Testing a model for developing, implementing and evaluating a strategy to improve the quality of nursing and midwifery care in an acute hospital trust.

Abstract:
Background: Health care organisations
worldwide are faced with the need to develop
and implement strategic organisational plans
to meet the challenges of modern health care.
There is a need for models for developing, implementing and evaluating strategic plans that engage practitioners, and make a measurable difference to the patients that they serve. These presentations describe the development, implementation and evaluation of such a model by a team of senior nurses and practice developers, to underpin a strategy for nursing and midwifery in an acute hospital trust. Developing a Strategy The PARIHS (Promoting Action on Research Implementation in Health Services) conceptual framework (Kitson et al, 1998) proposes that successful implementation of change in practice is a function of the interplay of three core elements: the level of evidence supporting the proposed change; the context or environment in which the change takes place, and the way in which change is facilitated. We chose to draw on this framework to develop our strategy and implementation plan (O’Halloran, Martin and Connolly, 2005). At the centre of the plan are ward managers. These professionals provide leadership for the majority of staff in the trust and so were seen to be a key group in the implementation process.

Application of a Generic Curriculum Change Management Process to Motivate and Excite Students

The School of Mechanical and Aerospace Engineering at Queen’s University Belfast is committed to enhancing the quality of student learning. A plan to implement curriculum change around this goal has been formulated and is already several years underway. A specific part of the plan involved instigating a first year introductory module to engage the students in the practice of their engineering discipline. The complicated nature of devising this type of module with regard to objectives, resources, timeframe and the number of students involved meant that a very systematic approach had to be adopted. This paper presents the simple but definitive change management process that facilitated in the creation of a first year Introduction to Engineering module. The generic nature of this process is described and its application to other facets of curriculum change is discussed. Within this process the importance of collaboration to establish a forward momentum is emphasised. This enables academic staff to progress as a group and build curriculum development based on their own experiences, expertise and established practice

Identifying strategies to maximise recruitment and retention of practices and patients in a multicentre randomised controlled trial of an intervention to optimise secondary prevention for coronary heart disease in primary care.

Background Recruitment and retention of patients and healthcare providers in randomised controlled trials (RCTs) is important in order to determine the effectiveness of interventions. However, failure to achieve recruitment targets is common and reasons why a particular recruitment strategy works for one study and not another remain unclear. We sought to describe a strategy used in a multicentre RCT in primary care, to report researchers’ and participants’ experiences of its implementation and to inform future strategies to maximise recruitment and retention. Methods In total 48 general practices and 903 patients were recruited from three different areas of Ireland to a RCT of an intervention designed to optimise secondary prevention of coronary heart disease. The recruitment process involved telephoning practices, posting information, visiting practices, identifying potential participants, posting invitations and obtaining consent. Retention involved patients attending reviews and responding to questionnaires and practices facilitating data collection. Results We achieved high retention rates for practices (100%) and for patients (85%) over an 18-month intervention period. Pilot work, knowledge of the setting, awareness of change in staff and organisation amongst participant sites, rapid responses to queries and acknowledgement of practitioners’ contributions were identified as being important. Minor variations in protocol and research support helped to meet varied, complex and changing individual needs of practitioners and patients and encouraged retention in the trial. A collaborative relationship between researcher and practice staff which required time to develop was perceived as vital for both recruitment and retention. Conclusions Recruiting and retaining the numbers of practices and patients estimated as required to provide findings with adequate power contributes to increased confidence in the validity and generalisability of RCT results. A continuous dynamic process of monitoring progress within trials and tailoring strategies to particular circumstances, whilst not compromising trial protocols, should allow maximal recruitment and retention.

Do multinationals really prefer to enter culturally distant countries through greenfields rather than through acquisitions? The role of parent experience and subsidiary autonomy.

Prior research has argued that multinational enterprises (MNEs) prefer to enter culturally distant countries through greenfields rather than through acquisitions, since acquisitions in such countries are costlier to manage. This argument contains two hidden assumptions: (1) the additional costs of acquisitions in culturally distant countries are the same for all MNEs; and (2) such acquisitions have no benefits over their greenfield counterparts. In this paper we relax these two assumptions by arguing that an MNE's preference for greenfields in culturally distant countries depends on its international and host-country experience, and on the level of autonomy it plans to grant the focal subsidiary. Analyzing 171 wholly owned greenfield investments and full acquisitions made by Dutch MNEs in 35 countries, we find that these MNEs prefer to enter culturally distant countries through greenfields, but that this preference is lower when they have little international experience, or plan to grant the focal subsidiary considerable autonomy in marketing. [ABSTRACT FROM AUTHOR]

The use of material flow analysis and the ecological footprint in regional policy-making: application and insights from Northern Ireland.

