Goal setting as part of a holistic intervention to promote independence in older people with mild frailty: a process evaluation alongside a randomised controlled trial.

BACKGROUND: Frailty is a condition resulting from a decline in physiological reserves caused by an accumulation of several deficits, which progressively impairs the ability to recover from health adverse events. Following a promising feasibility study, the HomeHealth trial assessed a holistic tailored intervention for older adults with mild frailty to promote independence in their own homes, compared with usual care. We aimed to understand how goal setting worked among older people with mild frailty. METHODS: This study was a process evaluation alongside the HomeHealth randomised trial in older adults with mild frailty. The intervention was delivered at participants' homes, either in person or by telephone or videoconferencing. We carried out semi-structured interviews with older participants who had received the intervention (between three and six appointments), on average 233 days (range 68-465) after their last appointment, purposively sampled according to age, gender, number of sessions attended, adverse events, ethnicity, Index of Multiple Deprivation, Montreal Cognitive Assessment (MoCA) and Barthel scores, research site, and HomeHealth worker. We also conducted interviews with HomeHealth workers who delivered the intervention (n=7). Interviews explored the experience and process of goal setting, benefits and challenges, perceived progress, and behaviour change maintenance after the service had finished. Ethics approval was obtained, and all participants gave informed consent. Interviews were thematically analysed. HomeHealth workers kept formal records of goals set and assessed progress towards goals (0-2 rating scale) during six monthly-sessions, which were descriptively summarised. FINDINGS: 56 interviews were completed between July 15, 2022, and May 18, 2023. Study participants (n=49) had a mean age of 80 years (range 66-94), including 32 (65%) women and 17 (35%) men. Participants self-identified as White (n=42), Asian (n=3), Black (n=2), Mixed (n=1), and other ethnic (n=1) backgrounds. Findings suggested goal setting could be both a challenge and a motivator for older participants with mild frailty. Goal setting worked well when the older person could identify a clear need and set realistic goals linked to functioning, which led to a positive sense of achievement. Challenges occurred when older people were already accessing multiple resources and health services, or where the terminology of "goals" was off-putting due to work or school connotations. Average progress towards goals was 1·15/2. Most participants set goals around improving mobility (or a combination of mobility and another goal type such as socialising), and there was evidence of participants sustaining these behaviour changes after the intervention. INTERPRETATION: Older people with mild frailty can engage well with goal setting to promote independence. The lapse between receiving the intervention and being interviewed limited recall for some participants. However, the acceptability and adherence to the intervention for older people with mild frailty, and their moderate progress towards goals, should encourage further tailored and person-centred practices to promote their independence. FUNDING: National Institute for Health Research (NIHR) Health Technology Assessment.

Enabling health and maintaining independence for older people at home (HomeHealth trial): a multicentre randomised controlled trial.

BACKGROUND: NHS frailty services commonly target more severely frail older people, despite evidence suggesting frailty can be prevented or reversed when addressed at an earlier stage. HomeHealth is a new home-based, manualised voluntary sector service supporting older people with mild frailty to maintain their independence through behaviour change. Over six appointments, a trained HomeHealth worker discusses what matters to the older person and supports them to set and achieve goals around mobility, nutrition, socialising and/or psychological wellbeing. The service showed promising effects in a feasibility trial. We aimed to test the clinical and cost-effectiveness of HomeHealth for maintaining independence in older people with mild frailty compared with treatment as usual. METHODS: In this single-blind multicentre randomised controlled trial, we recruited community-dwelling older people aged 65 years or older with mild frailty from 27 general practices, community groups and sheltered housing in London, Yorkshire, and Hertfordshire. Participants were randomly assigned (1:1) to receive either HomeHealth monthly for 6 months or treatment as usual (usual GP and outpatient care, no specific frailty services). Our primary outcome was independence in activities of daily living, measured by blinded outcome assessors using the modified Barthel Index, and analysed using linear mixed models, including 6-month and 12-month data and controlling for baseline Barthel score and site. The study was approved by the Social Care Research Ethics Committee, and all participants provided written or orally recorded informed consent. This study is registered with the ISRCTN registry, ISRCTN54268283. FINDINGS: This trial took place between Jan 18, 2021, and July 4, 2023. We recruited 388 participants (mean age 81·4 years; 64% female [n=250], 94% White British/European [n=364], 2·5% Asian [n=10], 1·5% Black [n=6], 2·0% other [n=8]). We achieved high retention for 6-month follow-up (89%, 345/388), 12-month follow-up (86%, 334/388), and medical notes data (89%, 347/388). 182 (93%) of 195 participants in the intervention group completed the intervention, attending a mean of 5·6 appointments. HomeHealth had no effect on Barthel Index scores at 12 months (mean difference 0·250, 95% CI -0·932 to 1·432). At 6 months, there was a small reduction in psychological distress (-1·237, -2·127 to -0·348) and frailty (-0·124, -0·232 to -0·017), and at 12 months, we found small positive effects on wellbeing (1·449, 0·124 to 2·775) in those receiving HomeHealth. Other outcomes in analysis to date showed no significant difference. Health economic outcomes (including quality of life, capability, health services use and care needs or burden) are pending. INTERPRETATION: This high-quality trial showed that HomeHealth did not maintain independence in older people with mild frailty, and had limited effects upon secondary outcomes. Future studies need to explore different ways to promote health in this population. FUNDING: National Institute for Health and Care Research Health Technology Assessment (NIHR HTA).

