Managing pain medications in long-term care: nurses' views

The purpose of this study was to explore nurses' perceptions of their current practices related to administering pain medications to long-term care (LTC) residents. A cross-sectional survey design was used, including both quantitative and open-ended questions. Data were collected from 165 nurses (59% response rate) at nine LTC homes in southern Ontario, Canada. The majority (85%) felt that the medication administration system was adequate to help them manage residents' pain and 98% felt comfortable administering narcotics. In deciding to administer a narcotic, nurses were influenced by pain assessments, physician orders, diagnosis, past history, effectiveness of non-narcotics and fear of making dosage miscalculations or developing addictions. Finally, most nurses stated that they trusted the physicians and pharmacists to ensure orders were safe. These findings highlight nurses' perceptions of managing pain medications in LTC and related areas where continuing education initiatives for nurses are needed.

The Role and Effectiveness of Public – Private Partnerships (NHS LIFT) in the Development of Enhanced Primary Care Premises and Services:Report for the National Institute for Health Research Service Delivery and Organisation programme

The research project analysed the role and effectiveness of LIFT via a multi-method study which included semi-structured interviews with policy elites and users, as well as case studies and an exploratory analysis of the financial characteristics of three LIFT Companies. While the team felt that it was able to identify key aspects relating to the advantages and drawbacks surrounding LIFT, some aspects relating to the representativeness of the study was adversely affected by a reluctance of PCTs to participate in the case study analysis and commercial confidentiality restrictions. The study was nonetheless able to identify important issues in relation to the funding and procurement of primary care premises and services.

Risking peace in the ‘War against the Poor’? Social exclusion and the legacies of the Northern Ireland conflict

Discourses around poverty, dependency and austerity take a particular form when it comes to Northern Ireland which is seen as ripe for economic ‘rebalancing’ and public sector reduction. The Welfare Reform Act 2012 is pivotal in that it provides the muscle for disciplining claimants for a low-waged, flexible labour market. But the Northern Ireland Assembly has not passed the Act or agreed a budget and the return of Direct Rule beckons as a result. The article sheds light on the stand-off over the Welfare Reform Act using data from the 2012 PSE Survey. It demonstrates that the impact of violent conflict is imprinted on the population in terms of high rates of deprivation, poor physical and mental health, and significant differences between those experiencing little or no conflict, and those with ‘high’ experience. In ignoring these legacies of the conflict, the Westminster government is risking peace in its ‘war against the poor’.

Hypoxia in prostate cancer:a powerful shield against tumour destruction?

Tumour hypoxia is progressively emerging as a common feature of prostate tumours associated with poor prognosis. While the molecular basis of disease progression is increasingly well documented, the potential role of hypoxia in these processes remains poorly evaluated. By dissecting the impact of hypoxia-inducible factor 1 alpha on molecular responses, this review provides evidence for a powerful protecting role of oxygen deprivation against oxidative stress injury, androgen deprivation, chemotherapeutic and radiation cytotoxicity. We propose hypoxia as a potent tumour-induced shield against destruction and suggest its targeting may need to be routinely addressed in the management of prostate cancer.

The views of general practitioners on advance care planning for patients living with dementia

Background Advance care planning (ACP) facilitates communication
and understanding of preferences, nevertheless the use of
ACPs in primary care for patients with dementia is low. The disease’s
uncertain course and the inability to communicate with
the patient living with dementia are significant challenges for
GPs.
Aim The purpose of this study was to describe the attitudes and
practice preferences of GPs working within the UK’s National
Health System (NHS) regarding communication, and decisionmaking
for patients with dementia and their families
Methods A cross-sectional survey, using a purposive, cluster sample
of GPs across Northern Ireland with registered dementia
patients was used.
Results One hundred and thirty-three GPs (40.6%) participated
in the survey, representing 60.9% of surveyed practices. While
most respondents regarded dementia as a terminal disease
(96.2%) only 37.6% felt that palliative care applied equally from
the time of diagnosis to severe dementia. While most respondents
thought that early discussions would facilitate decision-making
during advanced dementia (61%), respondents were divided
on whether ACP should be initiated at the time of diagnoses
(39.8% in favour vs 45.8% disagreed). Interestingly, GPs who
were longer in practice placed greater importance on the presence
of an advance directive (F (2, 124) = 3.38, p = 0.037).
Discussion The timing of initiating ACP varies across individuals
requiring GPs to carefully consider strategies and receptiveness
of the patient and family carer.
Conclusion The findings promote both ongoing training in communication
and dementia management for GPs to meet the
needs of their patients living with dementia.