This paper aims to contribute to the ongoing debate on the use of resource accounting tools in regional policy making. The Northern Limits project applied Material Flow Analysis and Ecological Footprinting to regional policy making in Northern Ireland over a number of years. The early phase of the research informed the regions first sustainable development strategy which was published in 2006 with key targets relating to the Ecological Footprint and improving the resource efficiency of the economy. Phase II identified the next steps required to address data availability and quality and the use of MFA and EF in providing a measurement and monitoring framework for the strategy and in the development of the strategy implementation plan. The use of MFA and Ecological Footprinting in sustainable regional policy making and the monitoring of its implementation is an ongoing process which has raised a number of research issues which can inform the ongoing application and development of these and other resource accounting tools to within Northern Ireland, provide insights for their use in other regions and help set out the priorities for research to support this important policy area.

A comparison of biodegradable municipal waste (BMW) management strategies in Ireland and the Czech Republic and the lessons learned

In order to meet the recycling and recovery targets set forth by the European Union's (EU) Waste and Landfill Directives, both the Irish and Czech governments’ policy on waste management is changing to meet these pressures, with major emphasis being placed upon the management of biodegradable municipal waste (BMW). In particular, the EU Landfill Directive requires reductions in the rate of BMW going to landfill to 35% of 1995 values by 2016 and 2020 for Ireland and the Czech Republic, respectively. In this paper, the strategies of how Ireland and the Czech Republic plan to meet this challenge are compared. Ireland either landfills or exports its waste for recovery, while the Czech Republic has a relatively new waste management infrastructure. While Ireland met the first target of 75% diversion of BMW from landfill by 2010 and preliminary 2012 data indicate that Ireland is on track to meet the 2013 target, the achievement of the 2016 target remains at risk. Indicators that were developed to monitor the Czech Republic's path to meeting the targets demonstrate that it did not meet the first target that was set for 2010 and will probably not meet its 2013 target either. The evaluation reports on the implementation of Waste Management Plan of Czech Republic suggest that the currently applied strategy to divert biodegradable waste from landfill is not effective enough. For both countries, the EU Waste Framework and Landfill Directives will be a significant influence and driver of change in waste management practices and governance over the coming decade. This means that both countries will not only have to invest in infrastructure to achieve the targets, but will also have to increase awareness among the public in diverting this waste at the household level. Improving environmental education is part of increased awareness as it is imperative for citizens to understand the consequences of their actions as affluence continues to grow producing increased levels of waste.

Graphical abstract
Despite the differences in the levels of waste generation in both the Czech Republic and Ireland, each country can learn from each other in order to meet the recycling and recovery targets set by the European Union's (EU) Waste and Landfill Directives. Both countries will not only have to invest in infrastructure to achieve the targets, but will also have to increase awareness among the public in diverting this waste at the household level. In addition, there needs to be minimum safe standards when land-spreading organic agricultural and organic municipal and industrial materials on agricultural land used for food production, as well as incentives to increase BMW diversion from landfill such as the increased landfill levy implemented in Ireland and the acceptance of MBT and/or incineration as a means of treating residual waste.

The implausibility of ‘usual care’ in an open system: sedation and weaning practices in Paediatric Intensive Care Units (PICUs) in the United Kingdom (UK).

Background
The power of the randomised controlled trial depends upon its capacity to operate in a closed system whereby the intervention is the only causal force acting upon the experimental group and absent in the control group, permitting a valid assessment of intervention efficacy. Conversely, clinical arenas are open systems where factors relating to context, resources, interpretation and actions of individuals will affect implementation and effectiveness of interventions. Consequently, the comparator (usual care) can be difficult to define and variable in multi-centre trials. Hence outcomes cannot be understood without considering usual care and factors that may affect implementation and impact on the intervention.

Methods
Using a fieldwork approach, we describe PICU context, ‘usual’ practice in sedation and weaning from mechanical ventilation, and factors affecting implementation prior to designing a trial involving a sedation and ventilation weaning intervention. We collected data from 23 UK PICUs between June and November 2014 using observation, individual and multi-disciplinary group interviews with staff.

Results
Pain and sedation practices were broadly similar in terms of drug usage and assessment tools. Sedation protocols linking assessment to appropriate titration of sedatives and sedation holds were rarely used (9 % and 4 % of PICUs respectively). Ventilator weaning was primarily a medical-led process with 39 % of PICUs engaging senior nurses in the process: weaning protocols were rarely used (9 % of PICUs). Weaning methods were variably based on clinician preference. No formal criteria or use of spontaneous breathing trials were used to test weaning readiness. Seventeen PICUs (74 %) had prior engagement in multi-centre trials, but limited research nurse availability. Barriers to previous trial implementation were intervention complexity, lack of belief in the evidence and inadequate training. Facilitating factors were senior staff buy-in and dedicated research nurse provision.

