Non-medical practitioners in the staffing of emergency departments and urgent treatment centres in England: a mixed qualitative methods study of policy implementation.

BACKGROUND: Patient demand, internationally, on emergency departments and urgent care treatment centres has grown. Shortages of staff, particularly of emergency medicine doctors, have compounded problems. Some countries are pursuing solutions of including non-medical practitioners e.g., nurse practitioners and physician associates/assistants in their emergency department workforces. This study investigated at the macro and meso level of the health system in England: what the rationale was and the factors influencing the current and future employment, or otherwise, of non-medical practitioners in emergency departments and urgent treatment centres. METHODS: Mixed qualitative methods in the interpretative tradition were employed. We undertook, in 2021-2022, a documentary analysis of national, regional and subregional policy (2017-2021), followed by semi-structured interviews of a purposive sample (n = 18) of stakeholders from national, regional and subregional levels. The data were thematically analysed and then synthesised. RESULTS: There was general national policy support for increasing the presence of non-medical practitioners as part of the solution to shortages of emergency medicine doctors. However, evidence of policy support dissipated at regional and subregional levels. There were no published numbers for non-medical practitioners in emergency departments, but stakeholders suggested they were relatively small in number, unevenly distributed and faced uncertain growth. While the experience of the COVID-19 pandemic and its aftermath were said to have made senior decision makers more receptive to workforce innovation, many factors contributed to the uncertain growth. These factors included: limited evidence on the relative advantage of including non-medical practitioners; variation in the models of service being pursued to address patient demand on emergency departments and the place of non-medical practitioners within them; the lack of a national workforce plan with clear directives; and the variation in training for non-medical practitioner roles, combined with the lack of regulation of that level of practice. CONCLUSIONS: We identified many features of a system ready to introduce non-medical practitioners in emergency departments and urgent treatment centres but there were uncertainties and the potential for conflict with other professional groups. One area of uncertainty was evidence of relative advantage in including non-medical practitioners in staffing. This requires urgent attention to inform decision making for short- and long-term workforce planning. Further investigation is required to consider whether these findings are generalisable to other specialties, and to similar health systems in other countries.

Provision of acute care pathways for older major trauma patients in the UK.

BACKGROUND: The introduction of specific pathways of care for older trauma patients has been shown to decrease hospital length of stay and the overall rate of complications. The extent and scope of pathways and services for older major trauma patients in the UK is not currently known. OBJECTIVE: The primary objective of this study was to map the current care pathways and provision of services for older people following major trauma in the UK. METHODS: A cross-sectional survey of UK hospitals delivering care to major trauma patients (major trauma centres and trauma units). Data were collected on respondent and site characteristics, and local definitions of older trauma patients. To explore pathways for older people with major trauma, four clinical case examples were devised and respondents asked to complete responses that best illustrated the admission pathway for each. RESULTS: Responses from 56 hospitals were included in the analysis, including from 25 (84%) of all major trauma centres (MTCs) in the UK. The majority of respondents defined 'old' by chronological age, most commonly patients 65 years and over. The specialty team with overall responsibility for the patient in trauma units was most likely to be acute medicine or acute surgery. Patients in MTCs were not always admitted under the care of the major trauma service. Assessment by a geriatrician within 72 hours of admission varied in both major trauma centres and trauma units and was associated with increased age. CONCLUSIONS: This survey highlights variability in the admitting specialty team and subsequent management of older major trauma patients across hospitals in the UK. Variability appears to be related to patient condition as well as provision of local resources. Whilst lack of standardisation may be a result of local service configuration this has the potential to impact negatively on quality of care, multi-disciplinary working, and outcomes.

Physician associates in the UK: Development, status, and future.

ABSTRACT: Physician associates (PAs) have been part of the UK health workforce for almost 20 years. The profession is growing rapidly with statutory regulation, protection of the title, and career progression supported by a national-level framework all in the pipeline for the near future. This article provides a brief history of the profession in the United Kingdom and prospects for its future.

Building the evidence base-10 years of PA research in England.

