Encouraging, assisting, and time to eat : comparison of mealtime assistance interventions in elderly medical inpatients

BACKGROUND: The prevalence of protein-energy malnutrition in older adults is reported to be as high as 60% and is associated with poor health outcomes. Inadequate feeding assistance and mealtime interruptions may contribute to malnutrition and poor nutritional intake during hospitalisation. Despite being widely implemented in practice in the United Kingdom and increasingly in Australia, there have been few studies examining the impact of strategies such as Protected Mealtimes and dedicated feeding assistant roles on nutritional outcomes of elderly inpatients. AIMS: The aim of this research was to implement and compare three system-level interventions designed to specifically address mealtime barriers and improve energy intakes of medical inpatients aged ≥65 years. This research also aimed to evaluate the sustainability of any changes to mealtime routines six months post-intervention and to gain an understanding of staff perceptions of the post-intervention mealtime experience. METHODS: Three mealtime assistance interventions were implemented in three medical wards at Royal Brisbane and Women's Hospital: AIN-only: Additional assistant-in-nursing (AIN) with dedicated nutrition role. PM-only: Multidisciplinary approach to meals, including Protected Mealtimes. PM+AIN: Combined intervention: AIN + multidisciplinary approach to meals. An action research approach was used to carefully design and implement the three interventions in partnership with ward staff and managers. Significant time was spent in consultation with staff throughout the implementation period to facilitate ownership of the interventions and increase likelihood of successful implementation. A pre-post design was used to compare the implementation and nutritional outcomes of each intervention to a pre-intervention group. Using the same wards, eligible participants (medical inpatients aged ≥65 years) were recruited to the preintervention group between November 2007 and March 2008 and to the intervention groups between January and June 2009. The primary nutritional outcome was daily energy and protein intake, which was determined by visually estimating plate waste at each meal and mid-meal on Day 4 of admission. Energy and protein intakes were compared between the pre and post intervention groups. Data were collected on a range of covariates (demographics, nutritional status and known risk factors for poor food intake), which allowed for multivariate analysis of the impact of the interventions on nutritional intake. The provision of mealtime assistance to participants and activities of ward staff (including mealtime interruptions) were observed in the pre-intervention and intervention groups, with staff observations repeated six months post-intervention. Focus groups were conducted with nursing and allied health staff in June 2009 to explore their attitudes and behaviours in response to the three mealtime interventions. These focus group discussions were analysed using thematic analysis. RESULTS: A total of 254 participants were recruited to the study (pre-intervention: n=115, AIN-only: n=58, PM-only: n=39, PM+AIN: n=42). Participants had a mean age of 80 years (SD 8), and 40% (n=101) were malnourished on hospital admission, 50% (n=108) had anorexia and 38% (n=97) required some assistance at mealtimes. Occasions of mealtime assistance significantly increased in all interventions (p<0.01). However, no change was seen in mealtime interruptions. No significant difference was seen in mean total energy and protein intake between the preintervention and intervention groups. However, when total kilojoule intake was compared with estimated requirements at the individual level, participants in the intervention groups were more likely to achieve adequate energy intake (OR=3.4, p=0.01), with no difference noted between interventions (p=0.29). Despite small improvements in nutritional adequacy, the majority of participants in the intervention groups (76%, n=103) had inadequate energy intakes to meet their estimated energy requirements. Patients with cognitive impairment or feeding dependency appeared to gain substantial benefit from mealtime assistance interventions. The increase in occasions of mealtime assistance by nursing staff during the intervention period was maintained six-months post-intervention. Staff focus groups highlighted the importance of clearly designating and defining mealtime responsibilities in order to provide adequate mealtime care. While the purpose of the dedicated feeding assistant was to increase levels of mealtime assistance, staff indicated that responsibility for mealtime duties may have merely shifted from nursing staff to the assistant. Implementing the multidisciplinary interventions empowered nursing staff to "protect" the mealtime from external interruptions, but further work is required to empower nurses to prioritise mealtime activities within their own work schedules. Staff reported an increase in the profile of nutritional care on all wards, with additional non-nutritional benefits noted including improved mobility and functional independence, and better identification of swallowing difficulties. IMPLICATIONS: The PhD research provides clinicians with practical strategies to immediately introduce change to deliver better mealtime care in the hospital setting, and, as such, has initiated local and state-wide roll-out of mealtime assistance programs. Improved nutritional intakes of elderly inpatients was observed; however given the modest effect size and reducing lengths of hospital stays, better nutritional outcomes may be achieved by targeting the hospital-to-home transition period. Findings from this study suggest that mealtime assistance interventions for elderly inpatients with cognitive impairment and/or functional dependency show promise.

