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BackgroundInadequate assessment of the severity and urgency of medical problems is one of the factors contributing to unnecessary emergency department (ED) visits. The implementation of a software-based instrument for standardized initial assessment—Standardisierte medizinische Ersteinschätzung in Deutschland (SmED) (Standardized medical Initial Assessment in Germany in English)—aims to support health care professionals and steer patients toward the right health care provider. This study aimed to explore the implementation process of SmED from a user perspective. ObjectiveThis study aims to evaluate the overall perception of SmED by health care professionals using the software, to examine to what extent SmED influences the workload and work routines of health care professionals, and to determine which factors are associated with the use of SmED. MethodsAn early qualitative process evaluation on the basis of interviews was carried out alongside the implementation of SmED in 26 outpatient emergency care services within 11 federal states in Germany. Participants were 30 health care professionals who work with SmED either at the joint central contact points of the outpatient emergency care service and the EDs of hospitals (ie, the Joint Counter; Gemeinsamer Tresen in German) or at the initial telephone contact points of the outpatient emergency care service (phone number 116117). Matrix-based framework analysis was applied to analyze the interview data. ResultsHealth care professionals perceived that workload increased initially, due to additional time needed per patient. When using SmED more frequently and over a longer time period, its use became more routine and the time needed per call, per patient, decreased. SmED was perceived to support decision making regarding urgency for medical treatment, but not all types of patients were eligible. Technical problems, lack of integration with other software, and lack of practicability during peak times affected the implementation of SmED. ConclusionsInitial experiences with SmED were positive, in general, but also highlighted organizational issues that need to be addressed to enhance sustainability. Trial RegistrationGerman Clinical Trials Register DRKS00017014; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00017014

Abstract Unlike metals where dislocations carry strain singularity but no charge, dislocations in oxide ceramics are characterized by both a strain field and a local charge with a compensating charge envelope. Oxide ceramics with their deliberate engineering and manipulation are pivotal in numerous modern technologies such as semiconductors, superconductors, solar cells, and ferroics. Dislocations facilitate plastic deformation in metals and lead to a monotonous increase in the strength of metallic materials in accordance with the widely recognized Taylor hardening law. However, achieving the objective of tailoring the functionality of oxide ceramics by dislocation density still remains elusive. Here a strategy to imprint dislocations with {100} slip systems and a tenfold change in dislocation density of BaTiO3 single crystals using high‐temperature uniaxial compression are reported. Through a dislocation density‐based approach, dielectric permittivity, converse piezoelectric coefficient, and alternating current conductivity are tailored, exhibiting a peak at medium dislocation density. Combined with phase‐field simulations and domain wall potential energy analyses, the dislocation‐density‐based design in bulk ferroelectrics is mechanistically rationalized. These findings may provide a new dimension for employing plastic strain engineering to tune the electrical properties of ferroics, potentially paving the way for advancing dislocation technology in functional ceramics.

IntroductionWorldwide, the primary care sector played a key role in coping with the challenges of the SARS-CoV-2 pandemic.MethodsThe aim of this study was to explore the resilience of the German primary healthcare system during the second wave of the pandemic from the perspective of identified interface stakeholders, i.e., representatives of hospitals, district offices, and medical associations. Qualitative data from interviews and focus groups were analyzed according to a resilience framework.ResultsThe main findings include a gap in knowledge transfer, unstructured allocation of responsibilities, and a resulting unregulated flow of patients. Social brokers supported care coordination and knowledge transfer. The response to the capacity to cope with uncertainties was slow and chaotic at the system level and heterogeneous at the individual level. Building on previous relationships fostered functioning communication, while competition in primary care was identified as a barrier to resilience.ConclusionImplications for further research and for strengthening the resilience of primary care can be derived based on this study.

