Factors influencing the provision of end-of-life care in critical care settings : development and testing of a survey instrument

Aim. To develop and psychometrically test a survey instrument to identify the factors influencing the provision of end-of-life care by critical care nurses. Background. Following a decision to withdraw life-sustaining treatment, critical care nurses remain with the patient and their family providing end-of-life care. Identification of factors influencing the provision of this care can give evidence to inform practice development and support nurses. Design. A cross-sectional survey of critical care nurses. Method. An online survey was developed, reviewed by an expert panel and pilot tested to obtain preliminary evidence of its reliability and validity. In May 2011, a convenience sample of critical care nurses (n = 392, response rate 25%) completed the survey. The analytical approach to data obtained from the 58 items measured on a Likert scale included exploratory factor analysis and descriptive statistics. Results. Exploratory factor analysis identified eight factors influencing the provision of end-of-life care: emotional support for nurses, palliative values, patient and family preferences, resources, organizational support, care planning, knowledge and preparedness. Internal consistency of each latent construct was deemed satisfactory. The results of descriptive statistics revealed a strong commitment to the inclusion of families in end-of-life care and the value of this care in the critical care setting. Conclusion. This paper reports preliminary evidence of the psychometric properties of a new survey instrument. The findings may inform practice development opportunities to support critical care nurses in the provision of endof- life care and improve the care that patients and their families receive.

Procurement-related critical factors for briefing in public-private partnership projects: Case of Hong Kong

Public private partnerships (PPP) are widely used for construction project procurement. However, the briefing stage of PPP projects has been largely overlooked, although it has a far-reaching influence throughout the project life cycle. In response, we rectify this by exploring the critical factors involved. A set of 15 procurement-related factors are first identified from the existing literature. Then the effects of four background variables on the factors are tested with Hong Kong government data by an exploratory factor analysis extracting four major dimensions. The relationships between these dimensions and background variables indicate the need to take the background variables into account when ranking the factors. The ranking of the factors is then obtained by considering their weighted importance. Finally, the final practical value of the results is discussed.

Modelling end-of-life care practices: Factors associated with critical care nurse engagement in care provision

Objective To identify factors associated with critical care nurses’ engagement in end-of-life care practices. Methods Multivariable regression modelling was undertaken on 392 responses to an online self-report survey of end-of-life care practices and factors influencing practice by Australian critical care nurses’. Univariate general linear models were built for six end-of-life care practice areas. Results Six statistically significant (p < 0.001) models were developed: Information sharing F(3, 377) = 40.53, adjusted R2 23.8%; Environmental modification F(5, 380) = 19.55, adjusted R2 19.4%; Emotional support F(10, 366) = 12.10, adjusted R2 22.8%; Patient and family centred decision making F(8, 362) = 17.61 adjusted R2 26.4%; Symptom management F(8, 376) = 7.10, adjusted R2 11.3%; and Spiritual support F(9, 367) = 14.66, adjusted R2 24.6%. Stronger agreement with values consistent with a palliative approach, and greater support for patient and family preferences were associated with higher levels of engagement in end-of-life care practices. Higher levels of preparedness and access to opportunities for knowledge acquisition were associated with engagement in the interpersonal practices of patient and family centred decision making and emotional support. Conclusion This study provides evidence for interventions to address factors associated with nurse engagement to increase participation in all end-of-life care practice areas.

Autoethnography : critical appreciation of an emerging art

In this article, the author discusses how she applied autoethnography in a study of the design of hypermedia educational resources and shows how she addressed problematic issues related to autoethnographic legitimacy and representation. The study covered a 6-year period during which the practitioner’s perspective on the internal and external factors influencing the creation of three hypermedia CD-ROMs contributed to an emerging theory of design. The author highlights the interrelationship between perception and reality as vital to qualitative approaches and encourages researchers to investigate their reality more fully by practicing the art of autoethnography.

Relationship between indoor/outdoor concentrations of particles : a critical review

The relationship between indoor and outdoor concentration levels of particles in the absence and in the presence of indoor sources has been attracting an increasing level of attention. Understanding of the relationship and the mechanisms driving it, as well as the ability to quantify it, are of importance for assessment of source contribution, assessment of human exposure and for control and management of particles. It became particularly important to address this topic when evidence came from epidemiological studies on the close association between outdoor concentration levels of particles and health effects, yet with many studies showing that indoor concentrations could be significantly higher than those outdoors. This paper presents a summary of an extensive literature review on this topic conducted with an aim to identify general trends in relation to the I/O relationship emerging from studies conducted worldwide. The review considered separately a larger body of papers published on PM10, PM2.5, as well as the smaller database on particle number and number or volume size distribution. A specific focus of this paper is on naturally ventilated houses. The conclusion from the review is that despite the multiplicity of factors that play role in affecting the relationship, there are clear trends emerging in relation to the I/O relationship for particle mass concentration, enabling more general predictions to be made about the relationship. However, more research is still needed on particle number concentration and size distribution.

