Delineation of target volume by radiation therapists during online adaptive radiation therapy: What authorization?

The evolution of radiation therapy techniques goes hand in hand with the evolution of the profession of radiation therapist. In the particular context of online adaptive radiotherapy based on cone beam computed tomography images, delegation of certain tasks from the physician to the radiation therapist is possible within the framework of a cooperation protocol. This delegation requires prior theoretical and practical training. It enriches the practice of radiation therapists by allowing them to acquire new skills and greater autonomy. It foreshadows access for radiation therapists to advanced practice.

Catheter removal after interstitial brachytherapy for breast cancer: Feasibility study for task delegation.

Purpose: This study aims to assess the impact of delegating brachytherapy device removal to radiation therapists (RTTs) in the treatment of breast cancer, in terms of safety and efficacy of treatment. Material and Methods: A retrospective, observational study was conducted to analyze breast cancer brachytherapy patients. Standardized protocols were drawn up and the RTTs were gradually trained to remove brachytherapy devices under medical supervision. Results: 423 patients were included in the study over a period of 15 years. The move to involve RTTs in device removal did not lead to a significant increase in complications. Efficient management of complications was observed, with a stable rate of complications whatever the indication for treatment. Conclusion: Delegating removal of brachytherapy devices to RTTs is a move towards the optimization of breast cancer care. This inter-professional approach guarantees diligent, safe care for patients while offering RTTs new opportunities for career development.

Building the private practice workforce in the Northern Territory: Barriers and facilitators for implementation of the allied health assistant role.

OBJECTIVE: To identify barriers and facilitators contributing to the successful implementation of the allied health assistant role in private disability practice to better meet population needs. DESIGN: A qualitative case study. SETTING: This study was completed with staff working in private disability practices in a regional context in the Northern Territory. PARTICIPANTS: Eight participants were interviewed, including three allied health assistants, three allied health professionals, and two managers with allied health backgrounds. RESULTS: More barriers were reported than facilitators, with four key themes identified. Financial risk was a barrier when employing allied health assistants. This risk was mediated by providing part-time employment or having allied health assistants in dual roles. Reduced confidence from allied health professionals and assistants to complete delegation work was the second barrier. A facilitator was increasing allied health assistants' task variation, which participants reported increased retention. Finally, a positive working relationship between allied health professionals and assistants facilitates delegation. CONCLUSION: This research offers private disability providers insight into the realities of employing an allied health assistant. It also suggests that formal training programs for both allied health assistants and professionals require increased focus on delegation in the private disability sector. On a government level, a review of the NDIS price guide for allied health assistant rates is needed if private providers are to better meet the requirements for NDIS participants in regional areas.

Musculoskeletal patients' preferences for care from physiotherapists or support workers: a discrete choice experiment.

BACKGROUND: Delegation of clinical tasks from physiotherapists to physiotherapy support workers is common yet varies considerably in musculoskeletal outpatient physiotherapy services, leading to variation in patient care. This study aimed to explore patients' preferences and estimate specific trade-offs patients are willing to make in treatment choices when treated in musculoskeletal outpatient physiotherapy services. METHODS: A discrete choice experiment was conducted using an efficient design with 16 choice scenarios, divided into two blocks. Adult patients with musculoskeletal conditions recruited from a physiotherapy service completed a cross-sectional, online questionnaire. Choice data analyses were conducted using a multinomial logit model. The marginal rate of substitution for waiting time to first follow-up physiotherapy appointment and distance from the physiotherapy clinic was calculated and a probability model was built to estimate the probability of choosing between two distinct physiotherapy service options under different scenarios. RESULTS: 382 patient questionnaires were completed; 302 participants were treated by physiotherapists and 80 by physiotherapists and support workers. There was a significant preference to be seen by a physiotherapist, have more follow-up treatments, to wait less time for the first follow-up appointment, to be seen one-to-one, to see the same clinician, to travel a shorter distance to get to the clinic and to go to clinics with ample parking. Participants treated by support workers did not have a significant preference to be seen by a physiotherapist and it was more likely that they would choose to be seen by a support worker for clinic scenarios where the characteristics of the physiotherapy service were as good or better. CONCLUSIONS: Findings highlight that patients treated by support workers are likely to choose to be treated by support workers again if the other service characteristics are as good or better compared to a service where treatment is provided only by physiotherapists. Findings have implications for the design of physiotherapy services to enhance patient experience when patients are treated by support workers. The findings will contribute to the development of "best practice" recommendations to guide physiotherapists in delegating clinical work to physiotherapy support workers for patients with musculoskeletal conditions.