Abstract Aim Examine perceptions of nurses who obtained a recognised nursing qualification in Germany about the integration of internationally qualified nurses (IQN) in the German nursing workforce. Design Qualitative interview study. Methods Semi‐structured interviews with 21 state‐qualified nurses who had graduated from a German nursing program were conducted either face‐to‐face or by telephone. Nurses were selected using the purposive sampling method. Additionally, to reach a sufficient sample size, snowball sampling was applied. Each interview was pseudonymized and transcribed. Transcripts were coded according to Qualitative Content Analysis with data structured into themes and sub‐themes. The study was reported according to the Consolidated Criteria for Reporting Qualitative Studies (COREQ) checklist for qualitative research. Results Two main themes including sub‐themes were identified: (a) Enabling Factors to Workplace Integration: motivated nursing team, structured orientation program, support by a preceptor, additional practical skills and specific language training and (b) Barriers to Workplace Integration: lack of language proficiency, cultural differences, othering and racism/discrimination. The findings of the study suggest that working in a diverse workplace can be challenging, it is therefore important for successful integration to recognise not only the experiences of IQN but also the perceptions of nurses who work with internationally qualified peers. No patient or public contribution. Registration number The study has been prospectively registered (27 June 2019) at the German Clinical Trial Register (REDACTED).

Dislocations are often perceived as a culprit for degradation in functionality. Here, the authors introduce a general framework for engineering dislocations and domain walls and demonstrate its full potential on a ferroelectric BaTiO3 single crystal.

Abstract Background Primary care is a relevant pillar in managing not only individual, but also societal medical crises. The COVID-19 pandemic has demanded a rapid response from primary care with interventions in the health care system. The aim of this paper was to explore the responses of primary care practitioners (PCP) during the early COVID-19 pandemic and to analyze these with a view on the resilience of the primary health care system from the PCPs perspective. Methods Shortly after the first COVID-19 wave (July—October 2020) n = 39, semi-structured telephone interviews were conducted with PCP in practices and at Corona contact points (CCP) in Baden-Wuerttemberg (Germany). Qualitative content analysis was applied, and the evolved categories were related to in a framework for resilience. Results Primary care had an overall strong ability to adapt and show resilience, albeit with wide variance in speed and scope of the responses. When coping with uncertainty, the reasons given by PCPs in favor of opening a CCP mainly involved intrinsic motivation and self-initiative; the reasons against doing so were i.e. the lack of personal protective equipment, problems with space, and worries about organizational burden. A strong association existed between the establishment of a CCP and the use of resources (i.e. existing networks, personal protective equipment, exercising an office of professional political function). Our study predominantly found adaptive aspects for measures taken at medical practices and transformative aspects for setting up outpatient infection centers. PCPs played an important role in the coordination process (i.e. actively transferring knowledge, integration in crisis management teams, inclusion in regional strategic efforts) reaching a high level in the dimensions knowledge and legitimacy. The dimension interdependence repeatedly came into focus (i.e. working with stakeholders to open CCP, interacting among different types of primary care facilities, intersectoral interfaces). A need for regional capacity planning was visible at the time of the interviews. Conclusions The results can be used for practical and research-based institutional and capacity planning, for developing resilience in primary care and for augmentation by perspectives from other stakeholders in the primary health care system.

