Why do Queenslanders seek care in emergency departments? A population study

Objective This study aims to identify the main reasons for which first time and multiple users seek medical care through Queensland emergency departments (ED). Methods A cross-sectional survey was conducted at eight public EDs among presenting patients (n = 911). The questions measured the socio-demographic characteristics of patients, their beliefs and attitudes towards EDs services, and perceptions of health status. Bivariate and binary logistic regression analyses were performed to examine the differences between first time and multiple users of EDs. Results First time and multiple users accounted for 55.5% and 44.5%, respectively. Multiple users themselves believed to be sicker, have poorer health status, and additional and/or chronic health conditions. Multiple users more strongly believed that their condition required treatment at an ED and perceived their condition as being very serious. Multiple users reported weekly household incomes below $600, and half of the multiple users were not working as compared to 35% first time users. Multivariate analysis showed that multiple use was significantly associated with the existence of additional health problems, having chronic condition, lower self-efficacy, and need for ED treatment. Conclusions Patients who sought care for multiple times at EDs more often than first time users suffered from additional and chronic conditions. Their opinion of an ED as the most suitable place to address their current health problem was stronger than first time users. Any proposed demand management strategies need to address these beliefs together with the reasoning of patients to provide effective and appropriate care outside or within ED services.

Psychiatrists' views on pathways to care for people with schizophrenia in Vietnam

Objectives: Research about the outcomes of schizophrenia and the factors that determine them in developing countries is still limited. In this study, we interviewed experienced Vietnamese psychiatrists to examine their perspectives on outcome determinants in their country. The qualitative approach aimed to complement existing epidemiological knowledge and contribute to debate around the hypothesis that recovery is better in developing countries. Methods: Fifteen Vietnamese psychiatrists working in five leading psychiatric facilities participated in semi-structured interviews. Thematic content analysis of their expressed views identified three themes related to important outcome determinants in Vietnam: access to contemporary treatment, established patient-level prognostic indicators, and sociocultural variables. Results: The improving accessibility of modern treatment (including new medications, specialist staff and facilities) and increasing community adoption of a medical perspective on mental illness were seen as factors leading to improved outcomes, particularly in urban areas. However, some psychiatrists also identified the potentially beneficial nature of some aspects of Vietnamese society and culture being eroded by modernization, including traditional family structures, forms of employment and lifestyles. Conclusions: The perspectives of psychiatrists in this study suggest that socioeconomic change may be exerting conflicting influences on the outcomes of schizophrenia in Vietnam and other developing countries. Their views have implications in terms of how adequate treatment and support for people with severe mental illness can be provided in the context of limited resources, staffing and formal treatment options. Further research is needed to establish current recovery rates and prospectively explore the impact of modernization on outcomes.

The treatment of recurrent abdominal pain in children : a controlled comparison of cognitive-behavioral family intervention and standard pediatric care

This study describes the results of a controlled clinical trial involving 44 7- to 14-year-old children with recurrent abdominal pain who were randomly allocated to either cognitive-behavioral family intervention (CBFI) or standard pediatric care (SPC). Both treatment conditions resulted in significant improvements on measures of pain intensity and pain behavior. However, the children receiving CBFI had a higher rate of complete elimination of pain, lower levels of relapse at 6- and 12-month follow-up, and lower levels of interference with their activities as a result of pain and parents reported a higher level of satisfaction with the treatment than children receiving SPC. After controlling for pretreatment levels of pain, children's active self-coping and mothers' caregiving strategies were significant independent predictors of pain behavior at posttreatment.

'Work it out': Evaluation of a chronic condition self-management program for urban Aboriginal and Torres Strait Islander people with or at risk of cardiovascular disease

This thesis evaluates a chronic condition self-management program for Aboriginal and Torres Strait Islander people in urban south-east Queensland who have or are at risk of cardiovascular disease. Outcomes showed short-term improvements for some anthropometry measures which could be a trend for improvement in other anthropometry indicators over the longer term. The program was of particular benefit for participants who had several social and emotional wellbeing conditions. The use of an Aboriginal and Torres Strait Islander conceptual framework was critical in undertaking culturally competent quantitative research in this project.

