Evaluating the process of practice enhancement for exclusive breastfeeding (PEEB): a participatory action research approach for clinical innovation.

BACKGROUND: Despite the known benefits of exclusive breastfeeding, global rates remain below recommended targets, with Ireland having one of the lowest rates in the world. This study explores the efficacy of Participatory Action Research (PAR) and Work-Based Learning Groups (WBLGs) to enhance breastfeeding practices within Irish healthcare settings from the perspective of WBLG participants and facilitators. METHODS: Employing a PAR approach, interdisciplinary healthcare professionals across maternity, primary, and community care settings (n = 94) participated in monthly WBLGs facilitated by three research and practice experts. These sessions, conducted over nine months (November 2021 - July 2022), focused on critical reflective and experiential learning to identify and understand existing breastfeeding culture and practices. Data were collected through participant feedback, facilitator notes, and reflective exercises, with analysis centered on participant engagement and the effectiveness of WBLGs. This approach facilitated a comprehensive understanding of breastfeeding support challenges and opportunities, leading to the development of actionable themes and strategies for practice improvement. RESULTS: Data analysis from WBLG participants led to the identification of five key themes: Empowerment, Ethos, Journey, Vision, and Personal Experience. These themes shaped the participants' meta-narrative, emphasising a journey of knowledge-building and empowerment for breastfeeding women and supporting staff, underlining the importance of teamwork and multidisciplinary approaches. The project team's evaluation highlighted four additional themes: Building Momentum, Balancing, Space Matters, and Being Present. These themes reflect the dynamics of the PAR process, highlighting the significance of creating a conducive environment for discussion, ensuring diverse engagement, and maintaining energy and focus to foster meaningful practice changes in breastfeeding support. CONCLUSION: This study highlights the potential of WBLGs and PAR to enhance the understanding and approach of healthcare professionals towards breastfeeding support. By fostering reflective and collaborative learning environments, the study has contributed to a deeper understanding of the challenges in breastfeeding support and identified key areas for improvement. The methodologies and themes identified hold promise to inform future practice and policy development in maternal and child health.

A PI(3,5)P2 reporter reveals PIKfyve activity and dynamics on macropinosomes and phagosomes.

Phosphoinositide signaling lipids (PIPs) are key regulators of membrane identity and trafficking. Of these, PI(3,5)P2 is one of the least well-understood, despite key roles in many endocytic pathways including phagocytosis and macropinocytosis. PI(3,5)P2 is generated by the phosphoinositide 5-kinase PIKfyve, which is critical for phagosomal digestion and antimicrobial activity. However PI(3,5)P2 dynamics and regulation remain unclear due to lack of reliable reporters. Using the amoeba Dictyostelium discoideum, we identify SnxA as a highly selective PI(3,5)P2-binding protein and characterize its use as a reporter for PI(3,5)P2 in both Dictyostelium and mammalian cells. Using GFP-SnxA, we demonstrate that Dictyostelium phagosomes and macropinosomes accumulate PI(3,5)P2 3 min after engulfment but are then retained differently, indicating pathway-specific regulation. We further find that PIKfyve recruitment and activity are separable and that PIKfyve activation stimulates its own dissociation. SnxA is therefore a new tool for reporting PI(3,5)P2 in live cells that reveals key mechanistic details of the role and regulation of PIKfyve/PI(3,5)P2.

The Experience of COVID-19 Visitor Restrictions among Families of People Living in Long-Term Residential Care Facilities during the First Wave of the Pandemic in Ireland.

Public health responses to COVID-19 in long-term residential care facilities (LTRCFs) have restricted family engagement with residents. These restrictions impact on quality of care and the psychosocial and emotional well-being of family caregivers. Following a national cross-sectional web-based survey, respondents were invited to provide personal reflections on visitor restrictions. This study aims to describe the consequences of these restrictions for individuals living in LTRCF and their families during the first wave of the COVID-19 pandemic. Data from open-ended questions contained within the survey were analyzed using Braun and Clarke's (2006) method of thematic analysis. Four themes were identified: 1. Altered Communication and Connection; 2. Emotional and Psychological Impact; 3. Protecting and Caring Role of Staff; 4. Family Role. Throughout the narrative accounts, it is evident that the visitor restrictions impacted on the emotional and mental well-being of families. Some respondents expressed frustration that they could not assist staff in essential care provision, reducing meaning and purpose in their own lives. COVID-19 LTRCF visitor restrictions made little distinction between those providing essential personal care and those who visit for social reasons. A partnership approach to care provision is important and should encompass strategies to maintain the psychosocial and emotional well-being of families and their relatives during times of self-isolating or restrictive measures.

