What might make nurses stay? A protocol for discrete choice experiments to understand NHS nurses' preferences at early-career and late-career stages.

INTRODUCTION: Like many countries, England has a national shortage of registered nurses. Employers strive to retain existing staff, to ease supply pressures. Disproportionate numbers of nurses leave the National Health Services (NHS) both early in their careers, and later, as they near retirement age. Research is needed to understand the job preferences of early-career and late-career nurses working in the NHS, so tailored policies can be developed to better retain these two groups. METHODS AND ANALYSIS: We will collect job preference data for early-career and late-career NHS nurses, respectively using two separate discrete choice experiments (DCEs). Findings from the literature, focus groups, academic experts and stakeholder discussions will be used to identify and select the DCE attributes (ie, job features) and levels. We will generate an orthogonal, fractional factorial design using the experimental software Ngene. The DCEs will be administered through online surveys distributed by the regulator Nursing and Midwifery Council. For each group, we expect to achieve a final sample of 2500 registered NHS nurses working in England. For early-career nurses, eligible participants will be registered nurses who graduated in the preceding 5 years (ie, 2019-2023). Eligible participants for the late-career survey will be registered nurses aged 55 years and above. We will use conditional and mixed logit models to analyse the data. Specifically, study 1 will estimate the job preferences of early-career nurses and the possible trade-offs. Study 2 will estimate the retirement preferences of late-career NHS nurses and the potential trade-offs. ETHICS AND DISSEMINATION: The research protocol was reviewed and approved by the host research organisation Ethics Committees Research Governance (University of Southampton, number 80610) (https://www.southampton.ac.uk/about/governance/regulations-policies/policies/ethics). The results will be disseminated via conference presentations, publications in peer-reviewed journals and annual reports to key stakeholders, the Department of Health and Social Care, and NHS England/Improvement retention leaders. REGISTRATION DETAILS: Registration on OSF http://doi.org/10.17605/OSF.IO/RDN9G.

Congenital duodenal obstruction repair with and without transanastomotic tube feeding: a systematic review and meta-analysis.

OBJECTIVE: To determine the impact of transanastomotic tube (TAT) feeding in congenital duodenal obstruction (CDO). DESIGN: Systematic review with meta-analysis. PATIENTS: Infants with CDO requiring surgical repair. INTERVENTIONS: TAT feeding following CDO repair versus no TAT feeding. MAIN OUTCOME MEASURES: The main outcome was time to full enteral feeds. Additional outcomes included use of parenteral nutrition (PN), cost and complications from either TAT or central venous catheter. Meta-analyses were undertaken using random-effects models (mean difference (MD) and risk difference (RD)), and risk of bias was assessed using the Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool. RESULTS: Twelve out of 373 articles screened met the inclusion criteria. All studies were observational and two were prospective. Nine studies, containing 469 infants, were available for meta-analysis; however, four were excluded due to serious or critical risk of bias. TAT feeding was associated with reduced time to full enteral feeds (-3.34; 95% CI -4.48 to -2.20 days), reduced duration of PN (-6.32; 95% CI -7.93 to -4.71 days) and reduction in nutrition cost of £867.36 (95% CI £304.72 to £1430.00). Other outcomes were similar between those with and without a TAT including inpatient length of stay (MD -0.97 (-5.03 to 3.09) days), mortality (RD -0.01 (-0.04 to 0.01)) and requirement for repeat surgery (RD 0.01 (-0.03 to 0.05)). CONCLUSION: TAT feeding following CDO repair appears beneficial, without increased risk of adverse events; however, certainty of available evidence is low. Earlier enteral feeding and reduced PN use are known to decrease central venous catheter-associated risks while significantly reducing cost of care. PROSPERO REGISTRATION NUMBER: CRD42022328381.

Evaluation of Telephone Cardiopulmonary Resuscitation Performance in Current Practice in Saudi Arabia.

