality of life and showed clear potential to be cost-effective. However, provision of PFMT for prolapse continues to vary across the UK, with limited numbers of women’s health physiotherapists specialising in its delivery. Implementation of this robust evidence from the POPPY trial will require attention to different models of delivery (e.g. staff skill mix) to fit with differing care environments. Methods A Realist Evaluation (RE) of implementation and outcomes of PFMT delivery in contrasting NHS settings will be conducted using multiple case study sites. Involving substantial local stakeholder engagement will permit a detailed exploration of how local sites make decisions on how to deliver PFMT and how these lead to service change. The RE will track how implementation is working; identify what influences outcomes; and, guided by the RE-AIM framework, will collect robust outcomes data. This will require mixed methods data collection and analysis. Qualitative data will be collected at four time-points across each site to understand local contexts and decisions regarding options for intervention delivery and to monitor implementation, uptake, adherence and outcomes. Patient outcome data will be collected at baseline, six months and one year follow-up for 120 women. Primary outcome will be the Pelvic Organ Prolapse Symptom Score (POP-SS). An economic evaluation will assess the costs and benefits associated with different delivery models taking account of further health care resource use by the women. Cost data will be combined with the primary outcome in a cost effectiveness analysis, and the EQ-5D-5L data in a cost utility analysis for each of the different models of delivery. Discussion Study of the implementation of varying models of service delivery of PFMT across contrasting sites combined with outcomes data and a cost effectiveness analysis will provide insight into the implementation and value of different models of PFMT service delivery and the cost benefits to the NHS in the longer term

Implementing health research through academic and clinical partnerships : a realistic evaluation of the Collaborations for Leadership in Applied Health Research and Care (CLAHRC)

Background: The English National Health Service has made a major investment in nine partnerships between higher education institutions and local health services called Collaborations for Leadership in Applied Health Research and Care (CLAHRC). They have been funded to increase capacity and capability to produce and implement research through sustained interactions between academics and health services. CLAHRCs provide a natural ‘test bed’ for exploring questions about research implementation within a partnership model of delivery. This protocol describes an externally funded evaluation that focuses on implementation mechanisms and processes within three CLAHRCs. It seeks to uncover what works, for whom, how, and in what circumstances. Design and methods: This study is a longitudinal three-phase, multi-method realistic evaluation, which deliberately aims to explore the boundaries around knowledge use in context. The evaluation funder wishes to see it conducted for the process of learning, not for judging performance. The study is underpinned by a conceptual framework that combines the Promoting Action on Research Implementation in Health Services and Knowledge to Action frameworks to reflect the complexities of implementation. Three participating CLARHCS will provide indepth comparative case studies of research implementation using multiple data collection methods including interviews, observation, documents, and publicly available data to test and refine hypotheses over four rounds of data collection. We will test the wider applicability of emerging findings with a wider community using an interpretative forum. Discussion: The idea that collaboration between academics and services might lead to more applicable health research that is actually used in practice is theoretically and intuitively appealing; however the evidence for it is limited. Our evaluation is designed to capture the processes and impacts of collaborative approaches for implementing research, and therefore should contribute to the evidence base about an increasingly popular (e.g., Mode two, integrated knowledge transfer, interactive research), but poorly understood approach to knowledge translation. Additionally we hope to develop approaches for evaluating implementation processes and impacts particularly with respect to integrated stakeholder involvement

HETDEX pilot survey for emission-line galaxies - I. Survey design, performance, and catalog

We present a catalog of emission-line galaxies selected solely by their emission-line fluxes using a wide-field integral field spectrograph. This work is partially motivated as a pilot survey for the upcoming Hobby-Eberly Telescope Dark Energy Experiment (HETDEX). We describe the observations, reductions, detections, redshift classifications, line fluxes, and counterpart information for 397 emission-line galaxies detected over 169 sq.arcmin with a 3500-5800 Ang. bandpass under 5 Ang. full-width-half-maximum (FWHM) spectral resolution. The survey's best sensitivity for unresolved objects under photometric conditions is between 4-20 E-17 erg/s/sq.cm depending on the wavelength, and Ly-alpha luminosities between 3-6 E42 erg/s are detectable. This survey method complements narrowband and color-selection techniques in the search for high redshift galaxies with its different selection properties and large volume probed. The four survey fields within the COSMOS, GOODS-N, MUNICS, and XMM-LSS areas are rich with existing, complementary data. We find 104 galaxies via their high redshift Ly-alpha emission at 1.9<z<3.8, and the majority of the remainder objects are low redshift [OII]3727 emitters at z<0.56. The classification between low and high redshift objects depends on rest frame equivalent width, as well as other indicators, where available. Based on matches to X-ray catalogs, the active galactic nuclei (AGN) fraction amongst the Ly-alpha emitters (LAEs) is 6%. We also analyze the survey's completeness and contamination properties through simulations. We find five high-z, highly-significant, resolved objects with full-width-half-maximum sizes >44 sq.arcsec which appear to be extended Ly-alpha nebulae. We also find three high-z objects with rest frame Ly-alpha equivalent widths above the level believed to be achievable with normal star formation, EW(rest)>240 Ang.Comment: 45 pages, 36 figures, 5 tables, submitted to ApJ

