Feasibility and evaluation of an emergency department-based general practitioner streaming and treatment service.

RATIONALE: Offering a primary care service that can provide good quality primary care at emergency departments may reduce pressure on usual emergency department (ED) services. AIMS AND OBJECTIVES: To evaluate the acceptability, satisfaction, and potential impacts of a co-located primary care service at an emergency department. METHODS: This is a prospective feasibility study and service evaluation comprising a narrative summary of activity, satisfaction, well-being, and safety, and comparisons of wait times for ED services by patient category ('minor', 'majors', 'paediatric' or 'resus') before and during the service operation. Patients and staff were asked using semistructured interview topic guides about service perception, well-being, representation within 48 h, safety concerns, and/or satisfaction. Wait times for patient categories in usual ED care service were in secondary care electronic records. Pathway changes were captured under primary care electronic records. RESULTS: Approximately 96% of general practitioner streaming and treatment (GPST) patients were seen within 1 h. There was a statistically significant reduction in ED patients with minor injuries or illnesses waiting >4 h for admission or discharge 'breaches' during the 3 months that GPST was operating compared with the previous 3 months (p ≤ 0.005). Wait times for other ED services did not significantly improve. A total of 769 walk-in patients received GPST consultation and 661 (86%) needed no further ED intervention. Fast discharge was a major determinant of patient satisfaction. No staff expressed dissatisfaction, but some suggested possible improvements in eligibility criteria and built environment design features. CONCLUSION: Provision of GPST correlated with shorter waits for discharge from ED. Patient and staff experiences of GPST were positive.

Empowerment of care home staff through effective collaboration with healthcare.

Integrative local health delivery models in the UK, under the framework of Enhanced Health in Care Homes (EHICH), have been developed to improve joint working between health and social care to benefit the patient. Despite this drive toward health and social care integration, research on the barriers, facilitators, and impact of partnership working on role of care home staff is underdeveloped. This study set out to explore views on how closer working between health and social care can impact on the role of care home staff and any barriers to effective integration. Staff from 25 care homes and GPs from their partnered practices were interviewed to explore the impact of the partnership. Homes receiving regular visits from the same health professional found the relationship between the two sectors had benefitted both residents and staff. The development of trusting relationships, access to support and information, and recognition and respect were all seen as facilitating the partnership and enhancing patient care. Regular and effective interactions with health-care professionals were key and had the potential to empower and increase confidence of care home staff in their role around health care. Factors negatively impacting on strength of relationship such as visits by inconsistent professional and high turnover of care home staff were a barrier to successful partnerships. Experiences of poor interactions with those from health-care services where there was an absence of a trusting relationship were disempowering to care home staff and remain a barrier to effective wider health and social care collaboration.

Putting sheep scab in its place: A more relational approach.

Since the reintroduction of sheep scab within the UK, its prevalence has increased despite several industry-led initiatives to control and manage the disease. Some studies have suggested that initiatives or policies should instead focus on specific places, such as geographically high-risk areas for sheep scab, which could allow for a more targeted approach. However, this risk of sheep scab has been measured in set geographical areas, without the reference to the interplay of topography, host, pathogen and the way in which humans socially and culturally define risk and place, potentially limiting the effectiveness of preventative initiatives. Therefore, the aim of the current study was to understand how place influences sheep farmers' approaches to the identification and management of the risk of sheep scab in their flocks. Qualitative data was collected from 43 semi-structured interviews with sheep farmers from England, Scotland, and Wales and was analysed by using the constant comparative approach. The codes were grouped into four concepts that influenced farmers' decision-making strategies for sheep scab control: perception of place; risk identification; risk categorisation; and risk management. These concepts were used as an analytical framework to identify three different 'places': 'uncontrollable places', 'liminal places' and 'protective places'. Each place reflects a different sheep scab control strategy used by farmers and shaped by their perceptions of place and risk. The 'uncontrollable places' category represented farmers who were located in areas that were geographically high-risk for sheep scab and who experienced a high frequency of sheep scab infestations in their flocks. The risk posed by their local landscape and neighbouring farmers, who neglected to engage in preventative behaviours, led them to feel unable to engage in effective risk management. Thus, they viewed scab as uncontrollable. The farmers within the 'liminal places' category were characterised as farmers who were located in high-risk areas for sheep scab, but experienced low levels of sheep scab infestations. These farmers characterised the risks associated with sheep scab management in terms of needing to protect their reputation and felt more responsibility for controlling sheep scab, which influenced them to engage in more protective measures. The farmers within the 'protective places' category were characterised as farming within low-risk areas and thus experienced a low level of sheep scab infestations. These farmers also described their risk in terms of their reputation and the responsibility they held for protecting others. However, they sought to rely on their low geographical risk of sheep scab as a main source of protection and therefore did not always engage in protective measures. These results suggest that place-based effects have significant impacts on sheep farmers' beliefs and behaviours and thus should be considered by policymakers when developing future strategies for sheep scab control.

