... J. KIDD, D. NESTEL & R. O'HARA Imperial College School of Medicine (ICSM), London, U... more ... J. KIDD, D. NESTEL & R. O'HARA Imperial College School of Medicine (ICSM), London, UK ... Temple-Smith et al., 1999) and medical students are often uncertain as to how to go about taking a sexual history, reporting little experience in talking to patients about sex (Merrill et al ...
Journal of Health Services Research & Policy, 2010
Patients with chronic obstructive pulmonary disease (COPD) have recently been offered severe weat... more Patients with chronic obstructive pulmonary disease (COPD) have recently been offered severe weather warnings and medication reminders using an automated telephone service and interactive voice recognition technology. Our aim was to explore patients' and health care staffs' perceptions and experiences of the technologies, their contribution to the management of COPD and implementation issues. Qualitative semi-structured telephone interviews were undertaken with 18 patients and six staff from five primary care centres in the Bradford area, England. Interview transcripts were thematically analysed. Patients considered the telephone service was an appropriate way to deliver information but there was some variation in perceived usefulness. Many patients praised the service, valuing reassurance and medication reminders, but others were indifferent and even critical. Criticism tended to reflect scepticism over the reliability of weather forecasts information rather than the automated telephone service itself. There was limited impact on the management strategies of patients apart from some patients ordering medication. Primary care staff considered the service a success but some felt that it lacked participation by hard-to-reach groups (non-English speaking, mild COPD patients). Our concerns about the resource implications of successful implementation were also raised. An automated telephone service was generally acceptable to patients but changes in COPD management were limited, possibly because the patients already had a good understanding of their condition and self-management strategies. Implications for practice include the need for strategies to target hard-to-reach groups which may need more resources.
Poor nutrition is an unexpected risk faced by refugees and immigrants upon resettling in the Unit... more Poor nutrition is an unexpected risk faced by refugees and immigrants upon resettling in the United States. Levels of obesity are at 8 % for foreign born populations living in the United States for less than 1 year and 19 %for those who have lived in the US for more than 15 years. In 2005, with funding from the Office of Refugee Resettlement, the U.S. Committee for Refugees and Immigrants (USCRI) launched a Food and Nutrition Outreach Program. This program focuses on strengthening the capacity of resettlement agencies to deliver culturally appropriate nutrition education through existing services. The goal of the program is to communicate culturally relevant nutrition information to refugee communities, empowering refugees to establish positive nutrition habits and prevent disease. Program objectives are to create a comprehensive nutrition manual, to train service providers in the delivery of credible nutrition information and to collect, create and disseminate materials that commun...
The contribution of service users to identifying and prioritising research issues is vital to mak... more The contribution of service users to identifying and prioritising research issues is vital to make practice and policy more relevant to their needs. Their experiences and knowledge can complement those of clinicians, health professionals and researchers. The aim of this research was to explore service-user perceptions of ambulance service care and patient safety. Three service-users focus groups (n=23) were conducted in three different Ambulance Service Trust regions and enabled participants to discuss their respective perceptions, experiences and concerns. Discussions were audio-recorded, transcribed and thematically analysed. Service-users identified a number of concerns. The skills of call handlers in managing two-way communication at the initial call stage was perceived as critical to informing appropriate triage decisions; the risk at this stage was considered to be higher where callers have communication difficulties. Participants emphasised the importance of patient involveme...
Decisions made by ambulance staff are often time-critical and based on limited information. Wrong... more Decisions made by ambulance staff are often time-critical and based on limited information. Wrong decisions could have serious consequences for patients but little is known about areas of risk associated with decisions about patient care. We aimed to examine system influences on decision making in the ambulance service setting focusing on paramedic roles. An exploratory mixed methods qualitative study was conducted in three Ambulance Service Trusts. A document search and 16 interviews were conducted to understand service delivery in each Trust, how they link with other services and potential influences on decisions about patient care. Researchers observed ambulance crews on 34 shifts and 10 paramedics completed 'digital diaries' to report challenges for decision making or patient safety. Three focus groups with staff (N=21) and three with service users (N=23) were held to explore their views on decision making and patient safety. Data were charted to produce a typology of de...
