A mixed methods study of the work patterns of full-time nurse practitioners in nursing homes

Aims and objectives: The aim of this study was to explore the integration of the nurse practitioner role in Canadian nursing homes to enable its full potential to be realised for resident and family care. The objective was to determine nurse practitioners' patterns of work activities. 

Background: Nurse practitioners were introduced in Canadian nursing homes a decade ago on a pilot basis. In recent years, government and nursing home sector interest in the role has grown along with the need for data to inform planning efforts. 

Design: The study used a sequential mixed methods design using a national survey followed by case studies. 

Methods: A national survey of nurse practitioners included demographic items and the EverCare Nurse Practitioner Role and Activity Scale. Following the survey, case studies were conducted in four nursing homes. Data were collected using individual and focus group interviews, document reviews and field notes. 

Results: Twenty-three of a target population of 26 nurse practitioners responded to the survey, two-thirds of whom provided services in nursing homes with one site and the remainder in nursing homes with as many as four sites. On average, nurse practitioners performed activities in communicator, clinician, care manager/coordinator and coach/educator subscales at least three to four times per week and activities in the collaborator subscale once a week. Of the 43 activities, nurse practitioners performed daily, most were in the clinician and communicator subscales. Case study interviews involved 150 participants. Findings complemented those of the survey and identified additional leadership activities. 

Conclusion: Nurse practitioners undertake a range of primary health care and advanced practice activities which they adapt to meet the unique needs of nursing homes. Relevance to clinical practice: Knowledge of work patterns enables nursing homes to implement the full range of nurse practitioner roles and activities to enhance resident and family care.

International inter-school competition to encourage children to walk to school: a mixed methods feasibility study.

Background: Active travel to school can be an important contributor to the total physical activity of children but levels have declined and more novel approaches are required to stimulate this as an habitual behaviour. The aim of this mixed methods study was to investigate the feasibility of an international walk to school competition supported by novel swipecard technology to increase children's walking to/from school. Methods: Children aged 9-13 years old participated in an international walk to school competition to win points for themselves, their school and their country over a 4-week period. Walks to and from school were recorded using swipecard technology and a bespoke website. For each point earned by participants, 1 pence (£0.01) was donated to the charity of the school's choice. The primary outcome was number of walks to/from school objectively recorded using the swipecard tracking system over the intervention period. Other measures included attitudes towards walking collected at baseline and week 4 (post-intervention). A qualitative sub-study involving focus groups with children, parents and teachers provided further insight. Results: A total of 3817 children (mean age 11.5±SD 0.7) from 12 schools in three cities (London and Reading, England and Vancouver, Canada) took part in the intervention, representing a 95% intervention participation rate. Results show a gradual decline in the average number of children walking to and from school over the 4-week period (week 1 mean 29%±SD2.5; week 2 mean 18%±SD3.6; week 3 mean 14%±SD4.0; week 4 mean 12%±SD1.1). Post intervention, 97% of children felt that walking to school helped them stay healthy, feel happy (81%) and stay alert in class (76%). These results are supported by qualitative findings from children, parents and teachers. Key areas for improvement include the need to incorporate strategies for maintenance of behaviour change into the intervention and also to adopt novel methods of data collection to increase follow-up rates. Conclusions: This mixed methods study suggests that an international walk to school competition using innovative technology can be feasibly implemented and offers a novel way of engaging schools and motivating children to walk to school.

Density functional theory study of mixed-phase TiO2: heterostructures and electronic properties

In this work, density functional theory calculations have been performed to study the geometric, electronic, and energetic properties of two-phase TiO2 composites built by joining two single-phase TiO2 slabs, aiming at verifying possible improvement of the photo-activities of the composites through phase separation of excitons. We find that such desired electronic properties can be determined by several factors. When both the HOMO and LUMO levels of one of the two single-phase TiO2 slabs are higher than the corresponding ones of the other, the composite may have native electronic structures with phase-separated HOMO-LUMO states, especially when the two slabs exhibit highly matched surface lattices. For those pairs of TiO2 slabs with the HOMO and LUMO levels of one phase being within the range of those of the other, though the energetically favored composite give HOMO-LUMO states within one phase, one may still be able to separate them and move the HOMO state to the interface region by destabilizing the interactions between the two slabs.

