Doing involvement: A qualitative study exploring the 'work' of involvement enacted by older people and their carers during transition from hospital to home.

CONTEXT: Being involved in one's care is prioritised within UK healthcare policy to improve care quality and safety. However, research suggests that many older people struggle with this. DESIGN: We present focused ethnographic research exploring older peoples' involvement in healthcare from hospital to home. RESULTS: We propose that being involved in care is a dynamic form of labour, which we call 'involvement work' (IW). In hospital, many patients 'entrust' IW to others; indeed, when desired, maintaining control, or being actively involved, was challenging. Patient and professionals' expectations, alongside hospital processes, promoted delegation; staff frequently did IW on patients' behalf. Many people wanted to resume IW postdischarge, but struggled because they were out of practice. DISCUSSION: Preference and capacity for involvement was dynamic, fluctuating over time, according to context and resource accessibility. The challenges of resuming IW were frequently underestimated by patients and care providers, increasing dependence on others post-discharge and negatively affecting peoples' sense and experience of (in)dependence. CONCLUSIONS: A balance needs to be struck between respecting peoples' desire/capacity for non-involvement in hospital while recognising that 'delegating' IW can be detrimental. Increasing involvement will require patient and staff roles to be reframed, though this must be done acknowledging the limits of patient desire, capability,and resources. Hospital work should be (re)organised to maximise involvement where possible and desired. PATIENT/PUBLIC CONTRIBUTION: Our Patient and Public Involvement and Engagement Panel contributed to research design, especially developing interview guides and patient-facing documentation. Patients were key participants within the study; it is their experiences represented.

Embedding biodiversity research into climate adaptation policy and practice.

Addressing climate change risks requires collaboration and engagement across all sectors of society. In particular, effective partnerships are needed between research scientists producing new knowledge, policy-makers and practitioners who apply conservation actions on the ground. We describe the implementation of a model for increasing the application and useability of biodiversity research in climate adaptation policy and practice. The focus of the program was to increase the ability of a state government agency and natural resource practitioners in Australia to manage and protect biodiversity in a changing climate. The model comprised a five-stage process for enhancing impact (i) initiation of research projects that addressed priority conservation policy and management issues; (ii) co-design of the research using a collaborative approach involving multiple stakeholders; (iii) implementation of the research and design of decision tools and web-based resources; (iv) collaborative dissemination of the tools and resources via government and community working groups; and (v) evaluation of research impact. We report on the model development and implementation, and critically reflect on the model's impact. We share the lessons learnt from the challenges of operating within a stakeholder group with diverse objectives and criteria for success, and provide a template for creating an environmental research program with real world impact.

Combating ecosystem collapse from the tropics to the Antarctic.

Globally, collapse of ecosystems-potentially irreversible change to ecosystem structure, composition and function-imperils biodiversity, human health and well-being. We examine the current state and recent trajectories of 19 ecosystems, spanning 58° of latitude across 7.7 M km2 , from Australia's coral reefs to terrestrial Antarctica. Pressures from global climate change and regional human impacts, occurring as chronic 'presses' and/or acute 'pulses', drive ecosystem collapse. Ecosystem responses to 5-17 pressures were categorised as four collapse profiles-abrupt, smooth, stepped and fluctuating. The manifestation of widespread ecosystem collapse is a stark warning of the necessity to take action. We present a three-step assessment and management framework (3As Pathway Awareness, Anticipation and Action) to aid strategic and effective mitigation to alleviate further degradation to help secure our future.

A Pilot RCT of A Body-Oriented Group Therapy For Complex Trauma Survivors: An Adaptation of Sensorimotor Psychotherapy.