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.

Clinical and cost-effectiveness of a personalised health promotion intervention enabling independence in older people with mild frailty ('HomeHealth') compared to treatment as usual: study protocol for a randomised controlled trial.

BACKGROUND: Frailty is clinically associated with multiple adverse outcomes, including reduced quality of life and functioning, falls, hospitalisations, moves to long-term care and mortality. Health services commonly focus on the frailest, with highest levels of need. However, evidence suggests that frailty is likely to be more reversible in people who are less frail. Evidence is emerging on what interventions may help prevent or reduce frailty, such as resistance exercises and multi-component interventions, but few interventions are based on behaviour change theory. There is little evidence of cost-effectiveness. Previously, we co-designed a new behaviour change health promotion intervention ("HomeHealth") to support people with mild frailty. HomeHealth is delivered by trained voluntary sector support workers over six months who support older people to work on self-identified goals to maintain their independence, such as strength and balance exercises, nutrition, mood and enhancing social engagement. The service was well received in our feasibility randomised controlled trial and showed promising effects upon outcomes. AIM: To test the clinical and cost-effectiveness of the HomeHealth intervention on maintaining independence in older people with mild frailty in comparison to treatment as usual (TAU). METHODS: Single-blind individually randomised controlled trial comparing the HomeHealth intervention to TAU. We will recruit 386 participants from general practices and the community across three English regions. Participants are included if they are community-dwelling, aged 65 + , with mild frailty according to the Clinical Frailty Scale. Participants will be randomised 1:1 to receive HomeHealth or TAU for 6 months. The primary outcome is independence in activities of daily living (modified Barthel Index) at 12 months. Secondary outcomes include instrumental activities of daily living, quality of life, frailty, wellbeing, psychological distress, loneliness, cognition, capability, falls, carer burden, service use, costs and mortality. Outcomes will be analysed using linear mixed models, controlling for baseline Barthel score and site. A health economic analysis and embedded mixed-methods process evaluation will be conducted. DISCUSSION: This trial will provide definitive evidence on the effectiveness and cost-effectiveness of a home-based, individualised intervention to maintain independence in older people with mild frailty in comparison to TAU, that could be implemented at scale if effective. TRIAL REGISTRATION: ISRCTN, ISRCTN54268283 . Registered 06/04/2020.

The experience of working with anaesthesia associates in the United Kingdom and the impact on medical anaesthetic training.

Anaesthesia Associates have been established in the UK for over 10 years, but without statutory regulation. Renewed interest surfaced based on a widening gap between patient need and workforce supply in the UK and established advanced practice non-doctor roles within healthcare systems elsewhere. However, there are no robust data on their impact on patient or hospital outcomes, or training opportunities for medical anaesthetists, and perceptions of the profession within the anaesthetic community are mixed. This paper describes an investigation into the demographics and scope of practice of Anaesthesia Associates in the UK in 2017, and the experience of working together as an anaesthetic team. Through qualitative interviews, we explored the role and relationships, the impact on medical anaesthetic training and ideas about future development. The overall experience of working with Anaesthesia Associates was positive. Successful integration requires understanding of the educational needs and competencies of all. Future development relies on strong leadership and robust patient outcome and efficiency measures. Interviewees strongly supported statutory regulation, which was agreed by the government in 2019 but not yet implemented. Anaesthesia Associates were seen as a benefit to anaesthetic departments and as such may provide part of the solution to the prevailing workforce issues in UK Anaesthesia, further critically challenged by the SARS-CoV-2 pandemic.

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.

'It gives you the skills of how you can cope': Exploring the self-reported experience of patients receiving in-centre haemodialysis on participating in chosen art activities.