Risks and risk mitigation in homecare for people with dementia-A two-sided matter: A systematic review.

Policy guidance promotes supporting people to live in their own homes for as long as possible with support from homecare services. People living with dementia who need such support can experience a range of physical and cognitive difficulties, which can increase the risks associated with homecare for this group. We aimed to examine risk and safety issues for people with dementia and their homecare workers and risk mitigation practices adopted by homecare workers to address identified risks. We searched MEDLINE, EMBASE, AMED, CINAHL, PsycINFO, ASSIA and Cochrane Central Register of Controlled Trials databases 5 March 2021. Included studies focussed on homecare for people with dementia and had a risk or safety feature reported. Risk of bias was assessed with the Joanna Briggs Institute Critical Appraisal tools. Two authors assessed articles for potential eligibility and quality. A narrative synthesis combines the findings. The search identified 2259 records; 27 articles, relating to 21 studies, met the eligibility criteria. The review identified first-order risks that homecare workers in the studies sought to address. Two types of risk mitigation actions were reported: harmful interventions and beneficial interventions. Actions adopted to reduce risks produced intended benefits but also unintended consequences, creating second-order risks to both clients with dementia and homecare workers, placing them at greater risk. Risk mitigation interventions should be person-centred, the responsibility of all relevant professions, and planned to minimise the creation of unintended risks.

Home-care workers' experiences of assisting people with dementia with their personal care: A qualitative interview study.

Home-care workers are increasingly caring for clients living with dementia. Workers usually have limited dementia training and are low paid and often lone working. Little is known about how home-care workers assist people with dementia with their personal care. We aimed to explore the experiences of home-care workers and the knowledge and skills they rely on when providing personal care to people with dementia. In 2020, we conducted 17 semi-structured, face-to-face interviews with home-care workers in the East of England. Analysis was inductive and thematic. Two key themes were present in the data: 'structural conditions' and 'clients' dementia-related characteristics'. For each of these, we examined the challenges faced by home-care workers and the strategies they used to manage these challenges. Challenges included time allocation for visits, completing care plan tasks, lone working, communication and understanding, refusals of care, and client behaviours. To mitigate these challenges, home-care workers utilised system support, time management, training and experience and enacted a caring relationship, thought about their approach, and used distraction and communication skills. Workers relied on skills such as, relationship building, team working, observation, communication, decision making and interpersonal sensitivity. They drew on knowledge about the person, the person's needs, their own abilities, company policies and procedures and their role and responsibilities as a home-care worker. Home-care workers had more scope to mitigate client-based challenges by adapting care within client interactions, than to manage structural challenges where there was a limit to what workers could do. Despite a commissioning focus on time- and task-based care, when caring for people with dementia, home-care workers used interaction as a way to bring the person along and complete care activities. Home-care services should acknowledge the importance of interactions with people with dementia within home care and support their workers to develop interpersonal sensitivity.

