Implementation of cancer screening in rural primary care practices after joining an accountable care organisation: a multiple case study

ObjectiveTo describe common strategies and practice-specific barriers, adaptations and determinants of cancer screening implementation in eight rural primary care practices in the Midwestern United States after joining an accountable care organisation (ACO).DesignThis study used a multiple case study design. Purposive sampling was used to identify a diverse group of practices within the ACO. Data were collected from focus group interviews and workflow mapping. The Consolidated Framework for Implementation Research (CFIR) was used to guide data collection and analysis. Data were cross-analysed by clinic and CFIR domains to identify common themes and practice-specific determinants of cancer screening implementation.SettingThe study included eight rural primary care practices, defined as Rural-Urban Continuum Codes 5–9, in one ACO in the Midwestern United States.ParticipantsProviders, staff and administrators who worked in the primary care practices participated in focus groups. 28 individuals participated including 10 physicians; one doctor of osteopathic medicine; three advanced practice registered nurses; eight registered nurses, quality assurance and licensed practical nurses; one medical assistant; one care coordination manager; and four administrators.ResultsWith integration into the ACO, practices adopted four new strategies to support cancer screening: care gap lists, huddle sheets, screening via annual wellness visits and information spread. Cross-case analysis revealed that all practices used both visit-based and population-based cancer screening strategies, although workflows varied widely across practices. Each of the four strategies was adapted for fit to the local context of the practice. Participants shared that joining the ACO provided a strong external incentive for increasing cancer screening rates. Two predominant determinants of cancer screening success at the clinic level were use of the electronic health record (EHR) and fully engaging nurses in the screening process.ConclusionsJoining an ACO can be a positive driver for increasing cancer screening practices in rural primary care practices. Characteristics of the practice can impact the success of ACO-related cancer screening efforts; engaging nurses to the fullest extent of their education and training and integrating cancer screening into the EHR can optimise the cancer screening workflow.

Digitally Enabled Health Service for the Integrated Management of Hypertension: A Participatory User-Centred Design Process

This article describes a user-centred approach taken by a group of five procurers to set specifications for the procurement of value-based research and development services for IT-supported integrated hypertension management. The approach considered the unmet needs of patients and health systems of the involved regions. The procurers established a framework for requirements and a solution design consisting of nine building blocks, divided into three domains: service delivery, devices and integration, and health care organisation. The approach included the development of questionnaires, capturing patients’ and professionals’ views on possible system functionalities, and a template collecting information about the organisation of healthcare, professionals involved and existing IT systems at the procurers’ premises. A total of 28 patients diagnosed with hypertension and 26 professionals were interviewed. The interviewees identified 98 functional requirements, grouped in the nine building blocks. A total of nine use cases and their corresponding process models were defined by the procurers’ working group. As result, a digitally enabled integrated approach to hypertension has been designed to allow citizens to learn how to prevent the development of hypertension and lead a healthy lifestyle, and to receive comprehensive, individualised treatment in close collaboration with healthcare professionals.

Providing community intravenous therapy during the COVID-19 pandemic

Community intravenous therapy is well-established in most regions of the UK. Although there are national good practice recommendations detailing the service provision of outpatient parenteral antibiotic therapy (OPAT), examples of extended service delivery of other therapies are limited. This article describes the development of a community IV therapy service through integration with acute and primary care teams. IV therapies delivered in addition to antimicrobials safely outside of the hospital setting are also discussed with scope for future areas of development explored. The benefits of care closer to home for patients during the global COVID-19 pandemic are examined, as well as the potential for widening the whole gamut of practice for already established NHS community services through the development of integrated working in a local care organisation.

Improving Customisation in Clinical Pathways by Using a Modular Perspective

A standardised system of clinical pathways often conflicts with providing patient-centred heterogeneous care. Mental health care organisations are searching for new methods to become responsive towards unique treatment needs. Modularity is a method increasingly suggested to reconcile standardisation and customisation. The aim is to investigate the extent to which modularity can be applied to make clinical pathways in specialist mental health care more flexible in order to stimulate shared decision making (SDM) and thereby customise care processes to patient contexts while maintaining evidence-based standards. Methods consist of literature research and a theory-based case study including document analysis and semi-structured interviews, which were performed at a Dutch specialist mental health care organisation. The results show that in current literature two modularity-based structures are proposed that support flexibility and customisation, i.e., ‘Prototype’ and ‘Menu-based’. This study reveals that departments tend to use the prototype method if they have predictable patient needs, evidence-based methods are available and there is sequency in treatment components. The menu-based method is preferred if there are unpredictable needs, or the evidence needed to create interconnectedness in treatment is lacking. In conclusion, prototype or menu-based methods are both suitable for applying SDM and reaching customisation in practice. The choice is determined by three characteristics: predictability of needs, availability of evidence and the interconnectedness of treatment components.

