An individualized psychosocial approach for "treatment resistant" behavioral symptoms of dementia among aged care residents

Background: Behavioral symptoms of dementia are common among residents in mainstream aged care settings, and have a substantial impact on residents and professional caregivers. This study evaluated the impact of individualized psychosocial interventions for behavioral symptoms through a small preliminary study.
Method: Interventions were delivered to a patient group of 31 psychogeriatric aged care residents who presented with behavioral symptoms of dementia that had failed to respond to pharmacological treatment approaches. Outcome data on severity of behaviors, health service utilization and staff burden of care were collected.
Results: A modest but significant reduction in staff ratings of the severity of aggressive and verbally agitated behavioral symptoms was found, with an associated reduction in their perceptions of the burden of caring for these patients. Reduced behavioral disturbance was associated with a reduction in the requirement for primary care consultations, and all participants were able to continue to reside in mainstream aged care facilities, despite an increase in the severity of dementia.
Conclusions: This study supported the use of individualized psychological strategies for behavioral symptoms at all stages of dementia. Methodological limitations of this preliminary study are discussed.

Prevention of type 2 diabetes by lifestyle intervention in an Australian primary health care setting : Greater Green Triangle (GGT) Diabetes Prevention Project

Background
Randomised controlled trials demonstrate a 60% reduction in type 2 diabetes incidence through lifestyle modification programmes. The aim of this study is to determine whether such programmes are feasible in primary health care.

Methods
An intervention study including 237 individuals 40–75 years of age with moderate or high risk of developing type 2 diabetes. A structured group programme with six 90 minute sessions delivered during an eight month period by trained nurses in Australian primary health care in 2004–2006. Main outcome measures taken at baseline, three, and 12 months included weight, height, waist circumference, fasting plasma glucose and lipids, plasma glucose two hours after oral glucose challenge, blood pressure, measures of psychological distress and general health outcomes. To test differences between baseline and follow-up, paired t-tests and Wilcoxon rank sum tests were performed.

Results
At twelve months participants' mean weight reduced by 2.52 kg (95% confidence interval 1.85 to 3.19) and waist circumference by 4.17 cm (3.48 to 4.87). Mean fasting glucose reduced by 0.14 mmol/l (0.07 to 0.20), plasma glucose two hours after oral glucose challenge by 0.58 mmol/l (0.36 to 0.79), total cholesterol by 0.29 mmol/l (0.18 to 0.40), low density lipoprotein cholesterol by 0.25 mmol/l (0.16 to 0.34), triglycerides by 0.15 mmol/l (0.05 to 0.24) and diastolic blood pressure by 2.14 mmHg (0.94 to 3.33). Significant improvements were also found in most psychological measures.

Conclusion
This study provides evidence that a type 2 diabetes prevention programme using lifestyle intervention is feasible in primary health care settings, with reductions in risk factors approaching those observed in clinical trials.

Trial Number
Current Controlled Trials ISRCTN38031372

Rules and resources: a structuration approach to understanding the coordination of childrens`s inpatient health care

Aim. This paper presents findings from a multi-method study exploring the process of care coordination in children's inpatient health care.

Background. Existing work on care coordination is typified by 'black-box' type studies that measure inputs to and outcomes of care coordination roles and practices, without addressing the process of coordination.

Method. Using questionnaires, interviews and observation to collect data in multiple sites in the United Kingdom and Denmark between 1999 and 2005, the study gathered the perceptions of staff and compared these with observed practice. Giddens' structuration theory was used to provide an analytical and explanatory framework.

Findings. Current care coordination practice is diverse and inconsistent. It involves a wide range of clinical and non-clinical staff, many of whom perceive a lack of clarity about who should perform specific coordination activities. Staff draw upon a wide range of different material and non-material resources in coordinating care, the use of which is governed by largely tacit and informal rules.

Conclusions. Care coordination can be usefully conceptualized as a 'structurated' process – one that is continually produced and reproduced by staff using rules and resources to 'instantiate' or bring about care coordination through action. Potentially negative implications of this are manifested in diversity and inconsistency in care coordination practice. However, positive aspects such as the opportunity this provides to tailor care to the needs of the individual patient can be realized.

