Conor Farrington

Blended e-learning and end of life care in nursing homes: a small-scale mixed-methods case study

BackgroundA ‘blended’ (e-learning and facilitated workshops) training course for Group C staff (i.e. staff with relatively infrequent contact with end of life care) has been delivered across several English counties with the aim of improving end of life care in nursing and residential care homes. This paper evaluates the impact of the course on participants’ understandings of and confidence in delivering end of life care in one nursing home, while also considering barriers to change in practice.MethodsA mixed-methods case study approach, incorporating pre- and post-course questionnaires (SHA East of England End of Life Care Education Programme ‘ABC’ Project Work Force C or Non Nurse Workforce B Pre and Post Course Questionnaire; E-Learning in End of Life Care Study Pre and Post Course Questionnaire), documentary analysis, semi-structured interviews, and observation of course workshops. Participants were 20 members of staff at a nursing home in a city in the East of England, including 14 Health Care Assistants (carers) and 6 others (administrative, activities, hosting, and catering staff). The questionnaires and interviews assessed understandings of and confidence towards end of life care delivery.ResultsImprovements in participants’ confidence in delivering end of life care were observed, particularly in the core competency areas of symptom management, communication, and advance care planning. A shift towards more detailed and more holistic understandings of end of life care was in evidence; some participants also championed end of life care in the home as a result of the course. Several barriers to changes in practice were encountered, including uneven participation, the absence of mechanisms for disseminating new insights and knowledge within the home, and a widespread perception that nurses’ professional dominance in the home made sustainable change difficult to enact.ConclusionsWhile blended e-learning courses have the potential to generate positive change in participants’ understandings of and confidence about End of Life Care, organizational and inter-professional obstacles must be overcome in order to translate these changes into improved end of life care delivery in nursing (and residential) homes.

Experiences of closed-loop insulin delivery among pregnant women with Type 1 diabetes

To explore the experiences of pregnant women with Type 1 diabetes, and the relationships between perceptions of glucose control, attitudes to technology and glycaemic responses with regard to closed‐loop insulin delivery.

Day-and-Night Closed-Loop Insulin Delivery in a Broad Population of Pregnant Women With Type 1 Diabetes: A Randomized Controlled Crossover Trial

OBJECTIVE Despite advances in technology, optimal glucose control remains elusive and neonatal complications remain ubiquitous in type 1 diabetes (T1D) pregnancy. Our aim was to examine the safety, efficacy, and longer-term feasibility of day-and-night closed-loop insulin delivery. RESEARCH DESIGN AND METHODS We recruited 16 pregnant women (mean [SD]: age 32.8 [5.0] years, T1D duration 19.4 [10.2] years, HbA1c 8.0% [1.1], and BMI 26.6 [4.4] kg/m2) to an open-label, randomized, crossover trial. Participants completed 28 days of closed-loop and sensor-augmented pump (SAP) insulin delivery separated by a washout period. Afterward, participants could continue to use the closed-loop system up to 6 weeks postpartum. The primary end point was the proportion of time with glucose levels within the target range (63–140 mg/dL). RESULTS The proportion of time with glucose levels within target was comparable during closed-loop and SAP insulin delivery (62.3 vs. 60.1% [95% CI −4.1 to 8.3]; P = 0.47). Mean glucose and time spent hyperglycemic >140 mg/dL also did not differ (131.4 vs. 131.4 mg/dL [P = 0.85] and 36.6 vs. 36.1% [P = 0.86], respectively). During closed-loop, fewer hypoglycemic episodes occurred (median 8 [range 1–17] vs. 12.5 [1–53] over 28 days; P = 0.04) and less time at <63 mg/dL (1.6 vs. 2.7%; P = 0.02). Hypoglycemia <50 mg/dL (0.24 vs. 0.47%; P = 0.03) and low blood glucose index (1.0 vs. 1.4; P = 0.01) were lower. Less nocturnal hypoglycemia (2300–0700 h) during closed-loop therapy (1.1 vs. 2.7%; P = 0.008) and a trend toward higher overnight time in target (67.7 vs. 60.6%; P = 0.06) were found. CONCLUSIONS Closed-loop insulin delivery was associated with comparable glucose control and significantly less hypoglycemia than SAP therapy. Larger, longer-duration multicenter trials are now indicated to determine clinical efficacy of closed-loop insulin delivery in T1D pregnancy and the impact on neonatal outcomes.

Doctors’ engagements with patient experience surveys in primary and secondary care: a qualitative study

Patient experience surveys are increasingly important in the measurement of, and attempts to improve, health‐care quality. To date, little research has focused upon doctors’ attitudes to surveys which give them personalized feedback.

