Using staffing ratios for workforce planning : evidence on nine allied health professions - a narrative review

Background: Modern healthcare managers are faced with pressure to deliver effective, efficient services within the context of fixed budget constraints. This requires decisions regarding the skill mix of the workforce particularly when staffing new services. One measure used to identify numbers and mix of staff in healthcare settings is workforce ratio. The aim of this study was to identify workforce ratios in nine allied health professions and to identify whether these measures are useful for planning allied health workforce requirements. Method: A systematic literature search using relevant MeSH headings of business, medical and allied health databases and relevant grey literature for the period 2000-2008 was undertaken. Results: Twelve articles were identified which described the use of workforce ratios in allied health services. Only one of these was a staffing ratio linked to clinical outcomes. The most comprehensive measures were identified in rehabilitation medicine. Conclusions: The evidence for use of staffing ratios for allied health practitioners is scarce and lags behind the fields of nursing and medicine.

How do allied health professionals evaluate new models of care? What are we measuring and why?

The aim of this study was to identify what outcome measures or quality indicators are being used to evaluate advanced and new roles in nine allied health professions and whether the measures are evaluating outcomes of interest to the patient, the clinician, or the healthcare provider. A systematic search strategy was used. Medical and allied health databases were searched and relevant articles extracted. Relevant studies with at least 1 outcome measure were evaluated. A total of 106 articles were identified that described advanced roles, however, only 23 of these described an outcome measure in sufficient detail to be included for review. The majority of the reported measures fit into the economic and process categories. The most reported outcome related to patients was satisfaction surveys. Measures of patient health outcomes were infrequently reported. It is unclear from the studies evaluated whether new models of allied healthcare can be shown to be as safe and effective as traditional care for a given procedure. Outcome measures chosen to evaluate these services often reflect organizational need and not patient outcomes. Organizations need to ensure that high-quality performance measures are chosen to evaluate the success of new health service innovations. There needs to be a move away from in-house type surveys that add little or no valid evidence as to the effect of a new innovation. More importance needs to be placed on patient outcomes as a measure of the quality of allied health interventions.

Productivity and time use during occupational therapy and nutrition/dietetics clinical education : a cohort study

Background: Currently in the Australian higher education sector higher productivity from allied health clinical education placements are a contested issue. This paper will report results of a study that investigated output changes associated with occupational therapy and nutrition/dietetics clinical education placements in Queensland, Australia. Supervisors’ and students’ time use during placements and how this changes for supervisors compared to when students are not present in the workplace is also presented. Methodology/Principal Findings: A cohort design was used with students from four Queensland universities, and their supervisors employed by Queensland Health. There was an increasing trend in the number of occasions of service delivered when the students were present, and a statistically significant increase in the daily mean length of occasions of service delivered during the placement compared to pre-placement levels. For project-based placements that were not directly involved in patient care, supervisors’ project activity time decreased during placements, with students undertaking considerably more time in project activities. Conclusions/Significance: A novel method for estimating productivity and time use changes during clinical education programs for allied health disciplines has been applied. During clinical education placements there was a net increase in outputs, suggesting supervisors engage in longer consultations with patients for the purpose of training students, while maintaining patient numbers. Other activities are reduced. This paper is the first time these data have been shown and form a good basis for future assessments of the economic impact of student placements for allied health disciplines.

Development and testing of an iPad application for teaching self-management to heart failure patients. (Nursing/Allied Health Professional Investigator Award)- Abstract

