After 30 years of dissemination, have we achieved sustained practice change in motivational interviewing?

AIMS: Motivational interviewing (MI) is the most successfully disseminated evidence-based practice in the substance use disorder (SUD) treatment field. This systematic review considers two questions relevant to policymakers and service providers: (1) does training in MI achieve sustained practice change in clinicians delivering SUD treatment; and (2) do clinicians achieve a level of competence after training in MI that impacts upon client outcomes? METHODS: A systematic review was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, examining training outcomes for MI in the SUD treatment sector, and for clinicians working in a SUD treatment role. We determined a training method to have resulted in sustained practice change when over 75% of participants met beginning proficiency in MI spirit at a follow-up time-point. RESULTS: Of the 20 studies identified, 15 measured training at a follow-up time-point using standard fidelity measures. The proportion of clinicians who reached beginning proficiency was either reported or calculated for 11 of these studies. Only two studies met our criterion of 75% of clinicians achieving beginning proficiency in MI spirit after training. Of the 20 studies identified, two measured client substance use outcomes with mixed results. CONCLUSIONS: A broad range of training studies failed to achieve sustained practice change in MI according to our criteria. It is unlikely that 75% of clinicians can achieve beginning proficiency in MI spirit after training unless competency is benchmarked and monitored and training is ongoing. The impact of training on client outcomes requires future examination.

A university-based clinical exercise facility that serves as a clinical, teaching and research space

Deakin University opened its Clinical Exercise Learning Centre (CELC) in May 2011, initially staffed by four (now seven) Accredited Exercise Physiologists (AEP), and funded by the university. The main objectives of CELC are to provide (i) excellent clinical practicum learning opportunities for postgraduate students enrolled in the Master of Clinical Exercise Physiology that prepare students for subsequent external placements; (ii) learning opportunities that are vertically integrated with the preparatory components of the Masters, including pathophysiology units and pre-clinical units; (iii) learning opportunities that are also integrated with the external clinical practicum program that is embedded in the Masters; (iv) a clinical service to the community and strong referral networks with local GPs; (v) a research centre that is focussed on evaluating the efficacy of Accredited Exercise Physiology (AEP) services for a range of clinical situations, with a view to contributing to a future national evidence-based practice network supported by ESSA. Deakin University funds the CELC facility, equipment, consumables, limited car parking, practice management software and server and, most importantly, the staff. Therefore CELC runs at a loss even against fees charged and this was built into the original model. Staff include an AEP clinical practicum coordinator, two casual AEPs and several academic AEPs; the latter practise as a small part of their approved workloads. The practice model is for all AEPs to provide clinical services with referred clients who are billed as if CELC is a private practice, whilst concurrently teaching and mentoring students; the latter are expected to be active learners in CELC and have exposure to a wide range of pathologies and clinical situations. Billable hours are always provided by AEPs, not students, but students can assist. CELC provides clinical services 1:1:1 (client: AEP: student), 1:1:5 and 8:1:5. CELC was awarded national runner-up in the ESSA Exercise Physiology clinic of the year in 2011 and has grown its caseload to > 200 referrers in 2013. CELC recently designed a generic research platform and has begun to roll out research projects that are designed to translate 'traditional' research-based evidence of exercise benefits for chronic disease in order to evaluate AEP efficacy of practice in the Australian context. CELC provides a model for other universities, provided those universities see it for its learning value, and not to generate revenue or profit.

Translating research for evidence-based public health: key concepts and future directions

Applying research to guide evidence-based practice is an ongoing and significant challenge for public health. Developments in the emerging field of ‘translation’ have focused on different aspects of the problem, resulting in competing frameworks and terminology. In this paper the scope of ‘translation’ in public health is defined, and four related but conceptually different ‘translation processes’ that support evidence-based practice are outlined: (1) reviewing the transferability of evidence to new settings, (2) translation research, (3) knowledge translation, and (4) knowledge translation research. Finally, an integrated framework is presented to illustrate the relationship between these domains, and priority areas for further development and empirical research are identified.