Effects of work environments on satisfaction of nurses working for integrated care system in South Korea: a multisite cross-sectional investigation.

BACKGROUND: Nurses' satisfaction has an impact on organizational and patient outcomes. Integrated care system in South Korea was established in 2015 to improve care quality and decrease caregiving burden. Since then, nurses' satisfaction has increased due to an increase in nursing staffing. However, besides nurse staffing, various work environments still affect nurse satisfaction. METHODS: Individual online surveys were conducted with participants to determine their personal characteristics, work environments, and hospital characteristics. We used mixed-effects linear regression equation contained both fixed and random effects. RESULTS: This study included 2,913 nurses from 119 hospitals. Their average job satisfaction was less than 6 points out of 10 points. Age, shift type, perceived workload, and delegation criteria were significant factors influencing nurses' satisfaction. There was no significant factor among hospital characteristics. The satisfaction level of nurses was high for no-night rotating shift, low perceived workload, and clear delegation criteria. CONCLUSIONS: Nurses' satisfaction is affected by several work environmental factors. Low nurse satisfaction has a substantial impact on both patients and nurses. Therefore, nurse managers and hospitals should determine factors influencing their satisfaction and develop strategies to improve their satisfaction.

Time spent on activities that can be delegated and reasons for not delegating among acute care nurses: A mixed-methods study.

AIM: To describe the activities nurses perceived to be delegable to other staff (delegable activities) in order to estimate the time nurses spend on delegable activities and explore nurses' reasons for not delegating these activities. DESIGN: Mixed-methods explanatory sequential. METHODS: In total, 236 nurses from 27 medical and surgical wards of five hospitals in northern Italy completed a web-based survey during a single shift between June and July 2022. Minutes spent on delegable activities, staff member to whom participants could have delegated and reason(s) for not delegating were reported. Chief nurses provided specific wards' characteristics using a paper-and-pencil questionnaire. Twenty semi-structured interviews were conducted to explore delegable activities and reasons for not delegating. Quantitative and qualitative results were merged using joint displays. RESULTS: Participants spent approximately one-quarter of their time performing delegable activities, mainly delegable to nurse aides or nurse clerks, and performed due to a lack/shortage of staff or their concurrent participation in other activities. Participants recognized that activities requiring clinical assessment and decision-making skills cannot be delegated, whereas technical activities and indirect care should be delegated. Organizational, structural and cultural factors, as well as patient characteristics, available staff and experience affected delegation, leading nurses to perform delegable activities to ensure patient care. CONCLUSION: Nurses spend a considerable part of their time on delegable activities due to a lack of staff or support services and suboptimal organization, which could be addressed by optimal staff management, but also to the complexity of the contexts, including individual and cultural factors that should be addressed through policy interventions. IMPACT: This study estimates the time nurses spend on delegable activities in acute care settings. Our findings highlighted the reasons that sustain the decision not to delegate that policymakers, healthcare managers, and nurse educators should consider to promote nurses' delegation skills. REPORTING METHODS: MMR checklist. PATIENT/PUBLIC CONTRIBUTION: None.

The evaluation of health, disability and aged care-sector engagement with resources designed to support optimisation of the allied health assistant workforce: a qualitative study.