The guide to the project management body of knowledge (PMBOK Guide) : applicability and contribution to project success in Australia

The PMBOK Guide is one of the most influential publications concerning the knowledge of the project manangement. Moreover, the pervasion of this guide seems to be set to increase as the basis of accreditation - in conjunction with the increasing global trend toward obtaining project management professional status. However, despite the influence and strengthening profile of this guide, reports continue to be published that detail numerous project failures in a wide range of different industries. The PMBOK Guide comprises mainly declarative (know-what) and procedural (know-how) information. In this sense, the guide is largely normative and provides a very good example of the limitations of this approach as highlighted by proponents of a move to the genuine application of positibe theory in project management.----- The aim of this paper is to determine the applicability of the guide in Australia and to determine the extent to which project success can be attributed to the guide. Project Managers from a variety of organisations were surveyed. This postal survey yielded 48 replies. Descriptive statistics was used to assess the incidence and effectivieness of all the processes in the guide. The results indicate that there were no processes that could be considered as peripheral or as a candidate for elimination from the guide. More specifically, all the processes were identified as either a key routine process or a key selective process and positively related to the level of project success. However, the results also indicated that other major factors pertaining to causal knowledge (know-why) are, at least, equally important determinants of project success. It is concluded that declarative, procedural and causal knowledge are all valuable, and given the preponderance of the first two types of knowledge, there seems to be an urgent need to now ensure an equal quest for causal knowledge. In terms of developing causal knowledge, a good starting point would appear to be both positive theory from production and economics.

Harnessing assessment and feedback in the first year to support learning success, engagement and retention

It has been argued that intentional first year curriculum design has a critical role to play in enhancing first year student engagement, success and retention (Kift, 2008). A fundamental first year curriculum objective should be to assist students to make the successful transition to assessment in higher education. Scott (2006) has identified that ‘relevant, consistent and integrated assessment … [with] prompt and constructive feedback’ are particularly relevant to student retention generally; while Nicol (2007) suggests that ‘lack of clarity regarding expectations in the first year, low levels of teacher feedback and poor motivation’ are key issues in the first year. At the very minimum, if we expect first year students to become independent and self-managing learners, they need to be supported in their early development and acquisition of tertiary assessment literacies (Orrell, 2005). Critical to this attainment is the necessity to alleviate early anxieties around assessment information, instructions, guidance, and performance. This includes, for example:  inducting students thoroughly into the academic languages and assessment genres they will encounter as the vehicles for evidencing learning success; and  making expectations about the quality of this evidence clear. Most importantly, students should receive regular formative feedback of their work early in their program of study to aid their learning and to provide information to both students and teachers on progress and achievement. Leveraging research conducted under an ALTC Senior Fellowship that has sought to articulate a research-based 'transition pedagogy' (Kift & Nelson, 2005) – a guiding philosophy for intentional first year curriculum design and support that carefully scaffolds and mediates the first year learning experience for contemporary heterogeneous cohorts – this paper will discuss theoretical and practical strategies and examples that should be of assistance in implementing good assessment and feedback practices across a range of disciplines in the first year.

Bifocal lens control of myopia progression in children

This research investigated underlying issues that were critical to the success of the bifocal trial and comprised of three studies. The first study evaluated if Chinese-Canadian children were suitable subjects for the bifocal trial. The high prevalence of myopia in Chinese children suggests that genetic input plays a role in myopia development, but the rapid increase in prevalence over the last few decades indicates environmental factors are also important. Since this bifocal trial was conducted in Canada, this work aimed to determine whether Chinese children who had migrated to Canada would still have high myopia prevalence and a high rate of myopia progression. The second study determined the optimal bifocal lens power for myopia treatment and the effect of incorporating base-in prism into the bifocal. In the majority of published myopia control studies, the power of the prescribed near addition was usually predetermined in the belief that the near addition would always help to improve the near focus. In fact, the effect of near addition on the accommodative error might be quite different even for individuals in which the same magnitude of accommodation lag had been measured. Therefore, this work was necessary to guide the selection of bifocal and prism powers most suitable for the subsequent bifocal trial. The third study, the ultimate goal of this research, was to conduct a longitudinal clinical trial to determine if bifocals and prismatic bifocals could control myopia progression in children.