Re-dispersion of gold supported on a ‘mixed’ oxide support

The ability to reactivate, stabilize and increase the lifetime of gold catalysts by dispersing large, inactive gold nanoparticles to smaller nanoparticles provides an opportunity to make gold catalysts more practical for industrial applications. Previously it has been demonstrated that mild treatment with iodomethane (CH3I) (J. Am. Chem. Soc., 2009, 131, 6973; Angew. Chem. Int. Ed., 2011, 50, 8912) was able to re-disperse gold on carbon and metal oxide supports. In the current work, we show that this technique can be applied to re-disperse gold on a ‘mixed’ metal oxide, namely a mechanical mixture of ceria, zirconia and titania. Characterization was conducted to gage the impact of the iodomethane (CH3I) treatment on a previously sintered catalyst.

A Numerical Study of Inlet Geometry for a Low Inertia Mixed Flow Turbocharger Turbine

Mixed flow turbines can offer improvements over typical radial turbines used in automotive turbochargers, with regards to transient performance and low velocity ratio efficiency. Turbine rotor mass dominates the rotating inertia of the turbocharger, and any reductions of mass in the outer radii of the wheel, including the rotor back-disk, can significantly reduce this inertia and improve the acceleration of the assembly. Off-design, low velocity ratio conditions are typified by highly tangential flow at the rotor inlet and a non-zero inlet blade angle is preferred for such operating conditions. This is achievable in a Mixed Flow Turbine without increasing bending stresses within the rotor blade, which is beneficial in high speed and high inlet temperature turbine design. A range of mixed flow turbine rotors was designed with varying cone angle and inlet blade angle and each was assessed at a number of operating points. These rotors were based on an existing radial flow turbine, and both the hub and shroud contours and exducer geometry were maintained. The inertia of each rotor was also considered. The results indicated that there was a trade-off between efficiency and inertia for the rotors and certain designs may be beneficial for the transient performance of downsized, turbocharged engines.

Proportioning variability in the dispensation of hand-mixed dental cements

Objectives: The purpose of this investigation was to determine for dispensed multiples (1 through 4) of powder (P) and liquid (L) in hand-mixed dental cement whether: (1) the mean (P/L) ratio (m/m) and (2) the maximum difference in (P/L) ratio is dependent on the number of multiples dispensed. The Null hypotheses were: (a) mean (P/L) ratio is independent of the number of multiples dispensed and (b) maximum difference in (P/L) ratio is independent of the number of multiples dispensed.
Methods: The materials investigated are listed in the Table. The masses of dispensed aliquots of powder and liquid were measured by a single operator (n=10, for multiples 1 through 4) on a 4-place analytical balance. All measurements were made independently and all possible (P/L) ratios calculated for each sample. The effect of multiple dispensations on (P/L) ratios and maximum (P/L) differences was by one-way ANOVA and linear regression, respectively, with the Tukey post-hoc correction for multiple comparisons.MULTIPLE DISPENSEDDISPENSED MU(x1)(x2)(x3)(x4)Zinc phosphateHeraeus12.271(0.691)a13.051(1.269)b13.215(0.824)b13.118(1.149)bFuji IXGC4.209(0.373)a4.085(0.275)b4.095(0.226)b4.095(0.217)bIRMDentsply7.933(0.767)a7.430(0.451)b7.977(0.729)a8.186(0.929)aKetac-Cem3M Espe9.6206(0.613)a9.714(0.523)a9.298(0.314)b9.321(0.292)bMean (SD) powder/liquid ratio (m/m). Superscript letters represent significances (α = 0.05) within each material
Results: Mean (SD) (P/L) ratios are presented in the Table. Null hypothesis (a) is rejected: either (x1) or (x2) dispensation yields a different (P/L) ratio to (x3) or (x4) (p < 0.05). Null hypothesis (b) is rejected: a negative correlation is observed in max (P/L) ratio difference with dispensed multiple for Ketac Cem (p = 0.029).
Conclusion: For hand-mixed dental cements: (1) more consistent (P/L) ratios may be observed with multiple dispensations of powder & liquid; (2) maximum differences in (P/L) ratio may be negatively correlated with dispensation multiple in some materials.

