Developing digital interventions: a methodological guide.

Digital interventions are becoming an increasingly popular method of delivering healthcare as they enable and promote patient self-management. This paper provides a methodological guide to the processes involved in developing effective digital interventions, detailing how to plan and develop such interventions to avoid common pitfalls. It demonstrates the need for mixed qualitative and quantitative methods in order to develop digital interventions which are effective, feasible, and acceptable to users and stakeholders

Lived experiences of multimorbidity: an interpretative meta-synthesis of patients', general practitioners' and trainees' perceptions

OBJECTIVES: Multimorbidity is an increasing challenge. Better understanding of lived experiences of patients, general practitioners and trainees, may advance patient care and medical education. This interpretative meta-synthesis sought to (i) understand lived experiences of patients, general practitioners and trainees regarding multimorbidity, (ii) identify how similarities and differences in experiences should shape future solutions. METHODS: Empirical studies containing qualitative data and pertaining to lived experiences from our recent realist synthesis (PROSPERO 2013:CRD42013003862) were included. Following quality assessment, data were extracted from key studies to build an integrated analytic framework. Data from remaining studies were utilised to expand and refine the framework through thematic analysis of concepts within and between perspectives. RESULTS: Twenty-one papers were included in the meta-synthesis. Analysis of 70 concepts produced five themes: (1) goals of care and decision making, (2) complexity, (3) meeting expectations, (4) logistics and (5) interpersonal dynamics. The complexities of multimorbidity lead to shared feelings of vulnerability, uncertainty and enforced compromises. Barriers to optimal care-education included system constraints, inadequate continuity and role uncertainty. DISCUSSION: There was little evidence of shared discussion of these challenges. Addressing these issues and more explicit exploration of the experiences of each group during interactions may improve delivery and satisfaction in care and education

Flux cancellation and the evolution of the eruptive filament of 2011 June 7

We investigate whether flux cancellation is responsible for the formation of a very massive filament resulting in the spectacular 2011 June 7 eruption. We analyse and quantify the amount of flux cancellation that occurs in NOAA AR 11226 and its two neighbouring ARs (11227 & 11233) using line-of-sight magnetograms from the Heliospheric Magnetic Imager. During a 3.6-day period building up to the filament eruption, 1.7 x 10^21 Mx, 21% of AR 11226's maximum magnetic flux, was cancelled along the polarity inversion line (PIL) where the filament formed. If the flux cancellation continued at the same rate up until the eruption then up to 2.8 x 10^21 Mx (34% of the AR flux) may have been built into the magnetic configuration that contains the filament plasma. The large flux cancellation rate is due to an unusual motion of the positive polarity sunspot, which splits, with the largest section moving rapidly towards the PIL. This motion compresses the negative polarity and leads to the formation of an orphan penumbra where one end of the filament is rooted. Dense plasma threads above the orphan penumbra build into the filament, extending its length, and presumably injecting material into it. We conclude that the exceptionally strong flux cancellation in AR 11226 played a significant role in the formation of its unusually massive filament. In addition, the presence and coherent evolution of bald patches in the vector magnetic field along the PIL suggests that the magnetic field configuration supporting the filament material is that of a flux rope.Comment: 18 pages, 7 figures. Submitted to ApJ in December 2015, accepted in June 201

Understanding the Potential for Pharmacy Expertise in Palliative Care: The Value of Stakeholder Engagement in a Theoretically Driven Mapping Process for Research

Potentially avoidable medication-related harm is an inherent risk in palliative care; medication management accounts for approximately 20% of reported serious incidents in England and Wales. Despite their expertise benefiting patient care, the routine contribution of pharmacists in addressing medication management failures is overlooked. Internationally, specialist pharmacist support for palliative care services remains under-resourced. By understanding experienced practices (‘what happens in the real world’) in palliative care medication management, compared with intended processes (‘what happens on paper’), patient safety issues can be identified and addressed. This commentary demonstrates the value of stakeholder engagement and consultation work carried out to inform a scoping review and empirical study. Our overall goal is to improve medication safety in palliative care. Informal conversations were undertaken with carers and various specialist and non-specialist professionals, including pharmacists. Themes were mapped to five steps: decision-making, prescribing, monitoring and supply, use (administration), and stopping and disposal. A visual representation of stakeholders’ understanding of intended medicines processes was produced. This work has implications for our own and others’ research by highlighting where pharmacy expertise could have a significant additional impact. Evidence is needed to support best practice and implementation, particularly with regard to supporting carers in monitoring and accessing medication, and communication between health professionals across settings