Dengue Virus Inhibition of Autophagic Flux and Dependency of Viral Replication on Proteasomal Degradation of the Autophagy Receptor p62

Autophagic flux involves formation of autophagosomes and their degradation by lysosomes. Autophagy can either promote or restrict viral replication. In the case of Dengue virus (DENV) several studies report that autophagy supports the viral replication cycle, and describe an increase of autophagic vesicles (AVs) following infection. However, it is unknown how autophagic flux is altered to result in increased AVs. To address this question, and gain insight into the role of autophagy during DENV infection, we established an unbiased, image-based flow cytometry approach to quantify autophagic flux under normal growth conditions and in response to activation by nutrient deprivation or the mTOR inhibitor Torin1. We found that DENV induced an initial activation of autophagic flux, followed by inhibition of general and specific autophagy. Early after infection, basal and activated autophagic flux was enhanced. However, during established replication, basal and Torin1-activated autophagic flux was blocked, while autophagic flux activated by nutrient deprivation was reduced, indicating a block to AV formation and reduced AV degradation capacity. During late infection AV levels increased as a result of inefficient fusion of autophagosomes with lysosomes. Additionally, endo-lysosomal trafficking was suppressed, while lysosomal activities were increased. We further determined that DENV infection progressively reduced levels of the autophagy receptor SQSTM1/p62 via proteasomal degradation. Importantly, stable over-expression of p62 significantly suppressed DENV replication suggesting a novel role for p62 as viral restriction factor. Overall our findings indicate that in the course of DENV infection, autophagy shifts from a supporting to an anti-viral role, which is countered by DENV.

IMPORTANCE: Autophagic flux is a dynamic process starting with the formation of autophagosomes and ending with their degradation after fusion with lysosomes. Autophagy impacts the replication cycle of many viruses. However, thus far the dynamics of autophagy in case of Dengue virus (DENV) infections has not been systematically quantified. Therefore, we employed high-content, imaging-based flow cytometry to quantify autophagic flux and endo-lysosomal trafficking in response to DENV infection. We report that DENV induced an initial activation of autophagic flux, followed by inhibition of general and specific autophagy. Further, lysosomal activity was increased, but endo-lysosomal trafficking was suppressed confirming the block of autophagic flux. Importantly, we provide evidence that p62, an autophagy receptor, restrict DENV replication and was specifically depleted in DENV-infected cells via increased proteasomal degradation. These results suggest that during DENV infection autophagy shifts from a pro- to an antiviral cellular process, which is counteracted by the virus.

Innovative interprofessional teaching session on labour and childbirth for undergraduate medical and midwifery students