Purpose: Heart failure (HF) is the leading cause of hospitalization and significant burden to the health care system in Australia. To reduce hospitalizations, multidisciplinary approaches and enhance self-management programs have been strongly advocated for HF patients globally. HF patients who can effectively manage their symptoms and adhere to complex medicine regimes will experience fewer hospitalizations. Research indicates that information technologies (IT) have a significant role in providing support to promote patients' self-management skills. The iPad utilizes user-friendly interfaces and to date an application for HF patient education has not been developed. This project aimed to develop the HF iPad teaching application in the way that would be engaging, interactive and simple to follow and usable for patients' carers and health care workers within both the hospital and community setting. Methods: The design for the development and evaluation of the application consisted of two action research cycles. Each cycle included 3 phases of testing and feedback from three groups comprising IT team, HF experts and patients. All patient education materials of the application were derived from national and international evidence based practice guidelines and patient self-care recommendations. Results: The iPad application has animated anatomy and physiology that simply and clearly teaches the concepts of the normal heart and the heart in failure. Patient Avatars throughout the application can be changed to reflect the sex and culture of the patient. There is voice-over presenting a script developed by the heart failure expert panel. Additional engagement processes included points of interaction throughout the application with touch screen responses and the ability of the patient to enter their weight and this data is secured and transferred to the clinic nurse and/or research data set. The application has been used independently, for instance, at home or using headphones in a clinic waiting room or most commonly to aid a nurse-led HF consultation. Conclusion: This project utilized iPad as an educational tool to standardize HF education from nurses who are not always heart failure specialists. Furthermore, study is currently ongoing to evaluate of the effectiveness of this tool on patient outcomes and to develop several specifically designed cultural adaptations [Hispanic (USA), Aboriginal (Australia), and Maori (New Zealand)].

Recruiting and engaging new mothers in nutrition research studies : lessons from the Australian NOURISH randomised controlled trial

Background: Despite important implications for the budgets, statistical power and generalisability of research findings, detailed reports of recruitment and retention in randomised controlled trials (RCTs) are rare. The NOURISH RCT evaluated a community-based intervention for first-time mothers that promoted protective infant feeding practices as a primary prevention strategy for childhood obesity. The aim of this paper is to provide a detailed description and evaluation of the recruitment and retention strategies used. Methods: A two stage recruitment process designed to provide a consecutive sampling framework was used. First time mothers delivering healthy term infants were initially approached in postnatal wards of the major maternity services in two Australian cities for consent to later contact (Stage 1). When infants were about four months old mothers were re-contacted by mail for enrolment (Stage 2), baseline measurements (Time 1) and subsequent random allocation to the intervention or control condition. Outcomes were assessed at infant ages 14 months (Time 2) and 24 months (Time 3). Results: At Stage 1, 86% of eligible mothers were approached and of these women, 76% consented to later contact. At Stage 2, 3% had become ineligible and 76% could be recontacted. Of the latter, 44% consented to full enrolment and were allocated. This represented 21% of mothers screened as eligible at Stage 1. Retention at Time 3 was 78%. Mothers who did not consent or discontinued the study were younger and less likely to have a university education. Conclusions: The consent and retention rates of our sample of first time mothers are comparable with or better than other similar studies. The recruitment strategy used allowed for detailed information from non-consenters to be collected; thus selection bias could be estimated. Recommendations for future studies include being able to contact participants via mobile phone (particular text messaging), offering home visits to reduce participant burden and considering the use of financial incentives to support participant retention.

Identifying competencies for Australian health professionals working in international health

A profile of the roles performed by Australian health professionals working in international health was constructed to identify the core competencies they require, and the implications for education and training of international health practitioners. The methods used included: literature review and document analysis of available training and education; an analysis of competencies required in job descriptions for international health positions; and consultations with key informants. The international health roles identified were classified in four main groups: Program Directors, Program Managers, Team Leaders and Health Specialists. Thirteen 'core' competencies were identified from the job analysis and key informant/group interviews. Contributing to international health development in resource poor countries requires high level cultural, interpersonal and team-work competencies. Technical expertise in health disciplines is required, with flexibility to adapt to new situations. International health professionals need to combine public health competencies with high level personal maturity to respond to emerging challenges.