Background: Healthcare systems globally are confronted with a shortage of nurses. Various strategies to address this have been applied, including active recruitment of internationally qualified nurses. Nurse managers may have a central role in supporting workplace integration. This study aimed to explore how domestically qualified nurses and internationally qualified nurses viewed the role of nursing management and its impact on workplace integration. Method: Semi-structured interviews with 21 domestically and 14 internationally qualified nurses were conducted. Nurses were selected using purposive sampling. Snowball sampling was applied to reach a sufficient sample size. Interviews were pseudonymized and transcribed. Transcripts were coded according to Qualitative Content Analysis with data structured into themes and subthemes. Results: Five key themes related to impact of nursing management on workplace integration were identified: (a) Appropriate Placement, (b) Recruitment Process, (c) Leadership Support, (d) Workforce Shortage, and (e) Additional Burden/ Increased Workload. Active support by nursing leadership and the opportunity for shared-decision making was seen as a key factor. Increased workload, additional time and resources requirements associated with orientation of internationally qualified nurses and pressures from staff shortages were highlighted as hindrances. Inappropriate placement of internationally qualified nurses was perceived as key hindrance that could be addressed by nursing management. An imbalanced ratio between domestically and internationally qualified nurses was perceived as challenging by domestically qualified nurses. Conclusion: Integration of internationally qualified nurses to clinical practice brings several challenges that may be positively impacted by nursing management through appropriate placement of internationally qualified nurses, supportive nurse managers and adequate preparation of domestically qualified nurse mentors/preceptor. Implications for practice: Nurse managers should ensure that internationally qualified nurses' work experience matches local clinical unit vacancies before hiring them. Peer support is a supportive factor for internationally qualified nurses. Nurse managers should find a balanced ratio between internationally and domestically qualified nurses in the roster. Introducing mentors or preceptors at ward level may be a strategy decrease work-related stress in both nursing groups. Registration number: The study has been prospectively registered (27 June 2019) at the German Clinical Trial Register (DRKS00017465). [ABSTRACT FROM AUTHOR]

Abstract Background Patients with multiple long-term conditions often face a variety of challenges arising from the requirements of their health care. Knowledge of perceived treatment burden is crucial for optimizing treatment. In this study, we aimed to create a German version of the Multimorbidity Treatment Burden Questionnaire (MTBQ) and to evaluate its validity. Methods The steps to translate the MTBQ included forward/back translation, cognitive interviews (n = 6) and a pilot test (n = 7). Psychometric properties of the scale were assessed in a cross-sectional survey with primary care patients aged 65 and older with at least 3 long-term conditions (n = 344). We examined the distribution of responses, dimensionality, internal reliability and construct validity. Results Cognitive interviewing and piloting led to minor modifications and showed overall good face validity and acceptability. As expected, we observed a positively skewed response distribution for all items. Reliability was acceptable with McDonald’s omega = 0.71. Factor analysis suggested one common factor while model fit indices were inconclusive. Predefined hypotheses regarding the construct validity were supported by negative associations between treatment burden and health-related quality of life, self-rated health, social support, patient activation and medication adherence, and positive associations between treatment burden and number of comorbidities. Treatment burden was found to be higher in female participants (Mdn 1 = 6.82, Mdn 2 = 4.55; U = 11,729, p = 0.001) and participants with mental health diagnoses (Mdn 1 = 9.10, Mdn 2 = 4.55; U = 3172, p = 0.024). Conclusions The German MTBQ exhibited good psychometric properties and can be used to assess the perceived treatment burden of patients with multimorbidity.

Abstract Background Patients with multimorbidity (here defined as three or more chronic conditions) require constant treatment and care. Furthermore, they have to manage their health and diseases in daily life. Offering support to patients’ medical self-management is an important task of primary care. The aim of this study was to explore, what further support is needed from the perspective of patients’ and primary care practitioners. Methods A qualitative study using individual semi-structed interviews with 17 patients with multimorbidity and 7 practitioners (4 primary care physicians and 3 practice assistants) was conducted in Germany. Data were audio-recorded, pseudonymised and transcribed verbatim. Data analysis was performed using qualitative content analysis to structure data into themes and subthemes. All data were managed and organised in MAXQDA. Results The three broad themes: current status, challenges and further support emerged. Patients reported on unfulfilled needs regarding role or emotional management, like coping with loneliness, loss of independence and, changing habits. The importance of social contact was highlighted by patients and practitioners. Patients articulated further support from their primary care practitioners on coping with the disease. Practitioners’ wished for further support in aspects of social participation, public transport, and community resources. Conclusion Challenges regarding self-management of elderly patients with multimorbidity may be addressed by harnessing social support and community initiatives.