BACKGROUND: Allied health assistants (AHAs) support allied health professionals (AHPs) to meet workforce demands in modern healthcare systems. In an Australian context historically, AHAs have been sub-optimally utilised. Prior research has identified that AHAs and AHPs working in health, disability and aged care sectors, and the Vocational Education and Training (VET) industry, may benefit from access to resources to support the optimisation of the AHA workforce. As a part of a Victorian department of health funded project, several resources were developed in line with workforce recommendations for use in each of the above sectors. Recommendations and resources covered the broad areas of pre-employment training, workforce planning and governance, consumer-centred therapy and supports, recruitment and induction and workplace training and development. This study aimed to evaluate the engagement with these newly designed resources to support optimisation of AHAs in the Victorian context. METHODS: Semi-structured interviews were conducted to evaluate engagement with resources, from the perspective of AHAs, AHPs and allied health leaders (AHLs) in the health, aged care or disability sectors, and educators and managers of allied health assistance training. Thematic analysis was conducted using team-based framework analysis. RESULTS: Thematic framework analysis of the interview data identified four themes; Why participants accessed the resources; How participants engaged with the resources; What (if any) changes in practice occurred as a result of engaging with the resources in a participant's local context, How did participants envision the resources being utilised for AHA workforce optimisation in the future. Responses were mapped to the AHA workforce career pathway at the career preparation, career development and career trajectory tiers. CONCLUSIONS: Appetite for AHA workforce development and optimal utilisation is evident across Victoria, Australia. Readily accessible resources that inform AHA role and scope of practice, delegation practice, or improve the ability for an AHA to state their own development needs, were identified as useful by participants. The potential for these resources to assist in the optimal utilisation and development of AHA workforces across the career continuum differs according to the role, sector and geographical location of the resource user. Further study is needed to investigate the transferability of these resources to national and global contexts.

The Art of Delegation.

The nurse staffing crisis requires nurses and administrators to think differently about how to get things done. Delegation is key to doing more work with fewer registered nurses (RNs) and retaining current RN staff. Responsibility for effective delegation does not rest solely with the RN but begins with the institution, and includes both the delegator and delegatee. While effective delegation has often been referred to as an art, knowing the science behind delegation can aid in honing a skill necessary for top of license practice.

Delegating care as a double-edged sword for quality of nursing care: a qualitative study.

BACKGROUND: Considering the significance of care delegation in enhancing the quality of nursing care and ensuring patient safety, it is imperative to explore nurses' experiences in this domain. As such, this study aimed to explore the experiences of Iranian nurses regarding the delegation of care. METHODS: This qualitative study was conducted between 2022 and 2023, employing the content analysis method with a conventional approach. The study utilized purposeful sampling method to select qualified participants. Data collection was carried out through in-depth and semi-structured interviews utilizing open-ended questions. The data analysis process followed the steps proposed by Graneheim and Lundman (2004) and involved the use of MAXQDA version 12 software. To ensure the trustworthiness of the data, the study employed the four rigor indices outlined by Lincoln and Guba (1985). RESULTS: In the present study, a total of 15 interviews were conducted with 12 participants, the majority of whom were women. The age range of the participants fell between 25 and 40 years. Through qualitative data analysis, eight subcategories and three main categories of "insourcing of care", "outsourcing of care" and "delegating of care to non-professionals" were identified. Additionally, the overarching theme that emerged from the analysis was "delegation of care, a double-edged sword". CONCLUSIONS: The results of the study revealed that the delegation of care occurred through three distinct avenues: to colleagues within the same unit, to colleagues in other units, and to non-professionals. Delegating care was found to have potential benefits, such as reducing the nursing workload and fostering teamwork. However, it was also observed that in certain instances, delegation was not only unhelpful but also led to missed nursing care. Therefore, it is crucial to adhere to standardized principles when delegating care to ensure the maintenance of high-quality nursing care.

Delegation of insulin administration: a survey of community nursing teams in England.

In community nursing, the administration of insulin for people with type 2 diabetes can be delegated by registered nurses to healthcare support workers. Although a voluntary framework in England provides national guidance, little is known about its uptake. The project aim was to determine the roll-out, characteristics and support needs in relation to the delegation of insulin administration in community settings. An online survey was disseminated to community nursing services in England via social media and nursing networks. Of the 115 responding organisations, 81% (n=93) had an insulin delegation programme, with most initiated since 2018. From these services, 41% (n=3704) of insulin injections were delegated daily, with benefits for patients, staff and services reported, along with some challenges. Delegation of insulin administration is an established and valued initiative. Awareness of the national voluntary framework is increasing. National guidance is considered important to support governance arrangements and safety.

Agreeing priority categories and items for inclusion in a future best practice delegation framework for musculoskeletal outpatient physiotherapy services: A consensus groups study.