BACKGROUND: Increasing numbers of patients are receiving dialysis, particularly in high-income countries. Patients receiving haemodialysis often experience fatigue, anxiety, depression and boredom. It is suggested that arts activities could have a therapeutic effect. OBJECTIVE: This study aimed to explore patients' perspectives of participating while on dialysis in chosen arts and creative living activities provided by tutors at the bedside. DESIGN: Qualitative semi-structured interviews in the interpretive tradition were conducted, with thematic analysis. SETTING AND PARTICIPANTS: Fifteen patients of different ages, genders and ethnicities who participated in an arts activity while receiving haemodialysis in an inner-city dialysis unit in England were included in this study. RESULTS: Participants reported positive experiences of engaging in art activities. Their views on the value of the activities were grouped into five themes: diversion from receiving haemodialysis, a sense of achievement, contribution to a more positive self-identity, increased confidence and motivation and a therapeutic talking relationship. Participants suggested that patient peer promotion of the activities could increase uptake, with patient choice of activity seen as important. CONCLUSIONS: Participation in a chosen arts activity while receiving haemodialysis was perceived by patients to have positive psychosocial effects. We theorize three potential explanatory mechanisms for these effects: That the experience of participating in the activities engendered positive psychological states of 'being in the flow'; enhanced self-esteem to add to personal coping mechanisms; and offered additional facets to the patient's identity that countered the stigmatizing effect of receiving dialysis. PATIENT OR PUBLIC CONTRIBUTION: Patients and public representatives advised on the design, research methods and tools.

Introducing physician associates to hospital patients: Development and feasibility testing of a patient experience-based intervention.

BACKGROUND: Physician associates (PAs) are one of many new mid-level health practitioner roles being introduced worldwide. They are a recent innovation in English hospitals. Patient confusion with novel mid-level practitioner titles and roles is well documented, alongside evidence of a positive association between patients' ability to identify practitioners and patient satisfaction. No prior research developed an intervention to introduce PAs or any other new practitioner role to hospital patients. OBJECTIVE: To develop, with patient and public involvement and engagement (PPIE), an intervention for introducing the PA role to hospital patients, and to test feasibility. METHODS: Intervention development was underpinned by an experience-based co-design approach. Workshop participants generated ideas for introducing PAs, subsequently explored in semi-structured interviews with hospital patients (n = 13). Interview findings were used by participants in a second workshop to design the intervention. Feasibility of the intervention was assessed in relation to its acceptability and efficacy using semi-structured interviews with hospital patients (n = 20) and PAs (n = 3). RESULTS: The intervention developed was a patient information leaflet. It was considered feasible to use in the hospital setting, helpful to patients in understanding the PA role and acceptable to both patients and PAs. The intervention was also appreciated by patients for providing reassurance of care and support. CONCLUSIONS: An experience-based co-design approach enabled development of an intervention tailored to patients' experiential preferences. Positive evidence of feasibility and utility is encouraging, supporting future larger-scale testing. PATIENT AND PUBLIC CONTRIBUTION: PPIE representatives were involved in the study design, intervention development and data interpretation.

Understanding the acceptability, barriers and facilitators for chlamydia and gonorrhoea screening in technical colleges: qualitative process evaluation of the "Test n Treat" trial.

BACKGROUND: Low uptake of sexually transmitted infection testing by sexually active young people is a worldwide public health problem. Screening in non-medical settings has been suggested as a method to improve uptake. The "Test n Treat" feasibility trial offered free, on-site rapid chlamydia/gonorrhoea tests with same day treatment for chlamydia (and gonorrhoea treatment at a local clinic,) to sexually active students (median age 17 years) at six technical colleges in London. Despite high rates of chlamydia (6% prevalence), uptake of testing was low (< 15%). In a qualitative study we explored the acceptability, including barriers and facilitators to uptake, of on-site chlamydia screening. METHODS: In 2016-17 we conducted a qualitative study in the interpretative tradition using face to face or telephone semi-structured interviews with students (n = 26), teaching staff (n = 3) and field researchers (n = 4). Interviews were digitally recorded, transcribed and thematically analysed. RESULTS: From the student perspective, feelings of embarrassment and the potential for stigma were deterrents to sexually transmitted infection testing. While the non-medical setting was viewed as mitigating against stigma, for some students volunteering to be screened exposed them to detrimental judgements by their peers. A small financial incentive to be screened was regarded as legitimising volunteering in a non-discrediting way. Staff and researchers confirmed these views. The very low level of knowledge about sexually transmitted infections influenced students to not view themselves as candidates for testing. There were also suggestions that some teenagers considered themselves invulnerable to sexually transmitted infections despite engaging in risky sexual behaviours. Students and researchers reported the strong influence peers had on uptake, or not, of sexually transmitted infection testing. CONCLUSIONS: This study offers new insights into the acceptability of college-based sexually transmitted infection screening to young, multi-ethnic students. Future studies in similar high risk, hard to reach groups should consider linking testing with education about sexually transmitted infections, offering non stigmatising incentives and engaging peer influencers.