Nursing administration of medication via enteral tubes in adults : a systematic review

Background Enteral tubes are frequently inserted as part of medical treatment in a wide range of patient situations. Patients with an enteral tube are cared for by nurses in a variety of settings, including general and specialised acute care areas, aged care facilities and at home. Regardless of the setting, nurses have the primary responsibility for administering medication through enteral tubes. Medication administration via an enteral tube is a reasonably common nursing intervention that entails a number of skills, including preparing the medication, verifying the tube position, flushing the tube and assessing for potential complications. If medications are not given effectively through an enteral tube, harmful consequences may result leading to increased morbidity, for example, tube occlusion, diarrhoea and aspiration pneumonia. There are resultant costs for the health-care system related to possible increased length of stay and increased use of equipment. Presently what is considered to be best practice to give medications through enteral tubes is unknown.

Objectives The objective of this systematic review was to determine the best available evidence on which nursing interventions are effective in minimising the complications associated with the administration of medications via enteral tubes in adults. Nursing interventions and considerations related to medication administration included form of medication, verifying tube placement before administration, methods used to give medication, methods used to flush tubes, maintenance of tube patency and specific practices to prevent possible complications related to the administration of enteral medications.

Search strategy The following databases were searched for literature reported in English only: CINAHL, MEDLINE, The Cochrane Library, Current Contents/All Editions, EMBASE, Australasian Medical Index and PsychINFO. There was no date restriction applied. In addition, the reference lists of all included studies were scrutinised for other potentially relevant studies.

Selection criteria Systematic reviews of randomised controlled trials (RCTs) and RCTs that compared the effectiveness of nursing interventions and considerations used in the administration of medications via enteral tubes. Other research methods, such as non-randomised controlled trials, longitudinal studies, cohort and case control studies, were also included. Exclusion criteria included studies investigating drug–nutrient interactions or the bioavailability of specific medications.

Data collection and analysis Initial consideration of potential relevance to the review was carried out by the primary author (NP). Two reviewers independently assessed study eligibility for inclusion. A meta-analysis could not be undertaken, as there were no comparable RCTs identified. All data were presented in a narrative summary.

Results There is very limited evidence regarding the effectiveness of nursing interventions in minimising the complications associated with enteral tube medication administration in adults. The review highlights a lack of high quality research on many important nursing issues relating to enteral medication administration. There is huge scope for further research. Some of the evidence that was identified included that nurses should consider the use of liquid form medications as there may be fewer tube occlusions than with solid forms in nasoenteral tubes and silicone percutaneous endoscopic gastronomy tubes. Nurses may need to consider the sorbitol content of some liquid medications, for example, elixirs, as diarrhoea has been attributed to the sorbitol content of the elixir, not the drug itself. In addition, the use of 30 mL of water for irrigation when administering medications or flushing small-diameter nasoenteral tubes may reduce the number of tube occlusions.

Critical care nurses' decision-making activities in the natural clinical setting

• This article reports on observation of 18 nurses in urban and rural based critical care settings.

• The purpose of the study was to observe and describe the decision-making activities of critical care nurses within natural clinical settings.

• During the 2-hour observation, the researcher dictated a detailed commentary on to audio-tape of each nurse's actions. Tapes were transcribed and subjected to content analysis.

• Findings indicated three main categories of decisions. Decision frequencies were linked to nurses' critical care experience, appointment level, and location, as well as nursing shifts.

• The findings are discussed in relation to previous empirical evidence and the implications for practice.

• The author concludes that future research should be directed towards measuring the contextual influences on nurses' decision-making on the outcome of patient care.

Continence prevalence and management in an acute hospital

Learning Objective 1: describe the prevalence of incontinence within an Australian acute care hospital

Learning Objective 2: describe the current management practices for incontinence with regard to patients in an acute care hospital
Introduction: In 1998 the World Health Organisation recognised the international problem of incontinence. However, incontinence remains a major problem that affects more than 3.8 million Australians. Currently, there are no Australian guidelines governing the management of continence within the acute healthcare setting. Cabrini Health sought to identify the prevalence of incontinence in the acute inpatient setting and pilot a Continence Management Program to improve patient safety and patient outcomes.

Aim: The aim of this study was to determine the prevalence of and current management practices for incontinence with regard to Cabrini Health inpatients.

Method: The sample comprised 392 inpatients across three campuses of Cabrini Health (mean age= 68.3 years). Continence prevalence was assessed using a validated Continence Point Prevalence Tool.