Objectives: Out-of-hospital cardiac arrest (OHCA) is a global health problem with a low survival rate. Telephone cardiopulmonary resuscitation (T-CPR) guidance by emergency medical services (EMS) dispatchers can improve CPR performance and, consequently, survival rates. Accordingly, the American Heart Association (AHA) has released performance standards for T-CPR in current practice to improve its quality. However, no study has examined T-CPR performance in Saudi Arabia. Therefore, this study aims to evaluate T-CPR performance in the Saudi Arabian EMS system. Methods: A retrospective observation of OHCA calls in current practice was conducted in Riyadh, Saudi Arabia. OHCA calls were reviewed to identify those that met the selection criteria. Variables collected included return of spontaneous circulation (ROSC), OHCA recognition rate, time from EMS call receipt to location acquisition, to OHCA recognition and to commencement of CPR. Results: A total of 308 OHCA cases were reviewed, and 100 calls were included. ROSC was identified in 10% of the included calls. OHCA was correctly recognized in 62% of the calls. The time to OHCA identification and CPR performance from EMS call receipt were found to be 303 s and 367 s, respectively. Conclusion: T-CPR performance in Saudi Arabia is below AHA standards. However, this is similar to what has been reported in the literature. Avoiding any unnecessary call transfer during OHCA calls and prompt identification of callers' locations could improve T-CPR performance.

Emergency department staff views of NHS 111 First: qualitative interview study in England.

BACKGROUND: NHS 111 is a phone and online urgent care triage and assessment system that aims to reduce UK ED demand. In 2020, 111 First was introduced to triage patients before entry to the ED and to offer direct booking for patients needing ED or urgent care into same-day arrival time slots. 111 First continues to be used post pandemic, but concerns about patient safety, delays or inequities in accessing care have been voiced. This paper examines ED and urgent care centre (UCC) staff experiences of NHS 111 First. METHOD: Semistructured telephone interviews were conducted with ED/UCC practitioners across England between October 2020 and July 2021 as part of a larger multimethod study examining the impact of NHS 111 online. We purposively recruited from areas with high need/demand likely to be using NHS 111 services. Interviews were transcribed verbatim and coded inductively by the primary researcher. We coded all items to capture experiences of 111 First within the full project coding tree and from this constructed two explanatory themes which were refined by the wider research team. RESULTS: We recruited 27 participants (10 nurses, 9 doctors and 8 administrator/managers) working in ED/UCCs serving areas with high deprivation and mixed sociodemographic profiles. Participants reported local triage/streaming systems predating 111 First continued to operate so that, despite prebooked arrival slots at the ED, all attendances were funnelled into a single queue. This was described by participants as a source of frustration for staff and patients. Interviewees perceived remote algorithm-based assessments as less robust than in-person assessments which drew on more nuanced clinical expertise. DISCUSSION: While remote preassessment of patients before they present at ED is attractive, existing triage and streaming systems based on acuity, and staff views about the superiority of clinical acumen, are likely to remain barriers to the effective use of 111 First as a demand management strategy.

A multimethod study of NHS 111 online.

