Shifts in Homecare Nursing Practices and Their Implications for Families and Clients Receiving Palliative Care at Home.

Homecare nurses provide essential healthcare services at home. Changes in the nature of homecare nursing practice, however, suggest that older and frail homecare clients are less likely to have timely access to needed homecare nursing services as acute management takes priority. This has an impact on people's ability to be cared for and to die at home, a reported priority for many Canadians. This study highlights how health system changes may be constraining homecare nurses' abilities to enact care that is consistent with palliative care principles and philosophies, and calls for consideration of how shifts in homecare nursing practice have implications for families and clients receiving palliative care at home.

A realist review of the home care literature and its blind spots.

RATIONALE, AIMS AND OBJECTIVES: There is a large body of literature from all over the world that describes, analyzes, or evaluates home care models and interventions. The present article aims to identify the practical lessons that can be gained from a systematic examination of that literature. METHOD: We conducted a three-step sequential search process from which 113 documents were selected. That corpus was then narratively analysed according to a realist review approach. RESULTS: A first level of observation is that there are multiple blind spots in the existing literature on home care. The definition and delimitation of what constitutes home care services is generally under-discussed. In the same way, the composition of the basket of care provided and its fit with the need of recipients is under-addressed. Finally, the literature relies heavily on RCTs whose practical contribution to decisions or policy is disputable. At a second level, our analysis suggests that three mechanisms (system integration, case management and relational continuity) are core characteristics of home care models' effectiveness. CONCLUSION: We conclude by providing advice for supporting the design and implementation of stronger home care delivery systems. Our analysis suggests that doing so implies a series of sequential steps: identify what system-level goals the model should achieve and which populations it should serve; identify what type of services are likely to achieve those goals in order to establish a basket of services; and finally, identify the best ways and specific means to effectively and efficiently provide those services. Those same steps can also support ex-post evaluations of existing home care systems.

Self-Perceived Competence of Nurses and Care Aides Providing a Palliative Approach in Home, Hospital, and Residential Care Settings: A Cross-Sectional Survey.

BACKGROUND AND PURPOSE: A palliative approach involves adapting and integrating palliative care knowledge and expertise earlier on and across sectors of care for people who have life-limiting chronic conditions. This study explored the extent to which nurses' and care aides' self-perceived palliative care competence may explain variation in the application of a palliative approach across nursing care settings that do not specialize in palliative care. A secondary objective was to psychometrically evaluate an instrument for measuring self-perceived palliative care competence.Methods and procedures: Data were collected via a cross-sectional survey (N = 1468) of registered nurses, licensed practical nurses, and care aides at 114 randomly selected hospital-based medical units, home care offices, and residential care facilities. The questionnaire included the Palliative Care Nursing Self-Competence Scale. Multilevel logistic regression and multigroup confirmatory factor analyses were conducted. RESULTS: In addition to self-perceived competence, factors associated with a palliative approach include identification of patients who have life-limiting conditions and who would benefit from a palliative approach, and work environment. The psychometric analyses of the Palliative Care Nursing Self-Competence Scale confirmed a 10-dimensional structure, strong internal consistency reliability, and measurement equivalence.Discussion and conclusion: This study provides information for future development and research on interventions for integrating a palliative approach.

Family 6 carbohydrate binding modules in beta-agarases display exquisite selectivity for the non-reducing termini of agarose chains.

Carbohydrate recognition is central to the biological and industrial exploitation of plant structural polysaccharides. These insoluble polymers are recalcitrant to microbial degradation, and enzymes that catalyze this process generally contain non-catalytic carbohydrate binding modules (CBMs) that potentiate activity by increasing substrate binding. Agarose, a repeat of the disaccharide 3,6-anhydro-alpha-L-galactose-(1,3)-beta-D-galactopyranose-(1,4), is the dominant matrix polysaccharide in marine algae, yet the role of CBMs in the hydrolysis of this important polymer has not previously been explored. Here we show that family 6 CBMs, present in two different beta-agarases, bind specifically to the non-reducing end of agarose chains, recognizing only the first repeat of the disaccharide. The crystal structure of one of these modules Aga16B-CBM6-2, in complex with neoagarohexaose, reveals the mechanism by which the protein displays exquisite specificity, targeting the equatorial O4 and the axial O3 of the anhydro-L-galactose. Targeting of the CBM6 to the non-reducing end of agarose chains may direct the appended catalytic modules to areas of the plant cell wall attacked by beta-agarases where the matrix polysaccharide is likely to be more amenable to further enzymic hydrolysis.