Farmers' Perceptions of Preventing Antibiotic Resistance on Sheep and Beef Farms: Risk, Responsibility, and Action.

Antibiotic resistance is one of the most serious public health risks facing humanity. The overuse of antibiotics in the treatment of infectious disease have been identified as sources of the global threat of antibiotic resistance. This paper examines how farmers perceive and manage risks associated with overuse of antibiotics. Specifically, the paper examines the role of habitus and risk in determining farmers' decisions to adopt national antibiotic reduction targets set by members of the Responsible Use of Medicines in Agriculture Alliance's Targets Task Force. Semi-structured interviews were conducted with 34 sheep and beef farmers in England and Wales. Farmers presented four scripts which illuminated reasons for limited adoption of the targets. The scripts presented the farmers as "good farmers" facing an emerging threat to their ontological security. Scripts suggested that they engaged in preventative measures but deflected responsibility for reducing antibiotic resistance to veterinarians and poorly run farms. This research provides valuable insights for policy makers and highlight the benefits of including social science research to support effective implementation.

Technology adoption on farms: Using Normalisation Process Theory to understand sheep farmers' attitudes and behaviours in relation to using precision technology in flock management.

Evidence suggests that UK sheep farmers experience lower productivity and profit margins than other livestock sectors and that they do not necessarily know where they gain or lose income from their flocks. More efficient use of precision technology has been identified as a potential way of addressing this problem. The mandatory requirement for Electronic Identification (EID) tags to be placed on all sheep offers an opportunity for sheep farmers to adopt precision technologies to manage herd health and maximise production and profit. Although the charactistics of farmers that are associated with adoption or non adoption of technology have been identified little is known about the social processes, meanings and experiences that influence uptake. This paper is novel as it draws on data from 36 sheep farmers in the UK and applies Normalization Process Theory (NPT) to gain an understanding of the reasons they do or do not use EID related precision technology on their farms. The interviews were tape recorded, transcribed verbatim and analysed using NVivo. Although respondents acknowledged the potential value of precision technology to improve their farm businesses they appeared to have alternative beliefs that were counter productive. Their beliefs that using precision technology posed a threat to their role as a good stockman, that it could not replace the need for hands-on interaction with their animals and that it was costly and difficult to use created an implementation gap. The use of NPT as an evaluation framework provided a valuable tool for increasing the understanding of contextual characteristics that undermine the routine embedding of such technology by sheep farmers. The data suggests that normalisation of the use of precision technology amongst sheep farmers could potentially be increased if manufacturers/suppliers co-design and work with farmer's to ensure that the technology enables the farmer to be in control and operates as an aid to achieving high quality stockmanship rather than a mechanism for profit maximisation.

Broken biosecurity? Veterinarians' framing of biosecurity on dairy farms in England.

There is seen to be a need for better biosecurity - the control of disease spread on and off farm - in the dairy sector. Veterinarians play a key role in communicating and implementing biosecurity measures on farm, and little research has been carried out on how veterinarians see their own and farmers' roles in improving biosecurity. In order to help address this gap, qualitative interviews were carried out with 28 veterinarians from Royal College of Veterinary Surgeon farm accredited practices in England. The results were analysed using a social ecology framework and frame analysis to explore not only what barriers vets identified, but also how vets saw the problem of inadequate biosecurity as being located. Veterinarians' frames of biosecurity were analysed at the individual, interpersonal and contextual scales, following the social ecology framework, which see the problem in different ways with different solutions. Farmers and veterinarians were both framed by veterinarians as individualised groups lacking consistency. This means that best practice is not spread and veterinarians are finding it difficult to work as a group to move towards a "predict and prevent" model of veterinary intervention. But diversity and individualism were also framed as positive and necessary among veterinarians to the extent that they can tailor advice to individual farmers. Veterinarians saw their role in educating the farmer as not only being about giving advice to farmers, but trying to convince the farmer of their perspective and values on disease problems. Vets felt they were meeting with limited success because vets and farmers may be emphasising different framings of biosecurity. Vets emphasise the individual and interpersonal frames that disease problems are a problem on farm that can and should be controlled by individual farmers working with vets. According to vets, farmers may emphasise the contextual frame that biosecurity is largely outside of their control on dairy farms because of logistical, economic and geographical factors, and so some level of disease on dairy farms is not entirely unexpected or controllable. There needs to be a step back within the vet-farmer relationship to realise that there may be different perspectives at play, and within the wider debate to explore the question of what a biosecure dairy sector would look like within a rapidly changing agricultural landscape.