Journal of health services research & policy, 2015
Paramedics routinely make critical decisions about the most appropriate care to deliver in a comp... more Paramedics routinely make critical decisions about the most appropriate care to deliver in a complex system characterized by significant variation in patient case-mix, care pathways and linked service providers. There has been little research carried out in the ambulance service to identify areas of risk associated with decisions about patient care. The aim of this study was to explore systemic influences on decision making by paramedics relating to care transitions to identify potential risk factors. An exploratory multi-method qualitative study was conducted in three English National Health Service (NHS) Ambulance Service Trusts, focusing on decision making by paramedic and specialist paramedic staff. Researchers observed 57 staff across 34 shifts. Ten staff completed digital diaries and three focus groups were conducted with 21 staff. Nine types of decision were identified, ranging from emergency department conveyance and specialist emergency pathways to non-conveyance. Seven ove...
A random sample of general practitioners (GPs), practice nurses (PNs) and practice managers (PMs)... more A random sample of general practitioners (GPs), practice nurses (PNs) and practice managers (PMs) in Sheffield and Manchester was recruited into a study to evaluate the perceptions of occupational health (OH) in primary care.
Background Emergency Care Practitioners (ECPs) are operational in the UK in a variety of emergenc... more Background Emergency Care Practitioners (ECPs) are operational in the UK in a variety of emergency and urgent care settings. However, there is little evidence of the effectiveness of ECPs within these different settings. The aim of this study was to evaluate the impact of ECPs on patient pathways and care in different emergency care settings. Methods A pragmatic quasi-experimental multi-site community intervention trial comprising five matched pairs of intervention (ECP) and control services (usual care providers): ambulance, care home, minor injury unit, urgent care centre and GP out-of-hours. The main outcome being assessed was patient disposal pathway following the care episode. Results 5525 patient episodes (n¼2363 intervention and n¼3162 control) were included in the study. A significantly greater percentage of patients were discharged by ECPs working in mobile settings such as the ambulance service (percentage diff. 36.7%, 95% CI 30.8% to 42.7%) and care home service (36.8%, 26.7% to 46.8%). In static services such as out-of-hours (À17.9%, À30.8% to À42.7%) and urgent care centres (À11.5%, À18.0% to À5.1%), a significantly greater percentage of patients were discharged by usual care providers. Conclusions ECPs have a differential impact compared with usual care providers dependent on the operational service settings. Maximal impact occurs when they operate in mobile settings when care is taken to the patient. In these settings ECPs have a broader range of skills than the usual care providers (eg, paramedic), and are targeted to specific clinical groups who can benefit from alternative pathways of care (such as older people who have fallen). Trial Registration No ISRCTN22085282 (Controlled trials.com).
Background The emergency care practitioner (ECP) role in the UK health service involves paramedic... more Background The emergency care practitioner (ECP) role in the UK health service involves paramedic and nurse practitioners with advanced training to assess and treat minor illness and injury. Available evidence suggests that the introduction of this role has been advantageous in terms of managing an increased demand for emergency care, but there is little evidence regarding the quality and safety implications of ECP schemes. Objectives The objectives were to compare the quality and safety of care provided by ECPs with non-ECP (eg, paramedic, nurse practitioner) care across three different types of emergency care settings: static services (emergency department, walk-in-centre, minor injury unit); ambulance/care home services (mobile); primary care out of hours services. Methods A retrospective patient case note review was conducted to compare the quality and safety of care provided by ECPs and non-ECPs across matched sites in three types of emergency care settings. Retrospective assessment of care provided was conducted by experienced clinicians. The study was part of a larger trial evaluating ECP schemes (http://www.controlledtrials.com/ISRCTN22085282). Results Care provided by ECPs was rated significantly higher than that of non-ECPs across some aspects of care. The differences detected, although statistically significant, are small and may not reflect clinical significance. On other aspects of care, ECPs were rated as equal to their non-ECP counterparts. Conclusions As a minimum, care provided should meet the standards of existing service models and the findings from the study suggest that this is true of ECPs regardless of the service they are operational in.