Minding the gap between communication skills simulation and authentic experience

CONTEXT: Concurrent exposure to simulated and authentic experiences during undergraduate medical education is increasing. The impact of gaps or differences between contemporaneous experiences has not been adequately considered. We address two questions. How do new undergraduate medical students understand contemporaneous interactions with simulated and authentic patients? How and why do student perceptions of differences between simulated and authentic patient interactions shape their learning? METHODS: We conducted an interpretative thematic secondary analysis of research data comprising individual interviews (n = 23), focus groups (three groups, n = 16), and discussion groups (four groups, n = 26) with participants drawn from two different year cohorts of Year 1 medical students. These methods generated data from 48 different participants, of whom 17 provided longitudinal data. In addition, data from routinely collected written evaluations of three whole Year 1 cohorts (response rates ≥ 88%, n = 378) were incorporated into our secondary analysis dataset. The primary studies and our secondary analysis were conducted in a single UK medical school with an integrated curriculum. RESULTS: Our analysis identified that students generate knowledge and meaning from their simulated and authentic experiences relative to each other and that the resultant learning differs in quality according to meaning created by comparing and contrasting contemporaneous experiences. Three themes were identified that clarify how and why the contrasting of differences is an important process for learning outcomes. These are preparedness, responsibility for safety, and perceptions of a gap between theory and practice. CONCLUSIONS: We propose a conceptual framework generated by reframing common metaphors that refer to the concept of the gap to develop educational strategies that might maximise useful learning from perceived differences. Educators need to 'mind' gaps in collaboration with students if synergistic learning is to be constructed from contemporaneous exposure to simulated and authentic patient interactions. The strategies need to be tested in practice by teachers and learners for utility. Further research is needed to understand gaps in other contexts

‘What do we do, doctor?’ Transitions of identity and responsibility: a narrative analysis

Transitioning from student to doctor is notoriously challenging. Newly qualified doctors feel required to make decisions before owning their new identity. It is essential to understand how responsibility relates to identity formation to improve transitions for doctors and patients. This multiphase ethnographic study explores realities of transition through anticipatory, lived and reflective stages. We utilised Labov’s narrative framework (Labov in J Narrat Life Hist 7(1–4):395–415, 1997) to conduct in-depth analysis of complex relationships between changes in responsibility and development of professional identity. Our objective was to understand how these concepts interact. Newly qualified doctors acclimatise to their role requirements through participatory experience, perceived as a series of challenges, told as stories of adventure or quest. Rules of interaction within clinical teams were complex, context dependent and rarely explicit. Students, newly qualified and supervising doctors felt tensions around whether responsibility should be grasped or conferred. Perceived clinical necessity was a common determinant of responsibility rather than planned learning. Identity formation was chronologically mismatched to accepting responsibility. We provide a rich illumination of the complex relationship between responsibility and identity pre, during, and post-transition to qualified doctor: the two are inherently intertwined, each generating the other through successful actions in practice. This suggests successful transition requires a supported period of identity reconciliation during which responsibility may feel burdensome. During this, there is a fine line between too much and too little responsibility: seemingly innocuous assumptions can have a significant impact. More effort is needed to facilitate behaviours that delegate authority to the transitioning learner whilst maintaining true oversight

Delivering mental healthcare to patients with a depressive disorder alongside a life-limiting illness

The concurrent assessment and treatment of mental health disorders and palliative illnesses is complex. Affective disorders are more prevalent in people who need palliative care. Identifying the most suitable place of care and multi-professional multidisciplinary teams to provide support can be challenging and bewildering for professionals and patients. Mental health clinicians may be left with a sense of therapeutic nihilism, while palliative care teams can feel limited by the mental health resources available for treating those living with significant physical and mental health needs. We discuss the fictional case of a gentleman with metastatic bowel cancer who has developed symptoms of depressive disorder and identify how taking a pragmatic patient-centred approach can offer a route through potential dilemmas when seeking to provide individualised care based on needs. We used lay person experience alongside our own experiences of novel mechanisms for cross-specialty working in order to direct psychiatric trainees' approaches to such cases

Widespread Occurrence of High-Velocity Upflows in Solar Active Regions

We performed a systematic study of 12 active regions (ARs) with a broad range of areas, magnetic flux and associated solar activity in order to determine whether there are upflows present at the AR boundaries and if these upflows exist, whether there is a high speed asymmetric blue wing component present in the upflows. To identify the presence and locations of the AR upflows we derive relative Doppler velocity maps by fitting a Gaussian function to {\it Hinode}/EIS Fe XII 192.394\,\AA\ line profiles. To determine whether there is a high speed asymmetric component present in the AR upflows we fit a double Gaussian function to the Fe XII 192.394\,\AA\ mean spectrum that is computed in a region of interest situated in the AR upflows. Upflows are observed at both the east and west boundaries of all ARs in our sample with average upflow velocities ranging between -5 to -26~km s$^{-1}$. A blue wing asymmetry is present in every line profile. The intensity ratio between the minor high speed asymmetric Gaussian component compared to the main component is relatively small for the majority of regions however, in a minority of cases (8/30) the ratios are large and range between 20 to 56~\%. These results suggest that upflows and the high speed asymmetric blue wing component are a common feature of all ARs.Comment: Accepted in A&A, 5 pages, 3 figure