Air quality and its impact on health: focus on particulate matter

Inadequate air quality and the inhalation of airborne pollutants pose many risks to human health and wellbeing, and are listed among the top environmental risks worldwide. The importance of outdoor air quality was recognised in the 1950s and indoor air quality emerged as an issue some time later and was soon recognised as having an equal, if not greater importance than outdoor air quality. Identification of ambient air pollution as a health hazard was followed by steps, undertaken by a broad range of national and international professional and government organisations, aimed at reduction or elimination of the hazard. However, the process of achieving better air quality is still in progress. The last 10 years or so have seen an unprecedented increase in the interest in, and attention to, airborne particles, with a special focus on their finer size fractions, including ultrafine (< 0.1 m) and their subset, nano particles (< 0.05 m). This paper discusses the current status of scientific knowledge on the links between air quality and health, with a particular focus on airborne particulate matter, and the directions taken by national and international bodies to improve air quality.

Multiple types of child maltreatment and adolescent mental health in Viet Nam

Objective To examine the prevalence of multiple types of maltreatment (MTM), potentially confounding factors and associations with depression, anxiety and self-esteem among adolescents in Viet Nam. Methods In 2006 we conducted a cross-sectional survey of 2591 students (aged 12–18 years; 52.1% female) from randomly-selected classes in eight secondary schools in urban (Hanoi) and rural (Hai Duong) areas of northern Viet Nam (response rate, 94.7%). Sequential multiple regression analyses were performed to estimate the relative influence of individual, family and social characteristics and of eight types of maltreatment, including physical, emotional and sexual abuse and physical or emotional neglect, on adolescent mental health. Findings Females reported more neglect and emotional abuse, whereas males reported more physical abuse, but no statistically significant difference was found between genders in the prevalence of sexual abuse. Adolescents were classified as having nil (32.6%), one (25.9%), two (20.7%), three (14.5%) or all four (6.3%) maltreatment types. Linear bivariate associations between MTM and depression, anxiety and low self-esteem were observed. After controlling for demographic and family factors, MTM showed significant independent effects. The proportions of the variance explained by the models ranged from 21% to 28%. Conclusion The combined influence of adverse individual and family background factors and of child maltreatment upon mental health in adolescents in Viet Nam is consistent with research in non-Asian countries. Emotional abuse was strongly associated with each health indicator. In Asian communities where child abuse is often construed as severe physical violence, it is important to emphasize the equally pernicious effects of emotional maltreatment.

Access and Quality of Heart Failure Management Programs in Australia

Background/aim In response to the high burden of disease associated with chronic heart failure (CHF), in particular the high rates of hospital admissions, dedicated CHF management programs (CHF-MP) have been developed. Over the past five years there has been a rapid growth of CHF-MPs in Australia. Given the apparent mismatch between the demand for, and availability of CHF-MPs, this paper has been designed to discuss the accessibility to and quality of current CHF-MPs in Australia. Methods The data presented in this report has been combined from the research of the co-authors, in particular a review of the inequities in access to chronic heart failure which utilised geographical information systems (GIS) and the survey of heterogeneity in quality and service provision in Australian. Results Of the 62 CHF-MPs surveyed in this study 93% (58) centres had been located areas that are rated as Highly Accessible. This result indicated that most of the CHF-MPs have been located in capital cities or large regional cities. Six percent (4 CHF-MPs) had been located in Accessible areas which were country towns or cities. No CHF-MPs had been established outside of cities to service the estimated 72,000 individuals with CHF living in rural and remote areas. 16% of programs recruited NYHA Class I patients and of these 20% lacked confirmation (echocardiogram) of their diagnosis. Conclusion Overall, these data highlight the urgent need to provide equitable access to CHF-MP's. When establishing CHF-MPs consideration of current evidence based models to ensure quality in practice.

Psychometric properties of the parents' fever management scale in a Turkish population