This paper provides an overview of findings from the Health and Safety Laboratory investigation i... more This paper provides an overview of findings from the Health and Safety Laboratory investigation into human factors issues surrounding passenger escape and evacuation in the Ladbroke Grove train crash (1999). Drawing upon a range of contextual information the investigation focused upon identifying barriers and delays to evacuation following the incident. Findings highlight a number of important design shortcomings, as well as scope for the enhancement of both passive and active communication systems. The need to take account of passengers' mental models, intuitions and situation awareness when designing communication systems and emergency egress equipment for the railway carriage environment is highlighted. Crown
ABSTRACT A major reform of junior doctor training was undertaken in 2004–5, with the introduction... more ABSTRACT A major reform of junior doctor training was undertaken in 2004–5, with the introduction of foundation training (FT) to address perceived problems with work structure, conditions and training opportunities for postgraduate doctors. The well-being and motivation of junior doctors within the context of this change to training (and other changes such as restrictions in working hours of junior doctors and increasing demand for health care) and the consequent impact upon the quality of care provided is not well understood. Objectives This study aimed to evaluate the well-being of foundation year 2 (F2) doctors in training. Phase 1 describes the aims of delivering foundation training with a focus on the role of training in supporting the well-being of F2 doctors and assesses how FT is implemented on a regional basis, particularly in emergency medicine (EM). Phase 2 identifies how F2 doctor well-being and motivation are influenced over F2 and specifically in relation to EM placements and quality of care provided to patients. Methods Phase 1 used semistructured interviews and focus groups with postgraduate deanery leads, training leads (TLs) and F2 doctors to explore the strategic aims and implementation of FT, focusing on the specialty of EM. Phase 2 was a 12-month online longitudinal study of F2 doctors measuring levels of and changes in well-being and motivation. In a range of specialties, one of which was EM, data from measures of well-being, motivation, intention to quit, confidence and competence and job-related characteristics (e.g. work demands, task feedback, role clarity) were collected at four time points. In addition, we examined F2 doctor well-being in relation to quality of care by reviewing clinical records (criterion-based and holistic reviews) during the emergency department (ED) placement relating to head injury and chronic obstructive pulmonary disease (COPD). Results Phase 1 of the study found that variation exists in how successfully FT is implemented locally; F2 lacks a clearly defined end point; there is a minimal focus on the well-being of F2 doctors (only on the few already shown to be ‘in difficulty’); the ED presented a challenging but worthwhile learning environment requiring a significant amount of support from senior ED staff; and disagreement existed about the performance and confidence levels of F2 doctors. A total of 30 EDs in nine postgraduate medical deaneries participated in phase 2 with 217 foundation doctors completing the longitudinal study. F2 doctors reported significantly increased confidence in managing common acute conditions and undertaking practical procedures over their second foundation year, with the biggest increase in confidence and competence associated with their ED placement. F2 doctors had levels of job satisfaction and anxiety/depression that were comparable to or better than those of other NHS workers, and adequate quality and safety of care are being provided for head injury and COPD. Conclusions There are ongoing challenges in delivering high-quality FT at the local level, especially in time-pressured specialties such as EM. There are also challenges in how FT detects and manages doctors who are struggling with their work. The survey was the first to document the well-being of foundation doctors over the course of their second year, and average scores compared well with those of other doctors and health-care workers. F2 doctors are benefiting from the training provided as we found improvements in perceived confidence and competence over the year, with the ED placement being of most value to F2 doctors in this respect. Although adequate quality of care was demonstrated, we found no significant relationships between well-being of foundation doctors and the quality of care they provided to patients, suggesting the need for further work in this area. Funding The National Institute for Health Research Health Services and Delivery Research programme.