Challenges facing the farm animal veterinary profession in England: A qualitative study of veterinarians' perceptions and responses.

The farm animal veterinary profession in the UK has faced a number of challenges in recent decades related to the withdrawal of government funding and a contraction of the agricultural sector. They have come under pressure to respond by developing skills and focusing on disease prevention advisory services. However, this puts veterinarians in competition with other providers of these services, and moves in this direction have only been partial. Failure to respond to these challenges puts the veterinary profession at risk of de-professionalisation-a loss of their monopoly over knowledge, an erosion of client beliefs in their service ethos and a loss of work autonomy. This paper explores how farm animal veterinarians in England perceive these challenges and are responding to them. Semi-structured qualitative interviews were carried out with 28 veterinarians from Royal College of Veterinary Surgeon farm accredited practices. Veterinarians were chosen from high, medium and low density cattle farming regions. Interviews were recorded, transcribed and themes identified through the constant comparison method. The majority of respondents recognised the challenges facing the veterinary profession. Most believed their role had changed, moving towards that of a disease prevention adviser who was part of the farm management team. In terms of maintaining and redefining their professional status, farm animal veterinarians do have a defined body of knowledge and the ability to develop trusting relationships with clients, which enhances their competitiveness. However, while they recognise the changes and challenges, moves towards a disease prevention advisory model have only been partial. There seem to be little effort towards using Farm accreditation status or other strategies to promote their services. They do not appear to be finding effective strategies for putting their knowledge on disease prevention into practice. Disease prevention appears to be delivered on farm on an ad hoc basis, they are not promoting their disease prevention services to farmers effectively or using their professional position to stave off competition. Farm animals veterinarians will need to realign their veterinary expertise to the demands of the market, work together rather than in competition, improve their skills in preventive medicine, consolidate information given by non-veterinary advisors, develop new business models appropriate to their services and develop entrepreneurial skills to demonstrate their market value if they are to avoid becoming marginalised.

'If you feel that nobody wants you you'll withdraw into your own': Gypsies/Travellers, networks and healthcare utilisation.

Gypsies and Travellers are the unhealthiest group in British society, suffering from higher levels of physical and mental illness, lower life expectancy and with low levels of healthcare utilisation. They also continue to experience the highest level of prejudice and discrimination in society. While studies indicate that social networks play an important role in shaping health beliefs and the response to symptoms, evidence on the influence of networks on health is unclear and contradictory. This article draws on social network theory and research into the relation between discrimination and health to critically examine how networks mediate between collective experiences of racism and health-related behavior. Qualitative interviews with 39 adult Gypsies and Travellers were conducted in the South-East of England to explore the wider structural and institutional context and the influence those contexts play in shaping health beliefs and decisions whether to access formal health services. The findings indicate that the influence networks play in shaping health behaviour is dependent on the particular social context of the group and its status in relation to wider social structures, making generalization problematic.

Diabetes in the workplace - diabetic's perceptions and experiences of managing their disease at work: a qualitative study.

