A professional journal article from the list presented in the Library section of the classroom as explained above. Do not look fo

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110 British Journal of Community Nursing March 2021 Vol 26, No 3

Impact of technology on community nursing during the pandemic Kathryn Rose Grindle Advanced Nurse Practitioner, Liverpool John Moores University

[email protected]

The COVID-19 pandemic has been described by Vannabouathong et al (2020) as the largest and most rapidly spreading threat to global health since the Spanish flu of 1918, which is estimated to have killed over 50 million people. Fauci et al (2020) reported the disease as a global, life-threatening viral infection affecting the respiratory, gastrointestinal and neurological systems. There is minimal literature that can specifically define all characteristics of the virus, as its epidemiological characterisation remains in the nascent stage. In a study discussing genetic mutation, Grubaugh et al (2020) described the SARS-CoV-2 virus as causing ever-changing infection, and they further suggested there is no cure. In their recent article for Lancet Infectious Diseases, Baud et al (2020) reported that the global mortality rates from March to May 2020 increased by 5.7% solely due to the virus.

International evidence presented by Comas-Herrera et al (2020) and McMichael et al (2020) showed that patients residing in care homes are a particularly vulnerable group for severe COVID-19 infections, due to the nature of them having multiple underlying chronic and long-term conditions resulting in them requiring 24-hour care. At the height of

the pandemic in the weeks of 1–17 April 2020, Field et al (2020) reported that the death rate in UK care homes had risen by 500% due to COVID-19. This statistic is of utmost importance in understanding the required rapid rollout of new assessment processes for the vulnerable. Rekatsina et al (2020) described key factors shown to have affected some of the most vulnerable members of society during the COVID- 19 pandemic, including the severity of the virus and extremely high rates of mortality, coupled with the large volume of staff sickness resulting in care homes becoming overwhelmed and unable to provide care for their residents.

Recommendations made in a study relating to the reduction of patient and staff exposure to viruses via the use of telephone assessment strongly suggested the alternative use of telephone or virtual consultation for assessment (Milusheva, 2020). This has also been recommended by Shehata et al (2020), who described the emphasis clinical commissioning groups (CCGs) across the UK have placed on the importance of other mediums of assessment in the current climate. The use of other assessment mediums are evidenced as dating back as early as 1876. Pierce et al (2020) described the introduction of the telephone as being revolutionary within healthcare. The first incidence of it being used to seek medical attention was by the inventor himself, Alexander Graham Bell, when he used it to seek help after spilling sulphuric acid on himself; by 1970, enthusiasts described the telephone as being as much a part of the standard equipment for a clinician as a stethoscope. Greenhalgh et al (2020) stated that telephone triage and assessment have now become the first line in the provision of healthcare in the community in the wake of the COVID- 19 pandemic. Several groups emphasised the importance of using telemedicine to limit exposure and alleviate the burden placed on healthcare systems by the COVID-19 pandemic (Eurosurveillance Editorial Team, 2020; Reeves et al, 2020; Zhou et al, 2020). These were further supported by Smith et al (2020), who implored the prioritisation of moving all patient-facing assessments to triage via a telephone or video consultation to limit unnecessary exposure of staff and patients to the virus. Duffy and Lee (2018) went further in suggesting that in-person visits should be the second or third option in reducing the exposure and potential spread of infectious

ABSTRACT The purpose of this article is critical analysis, reflection and discussion in regards to the uses and impacts technology has had in community settings, specifically care homes during the COVID-19 pandemic. This will be investigated and supported with special emphasis on virtual assessment platforms and their use within the care homes settings, furthermore reviewing specific data collected in relation to the usage within community care homes. The article will outline the positive attributes and critically reflect upon the benefits of using audio and video conferencing when assessing patients and the beneficial impacts this has had on patients and the wider health community. While conversely addressing the obstacles and threats faced by clinicians in the use of assessment software.

KEY WORDS w Community w Care homes w Attend Anywhere w Infection risk w Emergency

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British Journal of Community Nursing March 2021 Vol 26, No 3 111

diseases, and they emphasised the protection of the most vulnerable members of society and the public by decreasing the required movement of symptomatic individuals.