Background: NHS 111 online offers 24-hour access to health assessment and triage. Objectives: This study examined pathways to care, differential access and use, and workforce impacts of NHS 111 online. This study compared NHS 111 with Healthdirect (Haymarket, Australia) virtual triage. Design: Interviews with 80 staff and stakeholders in English primary, urgent and emergency care, and 41 staff and stakeholders associated with Healthdirect. A survey of 2754 respondents, of whom 1137 (41.3%) had used NHS 111 online and 1617 (58.7%) had not. Results: NHS 111 online is one of several digital health-care technologies and was not differentiated from the NHS 111 telephone service or well understood. There is a similar lack of awareness of Healthdirect virtual triage. NHS 111 and Healthdirect virtual triage are perceived as creating additional work for health-care staff and inappropriate demand for some health services, especially emergency care. One-third of survey respondents reported that they had not used any NHS 111 service (telephone or online). Older people and those with less educational qualifications are less likely to use NHS 111 online. Respondents who had used NHS 111 online reported more use of other urgent care services and make more cumulative use of services than those who had not used NHS 111 online. Users of NHS 111 online had higher levels of self-reported eHealth literacy. There were differences in reported preferences for using NHS 111 online for different symptom presentations. Conclusions: Greater clarity about what the NHS 111 online service offers would allow better signposting and reduce confusion. Generic NHS 111 services are perceived as creating additional work in the primary, urgent and emergency care system. There are differences in eHealth literacy between users and those who have not used NHS 111 online, and this suggests that 'digital first' policies may increase health inequalities. Limitations: This research bridged the pandemic from 2020 to 2021; therefore, findings may change as services adjust going forward. Surveys used a digital platform so there is probably bias towards some level of e-Literacy, but this also means that our data may underestimate the digital divide. Future work: Further investigation of access to digital services could address concerns about digital exclusion. Research comparing the affordances and cost-benefits of different triage and assessment systems for users and health-care providers is needed. Research about trust in virtual assessments may show how duplication can be reduced. Mixed-methods studies looking at outcomes, impacts on work and costs, and ways to measure eHealth literacy, can inform the development NHS 111 online and opportunities for further international shared learning could be pursued. Study registration: This study is registered at the research registry (UIN 5392). Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research Programme and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 5. See the NIHR Journals Library website for further project information.

NHS 111 services help people who need health advice or care by telephone (using the 111 number) and online (using the web on a smartphone or a computer). Demand for general practitioner and emergency care services keeps increasing, and there are concerns that sometimes people do not use the right services for the health problems that they have. NHS 111 can direct people to services and give advice that helps them carry out more self-care. Previous research suggests that not everyone finds online services easy to use. There is a worry that NHS 111 services may increase work for other health services. Our research used interviews and surveys to find out about the NHS 111 online service. We interviewed 80 people working in or with NHS services to find out about their experiences of NHS 111 online. There was low awareness of NHS 111 online, partly because there are so many other computer technologies and different services available. Interviewees often mixed-up NHS 111 online with the 111 telephone service. People are confused about where to get help. Interviewees also said that NHS 111 creates 'extra work', especially for emergency departments (accident and emergency). We interviewed 41 staff and stakeholders linked with a similar system used in Australia, called Healthdirect, and they had similar concerns. Our survey found that people who had used NHS 111 online were younger and had higher levels of education. People who had used NHS 111 online also had higher eHealth literacy (they were more able to access and understand online health services); however, they were also sicker, reported having more long-term conditions and used more health services. Our research suggests that we need to reduce confusion about what NHS 111 online does, get rid of unnecessary extra work and see whether or not it improves access to care for everyone.

In Vitro Evolution to Increase the Titers of Difficult Bacteriophages: RAMP-UP Protocol.

Background: Bacteriophages are becoming increasingly important in the race to find alternatives to antibiotics. Unfortunately, bacteriophages that might otherwise be useful are sometimes discarded due to low titers making them unsuitable for downstream applications. Methods: Here, we present two distinct approaches used to experimentally evolve novel New Zealand Paenibacillus larvae bacteriophages. The first approach uses the traditional agar-overlay method, whereas the other was a 96-well plate liquid infection protocol that improved phage titers in as little as four days. We also used a mathematical model to probe the parameters and limits of the RAMP-UP approach to rapidly select mutants that improve bacteriophage titers. Results: Both experimental approaches resulted in an increase in plaque-forming units (PFU/mL). The liquid infection approach developed here, which we call RAMP-UP for Rapid Adaptive Mutation of Phage - UP, was significantly faster and simpler, and allowed us to evolve high titer bacteriophages in as little as four days. Titers were increased from 100-100,000-fold relative to their ancestors. The resultant titers were sufficient to extract and sequence DNA from these bacteriophages. An analysis of these phage genomes is provided. Conclusion: The RAMP-UP protocol is an effective method for experimentally evolving previously intractable bacteriophages in a high-throughput and expeditious manner.

The remarkable invisibility of NHS 111 online.