Results: Urinary incontinence prevalence was 14%. The resulting overall faecal incontinence prevalence was 7.4%. There were 113 (52.3%) patients who were not incontinent and were using a continence product/device. Fifteen (25.9%) patients were incontinent and were not using any form of continence product/device. There were 43 (74.1%) patients who were incontinent and were using a continence product/device. For the large majority of patients, the admission notes contained documentation of their bladder and bowel function. Specifically, 46 (11.8%) patients had no form of admission documentation relating to bowel function and 45 (11.5%) patients had no form of admission documentation regarding to bladder function.

Conclusions: This study provided baseline continence prevalence for Cabrini Health. There is a need for evidence-based guidelines to support the management of incontinent patients. These interventions will assist staff to educate patients on appropriate choice of continence products and enable patients to maintain or regain continence. Thereby, leading to improved outcomes for patients and improved risk management.

Knowledge of late-life depression : an empirical investigation of aged care staff

Objectives: This study examined knowledge of late-life depression among staff working in residential and community aged care settings, as well as their previous training in caring for older people with depression.

Method: A sample of 320 aged care staff (mean age = 42 years) completed a survey questionnaire. Participants included direct care staff, registered nurses and Care Managers from nursing and residential homes and community aged care services.

Results: Less than half of the participating aged care staff had received any training in depression, with particularly low rates in residential care. Although aware of the importance of engaging with depressed care recipients and demonstrating moderate knowledge of the symptoms of depression, a substantial proportion of staff members saw depression as a natural consequence of bereavement, aging or relocation to aged care.

Conclusion: Experience in aged care appears to be insufficient for staff to develop high levels of knowledge of depression. Specific training in depression is recommended for staff working in aged care settings in order to improve the detection and management of late-life depression, particularly among direct carers, who demonstrated least knowledge of this common disorder.

Study protocol for the translating research in elder care (TREC): Building context through case studies in long-term care project (project two)

Background: The organizational context in which healthcare is delivered is thought to play an important role in mediating the use of knowledge in practice. Additionally, a number of potentially modifiable contextual factors have been shown to make an organizational context more amenable to change. However, understanding of how these factors operate to influence organizational context and knowledge use remains limited. In particular, research to understand knowledge translation in the long-term care setting is scarce. Further research is therefore required to provide robust explanations of the characteristics of organizational context in relation to knowledge use.
Aim: To develop a robust explanation of the way organizational context mediates the use of knowledge in practice in long-term care facilities.
Design: This is longitudinal, in-depth qualitative case study research using exploratory and interpretive methods to explore the role of organizational context in influencing knowledge translation. The study will be conducted in two phases. In phase one, comprehensive case studies will be conducted in three facilities. Following data analysis and proposition development, phase two will continue with focused case studies to elaborate emerging themes and theory. Study sites will be purposively selected. In both phases, data will be collected using a variety of approaches, including non-participant observation, key informant interviews, family perspectives, focus groups, and documentary evidence (including, but not limited to, policies, notices, and photographs of physical resources). Data analysis will comprise an iterative process of identifying convergent evidence within each case study and then examining and comparing the evidence across multiple case studies to draw conclusions from the study as a whole. Additionally, findings that emerge through this project will be compared and considered alongside those that are emerging from project one. In this way, pattern matching based on explanation building will be used to frame the analysis and develop an explanation of organizational context and knowledge use over time. An improved understanding of the contextual factors that mediate knowledge use will inform future development and testing of interventions to enhance knowledge use, with the ultimate aim of improving the outcomes for residents in long-term care settings.

An evaluation of a community aged care nurse practitioner service

Evaluation aims: An evaluation is presented that aimed to augment current understandings of the nurse practitioner role by investigating potential outcomes of a community aged care nurse practitioner (ACNP) service on clients and the health care team.

Background: In Australia, the nurse practitioner role is being implemented in a variety of health care settings and is characterized by extended practice: prescribing of medications, requests for diagnostic investigations, referral to medical specialists and admitting clients to inpatient facilities.

Design: An exploratory qualitative evaluation method through data collection by interview and thematic analysis was undertaken.

Method: All clients referred to the ACNP service between June and August 2003, and a convenience sample of health professionals, were invited to participate in individual semi-structured interviews.