Do physical activity and dietary smartphone applications incorporate evidence-based behaviour change techniques?

BACKGROUND: There has been a recent proliferation in the development of smartphone applications (apps) aimed at modifying various health behaviours. While interventions that incorporate behaviour change techniques (BCTs) have been associated with greater effectiveness, it is not clear to what extent smartphone apps incorporate such techniques. The purpose of this study was to investigate the presence of BCTs in physical activity and dietary apps and determine how reliably the taxonomy checklist can be used to identify BCTs in smartphone apps.

METHODS: The top-20 paid and top-20 free physical activity and/or dietary behaviour apps from the New Zealand Apple App Store Health & Fitness category were downloaded to an iPhone. Four independent raters user-tested and coded each app for the presence/absence of BCTs using the taxonomy of behaviour change techniques (26 BCTs in total). The number of BCTs included in the 40 apps was calculated. Krippendorff's alpha was used to evaluate interrater reliability for each of the 26 BCTs.

RESULTS: Apps included an average of 8.1 (range 2-18) techniques, the number being slightly higher for paid (M = 9.7, range 2-18) than free apps (M = 6.6, range 3-14). The most frequently included BCTs were "provide instruction" (83% of the apps), "set graded tasks" (70%), and "prompt self-monitoring" (60%). Techniques such as "teach to use prompts/cues", "agree on behavioural contract", "relapse prevention" and "time management" were not present in the apps reviewed. Interrater reliability coefficients ranged from 0.1 to 0.9 (Mean 0.6, SD = 0.2).

CONCLUSIONS: Presence of BCTs varied by app type and price; however, BCTs associated with increased intervention effectiveness were in general more common in paid apps. The taxonomy checklist can be used by independent raters to reliably identify BCTs in physical activity and dietary behaviour smartphone apps.

Evidence-based learning: Interactive, online EBP modules for first year nursing. A case study

Deakin University Library designed a series of six modules to provide interactive, online learning for a first year nursing unit, Understanding Research Evidence. The modules were developed in response to the changing learning requirements of students in the digital age. Delivered using Smart Sparrow software, the modules were designed to assist students in the development and consolidation of their understandings of evidence-based practice (EBP).The development of the modules represents a shift from unilateral communication to interactive content. Previously, online support had largely consisted of static material that was not presented in the context of curriculum. The Library has now developed integrated content that allows for interactivity, but which may also be customised for other purposes or units across all health disciplines.Feedback and data collected from the modules indicate an encouraging degree of engagement with the content. Data also allows the Library to ensure the continuous improvement of the modules. Library staff have also reported on their improved capacity and confidence in creating learning experiences that integrate core information and digital literacy competencies with students' curriculum. Staff also report improvements in their ability to use technologies to create online learning objects.

'Motor magic' : evaluation of a community capacity-building approach to supporting the development of preschool children (part 2)

Background and Aims: This paper is the second in a series of two that presents and discusses an exploratory evaluation study of the 'Motor Magic' program conducted in Adelaide, South Australia.

Methods: A realist evaluation approach was used, and two focus groups (one with parents and one with kindergarten staff) were held to identify program outcomes and to develop and refine key hypotheses about how these outcomes occurred.

Results and Conclusions: Results for kindergarten staff involved in the program are presented and discussed in this paper, including improved early identification and early intervention for children with, or at risk of, fine motor developmental difficulties; increased confidence in the effectiveness of their practice with these children; improved practice of kindergarten staff with both targeted and all children; improved empathy with, and support for, parents; and increased interagency links and ongoing advocacy for further resources. These results suggest that the program provides an effective model for building the capacity of kindergarten staff to support children with, or at risk of, developmental difficulties.