Attend Anywhere In community nursing, a strong emphasis has been placed on the use of telephone triage followed by video assessment to reduce exposure to staff and patients, further preventing an increase in the prolific ‘reproductive number,’ which is indicative of the infection rate. In a qualitative study by Donaghy et al (2019) investigating the use of telemedicine, the results showed a positive reaction to the use of technology to decentralise the patient-centric model and allow it to catch up with the more modern requirements.

Attend Anywhere is a video conferencing medium that supports the visual and audio assessment of a patient, while limiting footfall in high-risk areas. This platform was implemented nationwide by NHS England in 2018 and has spread across 45 trusts and has been used effectively since its inception in Melbourne, Australia, in 1998. In an Australian study by Corden et al (2020) on the use of remote assessments, the authors credited the lower infection rate to remote assessing, and they recommended the use of remote assessment mediums. They reported on their experience in a dermatology setting, where 800 patients could be triaged, assessed and treated using video assessment, which reduced footfall and decreased the exposure risks and improved patient satisfaction.

Due to the COVID-19 pandemic, trusts throughout the UK were supported to rapidly roll out the Attend Anywhere tool, which was funded by NHS England. The goal was to use this medium amid the crisis, coinciding with Government regulations for the vulnerable to shield. Beland et al (2020) recounted the guidance of the banning of all but essential visits into care homes across the UK due to the pandemic. This guidance has only ever been encouraged on this scale once before, amid a norovirus outbreak in Scotland (Currie et al, 2016). With this being the new normal for the foreseeable future, most trusts were required to continue to provide nursing services, but had to be innovative in their delivery to protect staff and patients. This is how virtual assessments in care homes were born. However, this new way of working was met with trepidation and apprehension by many staff who found working through a pandemic already overwhelming without the added pressure of a new assessment medium being implemented. Therefore, the uses and effectiveness of virtual assessment mediums were assessed during this time.

Evaluation of effectiveness A recent evaluation of the provision of healthcare was conducted over a 2-week period with an emphasis on Attend Anywhere in care homes and a predominant focus on community matron assessment. According to the findings, a total of 30 visits were requested via the single point of contact service between 20 and 31 July 2020. Some 23.333% patients were seen in person; 60% were assessed via the telephone and 16.66% were seen via Attend Anywhere. The 66.66% of assessments completed via telephone or Attend Anywhere

represented a vast reduction in the footfall when compared with previous audits, which had showed that 79% of visits completed before March 2020 had been completed in person.

The results of this small snapshot of nursing care using a video conferencing platform suggested a reduction in footfall within the predominantly at-risk areas via the use of telephone and video conferencing. These data indicate that, during this time period, the use of such platforms was positive and effective in enabling assessment and reduction of exposure of both staff and patients, as face-to-face visits were not required.

The avoidance of face-to-face visits is paramount. Many care homes house patients with cognitive deficits, such as dementia or Alzheimer’s disease, which warrant one-to- one supervision (Livingston et al, 2017). In most cases, this cannot be provided, and, therefore, the use of large communal living spaces is required to ensure resident safety when they wander through the home, experience agitation when trying to redirect attention, attempt to physically engage with other residents and touch various objects, which could be dangerous. It has been suggested that these activities by people with cognitive impairments significantly increase the risk of rapid disease transmission (Killen et al, 2020; Suzuki et al, 2020). Therefore, all recommended guidance for the protection of vulnerable patients should be strictly adhered to. Brown et al (2020) supported the use of alternative assessment mediums in these cases. Corden et al (2020) went further to highly recommend video assessment for complaints that could be assessed visually, such as eye infections, rashes in areas that will not indecently expose patients, infected wounds and some new wounds (to give dressing advice). However, they said that home visits were generally required in the case of complaints that required audible assessment, such as a chest infection or possible bowel obstruction, which also required a manual assessment, including palpation (Corden et al, 2020).