This article describes the 10-year journey of a research group helping to build the research evidence base for physician assistants (PAs), known as physician associates in the United Kingdom, in the National Health Service in England. It draws out some key issues that may be of interest to those developing PA research programs in different specialties and different countries. PA research also can help healthcare policy makers address growing demand, issues of quality, and cost.

Development and feasibility of the use of an assessment tool measuring treatment efficacy in patients with trimethylaminuria: A mixed methods study.

Trimethylaminuria (TMAU) is a rare metabolic condition characterised by an unpleasant smell resembling rotting fish. Currently, the only measure of treatment efficacy is urine trimethylamine levels which do not always reflect the patient's experience of symptoms. A literature review did not find a specific tool to assess treatment efficacy from the patient's perspective. The aim of this study was to develop an assessment tool to provide a quantitative measure of treatment efficacy in patients diagnosed with TMAU before and after treatment and assess its acceptability (feasibility of use and face and content validity) to people living with TMAU. Mixed methods; a modified, four-round Delphi by email and semi-structured interviews conducted after clinical appointments. Delphi; Eight individuals living with TMAU from the TMAU forum, six medical consultants, and four dieticians in Metabolic Medicine in four National Health Service hospitals in England. Semi-structured interviews; three patients with TMAU in two National Health Service hospitals, United Kingdom. The assessment tool contains 27 items distributed across four domains; Odour characteristics with 6 items, mental well-being with 13 items, social well-being with 5 items, and healthcare professionals support with 3 items. Semi-structured interviews; views on the content and design of the tool. The co-produced tool was successfully developed and considered acceptable to people living with TMAU. While further testing is needed to evaluate the validity and reliability of the assessment tool, the tool may serve as a prompt for questioning for clinicians diagnosing and treating TMAU.

Understanding patients' satisfaction with physician assistant/associate encounters through communication experiences: a qualitative study in acute hospitals in England.

BACKGROUND: Physician assistants/associates (PAs) are a recent innovation in acute hospital teams in England and many other countries worldwide. Although existing evidence indicates generally high levels of patient satisfaction with their PA hospital encounters, little is known about the factors associated with this outcome. There is a lack of evidence on the process of PA-patient communication in hospital encounters and how this might influence satisfaction. This study therefore aimed to understand patients' satisfaction with PA acute hospital encounters through PA-patient communication experiences. METHODS: A qualitative study was conducted among patients and representatives of patients seen by or receiving care from one of the PAs working in acute hospital services in England. Semi-structured interviews were undertaken face-to-face with study participants in the hospital setting and shortly after their PA encounter. Data were coded and analysed using thematic analysis. The study was framed within a theoretical model of core functions of medical encounter communication. RESULTS: Fifteen patients and patient representatives who had experienced a PA encounter participated in interviews, across five hospitals in England. Four interrelated communication experiences were important to participants who were satisfied with the encounter in general: feeling trust and confidence in the relationship, sharing relevant and meaningful information, experiencing emotional care and support, and sharing discussion on illness management and treatment. However, many participants misconceived PAs to be doctors, raising a potential risk of reduced trust in the PA relationship and negative implications for satisfaction with their PA encounter. Participants considered it beneficial that patients be informed about the PA role to prevent confusion. CONCLUSIONS: PA encounters offer a constructive example of successful clinician-patient communication experiences in acute hospital encounters from the patient's perspective. Study participants were generally naïve to the PA role. Hospital services and organisations introducing these mid-level or advanced care practitioner roles should consider giving attention to informing patients about the roles.

Paramedic Assessment of Older Adults After Falls, Including Community Care Referral Pathway: Cluster Randomized Trial.