This study is a pilot randomized controlled trial that examined the efficacy of a body-oriented group therapy designed to address chronic fear states in the body due to complex trauma. The Trauma and the Body Group (TBG) is a 20-session group psychotherapy that draws upon the principles and techniques of sensorimotor psychotherapy. Thirty-two women with a history of childhood trauma were randomized to immediate treatment or a waitlist control condition. Assessments were conducted one month prior to treatment, immediately after treatment, and six months post-treatment. Significant improvements were found in body awareness, anxiety, and soothing receptivity when comparing treatment to no treatment. The TBG appears to be a valuable tool for helping clients acquire mindfulness and self soothing skills that they can use to reduce posttraumatic symptoms. This study provides preliminary evidence that the TBG provides complex trauma survivors an opportunity to challenge their avoidance of two prominent trauma-related triggers - their bodies and interpersonal relationships - and in so doing may help survivors develop greater body awareness, increase their capacity for self and relational soothing, and reduce their anxiety symptoms.

Research priorities for natural ecosystems in a changing global climate.

Climate change poses significant emerging risks to biodiversity, ecosystem function and associated socioecological systems. Adaptation responses must be initiated in parallel with mitigation efforts, but resources are limited. As climate risks are not distributed equally across taxa, ecosystems and processes, strategic prioritization of research that addresses stakeholder-relevant knowledge gaps will accelerate effective uptake into adaptation policy and management action. After a decade of climate change adaptation research within the Australian National Climate Change Adaptation Research Facility, we synthesize the National Adaptation Research Plans for marine, terrestrial and freshwater ecosystems. We identify the key, globally relevant priorities for ongoing research relevant to informing adaptation policy and environmental management aimed at maximizing the resilience of natural ecosystems to climate change. Informed by both global literature and an extensive stakeholder consultation across all ecosystems, sectors and regions in Australia, involving thousands of participants, we suggest 18 priority research topics based on their significance, urgency, technical and economic feasibility, existing knowledge gaps and potential for cobenefits across multiple sectors. These research priorities provide a unified guide for policymakers, funding organizations and researchers to strategically direct resources, maximize stakeholder uptake of resulting knowledge and minimize the impacts of climate change on natural ecosystems. Given the pace of climate change, it is imperative that we inform and accelerate adaptation progress in all regions around the world.

Patient experience feedback in UK hospitals: What types are available and what are their potential roles in quality improvement (QI)?

BACKGROUND & OBJECTIVES: The comparative uses of different types of patient experience (PE) feedback as data within quality improvement (QI) are poorly understood. This paper reviews what types are currently available and categorizes them by their characteristics in order to better understand their roles in QI. METHODS: A scoping review of types of feedback currently available to hospital staff in the UK was undertaken. This comprised academic database searches for "measures of PE outcomes" (2000-2016), and grey literature and websites for all types of "PE feedback" potentially available (2005-2016). Through an iterative consensus process, we developed a list of characteristics and used this to present categories of similar types. MAIN RESULTS: The scoping review returned 37 feedback types. A list of 12 characteristics was developed and applied, enabling identification of 4 categories that help understand potential use within QI-(1) Hospital-initiated (validated) quantitative surveys: for example the NHS Adult Inpatient Survey; (2) Patient-initiated qualitative feedback: for example complaints or twitter comments; (3) Hospital-initiated qualitative feedback: for example Experience Based Co-Design; (4) Other: for example Friends & Family Test. Of those routinely collected, few elicit "ready-to-use" data and those that do elicit data most suitable for measuring accountability, not for informing ward-based improvement. Guidance does exist for linking collection of feedback to QI for some feedback types in Category 3 but these types  are not routinely used. CONCLUSION: If feedback is to be used more frequently within QI, more attention must be paid to obtaining and making available the most appropriate types.

Climate readiness of recovery plans for threatened Australian species.

The rapidly changing climate is posing growing threats for all species, but particularly for those already considered threatened. We reviewed 100 recovery plans for Australian terrestrial threatened species (50 fauna and 50 flora plans) written from 1997 to 2017. We recorded the number of plans that acknowledged climate change as a threat and of these how many proposed specific actions to ameliorate the threat. We classified these actions along a continuum from passive or incremental to active or interventionist. Overall, just under 60% of the sampled recovery plans listed climate change as a current or potential threat to the threatened taxa, and the likelihood of this acknowledgment increased over time. A far smaller proportion of the plans, however, identified specific actions associated with ameliorating climate risk (22%) and even fewer (9%) recommended any interventionist action in response to a climate-change-associated threat. Our results point to a disconnect between the knowledge generated on climate-change-related risk and potential adaptation strategies and the extent to which this knowledge has been incorporated into an important instrument of conservation action.

