P.I.C.U., H.D.U., A.O.A. What treatment do we provide?: Current descriptions of the function of intensive care for inpatient Psychiatric Health Care.

Purpose – This paper adds to growing research of psychiatric intensive care units (PICU) by recounting descriptions of psychiatric intensive care settings and discusses the perceptions held by nurses of the organisational interfaces, arrangements and provisions of care in these settings. Design/methodology/approach – Data gathered from focus groups held with nurses from two PICUs was used to establish terminology, defining attributes, related concepts, antecedents, values, processes and concepts related to current practices. A literature search was conducted to permit a review of the conceptual arrangements and contemporary understanding of intensive care for people experiencing acute psychiatric illness based on the perspectives held by the nurses from the focus groups. Findings – Dissonance between service needs and the needs and management of individual patients overshadow strategies to implement comprehensive recovery-oriented approaches. Three factors are reported in this paper that influence standards and procedural practice in PICU; organisational structures; physical structures; and subtype nomenclature. Practical implications – Acute inpatient care is an important part of a comprehensive approach to mental health services. Commonly intensive acute care is delivered in specialised wards or units co-located with acute mental health inpatient units mostly known as PICU. Evidence of the most effective treatment and approaches in intensive care settings that support comprehensive recovery for improved outcomes is nascent. Originality/value – Current descriptions from nurses substantiate wide variations in the provisions, design and classifications of psychiatric intensive care. Idiosyncratic and localised conceptions of psychiatric intensive care are not adequately entailing effective treatment and methods in support of recovery principles for improved and comprehensive outcomes. The authors suggest that more concrete descriptions, guidelines, training and policies for provision of intensive psychiatric health care encompassing the perspective of nursing professionals, would reinforce conceptual construction and thus optimum treatments within a comprehensive, recovery-oriented approach to mental health services.

(Re)-regulating care : employing foreign carers for older persons in Taiwan

The purpose of this research was to develop a theoretical understanding of the social phenomenon of the employment of foreign carers for older Taiwanese in households. Foreign carers were introduced into Taiwan in 1992 to address the care needs of the older population. By 2012, over 200,000 foreign caregivers from Indonesia, Philippines, and Vietnam were providing care in households in Taiwan. There has been little research on the interactions between and experiences of family employers, foreign carers and older persons receiving care. The theoretical framework brought together symbolic interactionist concepts and the social constructionism of Berger and Luckmann. Data collection and analysis were informed by Charmaz‘s formulation of grounded theory. Two focus groups and 54 in-depth interviews with a total of 57 Indonesian and Vietnamese foreign carers, Taiwanese family employers and older persons receiving care were undertaken. The analytical findings of the research reflect the ways in which the foreign carer, older persons receiving care and family employer participants were socially situated within the research context and how their respective social realities were shaped differently by changing social structures and cultural values within a globalising context. (Re)-regulating care was generated as the core category, forming a coherent and overarching framework that integrated the three analytical dimensions of the reality of the social change, resituating roles and struggling for control. The reality of social change refers to the employment of foreign carers as a manifestation of the reshaping of the social worlds of the three groups of participants. Resituating roles reflects the processes that underpin the hierarchical positioning of participants, the resultant asymmetrical power relations and associated interactions. Struggling for control, depicts how each group employed strategies to create space and identities that would sustain a sense of self and autonomy. In the current situation of economic and social change in Taiwan the three participant groups shared a desire for control. The autonomy of the women employers was negotiated through employment of foreign carers; for the foreign carers, a pragmatic decision to work abroad became a means for personal empowerment; and the older persons receiving care regained some authority through relationships with carers.