Assessing performance in critical care nursing practice using the Benner Novice to expert model: A pilot study

Background It is often believed that by ensuring the ongoing completion of competency documents and life-long learning in nursing practice guarantees quality patient care. This is probably true in most cases where it provides reassurances that the nursing team is maintaining a safe “generalised” level of practice. However, competency does not always promise quality performance. There are a number of studies that have reported differences in what practitioners know and what they actually do despite being deemed competent. Aim The aim of this study was to assess whether our current competency documentation is fit for purpose and to ascertain whether performance assessment needs to be a key component in determining competence. Method 15 nurses within a General ICU who had been on the unit <4 years agreed to participate in this project. Using participant observation and assessing performance against key indicators of the Benner Novice to Expert5 model the participants were supported and assessed over the course of a ‘normal’ nursing shift. Results The results were surprising both positively and negatively. First, the nurses felt more empowered in their clinical decision making skills; second, it identified individual learning needs and milestones in educational development. There were some key challenges identified which included 5 nurses over estimating their level of competence, practice was still very much focused on task acquisition and skill and surprisingly some nurses still felt dominated by the other health professionals within the unit. Conclusion We found that the capacity and capabilities of our nursing workforce needs continual ongoing support especially if we want to move our staff from capable task-doer to competent performers. Using the key novice to expert indicators identified the way forward for us in how we assess performance and competence in practice particularly where promotion to higher grades is based on existing documentation.

Feeding mode of Australian infants in the first 12 months of life: An assessment against national breastfeeding indicators

Background: In 2011, Australia published a set of 6 population-level indicators assessing breastfeeding, formula use, and the introduction of soft/semisolid/solid foods. Objectives: This study aimed to report the feeding practices of Australian infants against these indicators and determine the predictors of early breastfeeding cessation and introduction of solids. Methods: Mother–infant dyads (N = 1470) were recruited postnatally in 2 Australian capital cities and regional areas of 1 state between February 2008 and March 2009. Demographic and feeding intention data were collected by self-completed questionnaire at infant birth, with feeding practices (current feeding mode, age of breastfeeding cessation, age of formula and/or solids introduction) reported when the infant was between 4 and 7 months of age, and around 13 months of age. Multiple logistic regression was used to determine the predictors of breastfeeding cessation and solids introduction. Results: Although initiation of breastfeeding was almost universal (93.3%), less than half of the infants were breastfed to 6 months (41.7%) and 33.3% were receiving solids by 4 months. Women who were socially disadvantaged, younger, less educated, unpartnered, primiparous, and/or overweight were most likely to have ceased breastfeeding before 6 months of age, and younger and/or less educated women were most likely to have introduced solid food by 4 months of age. Not producing adequate milk was the most common reason provided for cessation of breastfeeding. Conclusion: The feeding behaviors of Australian infants in the first 12 months fall well short of recommendations. Women need anticipatory guidance as to the indicators of breastfeeding success and the tendency of women to doubt the adequacy of their breast milk supply warrants further investigation.

Playing alone, playing with others: Differences in player experience and indicators of wellbeing

Video game play is becoming an increasingly social experience, yet we have little understanding of how social and solitary modes of play differ in terms of the player experience or interact with player wellbeing. An online survey (n = 446) collected data on players' current mode of play, their game play experience, social capital gained from game play and wellbeing. The results indicate that social and solitary players differ in terms of degree of autonomy, presence and relatedness experienced, while the different types of social play are associated with differences in relatedness and social capital experienced. Different predictors of wellbeing were also present across solitary and social player samples. People who play games on their own experience greater wellbeing when experiencing in-game autonomy. Social players experience greater wellbeing when playing with strangers, and when experiencing in-game bridging social capital. All players experienced increased wellbeing with age and decreased wellbeing with greater amounts of play.

Indicators of wellbeing in recreational video game players

Video game play is a popular entertainment choice, yet we have a limited understanding of the potential wellbeing benefits associated with recreational play. An online survey (final sample, n = 297) addresses this by investigating how the player experience related to wellbeing. The impact of amount of play, game genre, mode of play (social or solitary play) and the psychological experience of play (flow and need satisfaction) on a multi-dimensional measure of wellbeing (emotional, psychological and social) was examined via hierarchical regression. Age, gender, the play of casual games compared to shooters, and in-game experiences of flow, autonomy and relatedness were associated with increases in dimensions of wellbeing.

Safe to crush? A pilot study into solid dosage form modification in aged care

Aims To observe medication solid dosage form modification in aged care facilities (ACFs), and assess staff levels of self-perceived knowledge of medication modification and the types of resources available to them. Method Observation of medication rounds in a convenience sample of Australian Capital Territory ACFs and assessment of staff knowledge of dosage form modification and available resources. Results From 160 observations across six medication rounds, 29 residents had a total of 75 medications modified by the nursing staff prior to administration, with 32% of these instances identified as inappropriate. The methods used for crushing and administration resulted in drug mixing, spillage and incomplete dosing. The staff reported adequate resources; however, a lack of knowledge on how to locate and use these resources was evident. Conclusions Improved staff training on how to use available resources is needed to reduce the observed high incidence of inappropriate medication crushing.