Presteza Climática de los Planes de Recuperación para las Especies Amenazadas de Australia Resumen El clima rápidamente cambiante representa amenazas crecientes para todas las especies, pero más en particular para aquellas que ya se consideran como especies amenazadas. Revisamos 100 planes de recuperación para especies terrestres amenazadas de Australia (50 especies de fauna y 50 de flora) escritos entre 1997 y 2017. Registramos el número de planes que reconocían al cambio climático como una amenaza y cuántos de estos proponían acciones específicas para aminorar la amenaza. Clasificamos estas acciones en un continuo que abarcó desde acciones pasivas o incrementales hasta acciones activas o intervencionistas. En general, sólo un número menor al 60% de los planes de recuperación muestreados enlistaron al cambio climático como una amenaza actual o potencial para el taxón amenazado, y la probabilidad de este reconocimiento incrementó con el paso del tiempo. Sin embargo, una proporción mucho menor de los planes identificó acciones específicas asociadas con la reducción del riesgo climático (22%) y una fracción todavía menor (9%) recomendó una acción intervencionista como respuesta a las amenazas asociadas al cambio climático. Nuestros resultados evidencían una desconexión entre el conocimiento generado sobre el riesgo relacionado con el cambio climático y las estrategias potenciales de adaptación y la extensión a la que este conocimiento se ha incorporado dentro de un instrumento importante para las acciones de conservación.

"Change is what can actually make the tough times better": A patient-centred patient safety intervention delivered in collaboration with hospital volunteers.

BACKGROUND: The PRASE (Patient Reporting and Action for a Safe Environment) intervention provides a way to systematically collect patient feedback to support service improvement. To provide a sustainable mechanism for the PRASE intervention, a 2-year improvement project explored the potential for hospital volunteers to facilitate the collection of PRASE feedback. OBJECTIVE: To explore the implementation of the PRASE intervention delivered in collaboration with hospital volunteers from the perspectives of key stakeholders. DESIGN: A qualitative case study design was utilized across three acute NHS trusts in the United Kingdom between March 2016 and October 2016. Ward level data (staff interviews; action planning meeting recordings; implementation fidelity information) were analysed taking a pen portrait approach. We also carried out focus groups with hospital volunteers and interviews with voluntary services/patient experience staff, which were analysed thematically. RESULTS: Whilst most ward staff reported feeling engaged with the intervention, there were discordant views on its use and usefulness. The hospital volunteers were positive about their involvement, and on some wards, worked with staff to produce actions to improve services. The voluntary services/patient experience staff participants emphasised the need for PRASE to sit within an organisations' wider governance structure. CONCLUSION: From the perspective of key stakeholders, hospital volunteers facilitating the collection of PRASE feedback is a feasible means of implementing the PRASE intervention. However, the variability around ward staff being able to use the feedback to make changes to services demonstrates that it is this latter part of the PRASE intervention cycle that is more problematic.

Partners at Care Transitions (PACT) -e xploring older peoples' experiences of transitioning from hospital to home in the UK: protocol for an observation and interview study of older people and their families to understand patient experience and involvement in care at transitions.

INTRODUCTION: Length of hospital inpatient stays have reduced. This benefits patients, who prefer to be at home, and hospitals, which can treat more people when stays are shorter. Patients may, however, leave hospital sicker, with ongoing care needs. The transition period from hospital to home can be risky, particularly for older patients with complex health and social needs. Improving patient experience, especially through greater patient involvement, may improve outcomes for patients and is a key indicator of care quality and safety. In this research, we aim to: capture the experiences of older patients and their families during the transition from hospital to home, and identify opportunities for greater patient involvement in care, particularly where this contributes to greater individual-level and organisational-level resilience. METHODS AND ANALYSIS: A 'focused ethnography' comprising observations, 'Go-Along' and semistructured interviews will be used to capture patient and carer experiences during different points in the care transition from admission to 90 days after discharge. We will recruit 30 patients and their carers from six hospital departments across two National Health Service (NHS) Trusts. Analysis of observations and interviews will use a framework approach to identify themes to understand the experience of transitions and generate ideas about how patients could be more actively involved in their care. This will include exploring what 'good' care at transitions looks like and seeking out examples of success, as well as recommendations for improvement. ETHICS AND DISSEMINATION: Ethical approval was received from the NHS Research Ethics Committee in Wales. The research findings will add to a growing body of knowledge about patient experience of transitions, in particular providing insight into the experiences of patients and carers throughout the transitions process, in 'real time'. Importantly, the data will be used to inform the development of a patient-centred intervention to improve the quality and safety of transitions.