There is an increasing recognition of the need to improve interprofessional relationships within clinical practice (Midwifery 2020, 2010). Evidence supports the assertion that healthcare professionals who are able to communicate and work effectively together and who have a mutual respect and understanding for one another’s roles will provide a higher standard of care (McPherson et al, 2001; Miers et al, 2005; Begley, 2008). The joint Royal College of Obstetrics & Gynaecologists(RCOG) / Royal College of Midwives (RCM) report (2008 Page 8) on clinical learning environment and recruitment recommended that “Inter-professional learning strategies should be introduced and supported at an early stage in the medical and midwifery undergraduate students' experience and continued throughout training.” Providing interprofessional education within a University setting offers an opportunity for a non-threatening learning environment where students can develop confidence and build collaborative working relationships with one another (Saxell et al, 2009).Further research supports the influence of effective team working on increased client satisfaction. Additionally it identifies that the integration of interprofessional learning into a curriculum improves students’ abilities to interact professionally and provides a better understanding of role identification within the workplace than students who have only been exposed to uniprofessional education (Meterko et al, 2004; Pollard and Miers, 2008; Siassakos, et al, 2009; Wilhelmsson et al, 2011; Murray-Davis et al, 2012). An interprofessional education indicative has been developed by teaching staff from the School of Nursing and Midwifery and School of Medicine at Queen’s University Belfast. The aim of the collaboration was to enhance interprofessional learning by providing an opportunity for medical students and midwifery students to interact and communicate prior to medical students undertaking their obstetrics and gynaecology placements. This has improved medical students placement experience by facilitating them to learn about the process of birth and familiarisation of the delivery suite environment and it also has the potential to enhance interprofessional relationships. Midwifery students benefit through the provision of an opportunity to teach and facilitate learning in relation to normal labour and birth and has provided them with an opportunity to build stronger and more positive relationships with another profession. This opportunity also provides a positive, confidence building forum where midwifery students utilise teaching and learning strategies which would be transferable to their professional role as registered midwives. The midwifery students were provided with an outline agenda in relation to content for the workshop, but then were allowed creative licence with regard to delivery of the workshop. The interactive workshops are undertaken within the University’s clinical education centre, utilising low fidelity simulation. The sessions are delivered 6 times per year and precede the medical students’ obstetric/gynaecology placement. All 4th year medical and final year midwifery students have an opportunity to participate. Preliminary evaluations of the workshops have been positive from both midwifery and medical students. The teaching sessions provided both midwifery and medical students with an introduction to inter professional learning and gave them an opportunity to learn about and respect each other’s roles. The midwifery students have commented on the enjoyable aspects of team working for preparing for the workshop and also the confidence gained from teaching medical students. The medical students have evaluated the teaching by midwifery students positively and felt that it lowered their anxiety levels going into the labour setting. A number of midwifery and medical students have subsequently worked with one another within the practice setting which has been recognised as beneficial. Both Schools have recognised the benefits of interprofessional education and have subsequently made a commitment to embed it within each curriculum.

Oral rehabilitation for partially dentate elders: a qualitative analysis

Aims: This study aimed to gain insight into patient’s perceptions of natural tooth loss and explored their experiences of oral rehabilitation according to a functionally orientated approach (SDA) and Removable Partial Dentures (RPD).
Study Design: For this qualitative study, a purposive sample of 15 partially dentate older patients
were recruited from Cork Dental School and Hospital. These patients had previously participated in a randomised controlled clinical trial (RCT) where they were provided with either SDA treatment using adhesive bridgework or provided with Cobalt Chromium framework RPDs. In- depth interviews were undertaken and thematic analysis was utilised to interpret the data.
Results: The findings of this study indicated strong satisfaction with SDA treatment. Patients referred to the ease in which they adapted to the adhesive prostheses as they were “lightweight”, “neat” and “fixed”. Irrespective of treatment option, patients indicated that they felt
their new prostheses were durable and an improvement on previous treatments. Most patients indicated that, previous to the RCT, they had not attended a general dentist for a number of years and only then for acute issues. They had concerns that treatment which was provided to them as part of the RCT would not be available to them in primary care. Interestingly, although they do not want their condition to dis-improve, if their prostheses failed they stated that they would not seek alternative treatment but would revert back
to adopting previous coping mechanisms.
Conclusion: This study illustrates that partially dentate older patients were very satisfied with oral rehabilitation according to a functionally orientated approach. Unfortunately they did not believe that this treatment would currently be made available to them in a primary care setting.