The influence of patient complexity and nurses` experience on haemodynamic decision-making following cardiac surgery

Critical care nurses’ haemodynamic decision-making in the immediate postoperative cardiac surgical context is complex. To optimise patient outcomes, nurses of varying levels of experience are required to make complex decisions rapidly and accurately. In a dynamic clinical context such as critical care, the quality of such decision-making is likely to vary considerably. The aim of this study was to describe variability of nurses’ haemodynamic decision-making in the 2-hour period after cardiac surgery as a function of interplay between decision complexity, nurses’ levels of experience, and the support provided. A descriptive study based on naturalistic decision-making was used. Data were collected using continuous non-participant observation of clinical practice for a 2-hour period and follow-up interview. Purposive sampling was used to recruit 38 nurses for inclusion in the study. The quality of nurses’ decision-making was influenced by interplay between the complexity of patients’ haemodynamic presentations, nurses’ levels of cardiac surgical intensive care experience, and the form of decision support provided by nursing colleagues. Two factors specifically influenced decision-making quality: nurses’ utilisation of evidence for practice and the experience levels of both nurses and their colleagues. The findings have implications for staff resourcing decisions and postoperative patient management, and may be used to inform nurses’ professional development and education.

The tri-focal model of care : Advancing the teaching-nursing home concept

Providing residential aged care is challenging because of the complexity of residents' health status, difficulties recruiting and retaining skilled staff, and financial and regulatory constraints. This paper discusses some of these challenges and describes an innovative model of care, termed 'The Tri-focal model of care'. This model was developed based on the concepts of 'partnership-centred care', 'positive work environment' and the need for evidence-based practice to underpin all aspects of care. It is envisaged that the implementation of this model will provide a rich learning environment that advances the teaching-nursing home concept and the quality of residential aged care.

A systematic grounded approach to the development of complex interventions : The Australian WorkHealth Program – Arthritis as a case study

Despite demands for evidence-based research and practice, little attention has been given to systematic approaches to the development of complex interventions to tackle workplace health problems. This paper outlines an approach to the initial stages of a workplace program development which integrates health promotion and disease management. The approach commences with systematic and genuine processes of obtaining information from key stakeholders with broad experience of these interventions. This information is constructed into a program framework in which practice-based and research-informed elements are both valued. We used this approach to develop a workplace education program to reduce the onset and impact of a common chronic disease – osteoarthritis.

To gain information systematically at a national level, a structured concept mapping workshop with 47 participants from across Australia was undertaken. Participants were selected to maximise the whole-of-workplace perspective and included health education providers, academics, clinicians and policymakers. Participants generated statements in response to a seeding statement: Thinking as broadly as possible, what changes in education and support should occur in the workplace to help in the prevention and management of arthritis? Participants grouped the resulting statements into conceptually coherent groups and a computer program was used to generate a ‘cluster map’ along with a list of statements sorted according to cluster membership.

In combination with research-based evidence, the concept map informed the development of a program logic model incorporating the program's guiding principles, possible service providers, services, training modes, program elements and the causal processes by which participants might benefit. The program logic model components were further validated through research findings from diverse fields, including health education, coaching, organisational learning, workplace interventions, workforce development and osteoarthritis disability prevention.

In summary, wide and genuine consultation, concept mapping, and evidence-based program logic development were integrated to develop a whole-of-system complex intervention in which potential effectiveness and assimilation into the workplace for which optimised.

Community pharmacists' preferences for continuing education delivery in Australia

Introduction: New technologies such as the Internet offer an increasing number of options for the delivery of continuing education (CE) to community pharmacists. Many of these options are being utilized to overcome access- and cost-related problems. This paper identifies learning preferences of Australian community pharmacists for CE and identifies issues with the integration of these into contemporary models of CE delivery.
Methods: Four focus group teleconferences were conducted with practicing community pharmacists (n = 15) using a semistructured format and asking generally about their CE and continuing professional development (CPD) experiences.
Results: Pharmacists reported preferences for CE that were very closely aligned to the principles of adult learning. There was a strong preference for interactive and multidisciplinary CE. Engaging in CPD was seen as valuable in promoting reflective learning.
Discussion: These results suggest that pharmacists have a strong preference for CE that is based on adult learning principles. Professional organizations should take note of this and ensure that new CE formats do not compromise the ability of pharmacists to engage in interactive, multidisciplinary, and problem-based CE. Equally, the role of attendance-based CE in maintaining peer networks should not be overlooked.