Reprint of: The effectiveness of common thermo-regulatory behaviours in a cool temperate grasshopper.

Behavioural thermoregulation has the potential to alleviate the short-term impacts of climate change on some small ectotherms, without the need for changes to species distributions or genetic adaptation. We illustrate this by measuring the effect of behaviour in a cool temperate species of grasshopper (Phaulacridium vittatum) over a range of spatial and temporal scales in laboratory and natural field experiments. Microhabitat selection at the site scale was tested in free-ranging grasshoppers and related to changing thermal quality over a daily period. Artificial warming experiments were then used to measure the temperature at which common thermoregulatory behaviours are initiated and the subsequent reductions in body temperature. Behavioural means such as timing of activity, choice of substrates with optimum surface temperatures, shade seeking and postural adjustments (e.g. stilting, vertical orientation) were found to be highly effective at maintaining preferred body temperature. The maximum voluntarily tolerated temperature (MVT) was determined to be 44 °C ± 0.4 °C, indicating the upper bounds of thermal flexibility in this species. Behavioural thermoregulation effectively enables small ectotherms to regulate exposure to changing environmental temperatures and utilize the spatially and temporally heterogeneous environments they occupy. Species such as the wingless grasshopper, although adapted to cool temperate conditions, are likely to be well equipped to respond successfully to coarse scale climate change.

The effectiveness of common thermo-regulatory behaviours in a cool temperate grasshopper.

Behavioural thermoregulation has the potential to alleviate the short-term impacts of climate change on some small ectotherms, without the need for changes to species distributions or genetic adaptation. We illustrate this by measuring the effect of behaviour in a cool temperate species of grasshopper (Phaulacridium vittatum) over a range of spatial and temporal scales in laboratory and natural field experiments. Microhabitat selection at the site scale was tested in free-ranging grasshoppers and related to changing thermal quality over a daily period. Artificial warming experiments were then used to measure the temperature at which common thermoregulatory behaviours are initiated and the subsequent reductions in body temperature. Behavioural means such as timing of activity, choice of substrates with optimum surface temperatures, shade seeking and postural adjustments (e.g. stilting, vertical orientation) were found to be highly effective at maintaining preferred body temperature. The maximum voluntarily tolerated temperature (MVT) was determined to be 44°C±0.4°C, indicating the upper bounds of thermal flexibility in this species. Behavioural thermoregulation effectively enables small ectotherms to regulate exposure to changing environmental temperatures and utilize the spatially and temporally heterogeneous environments they occupy. Species such as the wingless grasshopper, although adapted to cool temperate conditions, are likely to be well equipped to respond successfully to coarse scale climate change.

A tool to assess potential for alien plant establishment and expansion under climate change.