Aim: This paper reports a study designed to assess the psychometric properties (validity and reliability) of a Turkish version of the Australian Parents’ Fever Management Scale (PFMS). Background: Little is known about childhood fever management among Turkish parents. No scales to measure parents’ fever management practices in Turkey are available. Design: This is a methodological study. Methods: Eighty parents, of febrile children aged six months to five years, were randomly selected from the paedaitric hospital and two community family health centers in Sakarya, Turkey. The PFMS was back translated; language equivalence and content validity were validated. PFMS and socio-demographic data were collected in 2009. Means and standard deviations were calculated for interval level data and p values greater than 0.05 were considered statistically significant. Unrotated principal component analysis was used to determine construct validity and Cronbach’s coefficient alpha determined the internal consistency reliability. Results: The PFMS was psychometrically sound in this population. Construct validity, confirmed by confirmatory factor analysis [KMO 0.812, Bartlett’s Specificity (χ² = 182.799, df=28, P < 0·001)] revealed the Turkish version to be comprised of the eight original PFMS items. Internal consistency reliability coefficient was 0.80 and the scale’s total-item correlation coefficients ranged from 0.15 to 0.66 and were significant (p<0.001). Interestingly parents reported high scores on the PFMS 34.52±4.60 (range 8-40 with 40 indicating a high burden of care for febrile children). Conclusion: The PFMS was as psychometrically robust in a Turkish population as in an Australian population and is, therefore, a useful tool for health professionals to identify parents’ practices, provide targeted education thereby in reducing the unnecessary burden of care they place on themselves when caring for a febrile child. Relevance to clinical practice. Testing in different populations, cultures and healthcare systems will further assist in reporting the PFMS usefulness in clinical practice and research.

Palliative care challenges : implications for nurses' practice in renal settings

The very act of withdrawing dialysis places renal nurses in a unique practice setting requiring a sudden shift in care delivery from one of providing Ife-sustaining, active treatment to that of palliation. The impact of this act on the renal nurse remains largely invisible. Minimal research has been conducted that explores the significant issues and challenges that exist for renal nurses in the delivery of palliation following withdrawal of dialysis treatment. This paper attempts to highlight the issues and challenges that do exist for renal nurses in providing palliation and the subsequent lack of available research knowledge to inform practice in the renal setting. It recommends further research be conducted into the renal setting so as to inform the development of appropriate education to support renal nurses practice in the future.

A qualitative study of older adults’ responses to sitting-time questions : do we get the information we want?

Background: In the last decade, there has been increasing interest in the health effects of sedentary behavior, which is often assessed using self-report sitting-time questions. The aim of this qualitative study was to document older adults’ understanding of sitting-time questions from the International Physical Activity (PA) Questionnaire (IPAQ) and the PA Scale for the Elderly (PASE). Methods: Australian community-dwelling adults aged 65+ years answered the IPAQ and PASE sitting questions in face-to-face semi-structured interviews. IPAQ uses one open-ended question to assess sitting on a weekday in the last 7 days 'at work, at home, while doing coursework and during leisure time'; PASE uses a three-part closed question about daily leisure-time sitting in the last 7 days. Participants expressed their thoughts out loud while answering each question. They were then probed about their responses. Interviews were recorded, transcribed and coded into themes. Results: Mean age of the 28 male and 27 female participants was 73 years (range 65-89). The most frequently reported activity was watching TV. For both questionnaires, many participants had difficulties understanding what activities to report. Some had difficulty understanding what activities should be classified as ‘leisure-time sitting’. Some assumed they were being asked to only report activities provided as examples. Most reported activities they normally do, rather than those performed on a day in the previous week. Participants used a variety of strategies to select ‘a day’ for which they reported their sitting activities and to calculate sitting time on that day. Therefore, many different ways of estimating sitting time were used. Participants had particular difficulty reporting their daily sitting-time when their schedules were not consistent across days. Some participants declared the IPAQ sitting question too difficult to answer. Conclusion: The accuracy of older adults’ self-reported sitting time is questionable given the challenges they have in answering sitting-time questions. Their responses to sitting-time questions may be more accurate if our recommendations for clarifying the sitting domains, providing examples relevant to older adults and suggesting strategies for formulating responses are incorporated. Future quantitative studies should include objective criterion measures to assess validity and reliability of these questions.

Grounded theory : a methodological spiral from positivism to postmodernism

Aim. Our aim in this paper is to explain a methodological/methods package devised to incorporate situational and social world mapping with frame analysis, based on a grounded theory study of Australian rural nurses' experiences of mentoring. Background. Situational analysis, as conceived by Adele Clarke, shifts the research methodology of grounded theory from being located within a postpositivist paradigm to a postmodern paradigm. Clarke uses three types of maps during this process: situational, social world and positional, in combination with discourse analysis. Method. During our grounded theory study, the process of concurrent interview data generation and analysis incorporated situational and social world mapping techniques. An outcome of this was our increased awareness of how outside actors influenced participants in their constructions of mentoring. In our attempts to use Clarke's methodological package, however, it became apparent that our constructivist beliefs about human agency could not be reconciled with the postmodern project of discourse analysis. We then turned to the literature on symbolic interactionism and adopted frame analysis as a method to examine the literature on rural nursing and mentoring as secondary form of data. Findings. While we found situational and social world mapping very useful, we were less successful in using positional maps. In retrospect, we would argue that collective action framing provides an alternative to analysing such positions in the literature. This is particularly so for researchers who locate themselves within a constructivist paradigm, and who are therefore unwilling to reject the notion of human agency and the ability of individuals to shape their world in some way. Conclusion. Our example of using this package of situational and social worlds mapping with frame analysis is intended to assist other researchers to locate participants more transparently in the social worlds that they negotiate in their everyday practice. © 2007 Blackwell Publishing Ltd.