Leading indigenous education in a remote location : reflections on teaching to be "proud and deadly"

This thesis is a critical reflection of the author’s time as a Principal of an Indigenous state school from 2003-2004. The purpose is to reassess the impact of her principalship in terms of the staff, students and Community change that affected learning outcomes at the school and to reanalyse to what actions and to whom positive changes could be attributed. This thesis reflects and identifies, in light of the literature, strategies which were effective in enhancing student learning outcomes. The focus of this thesis was the Doongal State School*, its students, staff and facilities. The author will attempt to draw out theoretical frameworks in terms of: (1) what changed educationally in Doongal State School, (2) what seemed to be important in the Principal’s role, (3) the processes that took place, and (4) the effect of being non- Indigenous and a female. Overall, the author undertook this critical reflection in order to understand and embrace educational practices that will (a) lessen the gap between the academic outcomes achieved by Indigenous and non-Indigenous students, and (b) enhance life choices for Indigenous children. The findings indicate that principal leadership is critical for success in Indigenous schools and is the centrepiece of the models developed to explain improvement at Doongal State School. School factors, Principal Leadership factors, Change factors and factors relating to being a non-Indigenous female principal, which, when implemented, will lead to improved educational outcomes for Indigenous students, have evolved as a result of this thesis. Principal Leadership factors were found to be the enablers for the effective implementation of the key components for success.

The Treatment of Neonatal Seizures: A Critical Review of the Evidence

In a critical review of the literature to assess the efficacy of monotherapy and subsequent combinant anticonvulsant therapy in the treatment of neonatal seizures, four studies were examined; three randomised control trials and one retrospective cohort study. Each study used phenobarbital for monotherapy with doses reaching a maximum of 40mg/kg. Anticonvulsant drugs used in conjunction with phenobarbitone for combinant therapy included midazolam, clonazepam, lorazepam, phenytoin and lignocaine. Each study used an electroencephalograph for seizure diagnosis and neonatal monitoring when determining therapy efficacy and final outcome assessments. Collectively the studies suggest neither monotherapy nor combinant therapy are entirely effective in seizure control. Monotherapy demonstrated a 29% - 50% success rate for complete seizure control whereas combinant therapy administered after the failure of monotherapy demonstrated a success rate of 43% - 100%. When these trials were combined the overall success for monotherapy was 44% (n = 34/78) and for combinant therapy 72% ( n = 56/78). Though the evidence was inconclusive, it would appear that combinant therapy is of greater benefit to infants unresponsive to monotherapy. Further research such as multi-site randomised controlled trials using standardised criteria and data collection are required within this specialised area.

Part 1. Chemical and Physical Restraints in the Management of Mechanically Ventilated Patients in the ICU: Contributing Factors

Chemical and physical restraints are frequently used in the intensive care unit (ICU) to control agitated patients and to prevent self-harm and unplanned extubations. Published work relating to the numerous issues of the care and treatment strategies for these patients remains conflicting and unclear. Literature regarding sedation and chemical restraint reveals a trend towards management with lighter sedation, use of sedation assessment tools and sedation protocols. It remains unclear which treatment is best for agitated and delirious patients, and the evidence on the effect of sedation is conflicting. A large portion of the literature on the use of physical restraint is from general hospital wards and residential homes, and not from the ICU environment. The purpose of this paper is to provide a summary of the existing literature on the use of physical and chemical restraints in the ICU setting. In Part 1 of this two-part paper, the evidence on chemical and physical restraints is explored with specific focus on definition of terms, unplanned

Resilience in critical infrastructures : the case of the Queensland electricity industry