Blackwell Science, LtdOxford, UKJEPJournal of Evaluation in Clinical Practice1365-2753Blackwell Publishing Ltd 200310 3387398 Original Article Introducing the Learning Practice -II

Abstract Rationale, aims and objectives This paper is the second of three related papers exploring the ways in which the principles of Learning Organizations (LOs) could be applied in Primary Care settings at the point of service delivery. Methods Based on a theoretical and empirical review of available evidence, here we introduce the process by which a Practice can start to become a Learning Practice (LP). Results and conclusions Steps taken to enhance both individual and organizational learning begin the process of moving towards a learning culture. Attention is given to the routines that can be established within the practice to make learning systematically an integral part of what the practice does. This involves focusing on all three of single-, double-and triple-loop learning. Within the paper, a distinction is made between individual, collective and organizational learning. We argue that individual and collective learning may be easier to achieve than organizational learning as processes and systems already exist within the Health Service to facilitate personal learning and development with some opportunities for collective and integrated learning and working. However, although organizational learning needs to spread beyond the LP to the wider Health Service to inform future training courses, policy and decisionmaking, there currently seem to be few processes by which this might be achieved. This paper contributes to the wider quality improvement debate in three main ways. First, by reviewing existing theoretical and empirical material on LOs in health care settings it provides both an informed vision and a set of practical guidelines on the ways in which a Practice could start to effect its own regime of learning, innovation and change. Second, it highlights the paucity of opportunities individual general practitioner practices have to share their learning more widely. Thirdly, it adds to the evidence base on how to apply LO theory and activate learning cultures in health care settings

From insect to man: Photorhabdus sheds light on the emergence of human pathogenicity

Photorhabdus are highly effective insect pathogenic bacteria that exist in a mutualistic relationship with Heterorhabditid nematodes. Unlike other members of the genus, Photorhabdus asymbiotica can also infect humans. Most Photorhabdus cannot replicate above 34°C, limiting their host-range to poikilothermic invertebrates. In contrast, P. asymbiotica must necessarily be able to replicate at 37°C or above. Many well-studied mammalian pathogens use the elevated temperature of their host as a signal to regulate the necessary changes in gene expression required for infection. Here we use RNA-seq, proteomics and phenotype microarrays to examine temperature dependent differences in transcription, translation and phenotype of P. asymbiotica at 28°C versus 37°C, relevant to the insect or human hosts respectively. Our findings reveal relatively few temperature dependant differences in gene expression. There is however a striking difference in metabolism at 37°C, with a significant reduction in the range of carbon and nitrogen sources that otherwise support respiration at 28°C. We propose that the key adaptation that enables P. asymbiotica to infect humans is to aggressively acquire amino acids, peptides and other nutrients from the human host, employing a so called “nutritional virulence” strategy. This would simultaneously cripple the host immune response while providing nutrients sufficient for reproduction. This might explain the severity of ulcerated lesions observed in clinical cases of Photorhabdosis. Furthermore, while P. asymbiotica can invade mammalian cells they must also resist immediate killing by humoral immunity components in serum. We observed an increase in the production of the insect Phenol-oxidase inhibitor Rhabduscin normally deployed to inhibit the melanisation immune cascade. Crucially we demonstrated this molecule also facilitates protection against killing by the alternative human complement pathway

The influence of both individual and area based socioeconomic status on temporal trends in Caesarean sections in Scotland 1980-2000

Background: Caesarean section rates have risen over the last 20 years. Elective Caesarean section rates have been shown to be linked to area deprivation in England, women in the most deprived areas were less likely to have an elective section than those in the most affluent areas. We examine whether individual social class, area deprivation or both are related to Caesarean sections in Scotland and investigate changes over time. Methods: Routine maternity discharge data from live singleton births in Scottish hospitals from three time periods were used; 1980-81 (n = 133,555), 1990-91 (n = 128,933) and 1999-2000 (n = 102,285). Multilevel logistic regression, with 3 levels (births, postcode sector and Health Board) was used to analyse emergency and elective Caesareans separately; analysis was further stratified by previous Caesarean section. The relative index of inequality (RII) was used to assess socioeconomic inequalities. Results: Between 1980-81 and 1999-2000 the emergency section rate increased from 6.3% to 11.9% and the elective rate from 3.6% to 5.5%. In 1980-81 and 1990-91 emergency Caesareans were more likely among women at the bottom of the social class hierarchy compared to those at the top (RII = 1.14, 95%CI 1.00-1.25 and RII = 1.13, 1.03-1.23 respectively) and also among women in the most deprived areas compared to those in the most affluent (RII = 1.18, 1.05-1.32 and RII = 1.13, 1.02-1.26 respectively). In 1999-2000 the odds of an elective section were lower for women at the bottom of the social class hierarchy than those at the top (RII = 0.87, 0.76-1.00) and also lower in women in the most deprived areas compared to those in the most affluent (RII = 0.85, 0.73-0.99). Conclusions: Both individual social class and area deprivation are independently associated with Caesarean sections in Scotland. The tendency for disadvantaged women to be more likely to receive emergency sections disappeared at the same time as the likelihood of advantaged groups receiving elective sections increased