Evaluating the use of participatory action research to implement evidence-based guidance on dementia palliative care in long-term care settings: A creative hermeneutic analysis.

BACKGROUND: Dementia affects a large proportion of society and places a significant burden on older people and healthcare systems internationally. Managing symptoms at the end of life for people with dementia is complex. Participatory action research can offer an approach that helps to encourage implementation of evidence-based practices in long-term care settings. METHODS: Three evidence-based guidance documents (pain assessment and management, medication management, nutrition and hydration management) were introduced in three long-term care settings for older people. Data generated from work-based learning groups were analysed using a critical hermeneutic approach to explore the use of participatory action research to support the implementation of guidance documents in these settings. RESULTS: Engagement and Facilitation emerged as key factors which both enabled and hindered the PAR processes at each study site. CONCLUSIONS: This study adds to the body of knowledge that emphasises the value of participatory action research in enabling practice change. It further identifies key practice development approaches that are necessary to enable a PAR approach to occur in care settings for older people with dementia. The study highlights the need to ensure that dedicated attention is paid to strategies that facilitate key transformations in clinical practice.

Implementation of evidence-based guidance for dementia palliative care using participatory action research: examining implementation through the Consolidated Framework for Implementation Research (CFIR).

BACKGROUND: The importance of providing evidence-based palliative care for people with dementia is increasingly acknowledged as important for patient outcomes. In Ireland, evidence-based guidance has been developed in order to address key features of dementia palliative care, including the management of pain, medications and hydration and nutrition. The aim of this study was to identify and explore the factors affecting the implementation of evidence-based guidance on dementia palliative care. METHODS: The Consolidated Framework for Implementation (CFIR) guided a mixed-method pre-post study. One guidance document pertaining to the management of pain, medication or hydration and nutrition was implemented in three long-term care facilities. Participatory action research in the form of work-based learning groups was used to implement the guidance, drawing on a situational analysis (pre-implementation). Staff questionnaires and audits were conducted pre- and post-implementation while champion interviews were also conducted post-implementation. RESULTS: Features of the guidance, the inner setting components such as readiness to change, and the process of implementation were most frequently identified as impacting implementation. Components of the outer setting, such as external policy incentives and individual characteristics, featured less commonly. Data from qualitative interviews revealed that the guidance was perceived as advantageous or complimentary to previous care provided. Within the inner setting, leadership and support from other colleagues facilitated implementation. However, limited availability of other healthcare professionals to assist with carrying out guidance actions presented a barrier in some facilities. The external facilitators of the work-based learning groups (WBLGs) were perceived as experienced and encouraged active participation and reflection on practices. Despite the challenge of releasing staff to attend the WBLGs, quantitative data demonstrated reduced staff de-motivation amongst those who did attend was noted post-implementation (pre-Mdn = 19.50 versus post-Mdn = 22.00, U = 497.00, p = 0.07). CONCLUSIONS: A situational analysis informed by the CFIR framework in conjunction with a participatory action research approach helped to advance the implementation of the guidance. The progress of implementation depended on the extent to which evidence-based care was previously being implemented at each site. Post-implementation analysis using CFIR identified challenges to address in future projects such as staff cover and timing of training to facilitate attendance for staff with different working hours. Facilitators included multidisciplinary engagement with the intervention and champions at each site to support the implementation process.

Psychosocial Impact of COVID-19 Nursing Home Restrictions on Visitors of Residents With Cognitive Impairment: A Cross-Sectional Study as Part of the Engaging Remotely in Care (ERiC) Project.