Outsider board activity, ownership structure and firm value : evidence from Korea

Using a sample of publicly listed firm in Korea from 2002 to 2006, this article examines the impact of board monitoring on firm value and productivity. We use outsider's attendance of board meetings as a proxy for board monitoring. Consistent with the commitment hypothesis, we find that outsider's attendance rate increases firm value, suggesting that attending board meeting itself is a strong signal that reflects outsider's intention to monitor insiders. While ownership of controlling shareholders negatively affects firm value, this relationship is not moderated by increased monitoring by outsiders. Our findings provide further evidence that the outside director system is less effective in chaebol-affiliated firms. Results also indicate that the effect of outsider's board monitoring activity on investor's valuation of the firm is greater than on productivity improvement of the firm. Our conclusions are robust for possible endogeneity in the relationship between firm value and board attendance by outside directors.

Sustainability of a successful health and nutrition program in a remote Aboriginal community

OBJECTIVE: To assess the long term effect of a nutrition program in a remote Aboriginal community (Minjilang). DESIGN: Evaluation of nutritional outcomes over the three years before and the three years after a health and nutrition program that ran from June 1989 to June 1990. Turnover of food items at the community store was used as a measure of dietary intake at Minjilang and a comparison community. SETTING: A community of about 150 Aboriginal people live at Minjilang on Croker Island, 240 km north-east of Darwin. A similar community of about 300 people on another island was used as the comparison. RESULTS: The program produced lasting improvements in dietary intake of most target foods (including fruit, vegetables and wholegrain bread) and nutrients (including folate, ascorbic acid and thiamine). Sugar intake fell in both communities before the program, but the additional decrease in sugar consumption during the program at Minjilang "rebounded" in the next year. Dietary improvements in the comparison community were delayed and smaller than at Minjilang. CONCLUSIONS: The success of the program at Minjilang was linked to an ongoing process of social change, which in turn provided a stimulus for dietary improvement in the comparison community. When Aboriginal people themselves control and maintain ownership of community-based intervention programs, nutritional improvements can be initiated and sustained.

‘Doing’ social justice in early childhood : the potential of leadership

Early childhood education has long been connected with objectives related to social justice. Australian Early Childhood Education and Care (ECEC) has its roots in philanthropic and educational reform movements prevalent at the turn of the 20th century. More recently, with the introduction of the National Early Childhood Reform Agenda, early childhood education has once more been linked to the achievement of aims associated with redressing inequality and disadvantage. According to Jean-Marie, Normore and Brooks (2009), educational leaders have a moral and social obligation to foster equitable practices through advocating for traditionally marginalised and poorly served students while creating a new social order “...that subverts the long standing system that has privileged certain students while oppressing or neglecting others” (p.4). Drawing on extant literature, including data from two previously reported Australian studies in which leadership emerged as having a transformational impact on service delivery, this paper examines the potential of early childhood leadership to generate ‘socially just’ educational communities. With reference to critical theory, we argue that critically informed, intentional and strategic organisational leadership can play a pivotal role in creating changed circumstances and opportunities for children and families. Such leadership includes positional and distributed elements, articulation of values and beliefs, and collective action that is mindful and informed.

Children's perspectives on values and rules in Australian early education

In recent years, issues relating to moral and conventional values have been emphasized in educational policies. This study examines young children’s (100 children aged 4–8 years) own understandings of values and rules for how to treat others and participate in school. Eleven classrooms, within seven different elementary schools in Queensland, were visited. Children were interviewed regarding their views about moral and conventional issues, rules and participation in everyday school life. According to the children, ‘doing the right thing’ in school involved both a concern for others’ wellbeing and for the social order in school, including conventions, rules and behaviour connected with discipline. The children’s responsibility seemed, however, to be to adapt to the (school) system, rather than being an active participant in constructing the system.