PURPOSE: Delegation of clinical tasks from physiotherapists to physiotherapy support workers varies considerably in musculoskeletal outpatient physiotherapy services leading to variation in patient care. This study aimed to develop consensus amongst physiotherapists, support workers and managers about what components should be included in a future framework to guide effective and safe delegation of clinical tasks to physiotherapy support workers in United Kingdom's National Health Service musculoskeletal outpatient physiotherapy services. METHODS: A consensus study was carried out, using Nominal Group Technique. Seven physiotherapists, ten physiotherapy support workers and ten physiotherapy operational/clinical leads from 13 musculoskeletal physiotherapy services within United Kingdom's National Health Service were recruited through the Chartered Society of Physiotherapy's professional networks and social media. Three separate, role-specific consensus groups were convened, involving participants generating, discussing and rating on a Likert scale, components for inclusion in a future delegation framework. RESULTS: 32 out of 38 generated items reached consensus of ≥70%, i.e. a mean of ≥4.9 on a 7-point Likert scale, across the three groups. Items were grouped under five main categories: 1) training/Continuous Professional Development for physiotherapists and support workers; 2) need for a clear delegation process; 3) competencies 4) defining the role of support workers and 5) safety net. CONCLUSION: Key stakeholder groups were able to reach consensus on five priority areas which will be developed into a best practice framework to standardise delegation and guide physiotherapists when delegating clinical tasks to support workers.

A Comprehensive Approach to User Delegation and Anonymity within Decentralized Identifiers for IoT.

Decentralized Identifiers have recently expanded into Internet of Things devices and are crucial in securing users' digital identities and data. However, Decentralized Identifiers face challenges in scenarios necessitating authority delegation and anonymity, such as when dealing with legal guardianship for minors, device loss or damage, and specific medical contexts involving patient information. This paper aims to strengthen data sovereignty within the Decentralized Identifier system by implementing a secure authority delegation and anonymity scheme. It suggests optimizing verifiable presentations by utilizing a sequential aggregate signature, a Non-Interactive Zero-Knowledge Proof, and a Merkle tree to prevent against linkage and Sybil attacks while facilitating delegation. This strategy mitigates security risks related to delegation and anonymity, efficiently reduces the computational and verification efforts for signatures, and reduces the size of verifiable presentations by about 1.2 to 2 times.

FIR agreement Indonesia - Singapore: What are the legal implications?

This paper explores the implications of Indonesia's agreement to delegate the Flight Information Region (FIR) of air navigation services to Singapore, specifically in the airspace of the Riau and Natuna islands, as stated in Presidential Regulation Number 109 of 2022. Using the normative juridical method, this study examines the intricate details of the agreement, with a focus on its potential legal consequences for Indonesia's national and international obligations. Although Indonesia retains sovereignty over its territory, this analysis scrutinizes the nuanced provisions of the agreement and their implications, particularly in terms of the technical aspects of air traffic services provided by the Singapore Air Traffic Services Provider above Indonesia's territories, which the agreement does not explicitly delineate the responsibilities or shared consequences in law. The purpose of this paper is to elucidate Indonesia's increased responsibility under the new agreement and emphasize the importance of a careful approach to its implementation. By exploring the multifaceted dimensions of national and international interests, this study seeks to highlight the imperative for Indonesia to navigate the agreement prudently. Ultimately, this analysis aims to provide a comprehensive understanding of Indonesia's obligations, potential challenges, and essential considerations under the renewed agreement of 2022, underscoring the significance of a balanced approach in safeguarding Indonesia's interests on both national and international fronts.

Factors impacting nursing assistants to accept a delegation in the acute care settings: A mixed method study.

AIMS: To investigate the experience of nursing assistants being delegated nursing tasks by registered nurses. DESIGN: Mixed method explanatory sequential design. METHODS: A total of 79 nursing assistants working in an acute hospital in Australia completed surveys that aimed to identify their experience of working with nurses and the activities they were delegated. The survey data were analysed using descriptive statistics. Interviews with 11 nursing assistants were conducted and analysed using Braun and Clarke's thematic analysis. Results were triangulated to provide a richer understanding of the phenomena. RESULTS: Most nursing assistants felt supported completing delegated care activities. However, there was confusion around their scope of practice, some felt overworked and believed that they did not have the right to refuse a delegation. Factors impacting the nursing assistant's decision to accept a delegation included the attitude of the nurses, wanting to be part of the team and the culture of the ward. Nursing assistants who were studying to be nurses felt more supported than those who were not. CONCLUSIONS: Delegation is a two-way relationship and both parties need to be cognisant of their roles and responsibilities to ensure safe and effective nursing care is provided. Incorrectly accepting or refusing delegated activities may impact patient safety. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Highlights the need for implementing strategies to support safe delegation practices between the registered and unregulated workforce to promote patient safety. IMPACT: Describes the experiences of nursing assistants working in the acute care environment when accepting delegated care from nurses. Reports a range of factors that inhibit or facilitate effective delegation practices between nurses and nursing assistants. Provides evidence to support the need for stronger education and policy development regarding delegation practices between nurses and unregulated staff. REPORTING METHOD: Complied with the APA Style JARS-MIXED reporting criteria for mixed method research. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