Background: COVID-19 has disproportionately affected older people. Visiting restrictions introduced since the start of the pandemic in residential care facilities (RCFs) may impact negatively on visitors including close family, friends, and guardians. We examined the effects of COVID-19 visiting restrictions on measures of perceived loneliness, well-being, and carer quality of life (QoL) amongst visitors of residents with and without cognitive impairment (CI) in Irish RCFs. Methods: We created a cross-sectional online survey. Loneliness was measured with the UCLA brief loneliness scale, psychological well-being with the WHO-5 Well-being Index and carer QoL with the Adult Carer QoL Questionnaire (support for caring subscale). Satisfaction with care ("increased/same" and "decreased") was measured. A history of CI was reported by respondents. Sampling was by convenience with the link circulated through university mail lists and targeted social media accounts for 2 weeks in June 2020. Results: In all, 225 responses were included of which 202 noted whether residents had reported CI. Most of the 202 identified themselves as immediate family (91%) and as female (82%). The majority (67%) were aged between 45 and 64 years. Most (80%) reported that their resident had CI. Approximately one-third indicated reduced satisfaction (27%) or that restrictions had impaired communication with nursing home staff (38%). Median loneliness scores were 4/9, well-being scores 60/100 and carer QoL scores 10/15. Visitors of those with CI reported significantly lower well-being (p = 0.006) but no difference in loneliness (p = 0.114) or QoL (p = 0.305). Reported CI (p = 0.04) remained an independent predictors of lower WHO-5 scores, after adjusting for age, sex, RCF location, and dementia stage (advanced), satisfaction with care (reduced), and perception of staff support measured on the Adult Carer QoL Questionnaire. Conclusion: This survey suggests that many RCF visitors experienced low psychosocial and emotional well-being during the COVID-19 lockdown. Visitors of residents with CI report significantly poorer well-being as measured by the WHO-5 than those without. Additional research is required to understand the importance of disrupted caregiving roles resulting from visiting restrictions on well-being, particularly on visitors of residents with CI and how RCFs and their staff can support visitors to mitigate these.

Telehealth for delivery of haemophilia comprehensive care during the COVID-19 pandemic.

INTRODUCTION: The COVID-19 pandemic caused an unprecedented impact to haemophilia healthcare delivery. In particular, rapid implementation of telehealth solutions was required to ensure continued access to comprehensive care. AIMS: To explore patient and healthcare provider (HCP) experience of telehealth in a European Haemophilia Comprehensive Care Centre. METHOD: A systematic evaluation was performed to survey patient and HCP experience and compare clinical activity levels with telehealth to in-person attendances. RESULTS: Public health measures implemented in March 2020 to reduce COVID-19 spread resulted in a 63% decrease in medical/nursing clinic consultation activity compared to the same period in 2019. Implementation of digital care pathways resulted in marked increase in activity (52% greater than 2019). Importantly, enhanced patient engagement was noted, with a 60% reduction in non-attendance rates. Survey of patients who had participated in medical/nursing teleconsultations demonstrated that teleconsultations improved access (79%), reduced inconvenience (82%), was easy to use (94%) and facilitated good communication with the HCP (97%). A survey exploring the telemedicine experience of HCPs, illustrated that HCPs were satisfied with teleconsultation and the majority (79%) would like to continue to offer teleconsultation as part of routine patient care. In addition to medical/nursing reviews, continued access to physiotherapy with virtual exercise classes for people with haemophilia and teleconsultation for acute dental issues was equally successful. CONCLUSION: During an unprecedented public health emergency, telehealth has enabled continued access to specialized haemophilia comprehensive care. Our novel findings show that this alternative is acceptable to both patients and HCPs and offers future novel opportunities.

Coordinated Ras and Rac Activity Shapes Macropinocytic Cups and Enables Phagocytosis of Geometrically Diverse Bacteria.