Predicting the influence of climate change on the potential distribution of naturalised alien plant species is an important and challenging task. While prioritisation of management actions for alien plants under current climatic conditions has been widely adopted, very few systems explicitly incorporate the potential of future changes in climate conditions to influence the distribution of alien plant species. Here, we develop an Australia-wide screening tool to assess the potential of naturalised alien plants to establish and spread under both current and future climatic conditions. The screening tool developed uses five spatially explicit criteria to establish the likelihood of alien plant population establishment and expansion under baseline climate conditions and future climates for the decades 2035 and 2065. Alien plants are then given a threat rating according to current and future threat to enable natural resource managers to focus on those species that pose the largest potential threat now and in the future. To demonstrate the screening tool, we present results for a representative sample of approximately 10% (n = 292) of Australia's known, naturalised alien plant species. Overall, most alien plant species showed decreases in area of habitat suitability under future conditions compared to current conditions and therefore the threat rating of most alien plant species declined between current and future conditions. Use of the screening tool is intended to assist natural resource managers in assessing the threat of alien plant establishment and spread under current and future conditions and thus prioritise detailed weed risk assessments for those species that pose the greatest threat. The screening tool is associated with a searchable database for all 292 alien plant species across a range of spatial scales, available through an interactive web-based portal at http://weedfutures.net/.

Small cell lung cancer presenting as severe thrombocytopenia and refractory hypokalemia.

A 70-year-old female with a history of mild cirrhosis was referred by her primary care provider for a platelet count of 36,000/ µ L which had dropped from 47,000/ µ L in a week along with mild pain in extremities. Serum potassium was low (2.9 mEq/L) in spite of the patient being recently started on potassium supplement on outpatient for hypokalemia. Initially thrombocytopenia was attributed to cirrhosis. However, platelet counts continued to drop to a nadir of 9000/ µ L in spite of several platelet transfusions. Hypokalemia was refractory to potassium supplements. Subsequent bone marrow biopsy revealed extensive marrow necrosis with a focus of small cell tumor cells of pulmonary origin. CT scan of the chest showed a spiculated left lung mass. The ACTH level was high, with normal rennin and aldosterone levels. The patient likely had ectopic ACTH syndrome from small cell lung cancer. She died within few days of diagnosis. Severe thrombocytopenia and refractory hypokalemia can rarely be initial presentations of small cell lung cancer. Thrombocytopenia should prompt an evaluation for bone marrow metastases and a search for undiagnosed systemic malignancy. In severe cases of metastases, bone marrow necrosis can be present. Refractory hypokalemia can be the sole presentation of ectopic ACTH production.

Which host-dependent insects are most prone to coextinction under changed climates?

Coextinction (loss of dependent species with their host or partner species) presents a threat to untold numbers of organisms. Climate change may act synergistically to accelerate rates of coextinction. In this review, we present the first synthesis of the available literature and propose a novel schematic diagram that can be used when assessing the potential risk climate change represents for dependent species. We highlight traits that may increase the susceptibility of insect species to coextinction induced by climate change, suggest the most influential host characteristics, and identify regions where climate change may have the greatest impact on dependent species. The aim of this review was to provide a platform for future research, directing efforts toward taxa and habitats at greatest risk of species loss through coextinction accelerated by climate change.

Continental-scale assessment of risk to the Australian odonata from climate change.

Climate change is expected to have substantial impacts on the composition of freshwater communities, and many species are threatened by the loss of climatically suitable habitat. In this study we identify Australian Odonata (dragonflies and damselflies) vulnerable to the effects of climate change on the basis of exposure, sensitivity and pressure to disperse in the future. We used an ensemble of species distribution models to predict the distribution of 270 (85%) species of Australian Odonata, continent-wide at the subcatchment scale, and for both current and future climates using two emissions scenarios each for 2055 and 2085. Exposure was scored according to the departure of temperature, precipitation and hydrology from current conditions. Sensitivity accounted for change in the area and suitability of projected climatic habitat, and pressure to disperse combined measurements of average habitat shifts and the loss experienced with lower dispersal rates. Streams and rivers important to future conservation efforts were identified based on the sensitivity-weighted sum of habitat suitability for the most vulnerable species. The overall extent of suitable habitat declined for 56-69% of the species modelled by 2085 depending on emissions scenario. The proportion of species at risk across all components (exposure, sensitivity, pressure to disperse) varied between 7 and 17% from 2055 to 2085 and a further 3-17% of species were also projected to be at high risk due to declines that did not require range shifts. If dispersal to Tasmania was limited, many south-eastern species are at significantly increased risk. Conservation efforts will need to focus on creating and preserving freshwater refugia as part of a broader conservation strategy that improves connectivity and promotes adaptive range shifts. The significant predicted shifts in suitable habitat could potentially exceed the dispersal capacity of Odonata and highlights the challenge faced by other freshwater species.