Barriers to telemedicine When reviewing wider data from the health community, Unadkat et al (2020) reported that video consultation systems can be impersonal, and difficulties with the speed of the IT system were reported. Conversely, Connor et al (2020) highly recommended the use of video assessment mediums, such as Attend Anywhere or Telehealth, in the provision of healthcare by allowing remote assessment of patients using electronic communication tools. The authors said that such systems are crucial in avoiding unnecessary attendance to hospitals and, therefore, reduce contamination risk. In addition, there is the benefit of not having to cancel appointments en masse to adhere to regulations.

The morality of offering patients a diagnosis over a video consultation, however, has been questioned by Humphreys et al (2020), who considered the ethical implications of offering a diagnosis without the usual support of specialist nurses or other appropriate persons. Family members banned from visits as per Government guidance cannot offer moral support or a more simplified explanation to their loved ones (Gardner et al, 2020). Consequently, Sorinmade (2020) proposed that this must be considered by the diagnosing clinician, who must be

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sympathetic and conscious as to what is appropriate to discuss over a video consultation. Further, family members joining the call where appropriate must be supported in relation to consent and lasting power of attorney (NHS England and NHS Improvement, 2020).

Further obstacles to the use of video assessments have also been described by staff and echoed by Gann (2020) and Hammersly et al (2019), who reported that COVID-19 has identified some communities, predominantly those of older people living in care homes, as experiencing social, economic and digital deprivation. To combat this, there are many digital initiatives across the UK during the pandemic, such as Attend Anywhere, telemedicine and IMedicine, which are supplying devices and education in relation to digital skills, in order to support the agenda that NHS England has implemented and reduce footfall in care homes to limit exposure (Hollis et al, 2015). However, deprivation in care home communities is a prevalent risk, and the complexities in different demographics correlate with access to digital technology. This has been highlighted by Holmes Finch and Hernández Finch (2020); despite this being an American study, the data translate and reflect the narrative in the global health community. The authors described how more affluent areas have access to modern technology supporting digital assessment as well as having the means to financially support high internet usage. Financial constraints when using virtual assessments have been addressed (Brouwer et al, 2017), where it has been reported that the technology is widely whitelisted, meaning that large telephonic and broadband companies allow the access of these digital services to be provided free so as not to disadvantage anyone. Most recently, Vodaphone and 02 have whitelisted Attend Anywhere in the UK, making it free to access.

Another barrier to the effective usage of the digital consultation system is staff members’ literacy and IT skills. Robinson et al (2020) and Visca et al (2020) reported on the impact of digital inequalities in different healthcare sectors in relation to the education level, and argued that there is a consequent impact on patient vulnerability to disparate healthcare. This is supported by earlier evidence, which suggested that people with poor literacy skills do not receive as effective healthcare, due to lack of understanding or lack of ability to implement healthcare plans owing to comprehension difficulty (Taylor et al, 2013). With regard to telemedicine, it can be the case that patients are being managed by staff who do not have compatible IT skills, and this could be one of many obstacles in the provision of care to the vulnerable (Blackburn et al, 2005).

The final threat to the implementation of the video conferencing system is change management for healthcare providers. Irrespective of sector, if change is to be effectively implemented and successful, leaders in the field must be advocates, lead by example and encourage usage (Zaman et al, 2020). Opinions offered by some are that there is evidence of positive digital leadership within trusts, but this is not reflected at team level. Sheninger (2019) discussed the importance of leaders in encouraging change and the use of technology in the best interest of patients.

Sellars et al (2020) encouraged leaders to share positive outcomes and opportunities with staff. In their review of the use of virtual consultation mediums, they reported very few patients as having difficulties with technology, and attendance for virtual appointments was very high; in fact, it was higher than that for face-to-face appointments. Further, 6685 miles of travel, equivalent to 148 hours of travelling time, were saved for patients, with savings for the total number of patients amounting to £1767, not including the approximately £33.56 that each patient may have saved by preventing loss of earnings. Additionally, the environmental impacts were massive, as carbon emissions were lowered by 4659 lb, which is the equivalent of over 250 000 charges of a smartphone.