Narratives of possession : reading for saga authorship

The aim of this thesis is to show how character analysis can be used to approach conceptions of saga authorship in medieval Iceland. The idea of possession is a metaphor that is adopted early in the thesis, and is used to describe Icelandic sagas as works in which traditional material is subtly interpreted by medieval authors. For example, we can say that if authors claim greater possession of the sagas, they interpret, and not merely record, the sagas' historical information. On the other hand, tradition holds onto its possession of the narrative whenever it is not possible for an author to develop his own creative and historical interests. The metaphor of possession also underpins the character analysis in the thesis, which is based on the idea that saga authors used characters as a vehicle by which to possess saga narratives and so develop their own historical interests. The idea of possession signals the kinds of problems of authorship study which are addressed here, in particular, the question of the authors' sense of saga writing as an act either of preservation or of creation. While, in that sense, the thesis represents an additional voice in a long-standing debate about the saga writers' relation to their source materials, I argue against a clear-cut distinction between creative and non-creative authors, and focus instead on the wide variation in authorial control over saga materials. This variation suggests that saga authorship is a multi-functional activity, or one which co-exists with tradition. Further, by emphasising characterisation as a method, I am adding to the weight of scholarship that seeks to understand the sagas in terms of their literary effects. The Introduction and chapter one lay out the theoretical scope of this thesis. My aim in these first two sections is to inform the reader of the type of critical questions that arise when authorship is approached in relation to characterisation, and to suggest an interpretive framework with which to approach these questions. In the Introduction this aim manifests as a brief discussion of the application of the term "authorship" to the medieval Icelandic corpus, a definition of the scope of this study, and an introduction to the connections, made throughout this thesis, between saga authors, the sagas' narrative style, and the style of characterisation in the sagas. Chapter one is a far more detailed discussion of our ability to make these connections. In particular, the chapter develops the definition of the analytical term "secondary authorship" that I introduce in order to delineate the type of characterisation that is of most interest in this thesis. "Secondary authorship" is a literary term that aims to sharpen our approach to saga authors' relationship to their characters by focusing on characters who make representations about the events of the saga. The term refers to any instance in which characters behave in a manner that resembles the creativity, interpretation, and understanding associated with authorship more generally. Character analysis cannot, however, be divorced from socio-historical approaches to the saga corpus. Most importantly, the sagas themselves are socio-historical representations that claim some degree of truth value. This claim that the sagas make by implication about their historicity is the starting point of a discussion of authorship in medieval Iceland. Therefore, at the beginning of chapter one I discuss some of the approaches to the social context of saga writing. This discussion serves as an introduction to both the culture of saga writing in medieval Iceland and to the nature of the sagas' historical perspective, and reflects my sense that literary interpretations of the sagas cannot be isolated from the historical discourses that frame them. The chapter also discusses possession, which, as I note above, is used alongside the concept of secondary authorship to describe the saga authors' relationship with the stories and characters of the past. At the close of chapter one, I offer a preliminary list the various functions of saga authorship, and give some examples of secondary authorship. From this point I am able to tie my argument about secondary authorship to specific examples from the sagas. Chapter two examines the effect of family obligations and domestic points of view in the depiction of characters' choices and conception of themselves. The examples that are given in that chapter - from Gisla saga Súrssonar and Íslendinga saga - are the first of a number of textual analyses that demonstrate the application of the concepts of secondary authorship and possession of saga narratives. The relationship between narratives about national and domestic matters shows how authorial creativity in the area of kinship obligation provides the basis for the saga's development of historical themes. Thus, the two major case studies given in chapter two tie authorial engagement with characters to the most influential social institution in early and medieval Iceland, the family. The remaining chapters represent similar attempts to relate authorial possession of saga characters to central socio-historical themes in the sagas, such as the settlement process in early Iceland and its influence on the development of regional political life (chapter three). Likewise, the strong authorial interest in an Icelander's journey to Norway in Heimskringla is presented as evidence of the author's use of a saga character to express an Icelandic interpretation of Norwegian history and to promote a sense that Iceland shared the ownership of regal history with Norway (chapter four). In that authorial engagement with the Icelander abroad, we witness saga characterisation being used as a basis for historical interpretation and the means by which foreign traditions and influence, not least the narratives of royal lives and of the Christianisation, are claimed as part of medieval Icelanders' self-conception. While saga authors observe the conventions of saga narration, characters are often subtly positioned as the authors' interpretive mirrors, especially clear than when they act as secondary authors. Nowhere is this more apparent than in Brennu- Njáls saga, which contains many characters who voice the author's claim to interpret the past. Even Hrútr Herjólfsson, through his remarkable perception of events and his conspicuous comments about them, acts as a secondary author by enabling the author to emphasise the importance of the disposition of characters. In Laxdœla saga and Þorgils saga ok Hafliða, authorial interest in characters' perception is matched by the thematising of learning, from the inception of knowledge as prophecy or advice to complete understanding by saga characters (chapter six). In Þorgils saga skarða, a character's inner development from an excessively ambitious and politically ruthless youth to a Christian leader killed by his kinsman allows the author to shape a political life into a lesson about leadership and the community's ability to moderate and contain the behaviour of extraordinary individuals. The portrayal draws on methods of characterisation that we can identify in Grettis saga Ásmundarson, Fóstbrœðra saga, and Orkneyinga saga. A comparison of the characterisation of figures with intense political or military ambitions suggests that saga authors were interested in the community's ability to balance their strength and ability with a degree of social moderation. The discussion of these sagas shows that character study can be used to analyse how the saga authors added their own voice to the voices passed down to medieval Icelanders in traditional narratives. Authorial engagement with characters allowed inherited traditions about early Norway and Iceland and records of thirteenth century events to be transformed into sophisticated historical works with highly creative elements. Through secondary authorship, saga authors took joint-possession of narratives and contested the power of tradition in setting the interpretive framework of a saga.