Qualitative evaluation of general practices developing training for a range of health disciplines.

This study adopted an interpretative approach, using focus groups and face-to-face interviews to evaluate the development of a five-year pilot project within general practice. The aim of the project is for these practices to offer training to a range of health disciplines from varying academic levels, develop capacity and provide interprofessional education as part of the learning ethos. Eight consortia are involved in the project, which is funded by the workforce and education directorate and the Deanery of the Yorkshire and Humber Strategic Health Authority. The evaluation was undertaken 18 months into the project, to understand the views and experiences of primary care practitioners and university educationalists, in order to identify achievements and barriers to the project's development. The study revealed positive attitudes towards the project, and that steps are being taken to engage in dialogue with universities to increase student numbers, but progress is slow. Early experiences of student nurses taking up placements in the practices reveal incompatible learning outcomes between what is expected for curriculum and learning opportunities within primary care. A common concern is the impact increased students may pose on existing support structures, and that this may compromise student learning. Concern is evident over self-belief and competencies to teach across professions, and the ambiguity over the learning outcomes for IPE and the training required to support this. It is recommended that a systems theory be adopted to provide strategic planning across clinical and education organisations to ensure that structures of communication, leadership and training adequately meet the aims of the project. The paper will be of interest to practitioners in primary care who may be considering expanding services and training, and to educationalists seeking to allocate students to placements in primary care.

Potential impacts of climate change on insect communities: a transplant experiment.

Climate change will have profound impacts on the distribution, abundance and ecology of all species. We used a multi-species transplant experiment to investigate the potential effects of a warmer climate on insect community composition and structure. Eight native Australian plant species were transplanted into sites approximately 2.5°C (mean annual temperature) warmer than their native range. Subsequent insect colonisation was monitored for 12 months. We compared the insect communities on transplanted host plants at the warmer sites with control plants transplanted within the species' native range. Comparisons of the insect communities were also made among transplanted plants at warmer sites and congeneric plant species native to the warmer transplant area. We found that the morphospecies composition of the colonising Coleoptera and Hemiptera communities differed markedly between transplants at the control compared to the warmer sites. Community structure, as described by the distribution of feeding guilds, was also found to be different between the controls and transplants when the entire Coleoptera and Hemiptera community, including non-herbivore feeding guilds, was considered. However, the structure of the herbivorous insect community showed a higher level of consistency between plants at control and warm sites. There were marked differences in community composition and feeding guild structure, for both herbivores and non-herbivores, between transplants and congenerics at the warm sites. These results suggest that as the climate warms, considerable turnover in the composition of insect communities may occur, but insect herbivore communities may retain elements of their present-day structure.

Experimental manipulation of melanism demonstrates the plasticity of preferred temperature in an agricultural pest (Phaulacridium vittatum).

Phenotypic plasticity is a key trait of successful pest species, and may increase the ability to cope with higher, more variable temperatures under climate change. We investigate the plasticity of preferred temperature in a widespread agricultural pest, the wingless grasshopper (Phaulacridium vittatum). Preferred temperature is a measure of thermoregulatory behaviour through habitat selection. It is influenced by melanism, which affects body temperature by determining the amount of radiation absorbed by the body. First we demonstrate that body temperature and preferred temperature in P. vittatum is influenced by melanism, by comparing the preferred temperature of the colour morphs in laboratory thermal gradients and field body temperatures in natural populations. We then test whether preferred temperature changes in response to changes in body temperature, by determining preferred temperature before and after manipulation of melanism by painting. When melanism was manipulated experimentally in live grasshoppers, preferred temperature changed to reflect the thermal qualities of the new colour. The preferred temperature of light grasshoppers increased after they were painted black, and decreased after being painted white. Similarly, dark individuals that were painted white behaved like a light individual, maintaining a lower body temperature. Preferred temperature in P.vittatum is a plastic thermoregulatory response to ambient temperature, mediated by the influence of melanism on body temperature.