Donna Luff

Knowledge, technology and nursing: The case of NHS Direct

NHS Direct is a relatively new, nurse-based, 24-hour health advice line run as part of the UK’s National Health Service (NHS). The service delivers health advice remotely via the telephone. A central aspect of the service is the attempt to provide a standard level of health advice regardless of time, space or the background of the nurse. At the heart of this attempt is an innovative health software called CLINICAL ASSESSMENT SYSTEM (CAS). Using a number of qualitative methods, this article highlights how the interaction between the nursing staff and this technology is key to the service. The technology is based on management’s attempt to standardize and control the caller-nurse relationship. Thus the software can be seen as part of an abstract rationality, whereas how it is deployed by nurses is based on a practical rationality that places practice and experience first and sees the technology and protocols as tools.

Viscoaugmentation as a treatment for leakage around the Provox 2 voice rehabilitation system.

Tracheo-oesophageal puncture for voice restoration is a well-established technique post-laryngectomy. A number of complications can occur with the creation of a tracheo-oesophageal fistula (TOF) and in the subsequent management of the patient with an indwelling voice rehabilitation system. This article is the first to report the use of Hylaform, a colourless viscoelastic gel, to treat an intractable case of leakage around a Provox 2 voice prosthesis. The procedure which required no anaesthesia resulted in no further leak around the valve to the present day, now more than four weeks post-viscoaugmentation.

Risk and the Responsible Health Consumer: The Problematics of Entitlement among Callers to NHS Direct

NHS Direct, the 24-hour telephone helpline, uses modern communications technology to offer easier and faster access to advice about health, illness and the NHS so that people are better able to care for themselves and their families. In-depth interviews with callers to the service show that they bring with them discourses of the ‘deserving’ and ‘ undeserving’ familiar in the provision of other welfare services. The figure of the ‘time-waster’ is the NHS equivalent of the welfare ‘scrounger’, acting as a mechanism to problematize entitlement. NHS Direct dispels such fears and legitimizes demand. At the same time, ever-rising levels of service use constitute a threat to what callers value most about it.

Patient-Provider Relationships Across the Transition From Pediatric to Adult Diabetes Care A Qualitative Study

Purpose The purpose of this study was to explore perceptions that emerging adults with type 1 diabetes (T1D) have of their patient-provider relationships across the transition from pediatric to adult care. Methods Twenty-six emerging adults with T1D (mean age 26.2 ± 2.5 years) participated in 5 focus groups stratified by current level of glycemic control (A1C). Coded audio-recorded data were analyzed using thematic analysis and aided by NVivo software. Results Three major themes emerged from the analysis: (1) loss and gain in provider relationships across the transition—patients expressed 3 key responses to leaving pediatric providers that differed by A1C levels: sad reluctance and “natural progression” (mean A1C ± SD 7.4% ± 0.6%) and wanting to go (mean A1C ± SD 9.8% ± 1.0%); (2) partners in care versus on one’s own—patients valued how adult providers’ collaborative conversations promoted their involvement and accountability compared to “parent-centric” interactions with pediatric providers, but they also expressed ambivalence over increased independence in adult care; (3) improving provider approaches to transition—patients recommended that pediatric providers actively promote emerging adults’ autonomy while maintaining parental support, communication with adult providers, and follow-up with transitioning patients. Conclusions Findings highlight the importance of enhanced provider awareness of T1D emerging adults’ complex feelings about the transition in care. Improved integration of individual- and family-centered approaches to developmentally tailored diabetes care is needed to augment patient and provider relationships.

Experiences of health care transition voiced by young adults with type 1 diabetes: a qualitative study

Objective This qualitative study aimed to explore the experience of transition from pediatric to adult diabetes care reported by posttransition emerging adults with type 1 diabetes (T1D), with a focus on preparation for the actual transfer in care. Methods Twenty-six T1D emerging adults (mean age 26.2±2.5 years) receiving adult diabetes care at a single center participated in five focus groups stratified by two levels of current glycemic control. A multidisciplinary team coded transcripts and conducted thematic analysis. Results Four key themes on the process of transfer to adult care emerged from a thematic analysis: 1) nonpurposeful transition (patients reported a lack of transition preparation by pediatric providers for the transfer to adult diabetes care); 2) vulnerability in the college years (patients conveyed periods of loss to follow-up during college and described health risks and diabetes management challenges specific to the college years that were inadequately addressed by pediatric or adult providers); 3) unexpected differences between pediatric and adult health care systems (patients were surprised by the different feel of adult diabetes care, especially with regards to an increased focus on diabetes complications); and 4) patients’ wish list for improving the transition process (patients recommended enhanced pediatric transition counseling, implementation of adult clinic orientation programs, and peer support for transitioning patients). Conclusion Our findings identify modifiable deficiencies in the T1D transition process and underscore the importance of a planned transition with enhanced preparation by pediatric clinics as well as developmentally tailored patient orientation in the adult clinic setting.