Near patient chlamydia and gonorrhoea screening and treatment in further education/technical colleges: a cost analysis of the 'Test n Treat' feasibility trial.

BACKGROUND: Community-based screening may be one solution to increase testing and treatment of sexually transmitted infections in sexually active teenagers, but there are few data on the practicalities and cost of running such a service. We estimate the cost of running a 'Test n Treat' service providing rapid chlamydia (CT) and gonorrhoea (NG) testing and same day on-site CT treatment in technical colleges. METHODS: Process data from a 2016/17 cluster randomised feasibility trial were used to estimate total costs and service uptake. Pathway mapping was used to model different uptake scenarios. Participants, from six London colleges, provided self-taken genitourinary samples in the nearest toilet. Included in the study were 509 sexually active students (mean 85/college): median age 17.9 years, 49% male, 50% black ethnicity, with a baseline CT and NG prevalence of 6 and 0.5%, respectively. All participants received information about CT and NG infections at recruitment. When the Test n Treat team visited, participants were texted/emailed invitations to attend for confidential testing. Three colleges were randomly allocated the intervention, to host (non-incentivised) Test n Treat one and four months after baseline. All six colleges hosted follow-up Test n Treat seven months after baseline when students received a £10 incentive (to participate). RESULTS: The mean non-incentivised daily uptake per college was 5 students (range 1 to 17), which cost £237 (range £1082 to £88) per student screened, and £4657 (range £21,281 to £1723) per CT infection detected, or £13,970 (range £63,842 to £5169) per NG infection detected. The mean incentivised daily uptake was 19 students which cost £91 per student screened, and £1408/CT infection or £7042/NG infection detected. If daily capacity for screening were achieved (49 students/day), costs including incentives would be £47 per person screened and £925/CT infection or £2774/NG infection detected. CONCLUSIONS: Delivering non-incentivised Test n Treat in technical colleges is more expensive per person screened than CT and NG screening in clinics. Targeting areas with high infection rates, combined with high, incentivised uptake could make costs comparable. TRIAL REGISTRATION: ISRCTN58038795, Assigned August 2016, registered prospectively.

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.

Global nurse shortages-the facts, the impact and action for change.

INTRODUCTION: Nurses comprise half the global health workforce. A nine million shortage estimated in 2014 is predicted to decrease by two million by 2030 but disproportionality effect regions such as Africa. This scoping review investigated: what is known about current nurse workforces and shortages and what can be done to forestall such shortages? SOURCES OF DATA: Published documents from international organisations with remits for nursing workforces, published reviews with forward citation and key author searches. AREAS OF AGREEMENT: Addressing nurse shortages requires a data informed, country specific model of the routes of supply and demand. It requires evidence informed policy and resource allocation at national, subnational and organisation levels. AREAS OF CONTROVERSY: The definition in law, type of education, levels and scope of practice of nurses varies between countries raising questions of factors and evidence underpinning such variation. Most policy solutions proposed by international bodies draws on data and research about the medical workforce and applies that to nurses, despite the different demographic profile, the work, the career options, the remuneration and the status. GROWING POINTS: Demand for nurses is increasing in all countries. Better workforce planning in nursing is crucial to reduce health inequalities and ensure sustainable health systems. AREAS TIMELY FOR DEVELOPING RESEARCH: Research is needed on: the nursing workforce in low income countries and in rural and remote areas; on the impact of scope of practice and task-shifting changes; on the impact over time of implementing system wide policies as well as raising the profile of nursing.

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.

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.

Health promotion interventions for community-dwelling older people with mild or pre-frailty: a systematic review and meta-analysis.