STUDY OBJECTIVE: We aim to determine clinical and cost-effectiveness of a paramedic protocol for the care of older people who fall. METHODS: We undertook a cluster randomized trial in 3 UK ambulance services between March 2011 and June 2012. We included patients aged 65 years or older after an emergency call for a fall, attended by paramedics based at trial stations. Intervention paramedics could refer the patient to a community-based falls service instead of transporting the patient to the emergency department. Control paramedics provided care as usual. The primary outcome was subsequent emergency contacts or death. RESULTS: One hundred five paramedics based at 14 intervention stations attended 3,073 eligible patients; 110 paramedics based at 11 control stations attended 2,841 eligible patients. We analyzed primary outcomes for 2,391 intervention and 2,264 control patients. One third of patients made further emergency contacts or died within 1 month, and two thirds within 6 months, with no difference between groups. Subsequent 999 call rates within 6 months were lower in the intervention arm (0.0125 versus 0.0172; adjusted difference -0.0045; 95% confidence interval -0.0073 to -0.0017). Intervention paramedics referred 8% of patients (204/2,420) to falls services and left fewer patients at the scene without any ongoing care. Intervention patients reported higher satisfaction with interpersonal aspects of care. There were no other differences between groups. Mean intervention cost was $23 per patient, with no difference in overall resource use between groups at 1 or 6 months. CONCLUSION: A clinical protocol for paramedics reduced emergency ambulance calls for patients attended for a fall safely and at modest cost.

Patients' experiences of consultations with physician associates in primary care in England: A qualitative study.

BACKGROUND: Physician associates are new to English general practice and set to expand in numbers. OBJECTIVE: To investigate the patients' perspective on consulting with physician associates in general practice. DESIGN: A qualitative study, using semi-structured interviews, with thematic analysis. SETTING AND PARTICIPANTS: Thirty volunteer patients of 430 who had consulted physician associates for a same-day appointment and had returned a satisfaction survey, in six general practices employing physician associates in England. FINDINGS: Some participants only consulted once with a physician associate and others more frequently. The conditions consulted for ranged from minor illnesses to those requiring immediate hospital admission. Understanding the role of the physician associate varied from 'certain and correct' to 'uncertain', to 'certain and incorrect', where the patient believed the physician associate to be a doctor. Most, but not all, reported positive experiences and outcomes of their consultation, with some choosing to consult the physician. Those with negative experiences described problems when the limits of the role were reached, requiring additional GP consultations or prescription delay. Trust and confidence in the physician associate was derived from trust in the NHS, the general practice and the individual physician associate. Willingness to consult a physician associate was contingent on the patient's assessment of the severity or complexity of the problem and the desire for provider continuity. CONCLUSION: Patients saw physician associates as an appropriate general practitioner substitute. Patients' experience could inform delivery redesign.

The determinants and consequences of adult nursing staff turnover: a systematic review of systematic reviews.

BACKGROUND: Nurses leaving their jobs and the profession are an issue of international concern, with supply-demand gaps for nurses reported to be widening. There is a large body of existing literature, much of which is already in review form. In order to advance the usefulness of the literature for nurse and human resource managers, we undertook an overview (review of systematic reviews). The aim of the overview was to identify high quality evidence of the determinants and consequences of turnover in adult nursing. METHODS: Reviews were identified which were published between 1990 and January 2015 in English using electronic databases (the Cochrane Database of Systematic Reviews, MEDLINE, EMBASE, Applied Social Sciences Index and Abstracts, CINAHL plus and SCOPUS) and forward searching. All stages of the review were conducted in parallel by two reviewers. Reviews were quality appraised using the Assessment of Multiple Systematic Reviews and their findings narratively synthesised. RESULTS: Nine reviews were included. We found that the current evidence is incomplete and has a number of important limitations. However, a body of moderate quality review evidence does exist giving a picture of multiple determinants of turnover in adult nursing, with - at the individual level - nurse stress and dissatisfaction being important factors and -at the organisational level - managerial style and supervisory support factors holding most weight. The consequences of turnover are only described in economic terms, but are considered significant. CONCLUSIONS: In making a quality assessment of the review as well as considering the quality of the included primary studies and specificity in the outcomes they measure, the overview found that the evidence is not as definitive as previously presented from individual reviews. Further research is required, of rigorous research design, whether quantitative or qualitative, particularly against the outcome of actual turnover as opposed to intention to leave. TRIAL REGISTRATION: PROSPERO Registration 17 March 2015: CRD42015017613 .

Physician associates working in secondary care teams in England: Interprofessional implications from a national survey.