Data as Transformational: Constrained and Liberated Bodies in an ‘Artificial Pancreas’ Study

Whether intervening within bodies or monitoring them externally, personal medical devices (PMDs) are a uniquely intimate and ubiquitous source of data, in many cases offering PMD users the ability to gain granular knowledge about hitherto unknown aspects of their own bodies. This chapter foregrounds the specific kinds of data generated by ‘artificial pancreas’ systems in Type 1 diabetes. Through analysis of interviews with participants in a study of pregnant women using the artificial pancreas, this chapter draws on ‘sensemaking’ theories to explore how PMD data can reconstitute micro-scale attitudes to the self and technology. The variability of such experiences illustrates the complexity of technology usage as it occurs in practice and the multiple ways in which data increasingly play important roles in experiences of health and illness.

Quantified Lives and Vital Data

This book raises questions about the changing relationships between technology, people and health. It examines the accelerating pace of technological development and a general shift to personalized, patient-led medicine. Such relationships are increasingly mediated through particular medical technologies, drawn together by the authors as ‘personal medical devices’ (PMDs) – devices that are attached to, worn by, interacted with, or carried by individuals for the purposes of generating biomedical data and carrying out medical interventions on the person concerned. The burgeoning PMD field is advancing rapidly across multiple domains and disciplines – so rapidly that conceptual and empirical research and thinking around PMDs, and their clinical, social and philosophical implications, often lag behind new technical developments and medical interventions. This timely and original volume explores the significant and under-researched impact of personal medical devices on contemporary understandings of health and illness. It will be a valuable read for scholars and practitioners of medicine, health, science and technology and social science.

Personal Medical Devices: People and Technology in the Context of Health

Why should we explore personal medical devices (PMDs)? Fuelled by the growth of so-called lifestyle conditions, shifts to personalised and patient-led medicine and the increasing sophistication and miniaturisation of devices themselves, PMDs have become increasingly significant in both clinical and non-clinical arenas. This chapter presents some of the intersections and new relationships, possibilities and constructions of health that the use and development of these technologies present. PMDs question existing concepts of bodily boundaries and processes (the ‘personal’), the purview of medicine and its handling of its objects of study (the ‘medical’) and wider consequences of these technologies (the ‘device’). Introducing the contributions to the book, the chapter argues that nuanced, critical and empirically grounded approaches are needed to interrogate and understand emerging issues in this field.

Quantified Lives and Vital Data: Some Concluding Remarks

Reflecting on the contributions to this edited volume, this chapter draws out some of the key themes and issues raised by social science approaches to personal medical devices (PMDs). The chapters illustrate that what PMDs (and other health technologies) ‘do’ and ‘are’ may be quite different. They are variously embedded through practices, spaces, times, and relationships and so cannot be considered as stand-alone objects. Likewise, particular boundaries that PMDs bring into focus—e.g., self/other, bodily boundaries, medicine and medical boundaries, and bodily/health data—are not fixed or prescriptive but rather dynamic and changing. Investigating PMDs therefore allows exploration of dynamic and situated intersections of people, health, and technology—the quantified lives that we increasingly live and the vital data produced by these.

Women’s Experiences of Day-and-Night Closed-Loop Insulin Delivery During Type 1 Diabetes Pregnancy

Aims: Closed-loop insulin delivery has the potential to improve day-to-day glucose control in type 1 diabetes pregnancy. However, the psychosocial impact of day-and-night usage of automated closed-loop systems during pregnancy is unknown. Our aim was to explore women’s experiences and relationships between technology experience and levels of trust in closed-loop therapy. Methods: We recruited 16 pregnant women with type 1 diabetes to a randomized crossover trial of sensor-augmented pump therapy compared to automated closed-loop therapy. We conducted semistructured qualitative interviews at baseline and follow-up. Findings from follow-up interviews are reported here. Results: Women described benefits and burdens of closed-loop systems during pregnancy. Feelings of improved glucose control, excitement and peace of mind were counterbalanced by concerns about technical glitches, CGM inaccuracy, and the burden of maintenance requirements. Women expressed varied but mostly high levels of trust in closed-loop therapy. Conclusions: Women displayed complex psychosocial responses to day-and-night closed-loop therapy in pregnancy. Clinicians should consider closed-loop therapy not just in terms of its potential impact on biomedical outcomes but also in terms of its impact on users’ lives.

Lords Reform: Some Inconvenient Truths

The failure of the Coalition government’s attempt to reform the House of Lords has by no means taken further reform off the political agenda. The commitment to installing an elected upper chamber is still widely shared across the political spectrum, on the basis of perceptions that the House of Lords lacks democratic legitimacy. Against this view, this article considers recent literature upon non-electoral representation, deliberative democracy and bicameralism, which together highlight the possibility of an unelected second chamber playing a legitimate role within a wider (democratic) system of government. The article then considers the House of Lords from this perspective, reflecting on changes in the upper chamber since the 1999 reforms and evaluating its role within the wider political system. The paper concludes by suggesting that political debate should focus upon small-scale reforms to ensure that the Lords becomes more effective, representative and legitimate, within the constraints of its present role.