Endolymphatic sac tumours.

Endolymphatic sac tumours (ELST) are rare tumours of the petrous temporal bone. They may arise sporadically or be associated with von Hippel-Lindau disease. Their differential diagnosis is discussed. We present the clinical and histopathological features of two new patients with ELST and outline the management of their condition. In addition, we review a third case previously reported as a choroid plexus papilloma in which the histology has been re-assessed and the diagnosis changed to ELST. The controversy regarding the cellular origins of adenomatous tumours of the temporal bone is highlighted.We present a case of a papillary tumour of the petrous bone. The established terminology for this rare neoplasm is endolymphatic sac tumour (ELST) but the true origin remains controversial. ELSTs are associated with von Hippel-Lindau disease. They are locally invasive, highly vascular and often require endovascular embolization prior to surgery. Both radiologically and histologically ELSTs are easily mistaken for other more common tumours such as paragangliomas and renal or papillary thyroid carcinoma metastases. This is important because local excision is curative.

Peripheral primitive neuroectodermal tumour (pPNET) of the cerebellopontine angle presenting in adult life.

We report a case of a peripheral neuroectodermal tumour (pPNET) of the cerebellopontine angle of a 67-year-old woman. The patients age at presentation was highly unusual. This case highlights the difficulties encountered, both clinically and pathologically, in securing the correct diagnosis of such a rare condition presenting in this relatively inaccessible area. The development of the nomenclature and classification of neuroectodermal tumours is traced. Recent advances in immunohistochemistry and genetic typing have shown the close relationship between pPNET and the previously difficult to classify Ewings sarcoma and Askins tumour.

Safety incidents in the primary care office setting

BACKGROUND: In the United Kingdom, 26% of child deaths have identifiable failures in care. Although children account for 40% of family physicians’ workload, little is known about the safety of care in the community setting. Using data from a national patient safety incident reporting system, this study aimed to characterize the pediatric safety incidents occurring in family practice. METHODS: We undertook a retrospective, cross-sectional, mixed methods study of pediatric reports submitted to the UK National Reporting and Learning System from family practice. Analysis involved detailed data coding using multiaxial frameworks, descriptive statistical analysis, and thematic analysis of a special-case sample of reports. Using frequency distributions and cross-tabulations, the relationships between incident types and contributory factors were explored. RESULTS: Of 1788 reports identified, 763 (42.7%) described harm to children. Three crosscutting priority areas were identified: medication management, assessment and referral, and treatment. The 4 incident types associated with the most harmful outcomes are errors associated with diagnosis and assessment, delivery of treatment and procedures, referrals, and medication provision. Poor referral and treatment decisions in severely unwell or vulnerable children, along with delayed diagnosis and insufficient assessment of such children, featured prominently in incidents resulting in severe harm or death. CONCLUSION: This is the first analysis of nationally collected, family practice–related pediatric safety incident reports. Recommendations to mitigate harm in these priority areas include mandatory pediatric training for all family physicians; use of electronic tools to support diagnosis, management, and referral decision-making; and use of technological adjuncts such as barcode scanning to reduce medication errors.

Parental Perspectives of Early Childhood Caries

Background. Parental perspectives of children with early childhood caries may help inform the development and improvement of caries prevention strategies. Objectives. This study aimed to explore parents’ experiences, perceptions, and expectations regarding prevention and management of early childhood caries. Methods. The authors conducted semistructured interviews with 25 parents of children aged 2 to 5 years, with a known history of caries. All interviews were transcribed and coded, and iterative analyses were conducted to identify key emergent themes within the data. Results. Parents had limited knowledge of behaviors contributing to early childhood caries and when to first seek regular dental care. Parents expected pediatricians to provide education on how to prevent childhood caries, conduct preliminary oral health assessments, and help establish early linkages between medical and dental care. Conclusion. The findings make a strong case for pediatricians to take responsibility for engaging and educating parents on fostering optimal oral health and helping to access early childhood dental care.

Male callers to NHS Direct: the assertive carer, the new dad and the reluctant patient.

It has been suggested in the light of mortality and morbidity rates, and men’s reluctance to seek medical help and advice, that there is a crisis in men’s health. Little is known about men’s experiences of using health care services, despite an emergent UK men’s health movement. NHS Direct, the new telephone advice line, was designed to be more accessible, convenient and responsive to the public’s needs for health care. In-depth interviews with male callers to the service, aged between 29 and 59, reveal that they sought help in their roles as fathers, partners and on their own behalf. Having used it once, they anticipated doing so again. Their learning about health matters, from both the formal structure and the informal agenda of the telephone consultation, suggests the potential of men’s use of this service for ‘normalizing’ help seeking by men, and thereby for longer-term improvements in men’s health.