Engulfment of extracellular material by phagocytosis or macropinocytosis depends on the ability of cells to generate specialized cup-shaped protrusions. To effectively capture and internalize their targets, these cups are organized into a ring or ruffle of actin-driven protrusion encircling a non-protrusive interior domain. These functional domains depend on the combined activities of multiple Ras and Rho family small GTPases, but how their activities are integrated and differentially regulated over space and time is unknown. Here, we show that the amoeba Dictyostelium discoideum coordinates Ras and Rac activity using the multidomain protein RGBARG (RCC1, RhoGEF, BAR, and RasGAP-containing protein). We find RGBARG uses a tripartite mechanism of Ras, Rac, and phospholipid interactions to localize at the protruding edge and interface with the interior of both macropinocytic and phagocytic cups. There, we propose RGBARG shapes the protrusion by expanding Rac activation at the rim while suppressing expansion of the active Ras interior domain. Consequently, cells lacking RGBARG form enlarged, flat interior domains unable to generate large macropinosomes. During phagocytosis, we find that disruption of RGBARG causes a geometry-specific defect in engulfing rod-shaped bacteria and ellipsoidal beads. This demonstrates the importance of coordinating small GTPase activities during engulfment of more complex shapes and thus the full physiological range of microbes, and how this is achieved in a model professional phagocyte.

Lipid-gated monovalent ion fluxes regulate endocytic traffic and support immune surveillance.

Despite ongoing (macro)pinocytosis of extracellular fluid, the volume of the endocytic pathway remains unchanged. To investigate the underlying mechanism, we used high-resolution video imaging to analyze the fate of macropinosomes formed by macrophages in vitro and in situ. Na+, the primary cationic osmolyte internalized, exited endocytic vacuoles via two-pore channels, accompanied by parallel efflux of Cl- and osmotically coupled water. The resulting shrinkage caused crenation of the membrane, which fostered recruitment of curvature-sensing proteins. These proteins stabilized tubules and promoted their elongation, driving vacuolar remodeling, receptor recycling, and resolution of the organelles. Failure to resolve internalized fluid impairs the tissue surveillance activity of resident macrophages. Thus, osmotically driven increases in the surface-to-volume ratio of endomembranes promote traffic between compartments and help to ensure tissue homeostasis.

PIKfyve/Fab1 is required for efficient V-ATPase and hydrolase delivery to phagosomes, phagosomal killing, and restriction of Legionella infection.

By engulfing potentially harmful microbes, professional phagocytes are continually at risk from intracellular pathogens. To avoid becoming infected, the host must kill pathogens in the phagosome before they can escape or establish a survival niche. Here, we analyse the role of the phosphoinositide (PI) 5-kinase PIKfyve in phagosome maturation and killing, using the amoeba and model phagocyte Dictyostelium discoideum. PIKfyve plays important but poorly understood roles in vesicular trafficking by catalysing formation of the lipids phosphatidylinositol (3,5)-bisphosphate (PI(3,5)2) and phosphatidylinositol-5-phosphate (PI(5)P). Here we show that its activity is essential during early phagosome maturation in Dictyostelium. Disruption of PIKfyve inhibited delivery of both the vacuolar V-ATPase and proteases, dramatically reducing the ability of cells to acidify newly formed phagosomes and digest their contents. Consequently, PIKfyve- cells were unable to generate an effective antimicrobial environment and efficiently kill captured bacteria. Moreover, we demonstrate that cells lacking PIKfyve are more susceptible to infection by the intracellular pathogen Legionella pneumophila. We conclude that PIKfyve-catalysed phosphoinositide production plays a crucial and general role in ensuring early phagosomal maturation, protecting host cells from diverse pathogenic microbes.

The incidence of injury in elite camogie, an in-season prospective study.