Jurisprudential Challenges to the Protection of the Natural Environment

Nature exists. Humans exist. The behaviour of one impacts upon the other. The behaviour of humans is governed by the artificial contrivance described as the law. While the law can in this way control the behaviour of humans and the impact that human behaviour has on nature, the behaviour of nature is governed – if at all- in accordance with nature’s own sets of values which are quintessentially a matter for nature. The relationship between nature and humans may be the object of rules of law, but traditional legal doctrine dictates that humans but not nature are the subjects of the rules of law. The jurisprudence of the earth – it would appear – seeks to equalise in the eyes of the law nature as part of the global environment and humans as part of the global environment. How might this be done?

Degree of value alignment : a grounded theory of rural nurse resignations

INTRODUCTION: The shortage of nurses willing to work in rural Australian healthcare settings continues to worsen. Australian rural areas have a lower retention rate of nurses than metropolitan counterparts, with more remote communities experiencing an even higher turnover of nursing staff. When retention rates are lower, patient outcomes are known to be poorer. This article reports a study that sought to explore the reasons why registered nurses resign from rural hospitals in the state of New South Wales, Australia. METHODS: Using grounded theory methods, this study explored the reasons why registered nurses resigned from New South Wales rural hospitals. Data were collected from 12 participants using semi-structured interviews; each participant was a registered nurse who had resigned from a rural hospital. Nurses who had resigned due to retirement, relocation or maternity leave were excluded. Interviews were transcribed verbatim and imported into NVivo software. The constant comparative method of data collection and analysis was followed until a core category emerged. RESULTS: Nurses resigned from rural hospitals when their personal value of how nursing should occur conflicted with the hospital's organisational values driving the practice of nursing. These conflicting values led to a change in the degree of value alignment between the nurse and hospital. The degree of value alignment occurred in three dynamic stages that nurses moved through prior to resigning. The first stage, sharing values, was a time when a nurse and a hospital shared similar values. The second stage was conceding values where, due to perceived changes in a hospital's values, a nurse felt that patient care became compromised and this led to a divergence of values. The final stage was resigning, a stage where a nurse 'gave up' as they felt that their professional integrity was severely compromised. The findings revealed that when a nurse and organisational values were not aligned, conflict was created for a nurse about how they could perform nursing that aligned with their internalised professional values and integrity. Resignation occurred when nurses were unable to realign their personal values to changed organisational values - the organisational values changed due to rural area health service restructures, centralisation of budgets and resources, cumbersome hierarchies and management structures that inhibited communication and decision making, out-dated and ineffective operating systems, insufficient and inexperienced staff, bullying, and a lack of connectedness and shared vision. CONCLUSIONS: To fully comprehend rural nurse resignations, this study identified three stages that nurses move through prior to resignation. Effective retention strategies for the nursing workforce should address contributors to a decrease in value alignment and work towards encouraging the coalescence of nurses' and hospitals' values. It is imperative that strategies enable nurses to provide high quality patient care and promote a sense of connectedness and a shared vision between nurse and hospital. Senior managers need to have clear ways to articulate and imbue organisational values and be explicit in how these values accommodate nurses' values. Ward-level nurse managers have a significant responsibility to ensure that a hospital's values (both explicit and implicit) are incorporated into ward culture.