Using positive deviance to improve timely access in primary care

BackgroundImproving timely access in primary care is a continued challenge in many countries. We used positive deviance to try and identify best practices for achieving timely access in our primary care organisation in Toronto, Canada.MethodsSemistructured interviews were used to identify practice strategies used by physicians who successfully maintained a low third next available appointment (TNA) (positive deviants, n=6). We then conducted a cross-sectional survey to understand the prevalence of identified promising practices among all physicians (n=70) in the practice. We used χ2 testing to understand whether uptake of promising practices among survey respondents was different for those with a median TNA of 7 days or less vs a median TNA over 7 days.ResultsWe identified seven promising practice strategies used by positive deviants: adjusting the appointment template based on demand; reviewing the appointment schedule in advance; max-packing of visits; using phone, email and secure messaging; customising care for complex patients; managing planned absences; and involving the interprofessional team. 65 of 70 physicians responded to the survey on promising practices. Uptake of the promising practices was variable among survey respondents. In general, we found no association between uptake of promising practices and median TNA. One exception was that those with a median TNA of 7 or less were more likely to review the schedule in advance to potentially mitigate a visit using phone/email (62% vs 31%, p=0.0159).ConclusionPromising practices used by a small group of physicians (‘positive deviants’) to maintain good access were generally not associated with timely access among a larger sample of physicians in the practice. Our findings highlight the difficulty of untangling physician practice style and its contribution to timely access in primary care.

Enabling patients with learning disabilities to self-manage lower limb lymphoedema

Kathryn Taylor, Lymphoedema Clinical Nurse Specialist and Service Lead, Community Lymphoedema Service, Manchester Local Care Organisation ( [email protected] ), was runner-up in the Chronic Oedema Nurse of the Year category in the BJN Awards 2021

Reproducing normative femininity: Women’s evaluations of their birth experiences analysed by means of word frequency and thematic analysis

Background Given the significance of the birth experience on women’s and babies’ well-being, assessing and understanding maternal satisfaction is important for providing optimal care. While previous research has thoroughly reviewed women’s levels of satisfaction with the childbirth experience from a multitude of different angles, there is a dearth of papers that use a gender lens in this area. The aim of this study is to explore through a gender perspective the circumstances attributed to both women’s assessment of a positive birth experience and those which contribute to a lack of satisfaction with their birth experience. Methods Through the use of a local birth evaluation form at a Swedish labour ward, 190 women gave written evaluations of their birth experiences. The evaluations were divided into groups of positive, ambiguous, and negative evaluations. By means of a latent and constructionist thematic analysis based on word count, women’s evaluations are discussed as reflections of the underlying sociocultural ideas, assumptions, and ideologies that shape women’s realities. Results Three themes were identified: Grateful women and nurturing midwives doing gender together demonstrates how a gender-normative behaviour may influence a positive birth experience when based on a reciprocal relationship. Managing ambiguous feelings by sympathising with the midwife shows how women’s internalised sense of gender can make women belittle their negative experiences and refrain from delivering criticism. The midwifery model of relational care impeded by the labour care organisation describes how the care women receive during labour and birth is regulated by an organisation not always adapted to the benefit of birthing women. Conclusions Most women were very satisfied, predominantly with emotional support they received from the midwives. The latent constructionist thematic analysis also elicited women’s mixed feelings towards the birth experience, with the majority of negative experiences directed towards the labour care organisation. Recognising the impact of institutional and medical discourses on childbirth, women’s birth evaluations demonstrate the benefits and challenges of gender-normative behaviour, where women’s internalised sense of gender was found to affect their experiences. A gender perspective may provide a useful tool in unveiling gender-normative complexities surrounding the childbirth experience.

Nursing Leadership Role in Pandemic

A Pandemic is an epidemic of disease that has spread across a large region, multiple continents orworldwide, COVID-19 is a large issue worldwide. A good nurse leader is someone who can inspireothers to work together in pursuit of a common goal, such as enhanced patient care. An effectiveleader has a distinctive set of personal qualities; integrity, courage, initiative and an ability to handlestress, and also taking the effort to think critically, set goals and skilfully communicates andcollaborate. Nurse’s leaders are faced with a variety of challenges in pandemics, including managingresources, advanced planning and goal setting, collaborating with other hospital and communityleaders, improving quality measures, cost-effectiveness, reporting to the board of directors, andmany more. Nurses as effective partners of the health care team, of necessity, have to meet thedemands of these changes adequately and appropriately in respect of their expanded and enrichedroles and responsibilities. Nurse leaders, however, are still confined within their nursing orbit, but,today they have to be visible and interactive members of the multi-disciplinary health team with avision and voice that can be heard. Methods: For the present review article collected a databasefrom Google scholar; search and scrutinize studies related to nurse’s leadership role duringpandemic and article related to Covid-19 outbreak, government, community effort and mitigationstrategies in reducing transmission. Result: Because it is a novel pandemic; results suggest thatmore researches are needed in this field related to driven factors, mitigation strategies and supportof governmental and non-governmental organizations. This review article is aimed that nursingleaders must continue to develop plans that can slow or prevent the progress of widespread illnessesand ensures that all client care provided by the team is carried out in keeping with the objectives ofthe health care organisation.

Leaving early or staying on? Retirement preferences and motives among older health-care professionals

There is a need for improved knowledge about how workplace conditions and organisational factors may obstruct or facilitate work in late life. By means of both quantitative and qualitative data, this study aims to explore retirement preferences among employees (aged 55 and older) in a large Swedish health-care organisation and to identify work-related motives influencing their retirement preferences. The quantitative analysis showed large variation in retirement preferences in the organisation. The qualitative results were summarised into two overarching types of motives for late and early retirement preferences, general and group-specific. The general motives were shared by the early and late preference groups, and included recognition, flexibility, health and work motivation. The group-specific motives were exclusively related to either an early or a late retirement preference. Criticism towards the organisation and strenuous working conditions were specific motives for an early retirement preference, while positive accounts of work and a wish to utilise one's own competencies as well as being financially dependent on work was stated as specific motives for wanting to retire late. The results illustrate the need to improve organisational practices and routines, as well as working conditions, in order to make an extended working life accessible for more than already-privileged groups of employees.