Physician associates (PAs) are a new type of healthcare professional to the United Kingdom; however, they are well established in the United States (where they are known as physician assistants). PAs are viewed as one potential solution to the current medical workforce doctor shortage. This study investigated the deployment of PAs within secondary care teams in England, through the use of a cross-sectional electronic, self-report survey. The findings from 14 questions are presented. Sixty-three PAs working in a range of specialties responded. A variety of work settings were reported, most frequently inpatient wards, with work generally taking place during weekdays. Both direct and non-direct patient care activities were reported, with the type of work undertaken varying at times, depending on the presence or absence of other healthcare professionals. PAs reported working within a variety of secondary care team staffing permutations, with the majority of these being interprofessional. Line management was largely provided by consultants; however day-to-day supervision varied, often relating to different work settings. A wide variation in ongoing supervision was also reported. Further research is required to understand the nature of PAs' contribution to collaborative care within secondary care teams in England.

Retaining nurses in metropolitan areas: insights from senior nurse and human resource managers.

AIM: To investigate the views of senior nurse and human resource managers of strategies to retain hospital nurses in a metropolitan area. BACKGROUND: Against a global shortage, retaining nurses is a management imperative for the quality of hospital services. METHOD: Semi-structured interviews, thematically analysed. RESULTS: Metropolitan areas have many health organisations in geographical proximity, offering nurses choices in employer and employment. Senior nurse and human resource managers recognised the complexity of factors influencing nurse turnover, including those that 'pulled' nurses out of their jobs to other posts and factors that 'pushed' nurses to leave. Four themes emerged in retaining nurses: strategy and leadership, including analysis of workforce and leavers' data, remuneration, the type of nursing work and career development and the immediate work environment. CONCLUSIONS: In contexts where multiple organisations compete for nurses, addressing retention through strategic leadership is likely to be important in paying due attention and apportioning resources to effective strategies. IMPLICATIONS FOR NURSING MANAGEMENT: Aside from good human resource management practices for all, strategies tailored to different segments of the nursing workforce are likely to be important. This metropolitan study suggests attention should be paid to strategies that address remuneration, progressing nursing careers and the immediate work environment.

The contribution of physician assistants in primary care: a systematic review.

BACKGROUND: Primary care provision is important in the delivery of health care but many countries face primary care workforce challenges. Increasing demand, enlarged workloads, and current and anticipated physician shortages in many countries have led to the introduction of mid-level professionals, such as Physician Assistants (PAs). OBJECTIVE: This systematic review aimed to appraise the evidence of the contribution of PAs within primary care, defined for this study as general practice, relevant to the UK or similar systems. METHODS: Medline, CINAHL, PsycINFO, BNI, SSCI and SCOPUS databases were searched from 1950 to 2010. ELIGIBILITY CRITERIA: PAs with a recognised PA qualification, general practice/family medicine included and the findings relevant to it presented separately and an English language journal publication. Two reviewers independently identified relevant publications, assessed quality using Critical Appraisal Skills Programme tools and extracted findings. Findings were classified and synthesised narratively as factors related to structure, process or outcome of care. RESULTS: 2167 publications were identified, of which 49 met our inclusion criteria, with 46 from the United States of America (USA). Structure: approximately half of PAs are reported to work in primary care in the USA with good support and a willingness to employ amongst doctors. PROCESS: the majority of PAs' workload is the management of patients with acute presentations. PAs tend to see younger patients and a different caseload to doctors, and require supervision. Studies of costs provide mixed results. OUTCOMES: acceptability to patients and potential patients is consistently found to be high, and studies of appropriateness report positively. Overall the evidence was appraised as of weak to moderate quality, with little comparative data presented and little change in research questions over time. LIMITATIONS: identification of a broad range of studies examining 'contribution' made meta analysis or meta synthesis untenable. CONCLUSIONS: The research evidence of the contribution of PAs to primary care was mixed and limited. However, the continued growth in employment of PAs in American primary care suggests that this professional group is judged to be of value by increasing numbers of employers. Further specific studies are needed to fill in the gaps in our knowledge about the effectiveness of PAs' contribution to the international primary care workforce.