Turnover intentions of employees with informal eldercare responsibilities: The role of core self-evaluations and supervisor support

As longevity increases, so does the need for care of older relatives by working family members. This research examined the interactive effect of core self-evaluations and supervisor support on turnover intentions in two samples of employees with informal caregiving responsibilities. Data were obtained from 57 employees from Australia (Study 1) and 66 employees from the United States and India (Study 2). Results of Study 1 revealed a resource compensation effect, that is, an inverse relationship between core self-evaluations and turnover intentions when supervisor care support was low. Results of Study 2 extended these findings by demonstrating resource boosting effects. Specifically, there was an inverse relationship between core self-evaluations and subsequent turnover intentions for those with high supervisor work and care support. In addition, employees' satisfaction and emotional exhaustion from their work mediated the inverse relationship between core self-evaluations and subsequent turnover intentions when supervisor work support and care support were high. Overall, these findings highlight the importance of employee- and supervisor-focused intervention strategies in organizations to support informal caregivers.

The development and preliminary testing of an instrument for assessing fatigue self-management outcomes in patients with advanced cancer

Background: Fatigue is one of the most distressing and commonly experienced symptoms in patients with advanced cancer. Although the self-management (SM) of cancer-related symptoms has received increasing attention, no research instrument assessing fatigue SM outcomes for patients with advanced cancer is available. Objectives: to describe the development and preliminary testing of an interviewer administered instrument for assessing the frequency, and perceived levels of effectiveness and self-efficacy associated with fatigue SM behaviors in patients with advanced cancer. Methods: The development and testing of the Self-efficacy in Managing Symptoms Scale- Fatigue Subscale for Patients with Advanced Cancer (SMSFS-A) involved a number of procedures: item-generation using a comprehensive literature review and semi-structured interviews, content validity evaluation using expert panel reviews, and face validity and test-retest reliability evaluation using pilot testing. Results: Initially, 23 items (22 specific behaviors with one global item) were generated from the literature review and semi-structured interviews. After two rounds of expert panel review, the final scale was reduced to 17 items (16 behaviors with one global item). Participants in the pilot test (n=10) confirmed that the questions in this scale were clear and easy to understand. Bland-Altman analysis showed agreement of results over a one-week interval. Conclusions: The SMSFS-A items were generated using multiple sources. This tool demonstrated preliminary validity and reliability. Implications for practice: The SMSFS-A has the potential to be used for clinical and research purposes. Nurses can use this instrument for collecting data to inform the initiation of appropriate fatigue SM support for this population.

Career adaptability predicts subjective career success above and beyond personality traits and core self-evaluations

The Career Adapt-Abilities Scale (CAAS) measures career adaptability as a higher-order construct that integrates four psychosocial resources of employees for managing their career development: concern, control, curiosity, and confidence. The goal of the present study was to investigate the validity of the CAAS with regard to its effects on two indicators of subjective career success (career satisfaction and self-rated career performance) above and beyond the effects of employees' Big Five personality traits and core self-evaluations. Data came from a large and heterogeneous sample of employees in Australia (N=1723). Results showed that overall career adaptability positively predicted career satisfaction and self-rated career performance above and beyond the Big Five personality traits and core self-evaluations. In addition, concern and confidence positively predicted the two indicators of subjective career success. The findings provide further support for the incremental validity of the CAAS.

A comparison of self-nominated and actual speeds in work zones

Despite significant research on drivers’ speeding behavior in work zones, little is known about how well drivers’ judgments of appropriate speeds match their actual speeds and what factors influence their judgments. This study aims to fill these two important gaps in the literature by comparing observed speeds in two work zones with drivers’ self-nominated speeds for the same work zones. In an online survey, drivers nominated speeds for the two work zones based on photographs in which the actual posted speed limits were not revealed. A simultaneous equation modelling approach was employed to examine the effects of driver characteristics on their self-nominated speeds. The results showed that survey participants nominated lower speeds (corresponding to higher compliance rates) than those which were observed. Higher speeds were nominated by males than females, young and middle aged drivers than older drivers, and drivers with truck driving experience than those who drive only cars. Larger differences between nominated and observed speeds were found among car drivers than truck drivers. These differences suggest that self-nominated speeds might not be valid indicators of the observed work zone speeds and therefore should not be used as an alternative to observed speed data.