Live my work : rural nurses and their multiple perspectives of self

Aim. This paper is a report of a study to explore rural nurses' experiences of mentoring. Background. Mentoring has recently been proposed by governments, advocates and academics as a solution to the problem for retaining rural nurses in the Australian workforce. Action in the form of mentor development workshops has changed the way that some rural nurses now construct supportive relationships as mentoring. Method. A grounded theory design was used with nine rural nurses. Eleven semi-structured interviews were conducted in various states of Australia during 2004-2005. Situational analysis mapping techniques and frame analysis were used in combination with concurrent data generation and analysis and theoretical sampling. Findings. Experienced rural nurses cultivate novices through supportive mentoring relationships. The impetus for such relationships comes from their own histories of living and working in the same community, and this was termed 'live my work'. Rural nurses use multiple perspectives of self in order to manage their interactions with others in their roles as community members, consumers of healthcare services and nurses. Personal strategies adapted to local context constitute the skills that experienced rural nurses pass-on to neophyte rural nurses through mentoring, while at the same time protecting them through troubleshooting and translating local cultural norms. Conclusion. Living and working in the same community creates a set of complex challenges for novice rural nurses that are better faced with a mentor in place. Thus, mentoring has become an integral part of experienced rural nurses' practice to promote staff retention. © 2007 The Authors.

Schizophrenia and the progression of emotional expression in relation to others

Gaining an improved understanding of people diagnosed with schizophrenia has the potential to influence priorities for therapy. Psychosis is commonly understood through the perspective of the medical model. However, the experience of social context surrounding psychosis is not well understood. In this research project we used a phenomenological methodology with a longitudinal design to interview 7 participants across a 12-month period to understand the social experiences surrounding psychosis. Eleven themes were explicated and divided into two phases of the illness experience: (a) transition into emotional shutdown included the experiences of not being acknowledged, relational confusion, not being expressive, detachment, reliving the past, and having no sense of direction; and (b) recovery from emotional shutdown included the experiences of being acknowledged, expression, resolution, independence, and a sense of direction. The experiential themes provide clinicians with new insights to better assess vulnerability, and have the potential to inform goals for therapy.

Lessons learnt : complementing good clinical renal questions with an appropriate research strategy

The purpose of this article is to present lessons learnt by nurses when conducting research to encourage colleagues to ask good clinical research questions. This is accomplished by presenting a study designed to challenge current practice which included research flaws. The longstanding practice of weighing renal patients at 0600 hours and then again prior to receiving haemodialysis was examined. Nurses believed that performing the assessment twice, often within a few hours, was unnecessary and that patients were angry when woken to be weighed. An observational study with convenience sampling collected data from 46 individuals requiring haemodialysis, who were repeatedly sampled to provide 139 episodes of data. Although the research hypotheses were rejected, invaluable experience was gained, with research and clinical practice lessons learnt, along with surprising findings.

By the day nurses bank up in a casual pool!

We suspect that the array of silly names used to refer to temporary staff worldwide may be indicative of the extent to which these nurses have been relegated to, and we would argue, remain in, a type of underclass – relatively unsupported by employers in terms of professional practice and ipso facto excluded from contributing professionally to team work, practice development, clinical governance and evidence based practice. This may be acceptable to some but in a climate of risk averseness and in the interests of strategic planning we would suggest it is an accident waiting to happen. The recent UK Royal College of Nursing (RCN) (Ball & Pike, 2006) survey of bank and agency nurses brings a welcome focus on a group of nurses that make a significant contribution to the smooth running of health services in many countries.

Pre-Admission and Post-Hospital Management of Heart Failure in Patients not Enrolled in Specialist Programs

Aim: To review the management of heart failure in patients not enrolled in specialist multidisciplinary programs. Method: A prospective clinical audit of patients admitted to hospital with either a current or past diagnosis of heart failure and not enrolled in a specialist heart failure program or under the direct care of the cardiology unit. Results: 81 eligible patients were enrolled (1 August to 1 October 2008). The median age was 81 9.4 years and 48% were male. Most patients (63%) were in New York Heart Association Class II or Class III heart failure. On discharge, 59% of patients were prescribed angiotensin converting enzyme inhibitors and 43% were prescribed beta-blockers. During hospitalisation, 8.6% of patients with a past diagnosis of heart failure were started on an angiotensin converting enzyme inhibitor and 4.9% on a beta-blocker. There was evidence of suboptimal dosage on admission and discharge for angiotensin converting enzyme inhibitors (19% and 7.4%) and beta-blockers (29% and 17%). The results compared well with international reports regarding the under-treatment of heart failure. Conclusion: The demonstrated practice gap provides excellent opportunities for the involvement of pharmacists to improve the continuation of care for heart failure patients discharged from hospital in the areas of medication management review, dose titration and monitoring.