BACKGROUND: Mild or pre-frailty is common and associated with increased risks of hospitalisation, functional decline, moves to long-term care, and death. Little is known about the effectiveness of health promotion in reducing these risks. This systematic review aimed to synthesise randomised controlled trials (RCTs) evaluating home and community-based health promotion interventions for older people with mild/pre-frailty. METHODS: We searched 20 bibliographic databases and 3 trials registers (January 1990 - May 2016) using mild/pre-frailty and associated terms. We included randomised controlled and crossover trials of health promotion interventions for community-dwelling older people (65+ years) with mild/pre-frailty and excluded studies focussing on populations in hospital, long term care facilities or with a specific condition. Risk of bias was assessed by two reviewers using the Cochrane Risk of Bias tool. We pooled study results using standardised mean differences (SMD) where possible and used narrative synthesis where insufficient outcome data were available. RESULTS: We included 10 articles reporting on seven trials (total n = 506 participants) and included five trials in a meta-analysis. Studies were predominantly small, of limited quality and six studies tested group exercise alone. One study additionally investigated a nutrition and exercise intervention and one evaluated telemonitoring. Interventions of exercise in groups showed mixed effects on functioning (no effects on self-reported functioning SMD 0.19 (95% CI -0.57 to 0.95) n = 3 studies; positive effects on performance-based functioning SMD 0.37 (95% CI 0.07 to 0.68) n = 3 studies). No studies assessed moves to long-term care or hospitalisations. CONCLUSIONS: Currently the evidence base is of insufficient size, quality and breadth to recommend specific health promotion interventions for older people with mild or pre- frailty. High quality studies of rigorously developed interventions are needed. PROSPERO REGISTRATION: CRD42014010370 (Review 2).

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.

Exploring access and attitudes to regular sexually transmitted infection screening: the views of young, multi-ethnic, inner-city, female students.

BACKGROUND: Low uptake of sexually transmitted infection (STI) testing by young people is a major public health problem worldwide. The aims of this qualitative, community-based study were to explore access and attitudes to STI screening in high risk, young, ethnically diverse female students. METHODS: Qualitative semi-structured interviews were conducted at an inner-London further education college with 17 women aged 16-25 years. RESULTS: The women wanted convenient, regular STI testing and perceived this as responsible behaviour. However, they doubted the maturity of their peers who were unlikely to view themselves as candidates for testing, and feared the perceived stigma associated with testing. This was reflected in their preference for confidential testing. Despite attending their general practice for non-sexual health matters, most did not consider this option for STI testing. However, the long wait in specialist clinics was an important barrier. Many younger participants would not want postal STI sample kits sent to their homes. We found dissatisfaction with sexual health education. CONCLUSIONS: STI screening for underserved groups such as young sexually active ethnically diverse female college students needs to be confidential, convenient, easily accessed and offered in ways that allow them to consider themselves as candidates for such screening without fear of social stigma. Family doctors should be aware that young women often do not perceive primary care to be an option for accessing STI screening, and could consider ways of advertising these services. Policymakers and commissioners should be aware that clinic waiting times and lack of education remain barriers to testing.

Helping Aged Victims of Crime (the HAVoC Study): Common Crime, Older People and Mental Illness--ERRATUM.

The author list previously published for this article was incomplete when received by the journal. It should also have included Gerard Leavey, University College London, UK, as an author, as follows: Marc Serfaty, Anna Ridgewell, Vari Drennan, Chris R. Brewin, Gerard Leavey, Anwen Wright, Gloria Laycock, Martin Blanchard.

Helping Aged Victims of Crime (the HAVoC Study): Common Crime, Older People and Mental Illness.

BACKGOUND: Limited data suggest that crime may have a devastating impact on older people. Although identification and treatment may be beneficial, no well-designed studies have investigated the prevalence of mental disorder and the potential benefits of individual manualized CBT in older victims of crime. AIMS: To identify mental health problems in older victims of common crime, provide preliminary data on its prevalence, and conduct a feasibility randomized controlled trial (RCT) using mixed methods. METHOD: Older victims, identified through police teams, were screened for symptoms of anxiety, depression or post-traumatic stress disorder (PTSD) one (n = 581) and 3 months (n = 486) after experiencing a crime. Screen positive participants were offered diagnostic interviews. Of these, 26 participants with DSM-IV diagnoses agreed to be randomized to Treatment As Usual (TAU) or TAU plus our manualized CBT informed Victim Improvement Package (VIP). The latter provided feedback on the VIP. RESULTS: Recruitment, assessment and intervention are feasible and acceptable. At 3 months 120/486 screened as cases, 33 had DSM-IV criteria for a psychiatric disorder; 26 agreed to be randomized to a pilot trial. There were trends in favour of the VIP in all measures except PTSD at 6 months post crime. CONCLUSIONS: This feasibility RCT is the first step towards improving the lives of older victims of common crime. Without intervention, distress at 3 and 6 months after a crime remains high. However, the well-received VIP appeared promising for depressive and anxiety symptoms, but possibly not posttraumatic stress disorder.