... J. KIDD, D. NESTEL & R. O'HARA Imperial College School of Medicine (ICSM), London, U... more ... J. KIDD, D. NESTEL & R. O'HARA Imperial College School of Medicine (ICSM), London, UK ... Temple-Smith et al., 1999) and medical students are often uncertain as to how to go about taking a sexual history, reporting little experience in talking to patients about sex (Merrill et al ...
Journal of Health Services Research & Policy, 2010
Patients with chronic obstructive pulmonary disease (COPD) have recently been offered severe weat... more Patients with chronic obstructive pulmonary disease (COPD) have recently been offered severe weather warnings and medication reminders using an automated telephone service and interactive voice recognition technology. Our aim was to explore patients' and health care staffs' perceptions and experiences of the technologies, their contribution to the management of COPD and implementation issues. Qualitative semi-structured telephone interviews were undertaken with 18 patients and six staff from five primary care centres in the Bradford area, England. Interview transcripts were thematically analysed. Patients considered the telephone service was an appropriate way to deliver information but there was some variation in perceived usefulness. Many patients praised the service, valuing reassurance and medication reminders, but others were indifferent and even critical. Criticism tended to reflect scepticism over the reliability of weather forecasts information rather than the automated telephone service itself. There was limited impact on the management strategies of patients apart from some patients ordering medication. Primary care staff considered the service a success but some felt that it lacked participation by hard-to-reach groups (non-English speaking, mild COPD patients). Our concerns about the resource implications of successful implementation were also raised. An automated telephone service was generally acceptable to patients but changes in COPD management were limited, possibly because the patients already had a good understanding of their condition and self-management strategies. Implications for practice include the need for strategies to target hard-to-reach groups which may need more resources.
Poor nutrition is an unexpected risk faced by refugees and immigrants upon resettling in the Unit... more Poor nutrition is an unexpected risk faced by refugees and immigrants upon resettling in the United States. Levels of obesity are at 8 % for foreign born populations living in the United States for less than 1 year and 19 %for those who have lived in the US for more than 15 years. In 2005, with funding from the Office of Refugee Resettlement, the U.S. Committee for Refugees and Immigrants (USCRI) launched a Food and Nutrition Outreach Program. This program focuses on strengthening the capacity of resettlement agencies to deliver culturally appropriate nutrition education through existing services. The goal of the program is to communicate culturally relevant nutrition information to refugee communities, empowering refugees to establish positive nutrition habits and prevent disease. Program objectives are to create a comprehensive nutrition manual, to train service providers in the delivery of credible nutrition information and to collect, create and disseminate materials that commun...
The contribution of service users to identifying and prioritising research issues is vital to mak... more The contribution of service users to identifying and prioritising research issues is vital to make practice and policy more relevant to their needs. Their experiences and knowledge can complement those of clinicians, health professionals and researchers. The aim of this research was to explore service-user perceptions of ambulance service care and patient safety. Three service-users focus groups (n=23) were conducted in three different Ambulance Service Trust regions and enabled participants to discuss their respective perceptions, experiences and concerns. Discussions were audio-recorded, transcribed and thematically analysed. Service-users identified a number of concerns. The skills of call handlers in managing two-way communication at the initial call stage was perceived as critical to informing appropriate triage decisions; the risk at this stage was considered to be higher where callers have communication difficulties. Participants emphasised the importance of patient involveme...
Decisions made by ambulance staff are often time-critical and based on limited information. Wrong... more Decisions made by ambulance staff are often time-critical and based on limited information. Wrong decisions could have serious consequences for patients but little is known about areas of risk associated with decisions about patient care. We aimed to examine system influences on decision making in the ambulance service setting focusing on paramedic roles. An exploratory mixed methods qualitative study was conducted in three Ambulance Service Trusts. A document search and 16 interviews were conducted to understand service delivery in each Trust, how they link with other services and potential influences on decisions about patient care. Researchers observed ambulance crews on 34 shifts and 10 paramedics completed 'digital diaries' to report challenges for decision making or patient safety. Three focus groups with staff (N=21) and three with service users (N=23) were held to explore their views on decision making and patient safety. Data were charted to produce a typology of de...