Ziebland and Wyke (2012) proposed sharing good news, which positively impacts patients, and using it as a vehicle to encourage change. Further, they suggested that sharing data empowers the recipient to support change. Mannion and Goddard (2001), however, warned that, although sharing of data works positively in positive cultures, this practice in some areas in which there is a lack of professional belief in relation to the perception of the quality of data may have the opposite effect to the one desired. They concluded that informal verbal information is often better received and well thought of in the encouragement of change. The collaborative sharing of data should be a common practice according to the Nursing and Midwifery Council (NMC) (2018), and change is best supported with strong leadership and encouragement, evidence of positive results and caution in areas in which the validity of data will be questioned.

Summary Virtual consultations allow face-to-face visits to be completed in a safe way and in accordance with national guidance. Overall, the evaluation of virtual consultation usage was found to be positive, and was in line with feedback from the wider health community. The reduced exposure risk to patients and staff was paramount and outweighed any problems faced. Problems such as connectivity issues could be rectified. A recommendation from this evaluation is that other nurses within the community nursing sphere should endeavour to use virtual consultation mediums as an alternative whenever it is possible and safe, in order to reduce exposure risk. Threats to safe usage should be risk assessed, and appropriate action should be taken to minimise risk.

Conclusion The COVID-19 pandemic has forced the NHS to be progressive and innovative in its delivery of healthcare. The fatal nature of the SARS-CoV-2 virus is reflected in the volume of care home deaths. To prevent further risk and exposure, consultation mediums have to change and reflect what is now required to keep patients safe. The evidence shows that telephone and video assessment, which have been in place for many years and have been used effectively, are a possible option. Video assessment is relevant, now more than ever, for staff working through a pandemic and attempting to remain safe, as well as for vulnerable patients. The economic, environmental and physical benefits of video assessments

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KEY POINTS w The use of telephone triage and assessment and video assessment has been present for much longer worldwide than it has been in the UK

w The use of technology, in particular platforms supporting the audio and video assessment of a patient, reduce the risk to the patient or the wider nursing community by reducing foot fall into care homed

w At the author’s trust, a video consulting platform called Attend Anywhere provided positive outcomes for patients, while also providing cost efficacy

w A consideration is that the lack of face-to-face appointments would increase the vulnerability of patients with digitally deprivation, which is a worldwide risk

w The widespread use of technology in healthcare must be supported by effective change management, which must be driven by leaders

outweigh any risks, which can be managed effectively for the patients who reside in care homes. Thus, such alternative assessments methods should be encouraged wherever safe. Moving forward in an uncertain world, technology will be the basis of many healthcare assessments. As the famous author Matt Mullenweg once wrote, ‘Technology is best when it brings people together,’ and this technology will certainly allow people to come together in a new way. BJCN

Accepted for publication: January 2021

Conflicts of interest: none

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w What tasks within the remit of your role would you be able to complete over video? For what tasks might video consulting be inapplicable?

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Available online at www.ijpe-online.com

vol. 17, no. 3, March 2021, pp. 276-288

DOI: 10.23940/ijpe.21.03.p3.276288

* Corresponding author.

E-mail address: [email protected]; [email protected]

Code Confusion in White Box Crowdsourced Software Testing

Run Luo*, Song Huang*, Hao Chen, and MingYu Chen

Command and Control Engineering College, Army Engineering University of PLA, Nanjing, 210007, China

Abstract

In recent years, crowdsourcing software testing as a new testing service mode has been widely concerned. However, white box

crowdsourcing software testing is often regarded as an insecure testing service mode. The main threat comes from unknown attacks in the

crowdsourcing environment, which leads to the risk of source code leakage in white box testing. This paper discusses the weakness of white

box software testing in crowdsourcing software testing, as well as the possible mode of attack. This paper proposes to use code obfuscation

technology as a solution to this kind of attack and analyzes the impact of code obfuscation technology on crowdsourcing testing. This paper

is the first attempt at using code obfuscation technology in white bo

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