Configurations and outcomes of acute hospital care for frail and older patients with moderate to major trauma: a systematic review.

OBJECTIVE: To systematically review research on acute hospital care for frail or older adults experiencing moderate to major trauma. SETTING: Electronic databases (Medline, Embase, ASSIA, CINAHL Plus, SCOPUS, PsycINFO, EconLit, The Cochrane Library) were searched using index and key words, and reference lists and related articles hand-searched. INCLUDED ARTICLES: Peer-reviewed articles of any study design, published in English, 1999-2020 inclusive, referring to models of care for frail and/or older people in the acute hospital phase of care following traumatic injury defined as either moderate or major (mean or median Injury Severity Score ≥9). Excluded articles reported no empirical findings, were abstracts or literature reviews, or referred to frailty screening alone. METHODS: Screening abstracts and full text, and completing data extractions and quality assessments using QualSyst was a blinded parallel process. A narrative synthesis, grouped by intervention type, was undertaken. OUTCOME MEASURES: Any outcomes reported for patients, staff or care system. RESULTS: 17 603 references were identified and 518 read in full; 22 were included-frailty and major trauma (n=0), frailty and moderate trauma (n=1), older people and major trauma (n=8), moderate or major trauma (n=7) 0r moderate trauma (n=6) . Studies were observational, heterogeneous in intervention and with variable methodological quality.Specific attention given to the care of older and/or frail people with moderate to major trauma in the North American context resulted in improvements to in-hospital processes and clinical outcomes, but highlights a relative paucity of evidence, particularly in relation to the first 48 hours post-injury. CONCLUSIONS: This systematic review supports the need for, and further research into an intervention to address the care of frail and/or older patients with major trauma, and for the careful definition of age and frailty in relation to moderate or major trauma. INTERNATIONAL PROSPECTIVE REGISTER OF SYSTEMATIC REVIEWS PROSPERO: CRD42016032895.

Physician assistants in English primary care teams: a survey.

Ensuring that health care teams have a mix of skilled professionals to meet patient need, safely and effectively, is a priority in all health services. The United Kingdom, like a number of other countries, have been exploring the contribution physician assistants, who are well established in the United States of America, can make to health care teams including primary care. This study investigated the employment of physician assistants in English primary care and their contribution through an electronic, self report, survey. Sixteen physician assistants responded, who were working in a variety of types of general practice teams. A range of activities were reported but the greatest proportion of their time was described as seeing patients in booked surgery appointments for same day/urgent appointments. The scope of the survey was limited and questions remain as to patient and professional responses to a new professional group within English primary care.

Protocol for a scoping review on the development of policy, guidelines and protocols within emergency medical services.

Introduction: Emergency medical services (EMS) use a combination of policy, clinical practice guidelines and protocols to set out their expectations for service delivery and to inform patient care. While these are integral to how EMS now operate, relatively little is known about how they are developed, or the processes involved. Therefore, the aim of this scoping review is to understand what is known in the literature about the development of policy, guidelines and protocols within EMS. Methods: This scoping review will follow the Arksey and O'Malley (2005) methodological framework for scoping reviews. A search strategy has been developed using index term definitions, building from authors' knowledge of the field. The following electronic databases will be searched from 2002 to 2021 for all types of publication: CINAHL, Medline, Academic Search Complete and PsycINFO, EMBASE, Nursing and Allied Health, the Cochrane library, NICE Evidence, Scopus, OpenGrey, EThOS, Google Scholar, Google search and key EMS journal websites. The results will be downloaded using EndNoteX9 reference management software and duplicates will be removed. Titles and abstracts of the results will be independently screened for their relevance to the research question, and the full text of each selected publication will be assessed against pre-determined inclusion and exclusion criteria to determine its eligibility. The reference list and forward citations will be searched for articles meeting the eligibility criteria. A second researcher will independently assess a 10% sample of results to allow for validation of this assessment. Data will be extracted and charted on the characteristics of the publications and the knowledge they contribute on the development of policy, guidelines or protocols. Accompanying narratives will be presented to identify themes and gaps in the available evidence. A critical appraisal will be undertaken of the included publications, where empirical research is presented.