Journal of health services research & policy, 2015
Paramedics routinely make critical decisions about the most appropriate care to deliver in a comp... more Paramedics routinely make critical decisions about the most appropriate care to deliver in a complex system characterized by significant variation in patient case-mix, care pathways and linked service providers. There has been little research carried out in the ambulance service to identify areas of risk associated with decisions about patient care. The aim of this study was to explore systemic influences on decision making by paramedics relating to care transitions to identify potential risk factors. An exploratory multi-method qualitative study was conducted in three English National Health Service (NHS) Ambulance Service Trusts, focusing on decision making by paramedic and specialist paramedic staff. Researchers observed 57 staff across 34 shifts. Ten staff completed digital diaries and three focus groups were conducted with 21 staff. Nine types of decision were identified, ranging from emergency department conveyance and specialist emergency pathways to non-conveyance. Seven ove...
A random sample of general practitioners (GPs), practice nurses (PNs) and practice managers (PMs)... more A random sample of general practitioners (GPs), practice nurses (PNs) and practice managers (PMs) in Sheffield and Manchester was recruited into a study to evaluate the perceptions of occupational health (OH) in primary care.
Background Emergency Care Practitioners (ECPs) are operational in the UK in a variety of emergenc... more Background Emergency Care Practitioners (ECPs) are operational in the UK in a variety of emergency and urgent care settings. However, there is little evidence of the effectiveness of ECPs within these different settings. The aim of this study was to evaluate the impact of ECPs on patient pathways and care in different emergency care settings. Methods A pragmatic quasi-experimental multi-site community intervention trial comprising five matched pairs of intervention (ECP) and control services (usual care providers): ambulance, care home, minor injury unit, urgent care centre and GP out-of-hours. The main outcome being assessed was patient disposal pathway following the care episode. Results 5525 patient episodes (n¼2363 intervention and n¼3162 control) were included in the study. A significantly greater percentage of patients were discharged by ECPs working in mobile settings such as the ambulance service (percentage diff. 36.7%, 95% CI 30.8% to 42.7%) and care home service (36.8%, 26.7% to 46.8%). In static services such as out-of-hours (À17.9%, À30.8% to À42.7%) and urgent care centres (À11.5%, À18.0% to À5.1%), a significantly greater percentage of patients were discharged by usual care providers. Conclusions ECPs have a differential impact compared with usual care providers dependent on the operational service settings. Maximal impact occurs when they operate in mobile settings when care is taken to the patient. In these settings ECPs have a broader range of skills than the usual care providers (eg, paramedic), and are targeted to specific clinical groups who can benefit from alternative pathways of care (such as older people who have fallen). Trial Registration No ISRCTN22085282 (Controlled trials.com).
Background The emergency care practitioner (ECP) role in the UK health service involves paramedic... more Background The emergency care practitioner (ECP) role in the UK health service involves paramedic and nurse practitioners with advanced training to assess and treat minor illness and injury. Available evidence suggests that the introduction of this role has been advantageous in terms of managing an increased demand for emergency care, but there is little evidence regarding the quality and safety implications of ECP schemes. Objectives The objectives were to compare the quality and safety of care provided by ECPs with non-ECP (eg, paramedic, nurse practitioner) care across three different types of emergency care settings: static services (emergency department, walk-in-centre, minor injury unit); ambulance/care home services (mobile); primary care out of hours services. Methods A retrospective patient case note review was conducted to compare the quality and safety of care provided by ECPs and non-ECPs across matched sites in three types of emergency care settings. Retrospective assessment of care provided was conducted by experienced clinicians. The study was part of a larger trial evaluating ECP schemes (http://www.controlledtrials.com/ISRCTN22085282). Results Care provided by ECPs was rated significantly higher than that of non-ECPs across some aspects of care. The differences detected, although statistically significant, are small and may not reflect clinical significance. On other aspects of care, ECPs were rated as equal to their non-ECP counterparts. Conclusions As a minimum, care provided should meet the standards of existing service models and the findings from the study suggest that this is true of ECPs regardless of the service they are operational in.