In 2017, the NHS 111 telephone service was augmented by an online service. This is an exemplar of 'digital-first', the push to enrol digital technologies to deliver services, and is viewed by policymakers as an important vehicle for managing demand for overburdened health services. This article reports the qualitative component of a larger multi-method study of NHS 111 online. Qualitative telephone interviews with 80 staff and stakeholders implicated in primary, urgent and emergency care service delivery explored the impact of NHS 111 online on health-care work. The analysis presented here draws on Susie Scott's work on the 'sociology of nothing' and theories of the marked and unmarked, which we reached for when confronted by the remarkable invisibility of this seemingly core NHS service in the wider landscape of health care. Despite the apparently high use by patients and the public (30 million visits over 6 months in the 2020 pandemic), we were surprised to find very low awareness among our interviewees. Confusion about nomenclature, an exceedingly crowded digital field (littered with alternative technologies and ways of accessing care) and constant change in service provision provide some cogent reasons for this invisibility, and sociology helps explain our data about this digital technology.

Infrastructure challenges to doing health research "where populations with the most disease live" in Covid times-a response to Rai et al. (2021).

BACKGROUND: The failure of randomised controlled trials to adequately reflect areas of highest health need have been repeatedly highlighted. This has implications for the validity and generalisability of findings, for equity and efficiency, but also for research capacity-building. Rai et al. (BMC Med Res Methodol 21:80, 2021) recently argued that the poor alignment between UK clinical research activity (specifically multi-centre RCTs) and local prevalence of disease was, in part, the outcome of behaviour and decision-making by Chief Investigators involved in trial research. They argued that a shift in research culture was needed. Following our recent multi-site mixed methods evaluative study about NHS 111 online we identify some of the additional structural barriers to delivering health research "where populations with the most disease live", accounting for the Covid-19 disruption to processes and delivery. METHODS: The NHS 111 study used a mixed-method research design, including interviews with healthcare staff and stakeholders within the primary, urgent and emergency health care system, and a survey of users and potential users of the NHS 111 online service. This paper draws on data collated by the research team during site identification and selection, as we followed an action research cycle of planning, action, observation and reflection. The process results were discussed among the authors, and grouped into the two themes presented. RESULTS: We approached 22 primary and secondary care sites across England, successfully recruiting half of these. Time from initial approach to first participant recruitment in successful sites ranged from one to ten months. This paper describes frontline bureaucratic barriers to research delivery and recruitment in the local Clinical Research Network system and secondary care sites carrying large research portfolios, alongside the adaptive practices of research practitioners that mitigate these. CONCLUSIONS: This paper augments the recommendations of Rai et al., describing delays encountered during the COVID-19 pandemic, and suggesting in addition to cultural change, it may be additionally important to dismantle infrastructural barriers and improve support to research teams so they can conduct health research "where populations with the most disease live".

Death and dying in prehospital care: what are the experiences and issues for prehospital practitioners, families and bystanders? A scoping review.

OBJECTIVE: To identify the factors that shape and characterise experiences of prehospital practitioners (PHPs), families and bystanders in the context of death and dying outside of the hospital environment where PHPs respond. DESIGN: A scoping review using Arksey and O'Malley's five-stage framework. Papers were analysed using thematic analysis. DATA SOURCES: MEDLINE; Embase; CINAHL; Scopus; Social Sciences Citation Index (Web of Science), ProQuest Dissertations & Theses A&I (Proquest), Health Technology Assessment database; PsycINFO; Grey Literature Report and PapersFirst were searched from January 2000 to May 2019. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Qualitative and mixed methods studies reporting the experiences of PHPs, families and bystanders of death and dying in prehospital settings as a result of natural causes, trauma, suicide and homicide, >18 years of age, in Europe, USA, Canada, Australia and New Zealand. RESULTS: Searches identified 15 352 papers of which 51 met the inclusion criteria. The review found substantial evidence of PHP experiences, except call handlers, and papers reporting family and bystander experiences were limited. PHP work was varied and complex, while confident in clinical work, they felt less equipped to deal with the emotion work, especially with an increasing role in palliative and end-of-life care. Families and bystanders reported generally positive experiences but their support needs were rarely explored. CONCLUSIONS: To the best of our knowledge this is the first review that explores the experiences of PHPs, families and bystanders. An important outcome is identifying current gaps in knowledge where further empirical research is needed. The paucity of evidence suggested by this review on call handlers, families and bystanders presents opportunities to investigate their experiences in greater depth. Further research to address the current knowledge gaps will be important to inform future policy and practice.