Are advanced clinical practice roles in England's National Health Service a remedy for workforce problems? A qualitative study of senior staff perspectives.

OBJECTIVE: A major issue facing all health systems is improving population health while at the same time responding to both growing patient numbers and needs and developing and retaining the health care workforce. One policy response to workforce shortages has been the development of advanced clinical practice roles. In the context of an English national policy promoting such roles in the health service, we explored senior managers' and senior clinicians' perceptions of factors at the organization level that support or inhibit the introduction of advanced clinical practice roles. The investigation was framed by theories of the diffusion of innovation and the system of professions. METHODS: We conducted a qualitative interview study of 39 senior manager and clinicians in 19 National Health Service acute, community, mental health and ambulance organizations across a metropolitan area in 2019. RESULTS: Small numbers of advanced clinical practice roles were reported, often in single services. Four main influences were identified in the development of advanced clinical practice roles: staff shortages (particularly of doctors in training grades) combined with rising patient demand, the desire to retain individual experienced staff, external commissioners or purchasers of services looking to shape services in line with national policy, and commissioner-funded new roles in new ambulatory care services and primary care. Three factors were reported as enabling the roles: finance for substantive posts, evidence of value of the posts, and structural support within the organization. Three factors were perceived as inhibiting developing the roles: confusion and lack of knowledge amongst clinicians and managers, the availability of finance for the roles, and a nervousness (sometimes resistance) to introducing the new roles. CONCLUSIONS: While the national policy was to promote advanced clinical practice roles, the evidence suggested there was and would continue to be limited implementation at the operational level. Development scenarios that introduced new monies for such roles reduced some of the inhibiting factors. However, where the introduction of roles required funding to move from one part of a service to another, and potentially from one staff group to another, the growth of these roles was and is likely to be contested. In such scenarios, research and business evidence of relative advantage will be important, as too will be supporters in powerful positions. The paucity of publicly available evidence on the effectiveness of advanced clinical practice roles across the specialties and professions in different contexts requires urgent attention.

Complexity of the decision-making process of ambulance staff for assessment and referral of older people who have fallen: a qualitative study.

BACKGROUND: Older people who fall commonly present to the emergency ambulance service, and approximately 40% are not conveyed to the emergency department (ED), despite an historic lack of formal training for such decisions. This study aimed to understand the decision-making processes of emergency ambulance staff with older people who have fallen. METHODS: During 2005 ambulance staff in London tested a clinical assessment tool for use with the older person who had fallen. Documented use of the tool was low. Following the trial, 12 staff participated in semistructured interviews. Interviews were recorded and transcribed. Thematic analysis was carried out. RESULTS: The interviews revealed a similar assessment and decision-making process among participants: Prearrival: forming an early opinion from information from the emergency call. Initial contact: assessing the need for any immediate action and establishing a rapport. Continuing assessment: gathering and assimilating medical and social information. Making a conveyance decision: negotiation, referral and professional defence, using professional experience and instinct. CONCLUSIONS: An assessment process was described that highlights the complexity of making decisions about whether or not to convey older people who fall and present to the emergency ambulance service, and a predominance of informal decision-making processes. The need for support for ambulance staff in this area was highlighted, generating a significant challenge to those with education roles in the ambulance service. Further research is needed to look at how new care pathways, which offer an alternative to the ED may influence decision making around non-conveyance.

Knowledge, attitudes and practices of UK paramedics regarding pharmacology and the legal, management and administration aspects of medicines: a cross-sectional online quantitative survey.