Using low fidelity simulation in interactive workshops for undergraduate medical and midwifery students

There is recognition of the need to continuously improve inter-professional relationships within clinical practice. Mutual respect, effective communication and working together are factors which will contribute to higher standards of care (Miers et al, 2005; Begley, 2008). An inter-professional education initiative, using low-fidelity simulation has been piloted and subsequently embedded within a pre-registration midwifery curriculum. The aim of the collaboration is to enhance inter-professional learning by providing an opportunity for final year midwifery students and 4th year medical students within a non-threatening environment to interact and communicate prior to obstetric clinical placements. The midwifery students are provided with an outline agenda for the workshop, but are encouraged to use creative license with regard to workshop delivery. Preliminary evaluations have been positive from both midwifery and medical students. The teaching sessions have provided an opportunity to learn about and respect each other’s roles. The midwifery students have commented on the enjoyable aspects of team working during preparation and the confidence gained from teaching medical students. The medical students felt that the sessions lowered their anxiety levels going into the labour setting. This workshop will demonstrate how low-fidelity simulation can effectively enhance the students experience promoting team working and self-confidence.

"Should I prioritize medical problem solving or attentive listening?": the dilemmas and challenges that medical students experience when learning to conduct consultations

Objective: Communication skills can be trained alongside clinical reasoning, history taking or clinical examination skills. This is advocated as a solution to the low transfer of communication skills. Still, students have to integrate the knowledge/skills acquired during different curriculum parts in patient consultations at some point. How do medical students experience these integrated consultations within a simulated environment and in real practice when dealing with responsibility?

Methods: Six focus groups were conducted with (pre-)/clerkship students.

Results: Students were motivated to practice integrated consultations with simulated patients and felt like 'real physicians'. However, their focus on medical problem solving drew attention away from improving their communication skills. Responsibility for real patients triggered students' identity development. This identity formation guided the development of an own consultation style, a process that was hampered by conflicting demands of role models.

Conclusion: Practicing complete consultations results in the dilemma of prioritizing medical problem solving above attention for patient communication. Integrated consultation training advances this dilemma to the pre-clerkship period. During clerkships this dilemma is heightened because real patients trigger empathy and responsibility, which invites students to define their role as doctor.

Practice Implications: When training integrated consultations, educators should pay attention to students' learning priorities and support the development of students' professional identity.

Comparative Assessment of Methods for Measuring Consensual Poverty: Sort Card Versus CAPI

Poverty means more than having a low income and includes exclusion from a minimally accepted way of life. It is now common practice in Europe to measure progress against poverty in terms of low income, material deprivation rates and some combination of both. This makes material deprivation indicators, and their selection, highly significant in its own right. The ‘consensual poverty’ approach is to identify deprivation items which a majority of the population agree constitute life’s basic necessities, accepting that these items will need revised over time to reflect social change. Traditionally, this has been carried out in the UK through specialised poverty surveys using a Sort Card (SC) technique.

Based on analysis of a 2012 omnibus survey, and discussions with three interviewers, this article examines how perception of necessities is affected by mode of administration – SC and Computer Assisted Personal Interviewing (CAPI). More CAPI respondents scored deprivation items necessary. Greatest disparities are in material items where 25 out of 32 items were significantly higher via CAPI. Closer agreement is found in social participation with 3 out of 14 activities significantly different. Consensus is higher on children’s material deprivation.
We consider influencing variables which could account for the disparities and believe that the SC method produces a more considered response. However, in light of technological advances, we question how long the SC method will remain socially acceptable. This paper concludes that the CAPI method can be easily modified without compromising the benefits of the SC method in capturing thoughtful responses.

Factors that impact on the use of mechanical ventilation weaning protocols in critically ill adults and children: a qualitative-evidence synthesis

Background:
Prolonged mechanical ventilation is associated with a longer intensive care unit (ICU) length of stay and higher mortality. Consequently, methods to improve ventilator weaning processes have been sought. Two recent Cochrane systematic reviews in ICU adult and paediatric populations concluded that protocols can be effective in reducing the duration of mechanical ventilation, but there was significant heterogeneity in study findings. Growing awareness of the benefits of understanding the contextual factors impacting on effectiveness has encouraged the integration of qualitative evidence syntheses with effectiveness reviews, which has delivered important insights into the reasons underpinning (differential) effectiveness of healthcare interventions.