How do young people understand and communicate their heterosexual readiness: A Mixed Methods Systematic Review

Young people’s understandings of sexual readiness are under-researched and their perspectives are often missing in debates about sexuality and sex education. Research to date has predominantly focussed upon age and socio-cultural predictors of sexual debut, thus failing to explain how young people themselves conceptualise their readiness for sexual relations. Synthesised in this review is the evidence from 26 studies which included young people’s perspectives of their readiness to begin sexual intercourse, undertaken using either quantitative or qualitative methods. Available evidence suggests that young people may not view initiating sex as problematic, focusing instead on the rewards sex brings and less on health concerns. Gender differences emerged in conceptualisations of love, parenthood, respect and abuse within relationships and were further mediated by social class and ethnicity. Age was also significant in young people’s accounts. Those under 16 years may not be ‘sexually ready’ because their own retrospective analyses suggest they experienced difficulty negotiating their risk of coercion or exploitation. More research exploring more deeply young people’s understandings of sexual readiness is required. We recommend a rights-based approach to support young people’s participation in the research process and to include their voices in the development of relevant sex education and services.

A mixed cost-function adaptive algorithm for ADSL time-domain equalization

We propose a mixed cost-function adaptive initialization algorithm for the time domain equalizer in a discrete multitone (DMT)-based asymmetric digital subscriber line. Using our approach, a higher convergence rate than that of the commonly used least-mean square algorithm is obtained, whilst attaining bit rates close to the optimum maximum shortening SNR and the upper bound SNR. Furthermore, our proposed method outperforms the minimum mean-squared error design for a range of time domain equalizer (TEQ) filter lengths. The improved performance outweighs the small increase in computational complexity required. A block variant of our proposed algorithm is also presented to overcome the increased latency imposed on the feedback path of the adaptive system.

A numerical study of trailing edge geometry for low inertia automotive mixed flow turbines

Abstract. Mixed flow turbines can offer improvements over typical radial turbines used in automotive turbochargers, with respect to transient performance and low velocity ratio efficiency. Turbine rotor mass dominates the rotating inertia of the turbocharger’s rotating assembly, and any reductions of mass in the outer radii of the wheel, including the rotor back-disk, can significantly reduce this inertia and improve the acceleration of the assembly. Off-design, low velocity ratio conditions are typified by highly tangential flow at the rotor inlet and a non-zero inlet blade angle is desirable for such operating conditions. This is achievable in a Mixed Flow Turbine without increasing bending stresses within the rotor blade, which is beneficial in high speed and high inlet temperature turbine designs.
This study considers the meridional geometry of Mixed Flow Turbines using a multi-disciplinary study to assess both the structural and aerodynamic performance of each rotor, incorporating both CFD and FEA. Variations of rotor trailing edge were investigated at different operating conditions representing both on- and off-design operation within the constraints of existing hardware geometries. In all cases, the performance is benchmarked against an existing state-of-the-art radial turbocharger turbine with consideration of rotor inertia and its benefit for engine transient performance. The results indicate the influence of these parameters and this report details their benefits with respect to turbocharging a downsized, automotive engine.

'Talk to me': a mixed methods study on preferred physician behaviours during end-of-life communication from the patient perspective

Background
Despite the recognized importance of end-of-life (EOL) communication between patients and physicians, the extent and quality of such communication is lacking.

Objective
We sought to understand patient perspectives on physician behaviours during EOL communication.

Design
In this mixed methods study, we conducted quantitative and qualitative strands and then merged data sets during a mixed methods analysis phase. In the quantitative strand, we used the quality of communication tool (QOC) to measure physician behaviours that predict global rating of satisfaction in EOL communication skills, while in the qualitative strand we conducted semi-structured interviews. During the mixed methods analysis, we compared and contrasted qualitative and quantitative data.

Setting and Participants
Seriously ill inpatients at three tertiary care hospitals in Canada.