A conceptual model of urgent care sense-making and help-seeking: a qualitative interview study of urgent care users in England.

BACKGROUND: Theoretical models have sought to comprehend and conceptualise how people seek help from health professionals but it is unclear if such models apply to urgent care. Much previous research does not explain the complex interactions that influence how people make sense of urgent care and how this shapes service use. This paper aims to conceptualise the complexity of sense-making and help-seeking behaviour in peoples' everyday evaluations of when and how to access modern urgent care provision. METHODS: This study comprised longitudinal semi-structured interviews undertaken in the South of England. We purposively sampled participants 75+, 18-26 years, and from East/Central Europe (sub-sample of 41 received a second interview at + 6-12 months). Framework analysis was thematic and comparative. RESULTS: The amount and nature of the effort (work) undertaken to make sense of urgent care was an overarching theme of the analysis. We distinguished three distinct types of work: illness work, moral work and navigation work. These take place at an individual level but are also shared or delegated across social networks and shaped by social context and time. We have developed a conceptual model that shows how people make sense of urgent care through work which then influences help-seeking decisions and action. CONCLUSIONS: There are important intersections between individual work and their social networks, further shaped by social context and time, to influence help-seeking. Recognising different, hidden or additional work for some groups may help design and configure services to support patient work in understanding and navigating urgent care.

Navigating and making sense of urgent and emergency care processes and provision.

BACKGROUND: Whilst many health systems offer a range of urgent and emergency care services to deal with the need for unscheduled care, these can be problematic to navigate. OBJECTIVE: To explore how lay people make sense of urgent care provision and processes. DESIGN: Qualitative study, incorporating citizen panels and longitudinal semi-structured qualitative interviews. SETTING AND PARTICIPANTS: Two citizens' panels, comprising purposively selected public populations-a group of regular users and a group of potentially marginalized users of urgent and emergency care. Semi-structured interviews were conducted with 100 people, purposively sampled to include those over 75, aged 18-26 years, and from East/Central Europe. A sub-sample of 41 people received a second interview at +6-12 months. Framework analysis was thematic and comparative, moving through coding to narrative and interpretive summaries. FINDINGS AND DISCUSSION: Participants narratives illuminated considerable uncertainty and confusion regarding urgent and emergency care provision which in part could be traced to the contingent nature of urgent and emergency care need. Accounts of emergency care provision were underpinned by strong moral positioning of appropriate help-seeking, demarcating legitimate service use that echoed policy rhetoric, but did not necessarily translate into individual behaviour. People struggled to make sense of urgent care provision making navigating "appropriate" use problematic. CONCLUSIONS: The focus on help-seeking behaviour, rather than sense-making, makes it difficult to move beyond the polarization of "appropriate" and "inappropriate" service use. A deeper analysis of sense-making might shift the focus of attention and allow us to intervene to reshape understandings before this point.

Using the concept of hubots to understand the work entailed in using digital technologies in healthcare.