[Practice and challenges of delegating medical tasks in the interprofessional everyday work of inpatient healthcare in Germany - An exploratory survey]. / Praxis und Herausforderungen der Delegation ärztlicher Tätigkeiten im interprofessionellen Arbeitsalltag der stationären Krankenversorgung in Deutschland: eine explorative Befragung.

BACKGROUND: The delegation of medical tasks (DMT) plays a significant role in the everyday practice of inpatient care but also presents a potential challenge in interprofessional collaboration. Assessing the conditions of DMT in everyday work is crucial to identify areas for optimization. METHODS: In a nationwide exploratory study, physicians, nursing and allied health professionals working for inpatient care facilities were surveyed regarding various aspects of DMT using a standardized online questionnaire. RESULTS: The majority of the 757 participants (64.9% physicians), perceived DMT to be both economically and time-efficient (88.5% agreement) and in the best interest of patients (74%). For 78.7% of the respondents, DMT represents a potential conflict in their daily work, depending on the quality of interprofessional communication. Inadequate staffing was identified as a barrier to a broader implementation of DMT by 83.8% of participants. 63.2% of the participants considered their knowledge of legal aspects related to DMT to be at least good (participants with less than 5 years of professional experience: 52.6%). Physicians primarily acquire relevant knowledge through professional practice (71.3% vs. non-physicians 39.5%). CONCLUSION: Across the different professional groups DMT was considered beneficial and serving the interests of patients. Targeted promotion of safe and cost-effective DMT should be incorporated into medical education. Achieving greater benefits from DMT requires explicit legal frameworks, effective communication within the team and, in particular, adequate staffing among the professional groups responsible for delegated tasks.

Identity-based controlled delegated outsourcing data integrity auditing scheme.

With the continuous development of cloud computing, the application of cloud storage has become more and more popular. To ensure the integrity and availability of cloud data, scholars have proposed several cloud data auditing schemes. Still, most need help with outsourced data integrity, controlled outsourcing, and source file auditing. Therefore, we propose a controlled delegation outsourcing data integrity auditing scheme based on the identity-based encryption model. Our proposed scheme allows users to specify a dedicated agent to assist in uploading data to the cloud. These authorized proxies use recognizable identities for authentication and authorization, thus avoiding the need for cumbersome certificate management in a secure distributed computing system. While solving the above problems, our scheme adopts a bucket-based red-black tree structure to efficiently realize the dynamic updating of data, which can complete the updating of data and rebalancing of structural updates constantly and realize the high efficiency of data operations. We define the security model of the scheme in detail and prove the scheme's security under the difficult problem assumption. In the performance analysis section, the proposed scheme is analyzed experimentally in comparison with other schemes, and the results show that the proposed scheme is efficient and secure.

Hidden figures: how legal experts influence the design of international institutions.

Whose preferences influence the design of international institutions? Scholarship on the legalization of international politics and creation of international legal institutions largely adopts a state-centric perspective. Existing accounts, however, fail to recognize how states often delegate authority over institutional design tasks to independent legal experts whose preferences may diverge from those of states. We develop a principal-agent (PA) framework for theorizing relations between states (collective principals) and legal actors (agents) in the design process, and for explaining how legal actors influence the design of international institutions. The legal dimensions of the PA relationship increase the likelihood of preference divergence between the collective principal and the agent, but also create conditions that enable the agent to opportunistically advance its own design preferences. We argue that the more information on states' preferences the agent has, the more effectively it can exploit its legal expertise to strategically select and justify design choices that maximize its own preferences and the likelihood of states' acceptance. Our analysis of two cases of delegated institutional design concerning international criminal law at the United Nations and the African Union supports our theoretical expectations. Extensive archival and interview data elucidate how agents' variable information on states' preferences affects their ability to effectively advance their design preferences. Our theory reveals how independent legal experts with delegated authority over design tasks influence institutional design processes and outcomes, which has practical and normative implications for the legalization of international politics.