Results
We found convergence between qualitative and quantitative strands: patients desire candid information from their physician and a sense of familiarity. The quantitative results (n = 132) suggest a paucity of certain EOL communication behaviours in this seriously ill population with a limited prognosis. The qualitative findings (n = 16) suggest that at times, physicians did not engage in EOL communication despite patient readiness, while sometimes this may represent an appropriate deferral after assessment of a patient's lack of readiness.

Conclusions
Avoidance of certain EOL topics may not always be a failure if it is a result of an assessment of lack of patient readiness. This has implications for future tool development: a measure could be built in to assess whether physician behaviours align with patient readiness.

Developing the clinical components of a complex intervention for a glaucoma screening trial:a mixed methods study

BACKGROUND: Glaucoma is a leading cause of avoidable blindness worldwide. Open angle glaucoma is the most common type of glaucoma. No randomised controlled trials have been conducted evaluating the effectiveness of glaucoma screening for reducing sight loss. It is unclear what the most appropriate intervention to be evaluated in any glaucoma screening trial would be. The purpose of this study was to develop the clinical components of an intervention for evaluation in a glaucoma (open angle) screening trial that would be feasible and acceptable in a UK eye-care service.

METHODS: A mixed-methods study, based on the Medical Research Council (MRC) framework for complex interventions, integrating qualitative (semi-structured interviews with 46 UK eye-care providers, policy makers and health service commissioners), and quantitative (economic modelling) methods. Interview data were synthesised and used to revise the screening interventions compared within an existing economic model.

RESULTS: The qualitative data indicated broad based support for a glaucoma screening trial to take place in primary care, using ophthalmic trained technical assistants supported by optometry input. The precise location should be tailored to local circumstances. There was variability in opinion around the choice of screening test and target population. Integrating the interview findings with cost-effectiveness criteria reduced 189 potential components to a two test intervention including either optic nerve photography or screening mode perimetry (a measure of visual field sensitivity) with or without tonometry (a measure of intraocular pressure). It would be more cost-effective, and thus acceptable in a policy context, to target screening for open angle glaucoma to those at highest risk but for both practicality and equity arguments the optimal strategy was screening a general population cohort beginning at age forty.

CONCLUSIONS: Interventions for screening for open angle glaucoma that would be feasible from a service delivery perspective were identified. Integration within an economic modelling framework explicitly highlighted the trade-off between cost-effectiveness, feasibility and equity. This study exemplifies the MRC recommendation to integrate qualitative and quantitative methods in developing complex interventions. The next step in the development pathway should encompass the views of service users.

Characterization and structure–property relationship of melt-mixed high density polyethylene/multi-walled carbon nanotube composites under extensional deformation

Melt-mixed high density polyethylene (HDPE)/multi-walled carbon nanotube (MWCNT) nanocomposites with 1–10 wt% MWCNTs were prepared by twin screw extrusion and compression moulded into sheet form. The compression moulded nanocomposites exhibit a 112% increase in modulus at a MWCNT loading of 4 wt%, and a low electrical percolation threshold of 1.9 wt%. Subsequently, uniaxial, sequential (seq-) biaxial and simultaneous (sim-) biaxial stretching of the virgin HDPE and nanocomposite sheets was conducted at different strain rates and stretching temperatures to investigate the processability of HDPE with the addition of nanotubes and the influence of deformation on the structure and final properties of nanocomposites. The results show that the processability of HDPE is improved under all the uniaxial and biaxial deformation conditions due to a strengthened strain hardening behaviour with the addition of MWCNTs. Extensional deformation is observed to disentangle nanotube agglomerates and the disentanglement degree is shown to depend on the stretching mode, strain rate and stretching temperatures applied. The disentanglement effectiveness is: uniaxial stretching < sim-biaxial stretching < seq-biaxial stretching, under the same deformation parameters. In sim-biaxial stretching, reducing the strain rate and stretching temperature can lead to more nanotube agglomerate breakup. Enhanced nanotube agglomerate disentanglement exhibits a positive effect on the mechanical properties and a negative effect on the electrical properties of the deformed nanocomposites. The ultimate stress of the composite containing 4 wt% MWCNTs increased by ∼492% after seq-biaxial stretching, while the resistivity increased by ∼1012 Ω cm.