Purpose The purpose of this paper is to explore the human work entailed in the deployment of digital health care technology. It draws on imagined configurations of computers and machines in fiction and social science to think about the relationship between technology and people, and why this makes implementation of digital technology so difficult. The term hubots is employed as a metaphorical device to examine how machines and humans come together to do the work of healthcare. Design/methodology/approach This paper uses the fictional depiction of hubots to reconceptualise the deployment of a particular technology - a computer decision support system (CDSS) used in emergency and urgent care services. Data from two ethnographic studies are reanalysed to explore the deployment of digital technologies in health services. These studies used comparative mixed-methods case study approaches to examine the use of the CDSS in eight different English NHS settings. The data include approximately 900 hours of observation, with 64 semi-structured interviews, 47 focus groups, and surveys of some 700 staff in call centres and urgent care centres. The paper reanalyses these data, deductively, using the metaphor of the hubot as an analytical device. Findings This paper focuses on the interconnected but paradoxical features of both the fictional hubots and the CDSS. Health care call handling using a CDSS has created a new occupation, and enabled the substitution of some clinical labour. However, at the same time, the introduction of the technology has created additional work. There are more tasks, both physical and emotional, and more training activity is required. Thus, the labour has been intensified. Practical implications This paper implies that if we want to realise the promise of digital health care technologies, we need to understand that these technologies substitute for and intensify labour. Originality/value This is a novel analysis using a metaphor drawn from fiction. This allows the authors to recognise the human effort required to implement digital technologies.

Has the NHS 111 urgent care telephone service been a success? Case study and secondary data analysis in England.

OBJECTIVES: To explore the success of the introduction of the National Health Service (NHS) 111 urgent care service and describe service activity in the period 2014-2016. DESIGN: Comparative mixed method case study of five NHS 111 service providers and analysis of national level routine data on activity and service use. SETTINGS AND DATA: Our primary research involved five NHS 111 sites in England. We conducted 356 hours of non-participant observation in NHS 111 call centres and the urgent care centres and, linked to these observations, held 6 focus group interviews with 47 call advisors, clinical and managerial staff. This primary research is augmented by a secondary analysis of routine data about the 44 NHS 111 sites in England contained in the NHS 111 Minimum Data Set made available by NHS England. RESULTS: Opinions vary depending on the criteria used to judge the success of NHS 111. The service has been rolled out across 44 sites. The 111 phone number is operational and the service has replaced its predecessor NHS Direct. This new service has led to changes in who does the work of managing urgent care demand, achieving significant labour substitution. Judged against internal performance criteria, the service appears not to meet some targets such as call answering times, but it has seen a steady increase in use over time. Patients appear largely satisfied with NHS 111, but the view from some stakeholders is more mixed. The impact of NHS 111 on other health services is difficult to assess and cost-effectiveness has not been established. CONCLUSION: The new urgent care service NHS 111 has been brought into use but its success against some key criteria has not been comprehensively proven.

Biochemical characterization of TyrA enzymes from Ignicoccus hospitalis and Haemophilus influenzae: A comparative study of the bifunctional and monofunctional dehydrogenase forms.

Biosynthesis of l-tyrosine (l-Tyr) is directed by the interplay of two enzymes. Chorismate mutase (CM) catalyzes the rearrangement of chorismate to prephenate, which is then converted to hydroxyphenylpyruvate by prephenate dehydrogenase (PD). This work reports the first characterization of the independently expressed PD domain of bifunctional CM-PD from the crenarchaeon Ignicoccus hospitalis and the first functional studies of both full-length CM-PD and the PD domain from the bacterium Haemophilus influenzae. All proteins were hexa-histidine tagged, expressed in Escherichia coli and purified. Expression and purification of I. hospitalis CM-PD generated a degradation product identified as a PD fragment lacking the protein's first 80 residues, Δ80CM-PD. A comparable stable PD domain could also be generated by limited tryptic digestion of this bifunctional enzyme. Thus, Δ80CM-PD constructs were prepared in both organisms. CM-PD and Δ80CM-PD from both organisms were dimeric and displayed the predicted enzymatic activities and thermal stabilities in accord with their hyperthermophilic and mesophilic origins. In contrast with H. influenzae PD activity which was NAD+-specific and displayed >75% inhibition with 50µM l-Tyr, I. hospitalis PD demonstrated dual cofactor specificity with a preference for NADP+ and an insensitivity to l-Tyr. These properties are consistent with a model of the I. hospitalis PD domain based on the previously reported structure of the H. influenzae homolog. Our results highlight the similarities and differences between the archaeal and bacterial TyrA proteins and reveal that the PD activity of both prokaryotes can be successfully mapped to a functionally independent unit.