Results: Findings suggested that an ACNP could provide a high quality of holistic nursing care and positively affect clients' physical and psychological symptom management, enhance clients' quality of life, assist with supplies, provide health education and assist with advocacy. Health professionals commented on effective collaboration with the ACNP service during their partnerships in client care provision.

Conclusions: Overall, the positive effects of the ACNP service on clients and the health care team support the full implementation of the role within the community setting.

Relevance to clinical practice: Funding support for the nurse practitioner role is a vital addition to consideration in the development of international policy on advanced practice nursing. Without adequate funding, the full benefits of the nurse practitioner role in clinical practice, as suggested by the findings presented in this evaluation, will be compromised.

Nurses’ utilisation of complementary therapies : a pilot study exploring scope of practice

The increasing use of complementary therapies (CTs) by the public requires nurses to be fully informed about the use and safety of these modalities. In addition, nurses need to be aware of what constitutes complementary therapy practice, its overlap with nursing practice and how to respond appropriately to patients' requests for access to and information about CTs. A pilot study that aimed to describe nurses' knowledge about, and the use of CTs was conducted in four hospitals in southeast Queensland, Australia. One hundred and twenty-nine nurses (65% response rate) of varying levels of qualification and expertise completed a questionnaire. Over 80% of the participants indicated that they engaged in some form of complementary therapy (CT) activity. The entire sample worked in acute care hospitals but 5% engaged in CTs while employed in a second job. These nurses worked in either individual private practice or a multidisciplinary clinic setting. Only 2% of the sample had formal qualifications in a specific CT. Many nurses seemed unsure about what should be defined as a CT. The most common CTs engaged in by nurses were massage, music therapy and relaxation techniques but some nurses also participated in acupuncture, acupressure, hypnotherapy and osteopathy. Some nurses were confused about the difference between CT and usual nursing care. In addition, there were knowledge deficits relating to institutional policies and professional standards. Our findings suggest that nurses require more education about the scope of CT and how it differs from nursing practice. Nurses also require access to clear policies about the safe use of CTs in specific practice settings and about appropriate referral of clients to complementary therapists with accredited qualifications.

Intervention for depression among palliative care patients and their families : a study protocol for evaluation of a training program for professional care staff

Background: Clinical depression is highly prevalent yet under-detected and under-treated in palliative care settings and is associated with a number of adverse medical and psychological outcomes for patients and their family members. This article presents a study protocol to evaluate a training intervention for non-physician palliative care staff to improve the recognition of depression and provide support for depressed patients and their family members. Details of the hypotheses and expected outcomes, study design, training program development and evaluation measures are described.
Methods and Design: A randomised controlled trial will be implemented across two palliative care services to evaluate the “Training program for professional carers to recognise and manage depression in palliative care settings”. Pre-, post- and three-month follow-up data will be collected to assess: the impact of the training on the knowledge, attitudes, self-efficacy and perceived barriers of palliative care staff when working with depression; referral rates for depression; and changes to staff practices. Quantitative and qualitative methods, in the form of self-report questionnaires and interviews with staff and family members, will be used to evaluate the effectiveness of the intervention.
Discussion: This study will determine the effectiveness of an intervention that aims to respond to the urgent need for innovative programs to target depression in the palliative care setting. The expected outcome of this study is the validation of an evidence-based training program to improve staff recognition and appropriate referrals for depression, as well as improve psychosocial support for depressed patients and their family members.

Multifactorial influences on and deviations from medication administration safety and quality in the acute medical/surgical context

Background and Aims: Although numerous factors influence medication administration, our understanding of the interplay of these factors on medication quality and safety is limited. The aim of this study was to explore the multifactorial influences on medication quality and safety in the context of a single checking policy for medication administration in acute care.

Approach: An exploratory/descriptive study using non-participant observation and follow-up interview was used to identify factors influencing medication quality and safety in medication administration episodes (n = 30). Observations focused on nurses’ interactions with patients during medication administration, and the characteristics of the environment in which these took place. Confirmation of observed data occurred on completion of the observation period during short semi-structured interviews with participant nurses.

Findings: Findings showed nurses developed therapeutic relationships with patients in terms of assessing patients before administering medications and educating patients about drugs during medication administration. Nurses experienced more frequent distractions when medications were stored and prepared in a communal drug room according to ward design. Nurses deviated from best-practice guidelines during medication administration.