Conclusions
We examined and identified contextual and organisational factors that may impact on the implementation of our intervention. We found usual practice relating to sedation, analgesia and ventilator weaning broadly similar, yet distinctively different from our proposed intervention, providing assurance in our ability to evaluate intervention effects. The data will enable us to develop an implementation plan; considering these factors we can more fully understand their impact on study outcomes.

Contribution of sewage organic matter to the diet of the common limpet near the former outflow at Blackhead, Northern Ireland

Stable isotopes (δ13C, δ15N) have been used to document the utilisation of sewage effluent in coastal marine foodwebs in a number of studies (e.g. Rau et al. 1981; Risk et al. 2009; Rogers 1999; 2003). δ13C and, especially, δ15N showed clear differences in the diet of common limpets (Patella vulgata) collected in June 2010 near the untreated sewage outfall at Blackhead, Northern Ireland and a ‘clean’ site nearby. Because sewage contains a significant portion of fossil-fuel derived compounds (Law et al. 2013), 14C measurements enabled us to estimate the contribution of fossil carbon to the effluent and to the foodweb and hence of the level of sewage contamination. The effluent was found to contain 12.2 ± x % fossil carbon on the day sampled. The modern marine carbon endmember is enriched by the discharge from the Sellafield nuclear fuel reprocessing plant across the Irish Sea (c.f. Cook et al. 2004) so 14C analyses of samples from the ‘clean’ site were needed. We found that 38.5 ±x % of the diet of common limpets collected near the sewage was derived from fossil fuel. We plan to collect samples from the same two sites in June 2014 to establish whether the 2012 relocation of the outfall, with preliminary treated discharge farther out to sea has eliminated the contamination at Blackhead

Task sharing within a managed clinical network to improve child health in Malawi

BACKGROUND: Eighty per cent of Malawi's 8 million children live in rural areas, and there is an extensive tiered health system infrastructure from village health clinics to district hospitals which refers patients to one of the four central hospitals. The clinics and district hospitals are staffed by nurses, non-physician clinicians and recently qualified doctors. There are 16 paediatric specialists working in two of the four central hospitals which serve the urban population as well as accepting referrals from district hospitals. In order to provide expert paediatric care as close to home as possible, we describe our plan to task share within a managed clinical network and our hypothesis that this will improve paediatric care and child health.

PRESENTATION OF THE HYPOTHESIS: Managed clinical networks have been found to improve equity of care in rural districts and to ensure that the correct care is provided as close to home as possible. A network for paediatric care in Malawi with mentoring of non-physician clinicians based in a district hospital by paediatricians based at the central hospitals will establish and sustain clinical referral pathways in both directions. Ultimately, the plan envisages four managed paediatric clinical networks, each radiating from one of Malawi's four central hospitals and covering the entire country. This model of task sharing within four hub-and-spoke networks may facilitate wider dissemination of scarce expertise and improve child healthcare in Malawi close to the child's home.

TESTING THE HYPOTHESIS: Funding has been secured to train sufficient personnel to staff all central and district hospitals in Malawi with teams of paediatric specialists in the central hospitals and specialist non-physician clinicians in each government district hospital. The hypothesis will be tested using a natural experiment model. Data routinely collected by the Ministry of Health will be corroborated at the district. This will include case fatality rates for common childhood illness, perinatal mortality and process indicators. Data from different districts will be compared at baseline and annually until 2020 as the specialists of both cadres take up posts.

IMPLICATIONS OF THE HYPOTHESIS: If a managed clinical network improves child healthcare in Malawi, it may be a potential model for the other countries in sub-Saharan Africa with similar cadres in their healthcare system and face similar challenges in terms of scarcity of specialists.

Integrating Land Use Planning and Transportation: Policy formulation in the Belfast Metropolitan Area

Much of the interest in sustainable cities relates to the inexorable rise in the demand for car travel and the contribution that certain urban forms and land-use relationships can make to reducing energy consumption. Indeed, this demand is fuelled more by increased spatial separation of homes and workplaces, shops and schools than by any rise in trip making. This paper evaluates recent efforts to integrate land-use planning and transportation policy in the Belfast Metropolitan Area by reviewing the policy formulation process at both a regional and city scale. The paper suggests that considerable progress has been made in integrating these two areas of public policy, both institutionally and conceptually. However, concerns are expressed that the rhetoric of sustainability may prove difficult to translate into implementation, leading to a further dislocation of land-use and transportation.