BACKGROUND: Camogie is a stickhandling, high-velocity, multidirectional field sport for females which is native to Ireland, but is also played internationally. AIM: To establish the incidence, nature and severity of injuries in elite camogie players. METHODS: A prospective, observational cohort study was carried out during the Provincial Championships and extending into the All-Ireland Championship until a participating team was eliminated (11 weeks). A purposive sample of 62 players from 3 of the total 11 senior intercounty teams participated to generate geographical representation. Injury data were recorded and classified by team physiotherapists using a time loss definition, consistent with consensus statements. A concurrent measure of exposure to matches and training was recorded. RESULTS: Twenty-one incidents of injury were recorded with 14 players injured. Injury incidence rate was 26.4 (95% CI 13.44 to 47.16) per 1000 match hours and 4.2 (95% CI 2.12 to 7.46) per 1000 training hours. There were 11 contact and 10 non-contact injuries. The lower limb accounted for 71.4% (n=15), the upper limb 9.5% (n=2) and the trunk and head 19.1% (n=4) of injuries. The main tissues injured were both muscle and ligament, representing 57.2% (n=6 each). The mean duration time loss from sport per injury was 12.14 days. CONCLUSION: These results provide data on the incidence, nature and severity of camogie injuries using definitions that reflect international consensus statements. Further study of injury incidence over a full season or multiple seasons is recommended.

Working in a storied way-Narrative-based approaches to person-centred care and practice development in older adult residential care settings.

AIMS AND OBJECTIVES: To evaluate the effects of the implementation of a methodological framework for a narrative-based approach to practice development and person-centred care in residential aged care settings. BACKGROUND: Care in long-term residential settings for older people is moving away from the biomedical approach and adopting a more person-centred one. Narrative can help shape the way care is planned and organised. The provision of person-centred care that is holistic and that takes account of resident's beliefs and values can be enhanced by incorporating narrative approaches to care within a practice development framework. DESIGN: The chosen methodology was participatory action research. METHODS: Between 2010-2014, a methodological framework of narrative practice was implemented in two residential care settings, comprising 37 residents and 38 staff, using an action research approach. Three action cycles: (i) narrative practice and culture identification, (ii) developing narrative practice and (iii) working in a storied way emerged during the implementation. RESULTS: Key outcomes emerged in relation to the findings. These were based on narrative being, knowing and doing and centred around the key outcomes of (i) how people responded to change (narrative being), (ii) the development of shared understandings (narrative knowing) and (iii) intentional action (narrative doing). CONCLUSION: The implementation of a framework of narrative practice demonstrated that how people respond to change, the development of shared understandings and intentional action were interrelated and interlinked. It illustrated the importance of ensuring that practice context is taken account of in the implementation of action research and the importance of ensuring that narrative being, knowing and doing are clear and understandable for change to occur. RELEVANCE TO CLINICAL PRACTICE: Implementation of a narrative approach to care can develop new ways of working that value biography and promote the development of a co-constructed plan of care.

Drinking problems: mechanisms of macropinosome formation and maturation.

Macropinocytosis is a mechanism for the nonspecific bulk uptake and internalisation of extracellular fluid. This plays specific and distinct roles in diverse cell types such as macrophages, dendritic cells and neurons, by allowing cells to sample their environment, extract extracellular nutrients and regulate plasma membrane turnover. Macropinocytosis has recently been implicated in several diseases including cancer, neurodegenerative diseases and atherosclerosis. Uptake by macropinocytosis is also exploited by several intracellular pathogens to gain entry into host cells. Both capturing and subsequently processing large volumes of extracellular fluid poses a number of unique challenges for the cell. Macropinosome formation requires coordinated three-dimensional manipulation of the cytoskeleton to form shaped protrusions able to entrap extracellular fluid. The following maturation of these large vesicles then involves a complex series of membrane rearrangements to shrink and concentrate their contents, while delivering components required for digestion and recycling. Recognition of the diverse importance of macropinocytosis in physiology and disease has prompted a number of recent studies. In this article, we summarise advances in our understanding of both macropinosome formation and maturation, and seek to highlight the important unanswered questions.

WASH drives early recycling from macropinosomes and phagosomes to maintain surface phagocytic receptors.