BACKGROUND: Diabetes represents one of the biggest public health challenges facing the UK. It is also associated with increasing costs to the economy due to working days lost as people with diabetes have a sickness absence rate 2-3 times greater than the general population. Workplaces have the potential to support or hinder self- management of diabetes but little research has been undertaken to examine the relationship between work and diabetes in the UK. This paper seeks to go some way to addressing this gap by exploring the perceptions and experiences of employees with diabetes. METHODS: Forty three people with diabetes were purposively recruited to ascertain ways in which they managed their disease in the workplace. Semi-structured, interviews were undertaken, tape recorded and transcribed. Analysis was conducted using a constant comparative approach. RESULTS: Although respondents had informed managers of their diabetic status they felt that their managers had little concept of the effects of the work environment on their ability to manage their disease. They did not expect support from their managers and were concerned about being stigmatised or treated inappropriately. Work requirements took priority. They had to adapt their disease management to fit their job and reported running their blood glucose levels at higher than optimal levels, thereby putting themselves at higher risk of long term complications. CONCLUSIONS: Little research has examined the way in which employees with diabetes manage their disease in the workplace. This research shows there is a need to increase the awareness of managers of the short and long term economic benefit of supporting employees with diabetes to manage their disease effectively whist at work. Employees may need individually assessed and tailored support on the job in order to manage their disease effectively.

The rise and fall of complementary medicine in National Health Service hospitals in England.

Whilst Complementary and Alternative Medicine (CAM) has never been systematically integrated into National Health Service (NHS) provision, there has been some limited evidence of a developing presence of CAM in NHS hospital based nursing and midwifery. This paper reports on a qualitative study that sought to document the nature and extent of such integrative practice in England, and the interpersonal and organisational factors that facilitated or impeded it. The data revealed a history in which attempts to integrate CAM had some initial success underpinned by the enthusiasm of individual practitioners and a relatively permissive organisational context. However, this was followed by a decline in service provision. The fact that the services were established by individuals left them vulnerable when more restrictive funding and governance regimes emerged. Whilst the data revealed a consistent story about CAM within the NHS, it must be recognised that the use of a snowball sample limits the generalizability of the findings.

An evaluation of a training placement in general practice for paramedic practitioner students: improving patient-centred care through greater interprofessional understanding and supporting the development of autonomous practitioners.

OBJECTIVES: To report the extent to which the placement of paramedic practitioner students (PPSs) in accredited general practice (GP) training practices supported their development as autonomous, patient-centred practitioners and fostered interprofessional learning. DESIGN: A case study method was used. Sources of data included semi-structured telephone interviews (eight PPSs, eight GP trainers), an online end of placement survey and placement and assessment documentation. Interview data were transcribed and analysed using the constant comparative method. SETTING: Accredited training practices in South East England. RESULTS: All respondents were positive that the placement provided a high-quality interprofessional learning environment which provided PPSs with learning opportunities based on assessed need, the support of experienced trainers and access to a wide range of patients and learning situations. The placement enabled PPSs to acquire the appropriate skills, knowledge and understanding to act as autonomous, patient-centred practitioners. CONCLUSIONS: The placement provides a sound model for expanding the skills of paramedic practitioners in order to meet the increasing demands for patient-centred, community based health care. It provided them with the skills to treat patients closer to home rather than automatically transporting them to hospital.

Negotiating competency, professionalism and risk: the integration of complementary and alternative medicine by nurses and midwives in NHS hospitals.

This qualitative interview study examined the use of complementary and alternative medicine (CAM) by nurses and midwives in NHS hospital settings in 2008 in the UK. It showed that the groundswell of interest in CAM in the 1990s had diminished by this time due to changes to policy and funding, and increasingly stringent clinical governance. Nevertheless, CAM provided an opportunity for committed and self-motivated practitioners to extend their therapeutic repertoire and develop affective dimensions of practice. However, the integration of CAM did not afford the autonomy, status and material gains traditionally associated with a collective professional project. In practice, occupational strategies were individualistic, and grounded in the assertion of competency through expressions of professionalism rather than the credentialism which underpins classic professionalisation. Central to these strategies was CAM related risk, which became a means by which to claim occupational space. However, the extent to which the adoption of CAM enhanced the nurses' and midwives' roles was limited by traditional medical authority; the uncertain status of CAM knowledge; and the absence of collective strategies - which together often left practitioners in a position of vulnerability.