Real-valued fixed-complexity sphere decoder for high dimensional QAM-MIMO systems

The development of high performance, low computational complexity detection algorithms is a key challenge for real-time Multiple-Input Multiple-Output (MIMO) communication system design. The Fixed-Complexity Sphere Decoder (FSD) algorithm is one of the most promising approaches, enabling quasi-ML decoding accuracy and high performance implementation due to its deterministic, highly parallel structure. However, it suffers from exponential growth in computational complexity as the number of MIMO transmit antennas increases, critically limiting its scalability to larger MIMO system topologies. In this paper, we present a solution to this problem by applying a novel cutting protocol to the decoding tree of a real-valued FSD algorithm. The new Real-valued Fixed-Complexity Sphere Decoder (RFSD) algorithm derived achieves similar quasi-ML decoding performance as FSD, but with an average 70% reduction in computational complexity, as we demonstrate from both theoretical and implementation perspectives for Quadrature Amplitude Modulation (QAM)-MIMO systems.

FPGA based Soft-core SIMD Processing: A MIMO-OFDM Fixed-Complexity Sphere Decoder Case Study

To enable reliable data transfer in next generation Multiple-Input Multiple-Output (MIMO) communication systems, terminals must be able to react to fluctuating channel conditions by having flexible modulation schemes and antenna configurations. This creates a challenging real-time implementation problem: to provide the high performance required of cutting edge MIMO standards, such as 802.11n, with the flexibility for this behavioural variability. FPGA softcore processors offer a solution to this problem, and in this paper we show how heterogeneous SISD/SIMD/MIMD architectures can enable programmable multicore architectures on FPGA with similar performance and cost as traditional dedicated circuit-based architectures. When applied to a 4×4 16-QAM Fixed-Complexity Sphere Decoder (FSD) detector we present the first soft-processor based solution for real-time 802.11n MIMO.

The machinist landscape:Land Art Generator Initiative (Competition)

THE MACHINIST LANDSCAPE: AN ENTROPIC GRID OF VARIANCE
‘By drawing a diagram, a ground plan of a house, a street plan to the location of a site, or a topographic map, one draws a “logical two dimensional picture”. A “logical picture” differs from a natural or realistic picture in that it rarely looks like the thing it stands for.’
A Provisional Theory of Non-Sites, Robert Smithson (1968)

Between design and ground there are variances, deviations and gaps. These exist as physical interstices between what is conceptualised and what is realised; and they reveal moments in the design process that resist the reconciliation of people and their environment (McHarg 1963). The Machinist Landscape interrogates the significance of these variances through the contrasting processes of coppice and photovoltaic energy. It builds on the potential of these gaps, and in doing so proposes that these spaces of variance can reveal the complexity of relationships between consumption and remediation, design and nature.
Fresh Kills Park, and in particular the draft master plan (2006), offers a framework to explore this artificial construct. Central to the Machinist Landscape is the analysis of the landfill gas collection system, planned on a notional 200ft grid. Variations are revealed between this diagrammatic grid measure and that which has been constructed on the site. These variances between the abstract and the real offer the Machinist Landscape a powerful space of enquiry. Are these gaps a result of unexpected conditions below ground, topographic nuances or natural phenomena? Does this space of difference, between what is planned and what is constructed, have the potential to redefine the dynamic processes and relations with the land?
The Machinist Landscape is structured through this space of variance with an ‘entropic grid’, the under-storey of which hosts a carefully managed system of short-rotation coppice (SRC). The coppice, a medieval practice related to energy, product, and space, operates on theoretical and programmatic levels. It is planted along a structure of linear bunds, stabilized through coppice pole retaining structures and enriched with nutrients from coppice produced bio-char. Above the coppice is built an upper-storey of photovoltaic (PV); its structures fabricated from the coppiced timber and the PV produced with graphene from coppice charcoal processes.

Optimizing antibiotics in residents of nursing homes:protocol of a randomized trial.

BACKGROUND: Antibiotics are frequently prescribed for older adults who reside in long-term care facilities. A substantial proportion of antibiotic use in this setting is inappropriate. Antibiotics are often prescribed for asymptomatic bacteriuria, a condition for which randomized trials of antibiotic therapy indicate no benefit and in fact harm. This proposal describes a randomized trial of diagnostic and therapeutic algorithms to reduce the use of antibiotics in residents of long-term care facilities. METHODS: In this on-going study, 22 nursing homes have been randomized to either use of algorithms (11 nursing homes) or to usual practise (11 nursing homes). The algorithms describe signs and symptoms for which it would be appropriate to send urine cultures or to prescribe antibiotics. The algorithms are introduced by inservicing nursing staff and by conducting one-on-one sessions for physicians using case-scenarios. The primary outcome of the study is courses of antibiotics per 1000 resident days. Secondary outcomes include urine cultures sent and antibiotic courses for urinary indications. Focus groups and semi-structured interviews with key informants will be used to assess the process of implementation and to identify key factors for sustainability.