The effect of exercise training on sleep quality in heart failure

Background: Heart failure is a serious condition estimated to affect 1.5-2.0% of the Australian population with a point prevalence of approximately 1% in people aged 50-59 years, 10% in people aged 65 years or more and over 50% in people aged 85 years or over (National Heart Foundation of Australian and the Cardiac Society of Australia and New Zealand, 2006). Sleep disturbances are a common complaint of persons with heart failure. Disturbances of sleep can worsen heart failure symptoms, impair independence, reduce quality of life and lead to increased health care utilisation in patients with heart failure. Previous studies have identified exercise as a possible treatment for poor sleep in patients without cardiac disease however there is limited evidence of the effect of this form of treatment in heart failure. Aim: The primary objective of this study was to examine the effect of a supervised, hospital-based exercise training programme on subjective sleep quality in heart failure patients. Secondary objectives were to examine the association between changes in sleep quality and changes in depression, exercise performance and body mass index. Methods: The sample for the study was recruited from metropolitan and regional heart failure services across Brisbane, Queensland. Patients with a recent heart failure related hospital admission who met study inclusion criteria were recruited. Participants were screened by specialist heart failure exercise staff at each site to ensure exercise safety prior to study enrolment. Demographic data, medical history, medications, Pittsburgh Sleep Quality Index score, Geriatric Depression Score, exercise performance (six minute walk test), weight and height were collected at Baseline. Pittsburgh Sleep Quality Index score, Geriatric Depression Score, exercise performance and weight were repeated at 3 months. One hundred and six patients admitted to hospital with heart failure were randomly allocated to a 3-month disease-based management programme of education and self-management support including standard exercise advice (Control) or to the same disease management programme as the Control group with the addition of a tailored physical activity program (Intervention). The intervention consisted of 1 hour of aerobic and resistance exercise twice a week. Programs were designed and supervised by an exercise specialist. The main outcome measure was achievement of a clinically significant change (.3 points) in global Pittsburgh Sleep Quality score. Results: Intervention group participants reported significantly greater clinical improvement in global sleep quality than Control (p=0.016). These patients also exhibited significant improvements in component sleep disturbance (p=0.004), component sleep quality (p=0.015) and global sleep quality (p=0.032) after 3 months of supervised exercise intervention. Improvements in sleep quality correlated with improvements in depression (p<0.001) and six minute walk distance (p=0.04). When study results were examined categorically, with subjects classified as either "poor" or "good" sleepers, subjects in the Control group were significantly more likely to report "poor" sleep at 3 months (p=0.039) while Intervention participants were likely to report "good" sleep at this time (p=0.08). Conclusion: Three months of supervised, hospital based, aerobic and resistance exercise training improved subjective sleep quality in patients with heart failure. This is the first randomised controlled trial to examine the role of aerobic and resistance exercise training in the improvement of sleep quality for patients with this disease. While this study establishes exercise as a therapy for poor sleep quality, further research is needed to investigate the effect of exercise training on objective parameters of sleep in this population.

Mortality and cost outcomes of elderly trauma patients admitted to intensive care and the general wards of an Australian tertiary referral hospital

Mortality and cost outcomes of elderly intensive care unit (ICU) trauma patients were characterised in a retrospective cohort study from an Australian tertiary ICU. Trauma patients admitted between January 2000 and December 2005 were grouped into three major age categories: aged ≥65 years admitted into ICU (n=272); aged ≥65 years admitted into general ward (n=610) and aged <65 years admitted into ICU (n=1617). Hospital mortality predictors were characterised as odds ratios (OR) using logistic regression. The impact of predictor variables on (log) total hospital-stay costs was determined using least squares regression. An alternate treatment-effects regression model estimated the mortality cost-effect as an endogenous variable. Mortality predictors (P ≤0.0001, comparator: ICU ≥65 years, ventilated) were: ICU <65 not-ventilated (OR 0.014); ICU <65 ventilated (OR 0.090); ICU age ≥65 not-ventilated (OR 0.061) and ward ≥65 (OR 0.086); increasing injury severity score and increased Charlson comorbidity index of 1 and 2, compared with zero (OR 2.21 [1.40 to 3.48] and OR 2.57 [1.45 to 4.55]). The raw mean daily ICU and hospital costs in A$ 2005 (US$) for age <65 and ≥65 to ICU, and ≥65 to the ward were; for year 2000: ICU, $2717 (1462) and $2777 (1494); hospital, $1837 (988) and $1590 (855); ward $933 (502); for year 2005: ICU, $3202 (2393) and $3086 (2307); hospital, $1938 (1449) and $1914 (1431); ward $1180 (882). Cost increments were predicted by age ≥65 and ICU admission, increasing injury severity score, mechanical ventilation, Charlson comorbidity index increments and hospital survival. Mortalitycost-effect was estimated at -63% by least squares regression and -82% by treatment-effects regression model. Patient demographic factors, injury severity and its consequences predict both cost and survival in trauma. The cost mortality effect was biased upwards by conventional least squares regression estimation.

Internationalising Australian secondary education

This thesis presents the findings of a case study of international students who enrol in Australian secondary schools. Specifically, it focuses on the ways that staff in three schools and two international colleges position Eastern Asian international students through discourses of cultural difference. It draws together the Discourse Historical Approach to Critical Discourse Analysis with the work of Basil Bernstein and Pierre Bourdieu. The study finds that groups of students are positioned positively or negatively depending on their relationship to the dominant discourses of the Australian school. Australian students, while rarely mentioned, were positioned positively. By contrast, the Eastern Asian international students were positioned negatively in relation to the privileged discourses of Australian schooling. These discourses reflected the cultural capital that was valued in the schools. In particular, the cultural capital of active and willing engagement in competitive sports and being rough, rugged and an ‘ocker’ were privileged at the schools. International students from Papua New Guinea, and a few Eastern Asian students who behaved as ockers, were positioned positively because they realised cultural capital that was valued at the schools. By contrast, the students who were unable to be positioned through these discourses, because they did not realise cultural capital that was valued, were not viewed favourably. As a result, the data showed that there was a hierarchy of positions at the schools that were constructed in staff accounts. The analysis of data suggests that only some students are positioned favourably in Australian schools. The students who were already able to construct privileged Australian school discourses were positioned positively. The data suggest that the majority of the Eastern Asian students were represented through negative discourses because they did not realise cultural capital that was valued at the schools. Findings of this study may assist schools to identify international students who may experience their Australian school education negatively. The findings may also contribute to assisting staff to better engage with international students.