Folate fortification : a case study of public health policy-making

Introducing Evidence Based Health Policy: Problems and Possibilities, Section 1: What is the Problem?, 1: Competing Rationalities: Evidence based Health Policy, 2: Beyond Two Communities, Section 2: What does Evidence Mean?, 3: Evidence based Medicine - The Medical Profession and Health Policy, 4: Mind The Gap: Assessing the Quality of Evidence for Public Health Problems, 5: Health Policy and Normative Analysis: Ethics, Evidence and Politics, 6: What is New in Health Information? Evidence for Health Consumers and Policy Making, 7: From Evidence based Medicine to Evidence based Public Health, Section 3: Policy Case Studies, 8: The Viagra Affair: Evidence as the Terrain for Competing Partners, 9: Folate Fortification: A Case Study of Public Health Policy-Making in a Food Regulation Setting, 10: The Supply and Safety of Blood and Blood Products - Evidence, Risk and Policy, 11: The Development of Nurse Practitioner Policy, 12: Creating Healthy Public Policy for Oral Health: How was the Evidence Used?, 13: Regulation of Traditional Chinese Medicine in Victoria, 14: The Victorian Primary Health Care Reforms: A Case Study of Evidence-based Policy Making, 15: Evidence-based Practice in the Australian Drug Policy Community, 16: Challenging the Evidence - Women's Health Policy in Australia, 17: Evidence and Aboriginal Health Policy, 18: The Limits to Technical Rationality in the Health Inequalities Policy Process, 19: Evidence-based policy: A Technocratic Wish in a Political World, Section 4: Is the transfer of evidence into policy possible?, 20: The Community Model of Research Transfer, 21: Getting Research Transfer into Policy and Practice in Maternity Care, 22: Improving the Research and Policy Partnership: An Agenda for Research Transfer and Governance, 23: Framing and Taming 'Wicked' Problems

Folate fortification : a case study of public health policy-making

This thesis investigates the use of scientific evidence in the process of making public health policy. A case study located within a food regulation setting is used. The aim is to test theory against this case study. The outcome is a theoretical understanding of the use of scientific evidence in the policy-making process in a food regulation setting. Food regulation can influence food composition and food labelling and thereby affect the population's dietary intake. Frequently there are contested values, beliefs, ideologies and interests among stakeholders regarding the use of food regulation as a policy instrument to effect public health outcomes. The protection of public health and safety, taking into account evidence based practice, is generally employed by food regulators as the priority objective during the policy-making process to adjudicate among the competing expectations of stakeholders. However, this policy objective has not been clearly defined and is vulnerable to interpretation and application. The process by which folate fortification policy was made in Australia, in response to epidemiological evidence of a relationship between folate intake during the periconceptional period and reduced risk of neural tube defects, was analysed as a case study of the policy-making process. The folate fortification policy created a precedent for both food fortification and subsequently health claims policy in Australia. A social constructivist method was used to analyse the case study. The method involved deconstructing the food regulatory system into three levels; decision-making process; procedural; and political environment. Data aligned with each level of analysis was collected from 22 key informant interviews, documentary sources, field notes and surveys of both a random sample of the Australian population's knowledge of folate and use of folic acid-containing supplements (n = 5422), and the implementation of folate fortified food products into stores (n = 60). The insights that emerged from each of the three levels of analysis were assessed iteratively to identify a pattern of interrelationships associated with the policy-making process within the food regulatory system. The identified pattern was interpreted against existing theory to gain a theoretical understanding of the public health policy-making process in this political setting. The central argument of this thesis extends Sabatier and Jenkins-Smith's Advocacy Coalition Framework theory to a food regulation setting. The argument is that within the contemporary political climates of neoliberalism and globalisation, a coalition between corporate interests and the values of scientists with a positivist-reductionist approach to public health research is privileged so as to invoke certain scientific evidence to, in turn, legitimise food regulation policy decisions. The theory will help to inform policy-makers about how and why the public health policy objective in a food regulation setting is interpreted and applied. This will contribute to improving policy practice intended to effect public health outcomes. It is concluded that irrespective of the quantity and quality of the scientific evidence that is being made available, scientific evidence cannot be assumed to speak for itself Policy-making is an inherently political and value-laden process and the potential for politically motivated interpretation and application of otherwise value-neutral scientific evidence can undermine the investment in its generation. From this perspective, evidence based practice, far from liberating policy-making from political influence, can itself become part of the problem rather than the solution. Nevertheless, rational evidence based practice is an ideal to strive for and a series of recommendations is proposed to help make the use of evidence in current food regulation policy processes more transparent and democratic.