"Cooperation between physicians and physios fosters trust you know": a qualitative study exploring patients' experience with first-contact physiotherapy for low back pain in French primary care.

BACKGROUND: Physiotherapists working in collaboration with family physicians in French multidisciplinary primary healthcare clinics are now able to manage acute low back pain patients as first-contact practitioners in advanced practice roles. This includes medical act delegation such as making a medical diagnosis and prescribing medication. The aim of this study is to explore patients' experience and perceptions when attending a first-contact physiotherapist (FCP) in an advanced practice collaborative primary care model for acute low back pain (LBP). METHODS: A qualitative study using semi-structured interviews was conducted. Patients that consulted a FCP for acute LBP care in new collaborative model were included. Interviews were transcribed verbatim and inductive thematic analysis was performed to generate themes related to patients' experience and perceptions. RESULTS: Ten patients were interviewed (3 women, 7 men; mean age 36.5 ± 9.63 years). All LBP participants experienced important level of pain and disability. Four overarching themes related to patients' experience with the new FCP model were formalized: 1) "Going to see a physiotherapist who specializes in painful movements, well that makes sense to me", 2) "Physiotherapist offered to give me exercises to do at home to relieve the back pain", 3) "I went there feeling confident", 4) "The physiotherapist can do more than just send you to see more appropriate people". Participants highlighted the need to receive timely and high-quality care and were receptive with being autonomously managed by a FCP. Overall, patients' experiences with FCP model of care were positive. Participants were highly confident in the FCP's ability to perform delegated medical tasks including making a medical diagnosis and prescribing oral medication such as analgesic drugs. Patients felt that a greater expansion of FCPs' scope of practice was needed to improve the model. CONCLUSION: Findings from this study can inform the implementation of FCP in countries where patients are not typically granted FCP by underlining that patients are favourable towards the advance practice model as such models support timely and high-quality care. Further research is needed to better determine the future advance practice physiotherapists' scope of practice in French primary and secondary care settings.

The Only way is up? How Different Facets of Employee and Supervisor Perfectionism Help or Hinder Career Development.

Although the double-edged nature of perfectionism is widely acknowledged, little is known about how it shapes employee career development. By combining two field studies, we provide a multiperspective insight into the relevance of both employee and supervisor perfectionism for employee career development. While we expected self-oriented perfectionism (SOP) to have an ambivalent role for career development, we proposed that socially prescribed perfectionism (SPP) in particular, but also other-oriented perfectionism (OOP), would show maladaptive relationships with career-related indicators. In Study 1 (N = 116), we focused on the employee perspective and how multidimensional perfectionism relates to career aspirations (operationalized via work motivation) and subjective career success. Employees high in SOP reported higher, whereas those high in SPP reported lower perceived career success. OOP was negatively related to intrinsic motivation, but positively explained extrinsic (social) motivation and amotivation. In Study 2 (N = 146), we examined the role of supervisor perfectionism in supporting or hindering employees' career development by providing or draining resources. Our results show that supervisors high in SOP - and partly in OOP are reluctant to delegate highly responsible tasks; SPP even increased the likelihood of assigning illegitimate tasks to subordinates. Our findings suggest that both employee and supervisor perfectionism may boost or thwart employee career development and success. We discuss that supervisor perfectionism may limit employees' opportunities for experiential learning.

Practice (In)Efficiency in Veterinary Medicine: Moving from Chaos to Control.

The veterinary profession has long struggled with inefficiency. The challenges of the pandemic and the increase in case load have truly highlighted how significant the in-efficiencies were. By working on more efficient use of the physical plants where veterinary care is delivered; more efficient use of the inventory that is sold; more efficient use of the people that deliver service and care; and more efficient use of systems, processes, and checklists, the veterinary profession can improve its efficiency, its profitability, and even the enjoyment of working in the profession.