Objectives:
1. To locate, appraise and synthesize qualitative evidence concerning the barriers and facilitators of the use of protocols for weaning critically-ill adults and children from mechanical ventilation;

2. To integrate this synthesis with two Cochrane effectiveness reviews of protocolized weaning to help explain observed heterogeneity by identifying contextual factors that impact on the use of protocols for weaning critically-ill adults and children from mechanical ventilation;

3. To use the integrated body of evidence to suggest the circumstances in which weaning protocols are most likely to be used.

Search methods:
We used a range of search terms identified with the help of the SPICE (Setting, Perspective, Intervention, Comparison, Evaluation) mnemonic. Where available, we used appropriate methodological filters for specific databases. We searched the following databases: Ovid MEDLINE, Embase, OVID, PsycINFO, CINAHL Plus, EBSCOHost, Web of Science Core Collection, ASSIA, IBSS, Sociological Abstracts, ProQuest and LILACS on the 26th February 2015. In addition, we searched: the grey literature; the websites of professional associations for relevant publications; and the reference lists of all publications reviewed. We also contacted authors of the trials included in the effectiveness reviews as well as of studies (potentially) included in the qualitative synthesis, conducted citation searches of the publications reporting these studies, and contacted content experts.

We reran the search on 3rd July 2016 and found three studies, which are awaiting classification.

Selection criteria:
We included qualitative studies that described: the circumstances in which protocols are designed, implemented or used, or both, and the views and experiences of healthcare professionals either involved in the design, implementation or use of weaning protocols or involved in the weaning of critically-ill adults and children from mechanical ventilation not using protocols. We included studies that: reflected on any aspect of the use of protocols, explored contextual factors relevant to the development, implementation or use of weaning protocols, and reported contextual phenomena and outcomes identified as relevant to the effectiveness of protocolized weaning from mechanical ventilation.

Data collection and analysis:
At each stage, two review authors undertook designated tasks, with the results shared amongst the wider team for discussion and final development. We independently reviewed all retrieved titles, abstracts and full papers for inclusion, and independently extracted selected data from included studies. We used the findings of the included studies to develop a new set of analytic themes focused on the barriers and facilitators to the use of protocols, and further refined them to produce a set of summary statements. We used the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) framework to arrive at a final assessment of the overall confidence of the evidence used in the synthesis. We included all studies but undertook two sensitivity analyses to determine how the removal of certain bodies of evidence impacted on the content and confidence of the synthesis. We deployed a logic model to integrate the findings of the qualitative evidence synthesis with those of the Cochrane effectiveness reviews.

Main results:
We included 11 studies in our synthesis, involving 267 participants (one study did not report the number of participants). Five more studies are awaiting classification and will be dealt with when we update the review.

The quality of the evidence was mixed; of the 35 summary statements, we assessed 17 as ‘low’, 13 as ‘moderate’ and five as ‘high’ confidence. Our synthesis produced nine analytical themes, which report potential barriers and facilitators to the use of protocols. The themes are: the need for continual staff training and development; clinical experience as this promotes felt and perceived competence and confidence to wean; the vulnerability of weaning to disparate interprofessional working; an understanding of protocols as militating against a necessary proactivity in clinical practice; perceived nursing scope of practice and professional risk; ICU structure and processes of care; the ability of protocols to act as a prompt for shared care and consistency in weaning practice; maximizing the use of protocols through visibility and ease of implementation; and the ability of protocols to act as a framework for communication with parents.

Authors' conclusions:
There is a clear need for weaning protocols to take account of the social and cultural environment in which they are to be implemented. Irrespective of its inherent strengths, a protocol will not be used if it does not accommodate these complexities. In terms of protocol development, comprehensive interprofessional input will help to ensure broad-based understanding and a sense of ‘ownership’. In terms of implementation, all relevant ICU staff will benefit from general weaning as well as protocol-specific training; not only will this help secure a relevant clinical knowledge base and operational understanding, but will also demonstrate to others that this knowledge and understanding is in place. In order to maximize relevance and acceptability, protocols should be designed with the patient profile and requirements of the target ICU in mind. Predictably, an under-resourced ICU will impact adversely on protocol implementation, as staff will prioritize management of acutely deteriorating and critically-ill patients.