INTRODUCTION: Changes in the paramedic profession have seen an increased range of medicines available within UK ambulances services. However, poor practice in medicines management has been identified by the Care Quality Commission. Literature in this area is sparse. This study aimed to determine the perceived knowledge, attitudes and practices of paramedics regarding pharmacology and the legal and regulatory issues of medicines management and administration. METHODS: The study utilised a cross-sectional survey design, administering an anonymous online survey to all (approximately 1000) paramedics within one UK NHS ambulance trust. The survey focused on paramedic knowledge on pharmacology, legal supply and administration; self-assessment of knowledge and confidence related to medicine management and administration; and personal characteristics. The primary outcome was percentage of (pre-determined) correct answers. RESULTS: 251 responses were received. The mean percentage of correct answers was 79.0% (SD 10.0), with variation by question observed, from 34.7 to 97.2% correct responses. A higher correct knowledge was associated with: higher self-rated confidence, lower self-reported knowledge, being less likely to report errors and higher education-based initial route into the paramedic profession. CONCLUSION: This single-site UK-based survey highlighted variation in medicines knowledge among self-selecting paramedic respondents. The results indicate a need for medicines-specific further education for all paramedics, particularly those who have not experienced longer formal education entry routes, integrating a focus on confidence and self-perceived knowledge, and enhancing and embedding integrated improvement strategies. Further research is required with larger, multi-site samples, and to evaluate the impact of education packages developed.

How is the emerging role of domiciliary physiotherapists who treat residents with dementia in nursing homes perceived by allied health professionals? A phenomenological interview study.

Dementia affects majority of older residents in nursing homes and physiotherapists are regularly involved with this population. However, little is known about the role of physiotherapists who treat residents with dementia in nursing homes. The aim of this paper was to report on an interpretivist qualitative exploration of the perceptions of both the providers of and referrers to domiciliary physiotherapy for residents with dementia in nursing homes in London. In 2015, we conducted semi-structured interviews with 10 purposively sampled participants - two were providers of physiotherapy for residents with dementia in nursing homes, five were referrers to these providers and three occupied dual roles. A thematic analysis of the verbatim transcripts identified three main themes. First were perceptions of a multifaceted but unclear role, focused on both conventional 'physical' physiotherapy interventions and specialist care, the latter being reliant on knowledge and confidence that physiotherapists did not always feel they possessed. Second were the stated challenges to the role, including the focus and organisation of the nursing home setting, with perceived lack of emphasis on rehabilitation; the progressive and demanding nature of dementia itself; a lack of continuity of nursing home and visiting health professional staff with associated need to entrust physiotherapy intervention to multiple others and the final challenge was the difficulty measuring impact. Third, despite the challenges, enablers of the role were experienced, namely collaborative working and positive previous experiences of referrers. Joining these themes were underpinning concepts of complexity and uncertainty in relation to the physiotherapy role in this setting. This paper highlights a need for enhanced collaborative working in clinical practice, enabled at organisational level, to help address some of the uncertainties expressed around the physiotherapists' role with residents with dementia in nursing homes and thereby enable improvements to processes and outcomes of their interventions.

Factors Impacting on Eating in Pediatric Intestinal-Transplant Recipients: A Mixed-Methods Study.

BACKGROUND: No empirical data are found examining why eating may be difficult for some children and not others following intestinal transplant. This study aimed to describe the eating behaviors and nutrition intake of intestinal-transplant-recipient children and examine factors that may impact on their eating. METHODS: Caregivers of all (n = 34) intestinal-transplant recipients <18 years of age in the United Kingdom were invited to participate in this mixed-methods study comprising questionnaires, a 3-day food diary and interviews. Questionnaires included the Children's Eating Behaviour Questionnaire and demographic/nutrition-related items. Analysis was by descriptive statistics using SPSS. Semistructured telephone interviews explored caregiver perceptions of their child's eating. Analysis was thematic. RESULTS: Nine caregivers were recruited and completed the questionnaire and food diary. Eight of these were interviewed. Home tube feeding was required by 77% (n = 7) of children post transplant, 56% (n = 5) were "food avoidant", and median energy intake was 93% (range, 61%-137%) of requirements. The findings revealed complex, interrelated positive and negative medical, caregiver, and child-related influences on eating. Learning to eat at the recommended age and having positive and significant pretransplant eating experiences appeared protective, whereas receiving nothing by mouth and having aversive experiences were barriers. CONCLUSION: This study provides the first empirical evidence of factors that may influence eating after intestinal transplant in children. The findings suggest promoting eating pretransplant, when the negative physical consequences can be managed, may be protective, and there may be eating-difficulty predictors that could be used to facilitate targeted interventions.