This paper provides an overview of findings from the Health and Safety Laboratory investigation i... more This paper provides an overview of findings from the Health and Safety Laboratory investigation into human factors issues surrounding passenger escape and evacuation in the Ladbroke Grove train crash (1999). Drawing upon a range of contextual information the investigation focused upon identifying barriers and delays to evacuation following the incident. Findings highlight a number of important design shortcomings, as well as scope for the enhancement of both passive and active communication systems. The need to take account of passengers' mental models, intuitions and situation awareness when designing communication systems and emergency egress equipment for the railway carriage environment is highlighted. Crown
ABSTRACT A major reform of junior doctor training was undertaken in 2004–5, with the introduction... more ABSTRACT A major reform of junior doctor training was undertaken in 2004–5, with the introduction of foundation training (FT) to address perceived problems with work structure, conditions and training opportunities for postgraduate doctors. The well-being and motivation of junior doctors within the context of this change to training (and other changes such as restrictions in working hours of junior doctors and increasing demand for health care) and the consequent impact upon the quality of care provided is not well understood. Objectives This study aimed to evaluate the well-being of foundation year 2 (F2) doctors in training. Phase 1 describes the aims of delivering foundation training with a focus on the role of training in supporting the well-being of F2 doctors and assesses how FT is implemented on a regional basis, particularly in emergency medicine (EM). Phase 2 identifies how F2 doctor well-being and motivation are influenced over F2 and specifically in relation to EM placements and quality of care provided to patients. Methods Phase 1 used semistructured interviews and focus groups with postgraduate deanery leads, training leads (TLs) and F2 doctors to explore the strategic aims and implementation of FT, focusing on the specialty of EM. Phase 2 was a 12-month online longitudinal study of F2 doctors measuring levels of and changes in well-being and motivation. In a range of specialties, one of which was EM, data from measures of well-being, motivation, intention to quit, confidence and competence and job-related characteristics (e.g. work demands, task feedback, role clarity) were collected at four time points. In addition, we examined F2 doctor well-being in relation to quality of care by reviewing clinical records (criterion-based and holistic reviews) during the emergency department (ED) placement relating to head injury and chronic obstructive pulmonary disease (COPD). Results Phase 1 of the study found that variation exists in how successfully FT is implemented locally; F2 lacks a clearly defined end point; there is a minimal focus on the well-being of F2 doctors (only on the few already shown to be ‘in difficulty’); the ED presented a challenging but worthwhile learning environment requiring a significant amount of support from senior ED staff; and disagreement existed about the performance and confidence levels of F2 doctors. A total of 30 EDs in nine postgraduate medical deaneries participated in phase 2 with 217 foundation doctors completing the longitudinal study. F2 doctors reported significantly increased confidence in managing common acute conditions and undertaking practical procedures over their second foundation year, with the biggest increase in confidence and competence associated with their ED placement. F2 doctors had levels of job satisfaction and anxiety/depression that were comparable to or better than those of other NHS workers, and adequate quality and safety of care are being provided for head injury and COPD. Conclusions There are ongoing challenges in delivering high-quality FT at the local level, especially in time-pressured specialties such as EM. There are also challenges in how FT detects and manages doctors who are struggling with their work. The survey was the first to document the well-being of foundation doctors over the course of their second year, and average scores compared well with those of other doctors and health-care workers. F2 doctors are benefiting from the training provided as we found improvements in perceived confidence and competence over the year, with the ED placement being of most value to F2 doctors in this respect. Although adequate quality of care was demonstrated, we found no significant relationships between well-being of foundation doctors and the quality of care they provided to patients, suggesting the need for further work in this area. Funding The National Institute for Health Research Health Services and Delivery Research programme.
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