Death and late-stage dementia in institutions : a cultural analysis

The first purpose of this study was to describe the deaths of fifteen nursing home residents with late-stage dementia. The devastating effect of dementia on a person has been called a ‘living death’ (Woods, 1989). The caring which occurs when someone is going through this process in a nursing home was recorded and analysed. In analysing this act of caring, the second purpose was to look for the origins of the structures and the sources of pressure that shaped the context and therefore helped determine the behaviour of the various groups under observation. These groups were residents and their relatives, the staff of the nursing home and the treating doctors. Before commencing observations and carrying out this study, an understanding needed to be developed of: the condition of dementia as it is perceived by health professionals and presented in the media; the institutions in which the majority of people with dementia end their days; the background and conditions of the staff who nurse in them; the models of care that guide and determine policies; and the conceptions of life and death which underpin relevant laws and moral standpoints. Accordingly, in part 1. chapter 1 the history, causes, pathology and effects of dementing conditions are examined. Relevant medical and lay literature including media influences are examined which pertain to the subject of death and dementia and nursing home care. The history of this institutional care is briefly examined together with the growth of the discipline of gerontological nursing. Chapter 2 discusses some of the effects of this history on present day care and the concept of emotional work being carried out within the present day aged care public policy regulations. The moral arguments surrounding illness and dying in Australian society today are briefly discussed. Chapter 3 describes the conceptual framework for the study, the ethnographic method that has been employed and an outline of critical theory as the basis for analysis. The chapter concludes by recounting the practical steps taken to arrange the field work, secure the consent of participants, record data and gather documents, and outlines the ethical considerations given to the undertaking of the study. Chapter 4 describes the context in which the study took place and the first tentative exploration of the culture from an etic perspective. Part 2 describes the death trajectories observed and raises some questions about alternative strategies that may have been considered within a different paradigm of caring. In chapter 5 the death trajectories of each of the fifteen residents in the study are described, each written with a particular emphasis to illustrate aspects of the culture of care that emerged through thematic analysis. Observations, comments and feelings from staff and family are wound in and around these case studies. Chapter 6 looks more closely at the impact of policy and institutional pressure on the milieu in which these deaths took place. Part 3 draws conclusions from the observations and makes suggestions for emancipatory change as viewed from the author's standpoint of critical ethnographic analysis. In the final chapter an argument is presented for policy change that leads a movement towards palliative care practices for people with late-stage dementia. Approaches to implementation of palliative care will need to take account of any expression by the resident such as an advanced directive, indicating a preferred approach to treatment in the period prior to death; a need for a better understanding of such issues as the significance of body breakdown, the manifestations of pain and electrolyte imbalances; the surrounding ethical complexities and shift in public opinion, and perhaps, most of ail, the culture of the institutions in which this dying will take place. A definition of late-stage dementia which might be used in determining patterns of care is set out. A discussion about changes in practice which relate lo communication with treating doctors, the administering of antibiotics, the relief of pain, the mobilisation of residents and the provision of food and water takes place in light of the evidence found. The discussion of these issues is raised in the form of debate. Each aspect needs more rigorous analysis and information so that evidence-based practice, rather than care which is value-laden and emotional, can be used when treatment decisions are made for people with late-stage dementia.