Characterization of two key enzymes for aromatic amino acid biosynthesis in symbiotic archaea.

Biosynthesis of L-tyrosine (L-Tyr) and L-phenylalanine (L-Phe) is directed by the interplay of three enzymes. Chorismate mutase (CM) catalyzes the rearrangement of chorismate to prephenate, which can be either converted to hydroxyphenylpyruvate by prephenate dehydrogenase (PD) or to phenylpyruvate by prephenate dehydratase (PDT). This work reports the first characterization of a trifunctional PD-CM-PDT from the smallest hyperthermophilic archaeon Nanoarchaeum equitans and a bifunctional CM-PD from its host, the crenarchaeon Ignicoccus hospitalis. Hexa-histidine tagged proteins were expressed in Escherichia coli and purified by affinity chromatography. Specific activities determined for the trifunctional enzyme were 21, 80, and 30 U/mg for CM, PD, and PDT, respectively, and 47 and 21 U/mg for bifunctional CM and PD, respectively. Unlike most PDs, these two archaeal enzymes were insensitive to regulation by L-Tyr and preferred NADP(+) to NAD(+) as a cofactor. Both the enzymes were highly thermally stable and exhibited maximal activity at 90 °C. N. equitans PDT was feedback inhibited by L-Phe (Ki = 0.8 µM) in a non-competitive fashion consistent with L-Phe's combination at a site separate from that of prephenate. Our results suggest that PD from the unique symbiotic archaeal pair encompass a distinct subfamily of prephenate dehydrogenases with regard to their regulation and co-substrate specificity.

Cyborg practices: call-handlers and computerised decision support systems in urgent and emergency care.

This article draws on data collected during a 2-year project examining the deployment of a computerised decision support system. This computerised decision support system was designed to be used by non-clinical staff for dealing with calls to emergency (999) and urgent care (out-of-hours) services. One of the promises of computerised decisions support technologies is that they can 'hold' vast amounts of sophisticated clinical knowledge and combine it with decision algorithms to enable standardised decision-making by non-clinical (clerical) staff. This article draws on our ethnographic study of this computerised decision support system in use, and we use our analysis to question the 'automated' vision of decision-making in healthcare call-handling. We show that embodied and experiential (human) expertise remains central and highly salient in this work, and we propose that the deployment of the computerised decision support system creates something new, that this conjunction of computer and human creates a cyborg practice.

Using computer decision support systems in NHS emergency and urgent care: ethnographic study using normalisation process theory.

BACKGROUND: Information and communication technologies (ICTs) are often proposed as 'technological fixes' for problems facing healthcare. They promise to deliver services more quickly and cheaply. Yet research on the implementation of ICTs reveals a litany of delays, compromises and failures. Case studies have established that these technologies are difficult to embed in everyday healthcare. METHODS: We undertook an ethnographic comparative analysis of a single computer decision support system in three different settings to understand the implementation and everyday use of this technology which is designed to deal with calls to emergency and urgent care services. We examined the deployment of this technology in an established 999 ambulance call-handling service, a new single point of access for urgent care and an established general practice out-of-hours service. We used Normalization Process Theory as a framework to enable systematic cross-case analysis. RESULTS: Our data comprise nearly 500 hours of observation, interviews with 64 call-handlers, and stakeholders and documents about the technology and settings. The technology has been implemented and is used distinctively in each setting reflecting important differences between work and contexts. Using Normalisation Process Theory we show how the work (collective action) of implementing the system and maintaining its routine use was enabled by a range of actors who established coherence for the technology, secured buy-in (cognitive participation) and engaged in on-going appraisal and adjustment (reflexive monitoring). CONCLUSIONS: Huge effort was expended and continues to be required to implement and keep this technology in use. This innovation must be understood both as a computer technology and as a set of practices related to that technology, kept in place by a network of actors in particular contexts. While technologies can be 'made to work' in different settings, successful implementation has been achieved, and will only be maintained, through the efforts of those involved in the specific settings and if the wider context continues to support the coherence, cognitive participation, and reflective monitoring processes that surround this collective action. Implementation is more than simply putting technologies in place - it requires new resources and considerable effort, perhaps on an on-going basis.