A multicultural nursing workforce and cultural perspectives in Saudi Arabia : an overview

This paper provides an overview of the cultural perspectives and practices in Saudi Arabia that could help expatriate health care providers to understand Saudi culture and enhance cultural competence. The healthcare system in Gulf countries, particularly, Saudi Arabia, is mainly staffed by expatriate nurses, who account for 67.7% of the total number of nurses. This gives rise to a multicultural environment in the hospital, where people of different cultures interact with each other and take care of Saudi patients who are from the dominant culture. In this scenario, a lack of knowledge of Saudi culture among nurses can lead to cultural conflicts and misunderstanding of some of the behaviors and practices of the indigenous Saudi people. Culture is a complex notion; however, being aware of cultural differences and having cultural knowledge can help people to interact safely. Educating expatriate nurses about the cultural heritage of the Saudi people, which is mainly influenced by Islamic teachings, is important to increase cultural harmony.

Menopause as a long-term risk to health : implications of general practitioner accounts of prevention for women’s choice and decision-making

Over the past two decades medical researchers and modernist feminist researchers have contested the meaning of menopause. In this article we examine various meanings of menopause in major medical and feminist literature and the construction of menopause in a semi-structured interview study of general practitioners in rural South Australia. Three discursive themes are identified in these interviews; (i) the hormonal menopause – symptoms, risk, prevention; (ii) the informed menopausal woman; and (iii) decision-making and hormone replacement therapy. By using the discourse of prevention, general practitioners construct menopause in relation to women's health care choices, empowerment and autonomy. We argue that the ways in which these concepts are deployed by general practitioners in this study produces and constrains the options available to women. The implications of these general practitioner accounts are discussed in relation to the proposition that medical and feminist descriptions of menopause posit alternative but equally-fixed truths about menopause and their relationship with the range of responses available to women at menopause. Social and cultural explanations of disease causality (c.f.Germov 1998, Hardey 1998) are absent from the new menopause despite their being an integral part of the framework of the women's health movement and health promotion drawn on by these general practitioners. Further, the shift of responsibility for health to the individual woman reinforces practice claims to empower women, but oversimplifies power relations and constructs menopause as a site of self-surveillance. The use of concepts from the women's health movement and health promotion have nevertheless created change in both the positioning of women as having ‘choices’ and the positioning of some general practitioners in terms of greater information provision to women and an attention to the woman's autonomy. In conclusion, we propose that a new menopause has evolved from a discursive shift in medicine and that there exists within this new configuration, claiming the empowerment of women as an integral part of health care for menopause, the possibility for change in medical practice which will broaden, strengthen, and maintain this position.

Understanding body image disturbance in the promotion of mental health : a discourse analytic study

Health care interventions in the area of body image disturbance and eating disorders largely involve individual treatment approaches, while prevention and health promotion are relatively underexplored. A review of health promotion activities in the area of body image in Australia revealed three programmes, the most extensive and longest standing having been established in 1992. The aims of this programme are to reduce body image dissatisfaction and inappropriate eating behaviour, especially among women. Because health promotion is concerned with the social aspects of health, it was hypothesized by the authors that a social understanding of body image and eating disorders might be advanced in a health promotion setting and reflected in the approach to practice. In order to examine approaches to body image in health promotion, 10 health professionals responsible for the design and management of this programme participated in a series of semi-structured interviews between 1997 and 2000. Three discursive themes were evident in health workers' explanations of body image problems: (1) cognitive-behavioural themes; (2) gender themes; and (3) socio-cultural themes. While body image problems were constructed as psychological problems that are particularly experienced by women, their origins were largely conceived to be socio-cultural. The implications of these constructions are critically discussed in terms of the approach to health promotion used in this programme.

Evaluation in health outcomes research : linking theories, methodologies and practice in health promotion.