Macropinocytosis is an ancient mechanism that allows cells to harvest nutrients from extracellular media, which also allows immune cells to sample antigens from their surroundings. During macropinosome formation, bulk plasma membrane is internalized with all its integral proteins. It is vital for cells to salvage these proteins before degradation, but the mechanisms for sorting them are not known. Here we describe the evolutionarily conserved recruitment of the WASH (WASP and SCAR homolog) complex to both macropinosomes and phagosomes within a minute of internalization. Using Dictyostelium, we demonstrate that WASH drives protein sorting and recycling from macropinosomes and is thus essential to maintain surface receptor levels and sustain phagocytosis. WASH functionally interacts with the retromer complex at both early and late phases of macropinosome maturation, but mediates recycling via retromer-dependent and -independent pathways. WASH mutants consequently have decreased membrane levels of integrins and other surface proteins. This study reveals an important pathway enabling cells to sustain macropinocytosis without bulk degradation of plasma membrane components.

Reducing inappropriate urinary catheter use: quality care initiatives.

Healthcare-acquired urinary infection presents a substantial burden for patients and the healthcare system. Urinary tract infections have not gained the same level of media attention as other healthcare-associated infections, yet interventions to reduce urinary catheter use are one of the top ten recommended patient safety strategies. To improve practice around urinary catheter placement and removal requires interventions to change the expectations and habits of nurses, medical teams and patients regarding the need for a urinary catheter. In the authors' trust, a redesign of the existing urinary catheter device record was undertaken to help avoid unnecessary placement of catheters, and resulted in a reduction of urinary catheters in situ longer than 48 hours. Other strategies included implementation of catheter rounds in a high-usage area, and credit-card-sized education cards. A catheter 'passport' was introduced for patients discharged with a catheter to ensure information for insertion and ongoing use were effectively communicated.

Beliefs of students about growing older and perceptions of working in gerontology.

An ageing population that is increasing does not necessarily mean an increase in people who require health and social care. However, it is predicted that a wide range of such services is likely to be needed. This demand is set against a shortage of skilled healthcare professionals and a lack of interest in working with older people. There is a particular shortage of skilled gerontological workers in the developed world, made worse by a perceived lack of professional esteem, economic reward and poor working environments in the specialism. Most studies recommend education to enable individuals to develop accurate knowledge about the ageing process and interest in working with older people. There is a discrepancy in the literature as to whether health and social care workers hold positive or negative attitudes towards older people. As attitudes are strongly linked with perceptions of working with older people, this article presents a review of the literature and discussion on attitudes of health and social care students to ageing and perceptions of working with older people.

Lack of effect of seasonal trivalent influenza vaccine against influenza A(H3N2) infections in hospitalised patients in winter 2012.

AIM: This study sought to assess the effectiveness of the 2012 trivalent inactivated influenza vaccine in preventing admission with confirmed influenza A(H3N2) infection and whether vaccination status influenced the duration or outcome. METHODS: We used the CDHB Delphic Laboratory Information System to identify 100 consecutive patients with confirmed influenza A(H3N2) infection. The patients were contacted via telephone and asked whether they had received the seasonal influenza vaccine prior to their hospital admission. We collected information such as age, gender, documented co-morbidities, smoking status, ICU admission, length of stay, and final outcome of admission and compared these between the vaccinated and non-vaccinated groups. RESULTS: A total of 92 participants could be contacted and participated; 67 these reported having been vaccinated with the 2012 seasonal influenza vaccine prior to their admission. There were no significant differences in length of stay or final outcome in vaccinated and non-vaccinated patients. CONCLUSION: This audit shows that the 2012 seasonal influenza vaccine did not provide significant protection against the H3N2 influenza strain in Canterbury. Vaccination did not alter the clinical course or final outcome in patients infected with H3N2 influenza.

Implementing the Safety Thermometer tool in one NHS trust.

To address measurement of patient safety, the NHS in England has introduced the NHS Safety Thermometer using the Commissioning for Quality and Innovation (CQUIN) scheme. The scheme offers a financial reward to all providers of NHS care measuring four common harms using the NHS Safety Thermometer on one day each month, with further incentives to achieve improvement goals in subsequent years of the scheme. This article discusses the background to the scheme and a rationale for the focus on pressure ulcers, falls in care, catheter use and urinary tract infection, and venous thromboembolism. The implementation process for this scheme in a large NHS foundation trust is detailed together with its effect within the authors' organisation on harm-free care for their patients.