Undergraduate Student perceptions of a Restorative Dentistry OSCE

Objectives: The Objective Structured Clinical Exam (OSCE) is a widely accepted assessment method in undergraduate dental education. It aims to test higher order skills, attitudes and aspects of professionalism which other summative assessments such as MCQs and other written examinations are less able to do. The aim of this study was to evaluate the perceptions of 4th year undergraduate dental students of an OSCE undertaken in the Conservation Department.
Methods: On completion of the OSCE examination 51 fourth year undergraduate students were asked to complete an anonymised questionnaire. The questionnaire was made 22 questions, and requiring the students to provide both open and closed responses.
Results: A lot of positive aspects to the OSCE were observed in responses, students felt that the OSCE was a meaningful way for assessing their clinical skills (85%), it reflected real life conditions (79%) and that it was a fair method of assessment (75%).
A number of negative aspects were also noted. Most students felt the OSCE was stressful (72%) and they felt nervous during the examination (77%). Of the undergraduates asked 42% did not feel confident doing the OSCE.
A number of students felt it would be helpful to have additional information given to them on the OSCE prior to the assessment process.
Conclusion: In general the students found the OSCE a fair, meaningful form of assessment which reflected real life clinical situations, providing them with an opportunity to show their clinical knowledge and practical skills. A number study cohort did not feel confident during the OSCE and felt nervous and stressed by the experience. The information gained from the reflective nature of the feedback questionnaire has proved invaluable in the design of subsequent diets of the OSCE examination. 

Individual factors and perceived community characteristics in relation to mental health and mental well-being

Background
It has been argued that though correlated with mental health, mental well-being is a distinct entity. Despite the wealth of literature on mental health, less is known about mental well-being. Mental health is something experienced by individuals, whereas mental well-being can be assessed at the population level. Accordingly it is important to differentiate the individual and population level factors (environmental and social) that could be associated with mental health and well-being, and as people living in deprived areas have a higher prevalence of poor mental health, these relationships should be compared across different levels of neighbourhood deprivation.

Methods
A cross-sectional representative random sample of 1,209 adults from 62 Super Output Areas (SOAs) in Belfast, Northern Ireland (Feb 2010 – Jan 2011) were recruited in the PARC Study. Interview-administered questionnaires recorded data on socio-demographic characteristics, health-related behaviours, individual social capital, self-rated health, mental health (SF-8) and mental well-being (WEMWBS). Multi-variable linear regression analyses, with inclusion of clustering by SOAs, were used to explore the associations between individual and perceived community characteristics and mental health and mental well-being, and to investigate how these associations differed by the level of neighbourhood deprivation.

Results
Thirty-eight and 30 % of variability in the measures of mental well-being and mental health, respectively, could be explained by individual factors and the perceived community characteristics. In the total sample and stratified by neighbourhood deprivation, age, marital status and self-rated health were associated with both mental health and well-being, with the ‘social connections’ and local area satisfaction elements of social capital also emerging as explanatory variables. An increase of +1 in EQ-5D-3 L was associated with +1SD of the population mean in both mental health and well-being. Similarly, a change from ‘very dissatisfied’ to ‘very satisfied’ for local area satisfaction would result in +8.75 for mental well-being, but only in the more affluent of areas.

Conclusions
Self-rated health was associated with both mental health and mental well-being. Of the individual social capital explanatory variables, ‘social connections’ was more important for mental well-being. Although similarities in the explanatory variables of mental health and mental well-being exist, socio-ecological interventions designed to improve them may not have equivalent impacts in rich and poor neighbourhoods.

Failure to produce an anti-poverty strategy: The Committee on the Administration’s Application [2015] NIQB 59, June 30, 2015

This is a note on the Northern Ireland High Court decision of 30 June 2015 that the Northern Ireland Executive had acted unlawfully in failing to fulfil its statutory duty to adopt a strategy setting out proposals for tackling poverty, social exclusion and patterns of deprivation based on objective need.