The reliability of Critical Infrastructure is considered to be a fundamental expectation of modern societies. These large-scale socio-technical systems have always, due to their complex nature, been faced with threats challenging their ongoing functioning. However, increasing uncertainty in addition to the trend of infrastructure fragmentation has made reliable service provision not only a key organisational goal, but a major continuity challenge: especially given the highly interdependent network conditions that exist both regionally and globally. The notion of resilience as an adaptive capacity supporting infrastructure reliability under conditions of uncertainty and change has emerged as a critical capacity for systems of infrastructure and the organisations responsible for their reliable management. This study explores infrastructure reliability through the lens of resilience from an organisation and system perspective using two recognised resilience-enhancing management practices, High Reliability Theory (HRT) and Business Continuity Management (BCM) to better understand how this phenomenon manifests within a partially fragmented (corporatised) critical infrastructure industry – The Queensland Electricity Industry. The methodological approach involved a single case study design (industry) with embedded sub-units of analysis (organisations), utilising in-depth interviews and document analysis to illicit findings. Derived from detailed assessment of BCM and Reliability-Enhancing characteristics, findings suggest that the industry as a whole exhibits resilient functioning, however this was found to manifest at different levels across the industry and in different combinations. Whilst there were distinct differences in respect to resilient capabilities at the organisational level, differences were less marked at a systems (industry) level, with many common understandings carried over from the pre-corporatised operating environment. These Heritage Factors were central to understanding the systems level cohesion noted in the work. The findings of this study are intended to contribute to a body of knowledge encompassing resilience and high reliability in critical infrastructure industries. The research also has value from a practical perspective, as it suggests a range of opportunities to enhance resilient functioning under increasingly interdependent, networked conditions.

Modulation of dermal microvascular endithelial cell responses to growth factors and haemostatic factors in the presence of vitronectin

In order to effect permanent closure in burns patients suffering from full thickness wounds, replacing their skin via split thickness autografting, is essential. Dermal substitutes in conjunction with widely meshed split thickness autografts (+/- cultured keratinocytes) reduce scarring at the donor and recipient sites of burns patients by reducing demand for autologous skin (both surface area and thickness), without compromising dermal delivery at the wound face. Tissue engineered products such as Integra consist of a dermal template which is rapidly remodelled to form a neodermis, at which time the temporary silicone outer layer is removed and replaced with autologous split thickness skin. Whilst provision of a thick tissue engineered dermis at full thickness burn sites reduces scarring, it is hampered by delays in vascularisation which results in clinical failure. The ultimate success of any skin graft product is dependent upon a number of basic factors including adherence, haemostasis and in the case of viable tissue grafts, success is ultimately dependent upon restoration of a normal blood supply, and hence this study. Ultimately, the goal of this research is to improve the therapeutic properties of tissue replacements, through impregnation with growth factors aimed at stimulating migration and proliferation of microvascular endothelial cells into the donor tissue post grafting. For the purpose of my masters, the aim was to evaluate the responsiveness of a dermal microvascular endothelial cell line to growth factors and haemostatic factors, in the presence of the glycoprotein vitronectin. Vitronectin formed the backbone for my hypothesis and research due to its association with both epithelial and, more specifically, endothelial migration and proliferation. Early work using a platform technology referred to as VitroGro (Tissue Therapies Ltd), which is comprised of vitronectin bound BP5/IGF-1, aided keratinocyte proliferation. I hypothesised that this result would translate to another epithelium - endothelium. VitroGro had no effect on endothelial proliferation or migration. Vitronectin increases the presence of Fibroblast Growth Factor (FGF) and Vascular Endothelial Growth Factor (VEGF) receptors, enhancing cell responsiveness to their respective ligands. So, although Human Microvascular Endothelial Cell line 1 (HMEC-1) VEGF receptor expression is generally low, it was hypothesised that exposure to vitronectin would up-regulate this receptor. HMEC-1 migration, but not proliferation, was enhanced by vitronectin bound VEGF, as well as vitronectin bound Epidermal Growth Factor (EGF), both of which could be used to stimulate microvascular endothelial cell migration for the purpose of transplantation. In addition to vitronectin's synergy with various growth factors, it has also been shown to play a role in haemostasis. Vitronectin binds thrombin-antithrombin III (TAT) to form a trimeric complex that takes on many of the attributes of vitronectin, such as heparin affinity, which results in its adherence to endothelium via heparan sulfate proteoglycans (HSP), followed by unaltered transcytosis through the endothelium, and ultimately its removal from the circulation. This has been documented as a mechanism designed to remove thrombin from the circulation. Equally, it could be argued that it is a mechanism for delivering vitronectin to the matrix. My results show that matrix-bound vitronectin dramatically alters the effect that conformationally altered antithrombin three (cATIII) has on proliferation of microvascular endothelial cells. cATIII stimulates HMEC-1 proliferation in the presence of matrix-bound vitronectin, as opposed to inhibiting proliferation in its absence. Binding vitronectin to tissues and organs prior to transplant, in the presence of cATIII, will have a profound effect on microvascular infiltration of the graft, by preventing occlusion of existing vessels whilst stimulating migration and proliferation of endothelium within the tissue.