Fostering clinical engagement and medical leadership and aligning cultural values: an evaluation of a general practice specialty trainee integrated training placement in a primary care trust.

OBJECTIVES: To report on the extent to which a general practice specialty trainee integrated training placement (ITP) developed the leadership skills and knowledge of general practice specialty trainees (GPSTRs) and on the potential of the ITP to improve clinical engagement. DESIGN: A case study method was used in a Kent primary care trust (PCT). Sources of data included face-to-face and telephone interviews (three GPSTRs, three PCT clinical supervisors, three general practitioner (GP) clinical supervisors and three Deanery/PCT managers), reflective diaries, documentary sources and observation. Interview data were transcribed and analysed using the constant comparative method. RESULTS: All respondents were positive about the value and success of the ITP in developing the leadership skills of the GPSTRs covering three dimensions: leadership of self, leadership of teams and leadership of organisations within systems. The ITP had enabled GP trainees to understand the context for change, to develop skills to set the direction for change and to collect and apply evidence to decision making. The ITP was described as an effective means of breaking down cultural barriers between general practice and the PCT and as having the potential for improving clinical engagement. CONCLUSIONS: The ITP provided a model to enable the effective exchange of knowledge and understanding of differing cultures between GPSTRs, general practice and the PCT. It provided a sound basis for effective, dispersed clinical engagement and leadership.

Women's interpretation of cardiac symptoms at the time of their cardiac event: the effect of co-occurring illness.

BACKGROUND: Women tend to access medical help for a myocardial infarction later than men and are at a disproportionate risk of dying or of suffering disability as a consequence. Co-morbidity is associated with delay but little is known how this affects decision making. AIM: To examine the effect of co-occurring chronic illness or infections on women's interpretation of their symptoms and action at the time of their cardiac event. METHODS: Semi-structured interviews with 44 women admitted to 3 district hospitals following a cardiac event. For the purposes of analysis they were divided into those who arrived at the hospital within 12 h of onset of symptoms (<12 hour group) and those who took more than 12 h (>12 hour group). FINDINGS: Women utilised their mental records of knowledge and experiences to make sense of their cardiac symptoms. The mental records of the <12 hour group contained knowledge of symptoms and previous experiences relevant to cardiac problems. Those of the >12 hour group contained knowledge and experience of recent and co-occurring chronic illnesses, this provided persuasive 'evidence' to suggest that their symptoms were normal or typical for their current state of health and resulted in delay. CONCLUSION: Women's decision making and timely access to medical help at the time of a cardiac event is influenced by their repertoire of knowledge and experience. Interventions need to be designed to capture the process of symptom recognition and the influence of co-morbidity.

Factors influencing community nurses' treatment of leg ulcers.

Clinical effectiveness and evidence-based practice are a central feature of the clinical governance framework. Few studies have examined factors that motivate nurses to change practice in line with evidence-based guidelines. The overall aim of this exploratory study was to examine community nurses' experience of taking part in a clinical effectiveness programme for the management of leg ulcers in the community and to identify factors most likely to ensure a change in practice. The implementation programme was conducted in the general practices within one district of a primary care audit group. Face-to-face interviews were conducted with all practice nurses and district nurses involved in the care of patients with leg ulcers from the participating practices. Nurses identified the presence of a credible facilitator, visible benefits for patients and a desire to carry out their work in an evidence-based way as factors likely to influence change. However, the degree of change achieved was not uniform across all participants and three typologies of nurses were identified according to their attitudes and level of involvement.