The Chronic Heart-Failure Assistance by Telephone (CHAT) Study: Assessment of Telephone Support for Vulnerable Patients with Chronic Disease

Aim: To determine whether telephone support using an evidence-based protocol for chronic heart failure (CHF) management will improve patient outcomes and will reduce hospital readmission rates in patients without access to hospital-based management programs. Methods: The rationale and protocol for a cluster-design randomised controlled trial (RCT) of a semi-automated telephone intervention for the management of CHF, the Chronic Heart-failure Assistance by Telephone (CHAT) Study is described. Care is coordinated by trained cardiac nurses located in Heartline, the national call center of the National Heart Foundation of Australia in partnership with patients’ general practitioners (GPs). Conclusions: The CHAT Study model represents a potentially cost-effective and accessible model for the Australian health system in caring for CHF patients in rural and remote areas. The system of care could also be readily adapted for a range of chronic diseases and health systems. Key words: chronic disease management; chronic heart failure; integrated health care systems; nursing care, rural health services; telemedicine; telenursing

A Multifaceted Strategy for Implementation of the Ottawa Ankle Rules in Two Emergency Departments

Problem Despite widespread acceptance of the Ottawa ankle rules for assessment of acute ankle injuries, their application varies considerably. Design Before and after study. Background and setting Emergency departments of a tertiary teaching hospital and a community hospital in Australia. Key measures for improvement Documentation of the Ottawa ankle rules, proportion of patients referred for radiography, proportion of radiographs showing a fracture. Strategies for change Education, a problem specific radiography request form, reminders, audit and feedback, and using radiographers as “gatekeepers.” Effects of change Documentation of the Ottawa ankle rules improved from 57.5% to 94.7% at the tertiary hospital, and 51.6% to 80.8% at the community hospital (P<0.001 for both). The proportion of patients undergoing radiography fell from 95.8% to 87.2% at the tertiary hospital, and from 91.4% to 78.9% at the community hospital (P<0.001 for both). The proportion of radiographs showing a fracture increased from 20.4% to 27.1% at the tertiary hospital (P=0.069), and 15.2% to 27.2% (P=0.002) at the community hospital. The missed fracture rate increased from 0% to 2.9% at the tertiary hospital and from 0% to 1.6% at the community hospital compared with baseline (P=0.783 and P=0.747). Lessons learnt Assessment of case note documentation has limitations. Clinician groups seem to differ in their capacity and willingness to change their practice. A multifaceted change strategy including a problem specific radiography request form can improve the selection of patients for radiography.

What We Have Here is a Failure to Communicate! Improving Communication between Tertiary to Primary Care for Chronic Heart Failure Patients

Background:  The aims of this study were to determine the documentation of pharmacotherapy optimization goals in the discharge letters of patients with the principal diagnosis of chronic heart failure. Methods:  A retrospective practice audit of 212 patients discharged to the care of their local general practitioner from general medical units of a large tertiary hospital. Details of recommendations regarding ongoing pharmacological and non-pharmacological management were reviewed. The doses of medications on discharge were noted and whether they met current guidelines recommending titration of angiotensin-converting enzyme inhibitors and beta-blockers. Ongoing arrangements for specialist follow up were also reviewed. Results:  The mean age of patients whose letters were reviewed was 78.4 years (standard deviation ± 8.6); 50% were men. Patients had an overall median of six comorbidities and eight regular medications on discharge. Mean length of stay for each admission was 6 days. Discharge letters were posted a median of 4 days after discharge, with 25% not posted at 10 days. No discharge letter was sent in 9.4% (20) of the cases. Only six (2.8%) letters had any recommendations regarding future titration of angiotensin-converting enzyme inhibitors and 6.6% (14) for beta-blockers. Recommendations for future non-pharmacological management, for example, diuretic action plans, regular weight monitoring and exercise plans were not found in the letters in this audit. Conclusion:  Hospital discharge is an opportunity to communicate management plans for treatment optimization effectively, and while this opportunity is spurned, implementation gaps in the management of cardiac failure will probably remain.