Implications: Nurses’ abilities and readiness to develop therapeutic relationships with patients increased medication quality and safety, thereby protecting patients from potential adverse events. Deviations from best-practice medication administration had the potential to decrease medication safety. System factors such as ward design determining medication storage areas can be readily addressed to minimise potential error.

Conclusions: Nurses displayed behaviours that increased medication administration quality and safety; however, violations of practice standards were observed. These findings will inform future intervention studies to improve medication quality and safety.

The impact of bullying on health care administration staff : reduced commitment beyond the influences of negative affectivity

Background: Investigations of workplace bullying in health care settings have tended to focus on nurses or other clinical staff. However, the organizational and power structures enabling bullying in health care are present for all employees, including administrative staff.

Purposes: The purpose of this study was to specifically focus on health care administration staff and examine the prevalence and consequences of workplace bullying in this occupational group.

Methodology/Approach: A cross-sectional study was conducted based on questionnaire data from health care administration staff who work across facilities within a medium to large health care organization in Australia. The questionnaire included measures of bullying, negative affectivity (NA), job satisfaction, organizational commitment, well-being, and psychological distress. The three hypotheses of the study were that (a) workplace bullying will be linked to negative employee outcomes, (b) individual differences on demographic factors will have an impact on these outcomes, and (c) individual differences in NA will be a significant covariate in the analyses. The hypotheses were tested using t tests and analyses of covariances.

Findings: A total of 150 health care administration staff completed the questionnaire (76% response rate). Significant main effects were found for workplace bullying, with lower organizational commitment and well-being with the effect on commitment remaining over and above NA. Main effects were found for age on job satisfaction and for employment type on psychological distress. A significant interaction between bullying and employment type for psychological distress was also observed. Negative affectivity was a significant covariate for all analyses of covariance.

Practice Implications: The applications of these results include the need to consider the occupations receiving attention in health care to include administration employees, that bullying is present across health care occupations, and that some employees, particularly part-time staff, may need to be managed slightly differently to the full-time workforce.

Family-centred practice : empowerment, self-efficacy, and challenges for practitioners in early childhood education and care

Family-centred practice has been included in the Victoria, Australia Early Years Learning and Development Framework as a key practice principle for professionals working across all early years programs in that state. While this model of partnership for engaging and collaborating with families has long been used in the early intervention sector, the efficacy of adopting this model more widely across the wider early childhood education and care sector has not been explored. This article presents a discussion on family-centred practice as a model for engaging with families in the care and education of their children. Through an analysis of the underlying philosophy and an examination of the core principles and characteristics, the article explores family-centred practice as it sits within a broader theory of partnership. This analysis identifies that while there are essential principles and characteristics that position the model within a partnership framework, it is the notion of empowerment, an underpinning philosophy guiding the model, that adds another dimension to the way practitioners in early childhood education and care settings collaborate with families. In examining the broader early childhood context, the capacity of many early childhood practitioners to effectively implement empowering behaviours is challenged.

End-of-life care for aged care residents presenting to emergency departments

Background: The number of patients from Aged Care presenting to acute care is increasing, many of whom have a life limiting illness.

Aims: To identify differences in relation to Aged Care Residents presenting to Emergency departments who died during a hospital admission compared to those who were referred to the hospital based palliative care.

Methods: Review of a stratified random sample of 90 Aged Care residents transferred to acute care who died during admission in 2009; half the sample received palliative care. Comparisons were made with regard to age; gender; co-morbidities; symptoms, investigations and active treatment; prior admissions and costs.

Results: The median age of patients was 87.5 years, 61% were female and 38% had three or more admissions in the year prior to death. Patients with a length of stay of four or more days were 2.98 times (CI, 95%:1.11-8.03) and patients with agitation were 3.08 (CI 95%:1.10- 8.64) times more likely to be referred to palliative care. Patients who received palliative care had significantly fewer investigations or active treatment in the 24 hours prior to their death (p< 0.01) and palliated patients had significantly lower average costs per day of admission ($1022, SD=$441) compared to those who were not palliated ($ 831; SD= $ 1041) (p< 0.001).

Discussion: Our study indicates there is a difference between dying patients who received palliative care compared to those who did not in an acute care setting. Further research into the outcomes of patients discharged back to Aged Care facilities for palliative care warrants investigation.