Preparing culturally and linguistically diverse nursing students for clinical practice in the health care setting

The number of culturally and linguistically diverse (CALD) students seeking enrollment in higher education courses in Western countries where English is the predominant language has grown considerably in the past decade, especially in undergraduate health care courses. When enrolled in nursing courses, students are required to complete clinical placements. Such experiences can create significant challenges for CALD students where language, cultural differences, and interpretation of cultural norms complicate the learning process. To assist CALD nursing students to transition successfully, an extracurricular integrated curriculum program was developed and implemented at a university in Queensland, Australia. The program is a series of interactive workshops based on the principles of caring pedagogy and student-centered learning. The program applies strategies that combine small-group discussions with peers, role-plays, and interactions with final-year nursing student volunteers. Evaluation of the program suggests it has assisted most of the students surveyed to be successful in their clinical studies.

Trauma education : a multidisciplinary interface

Trauma education, both formal and informal, is an essential component of professional development for both nursing anf medical staff working in the Emergency Department. Ideally, this education will be multidisciplinary. As a result, the day to day aspects of emergency care such and team work and crew resource management are maintained.

Validation and consistency in the application of a trauma team activation system at a level 1 trauma centre

- The RAH was activated over 2500 trauma calls in 2009. This figure is over twice the number of calls put out by similar services. - Many trauma calls (in particular L2 trauma calls) from the existing system do not warrant activation of the trauma team - Sometimes trauma calls are activated for nontrauma reasons (eg rapid access to radiology, departmental pressures etc) - The excess of trauma calls has several deleterious effects particularly on time management for the trauma service staff: ward rounds/tertiary survey rounds, education, quality improvement, research

Development of the palliative care needs assessment tool (PC-NAT) for use by multi-disciplinary health professionals

Needs assessment strategies can facilitate prioritisation of resources. To develop a needs assessment tool for use with advanced cancer patients and caregivers, to prompt early intervation. A convenience sample of 103 health professionals viewed three videotaped consultations involving a simulated patient, his/her caregiver and a health professional, completed the Palliative Care Needs Assessment Tool (PC-NAT) and provided feedback on clarity, content and acceptability of the PC-NAT. Face and content validity, acceptability and feasibility of the PC-NAT were confirmed. Kappa scores indicated adequate inter-rater reliability for the majority of domains; the patient spirituality domain and the caregiver physical and family and relationship domains had low reliability. The PC-NAT can be used by health professionals with a range of clinical expertise to identify individuals' needs, thereby enabling early intervention. Further psychometric testing and an evaluation to assess the impact of the systematic use of the PC-NAT on quality of life, unmet needs and service utilisation of patients and caregivers are underway.

What should I say?: Qualitative findings on dilemmas in palliative care nursing

The nursing literature suggests that talking and listening to patients about issues associated with death and dying, is both important and difficult, and may be improved with training. This discussion presents the results of recent nursing research to confirm, and elaborate on, this theme. In this research participants touched on many central issues in communicating with patients that included articulating a sense of discomfort and inadequacy about the whole process, detailing the innumerable blocks to open communication [e.g., interference, denial, unrealistic optimism, resistance, collusion and anger] and sharing their sense of success and failure. The insights of nurses who participated in this research testify to the ongoing need to prioritize the development of nursing skills and support in this challenging but important area.

Mediating conflict and control : practice challenges for nurses working in palliative care

A work-based professional development program was offered to a group of registered nurses working in palliative care. The goal of the program was to improve skills in psychosocial care (Yates et al., 1996). Participants were encouraged to reflect critically on their practice experience within a group setting. The focus of the group discussion and reflection were shared practice incidents. Each participant was given the opportunity to identify and describe an incident from their professional practice that presented a challenging issue within palliative nursing. This paper explores the themes of conflict and control, evident within the collection of fifteen practice incidents and discusses the nurses role as mediator. The concepts of patient advocacy and professional autonomy are challenged through the nurses experience of providing care within a hierarchical and bureaucratic health service. The outcome of reflection for the organization is most effective when shared experience and collective action (rather than individual practice) are the focus.