The clinical effectiveness and cost-effectiveness of exercise referral schemes: A systematic review and economic evaluation

- Background Exercise referral schemes (ERS) aim to identify inactive adults in the primary-care setting. The GP or health-care professional then refers the patient to a third-party service, with this service taking responsibility for prescribing and monitoring an exercise programme tailored to the needs of the individual. - Objective To assess the clinical effectiveness and cost-effectiveness of ERS for people with a diagnosed medical condition known to benefit from physical activity (PA). The scope of this report was broadened to consider individuals without a diagnosed condition who are sedentary. - Data sources MEDLINE; EMBASE; PsycINFO; The Cochrane Library, ISI Web of Science; SPORTDiscus and ongoing trial registries were searched (from 1990 to October 2009) and included study references were checked. - Methods Systematic reviews: the effectiveness of ERS, predictors of ERS uptake and adherence, and the cost-effectiveness of ERS; and the development of a decision-analytic economic model to assess cost-effectiveness of ERS. - Results Seven randomised controlled trials (UK, n = 5; non-UK, n = 2) met the effectiveness inclusion criteria, five comparing ERS with usual care, two compared ERS with an alternative PA intervention, and one to an ERS plus a self-determination theory (SDT) intervention. In intention-to-treat analysis, compared with usual care, there was weak evidence of an increase in the number of ERS participants who achieved a self-reported 90-150 minutes of at least moderate-intensity PA per week at 6-12 months' follow-up [pooled relative risk (RR) 1.11, 95% confidence interval 0.99 to 1.25]. There was no consistent evidence of a difference between ERS and usual care in the duration of moderate/vigorous intensity and total PA or other outcomes, for example physical fitness, serum lipids, health-related quality of life (HRQoL). There was no between-group difference in outcomes between ERS and alternative PA interventions or ERS plus a SDT intervention. None of the included trials separately reported outcomes in individuals with medical diagnoses. Fourteen observational studies and five randomised controlled trials provided a numerical assessment of ERS uptake and adherence (UK, n = 16; non-UK, n = 3). Women and older people were more likely to take up ERS but women, when compared with men, were less likely to adhere. The four previous economic evaluations identified suggest ERS to be a cost-effective intervention. Indicative incremental cost per quality-adjusted life-year (QALY) estimates for ERS for various scenarios were based on a de novo model-based economic evaluation. Compared with usual care, the mean incremental cost for ERS was £169 and the mean incremental QALY was 0.008, with the base-case incremental cost-effectiveness ratio at £20,876 per QALY in sedentary people without a medical condition and a cost per QALY of £14,618 in sedentary obese individuals, £12,834 in sedentary hypertensive patients, and £8414 for sedentary individuals with depression. Estimates of cost-effectiveness were highly sensitive to plausible variations in the RR for change in PA and cost of ERS. - Limitations We found very limited evidence of the effectiveness of ERS. The estimates of the cost-effectiveness of ERS are based on a simple analytical framework. The economic evaluation reports small differences in costs and effects, and findings highlight the wide range of uncertainty associated with the estimates of effectiveness and the impact of effectiveness on HRQoL. No data were identified as part of the effectiveness review to allow for adjustment of the effect of ERS in different populations. - Conclusions There remains considerable uncertainty as to the effectiveness of ERS for increasing activity, fitness or health indicators or whether they are an efficient use of resources in sedentary people without a medical diagnosis. We failed to identify any trial-based evidence of the effectiveness of ERS in those with a medical diagnosis. Future work should include randomised controlled trials assessing the cinical effectiveness and cost-effectivenesss of ERS in disease groups that may benefit from PA. - Funding The National Institute for Health Research Health Technology Assessment programme.

Early childhood profiles of sleep problems and self-regulation predict later school adjustment

Background Children’s sleep problems and self-regulation problems have been independently associated with poorer adjustment to school, but there has been limited exploration of longitudinal early childhood profiles that include both indicators. Aims This study explores the normative developmental pathway for sleep problems and self-regulation across early childhood, and investigates whether departure from the normative pathway is associated with later social-emotional adjustment to school. Sample This study involved 2880 children participating in the Growing Up in Australia: The Longitudinal Study of Australian Children (LSAC) – Infant Cohort from Wave 1 (0-1 years) to Wave 4 (6-7 years). Method Mothers reported on children’s sleep problems, emotional, and attentional self-regulation at three time points from birth to 5 years. Teachers reported on children’s social-emotional adjustment to school at 6-7 years. Latent profile analysis was used to establish person-centred longitudinal profiles. Results Three profiles were found. The normative profile (69%) had consistently average or higher emotional and attentional regulation scores and sleep problems that steadily reduced from birth to 5. The remaining 31% of children were members of two non-normative self-regulation profiles, both characterised by escalating sleep problems across early childhood and below mean self-regulation. Non-normative group membership was associated with higher teacher-reported hyperactivity and emotional problems, and poorer classroom self-regulation and prosocial skills. Conclusion Early childhood profiles of self-regulation that include sleep problems offer a way to identify children at risk of poor school adjustment. Children with escalating early childhood sleep problems should be considered an important target group for school transition interventions.