Reconfiguring the emergency and urgent care workforce: mixed methods study of skills and the everyday work of non-clinical call-handlers in the NHS.

OBJECTIVES: To examine the skills and expertise required and used by non-clinical call-handlers doing telephone triage and assessment, supported by a computer decision support system (CDSS) in urgent and emergency care services. METHODS: Comparative case study of three different English emergency and urgent care services. Data consisted of nearly 500 hours of non-participant observation, 61 semi-structured interviews with health service staff, documentary analysis, and a survey of 106 call-handlers. RESULTS: Communication skills and 'allowing the CDSS to drive the assessment' are viewed by the CDSS developers and staff as key competencies for call-handling. Call-handlers demonstrated high levels of experience, skills and expertise in using the CDSS. These workers are often portrayed simply as 'trained users' of technology, but they used a broader set of skills including team work, flexibility and 'translation'. Call-handlers develop a 'pseudo-clinical' expertise and draw upon their experiential knowledge to bring the CDSS into everyday use. CONCLUSIONS: Clinical assessment and triage by non-clinical staff supported by a CDSS represents a major change in urgent and emergency care delivery, warranting a detailed examination of call-handlers' skills and expertise. We found that this work appears to have more in common with clinical work and expertise than with other call-centre work that it superficially resembles. Recognizing the range of skills call-handlers demonstrate and developing a better understanding of this should be incorporated into the training for, and management of, emergency and urgent care call-handling.

Management of out-of-hours calls by a general practice cooperative: a geographical analysis of telephone access and consultation.

BACKGROUND: Centralization of urgent care services may reduce access for patients living further away from primary care centres (PCCs). Telephone-based access is often proposed to remedy this. OBJECTIVE: To examine the effect of distance and rurality on the doctor's decision to manage the call by telephone or face-to-face. METHODS: Geographical analysis of routine data on calls to an out-of-hours cooperative, including logistic regression to examine the effects of distance and rurality on triage decisions. RESULTS: For distances >6 km, the likelihood of receiving telephone advice only increased progressively with increasing distance from the PCC (Model 1). However, for those patients seen face-to-face, overall, there was increased likelihood of receiving a home visit (compared with PCC attendance) with increasing distance (Model 2). CONCLUSIONS: Patients experience differences in how their call to out-of-hours services is managed depending on where they live. Telephone access and consultation can be used to overcome geographical barriers but do not necessarily make access geographically equitable. Those who live furthest away are more likely to receive telephone advice rather than being seen face-to-face, but paradoxically, those who do get a home visit are more likely to live at a greater distance from the PCC. These findings present important challenges to proposals to integrate urgent care services and increase telephone-based provision and suggest that attention should be given to configuring services to ensure geographical equity of access, regardless of how far away people live from health services.

Do telephones overcome geographical barriers to general practice out-of-hours services? Mixed-methods study of parents with young children.

OBJECTIVE: To examine if telephones overcome geographical barriers to accessing primary care out-of-hours by parents of young children. METHODS: Mixed methods including quantitative analysis of 5697 calls about children aged 0-4 years, 30 hours of observation at primary care centres, eight interviews with parents and a review of 80 telephone call recordings. RESULTS: Call rates for children (0-4 years) decreased with increasing distance: the 20% of people who lived furthest from a primary care centre made fewer calls, 570 per 1000 patients/year (95% CI 558 to 582) than the 20% living closest, 652 (95% CI 644 to 661). Overall, call rates decreased with increasing rurality. Qualitative analysis suggested that this geographical variation was linked to familiarity with the system (notably previous contact with health services) and the availability of services, legitimacy of demand (particularly for children) and negotiation about mode of care. CONCLUSIONS: People already disadvantaged by their distance from facilities or socioeconomic circumstances may continue to be at a disadvantage when services are provided by telephone.