Health outcomes research has developed as a means of evaluating the effectiveness of health care interventions and as an approach to informing resource allocation. The use of a health outcomes approach in health promotion has made increasing demands on evaluation methodologies to demonstrate program effectiveness. However, criticism of the contribution of health promotion to outcomes research has made several assumptions about the use of qualitative methodologies and the content of program objectives largely derived from a biomedical approach. In contrast to the measurement of biomedical interventions in clinical health care, health promotion practice involves social phenomena, wide-reaching cultural, psychological, political and ideological problems and issues. The integration of methodologies of health promotion evaluation will inform further conceptualisation of the health outcomes approach with the differentiation of three types of outcomes: health development outcomes; social health outcomes; and biomedical health outcomes. It is concluded that this differentiation moves away from dualist concepts that advocate the replacement of goals and targets with regional and locally based approaches. Rather, the future direction for health promotion evaluation needs to employ a framework that elaborates multiple methodologies and approaches necessary for establishing what relationships exist between morbidity, mortality, health advancement and equity.

A pre-post evaluation of an ambulatory nutrition support service for malnourished patients post hospital discharge: a pilot study

Introduction Malnutrition is common among hospitalised patients, with poor follow-up of nutrition support post-discharge. Published studies on the efficacy of ambulatory nutrition support (ANS) for malnourished patients post-discharge are scarce. The aims of this study were to evaluate the rate of dietetics follow-up of malnourished patients post-discharge, before (2008) and after (2010) implementation of a new ANS service, and to evaluate nutritional outcomes post-implementation. Materials and Methods Consecutive samples of 261 (2008) and 163 (2010) adult inpatients referred to dietetics and assessed as malnourished using Subjective Global Assessment (SGA) were enrolled. All subjects received inpatient nutrition intervention and dietetic outpatient clinic follow-up appointments. For the 2010 cohort, ANS was initiated to provide telephone follow-up and home visits for patients who failed to attend the outpatient clinic. Subjective Global Assessment, body weight, quality of life (EQ-5D VAS) and handgrip strength were measured at baseline and five months post-discharge. Paired t-test was used to compare pre- and post-intervention results. Results In 2008, only 15% of patients returned for follow-up with a dietitian within four months post-discharge. After implementation of ANS in 2010, the follow-up rate was 100%. Mean weight improved from 44.0 ± 8.5kg to 46.3 ± 9.6kg, EQ-5D VAS from 61.2 ± 19.8 to 71.6 ± 17.4 and handgrip strength from 15.1 ± 7.1 kg force to 17.5 ± 8.5 kg force; p<0.001 for all. Seventy-four percent of patients improved in SGA score. Conclusion Ambulatory nutrition support resulted in significant improvements in follow-up rate, nutritional status and quality of life of malnourished patients post-discharge.

Validity and reliability of 3-minute nutrition screening (3-MinNS)performed by nurses on oncology and surgical patients

Background Nutrition screening is usually administered by nurses. However, most studies on nutrition screening tools have not used nurses to validate the tools. The 3-Minute Nutrition Screening (3-MinNS) assesses weight loss, dietary intake and muscle wastage, with the composite score of each used to determine risk of malnutrition. The aim of the study was to determine the validity and reliability of 3-MinNS administered by nurses, who are the intended assessors. Methods In this cross sectional study, three ward-based nurses screened 121 patients aged 21 years and over using 3-MinNS in three wards within 24 hours of admission. A dietitian then assessed the patients’ nutritional status using Subjective Global Assessment within 48 hours of admission, whilst blinded to the results of the screening. To assess the reliability of 3-MinNS, 37 patients screened by the first nurse were re-screened by a second nurse within 24 hours, who was blinded to the results of the first nurse. The sensitivity, specificity and best cutoff score for 3-MinNS were determined using the Receiver Operator Characteristics Curve. Results The best cutoff score to identify all patients at risk of malnutrition using 3-MinNS was three, with sensitivity of 89% and specificity of 88%. This cutoff point also identified all (100%) severely malnourished patients. There was strong correlation between 3-MinNS and SGA (r=0.78, p<0.001). The agreement between two nurses conducting the 3-MinNS tool was 78.3%. Conclusion 3-Minute Nutrition Screening is a valid and reliable tool for nurses to identify patients at risk of malnutrition.