Building community capacity for end of life : an investigation of community capacity and its implications for health-promoting palliative care in the Australian Capital Territory

This study identified and examined community-based activities around death, dying and end-of-life care which might reflect a health-promoting palliative care (HPPC) philosophy. This approach is argued to restore community ownership of, and agency in, dying and death through the building of community capacity. However, the enactment of the HPPC approach has not been extensively examined in Australia. Current understandings of community capacity-building relating to end of life are orientated toward service provision. A qualitative interpretive approach was used to engage with local community groups in the Australian Capital Territory with an interest in death, dying and end-of-life care. Data were collected from ten in-depth, semi-structured interviews and thematically analysed. The themes of Practical Support, Respect and Responsiveness and Connection and Empowerment were identified, reflecting community activities initiated in response to the experience of life-limiting illness. Building community capacity offers to restore community agency in end-of-life concerns, while potentially enhancing health service provision through collaborative partnerships. This study indicates an existing community capacity, demonstrated by activities that promote socialisation, peer support and normalisation of death and dying. However, as these activities occur primarily in response to illness, proactive and preparatory interventions in HPPC are a priority.

Conceptual beliefs about human values and their implications: Human nature beliefs predict value importance, value trade-offs, and responses to value-laden rhetoric

Beliefs that may underlie the importance of human values were investigated in 4 studies, drawing on research that distinguishes natural-kind (natural), nominal-kind (conventional), and artifact (functional) beliefs. Values were best characterized by artifact and nominal-kind beliefs, as well as a natural-kind belief specific to the social domain, “human nature” (Studies 1 and 2). The extent to which values were considered central to human nature was associated with value importance in both Australia and Japan (Study 2), and experimentally manipulating human nature beliefs influenced value importance (Study 3). Beyond their association with importance, human nature beliefs predicted participants’ reactions to value trade-offs (Study 1) and to value-laden rhetorical statements (Study 4). Human nature beliefs therefore play a central role in the psychology of values.

The implicit structure of positive characteristics

The implicit structure of positive character traits was examined in two studies of 190 and 100 undergraduates. Participants judged the pairwise covariation or semantic similarity of 42 positive characteristics using a sorting or a rating task. Characteristics were drawn from a new classification of strengths and virtues, the Five-Factor Model, and a taxonomy of values. Participants showed consistent patterns of perceived association among the characteristics across the study conditions. Multidimensional scaling yielded three consistent dimensions underlying these judgments (“warmth vs. self-control,” “vivacity vs. decency,” and “wisdom vs. power”). Cluster analyses yielded six consistent groupings—“self-control,” “love,” “wisdom,” “drive,” “vivacity,” and “collaboration”—that corresponded only moderately to the virtue classification. All three taxonomies were systematically related to this implicit structure, but none captured it satisfactorily on its own. Revisions to positive psychology’s classification of strengths are proposed.

The legacy of David Unaipon

The historical case of David Unaipon is a good starting point for a wider discussion of Indigenous intellectual property law, practice and reform. His story is a microcosm of larger battles over the cultural appropriation of Indigenous culture, iconography and science. David Unaipon could be seen as a beneficiary of intellectual property law. He is a creator of copyright works; an inventor of patented inventions; and an iconic figure, worthy of personality rights. His creative and scientific work has been an inspiration for others. David Unaipon could also be seen as being disenfranchised by intellectual property law. He lost ownership of his economic rights in respect of literary works; and his moral rights have not been respected under copyright law. His case also highlights the deficiencies of copyright law in respect of its failure to provide comprehensive recognition of communal authorship and ownership of copyright works. While he was a patent applicant, David Unaipon never seemed to have benefitted from the patent system. His experience raises questions about access to justice. The government and commercial use of the persona of David Unaipon raises complex questions about trade mark law, passing off and personality rights. The story of David Unaipon highlights the need for the systematic and holistic reformation of intellectual property law, so that it better serves Indigenous communities and peoples.

Free Sherlock: The copyright battle of Baker Street

Sherlock Holmes faces his greatest challenge – since his fight to the death with Professor James Moriarty at Reichenbach Falls. Who owns Sherlock Holmes, the world’s greatest detective? Is it the estate of Sir Arthur Conan Doyle? Or the mysterious socialite Andrea Plunket? Or does Sherlock Holmes belong to the public? This is the question currently being debated in copyright litigation in the United States courts, raising larger questions about copyright law and the public domain, the ownership of literary characters, and the role of sequels, adaptations, and mash-ups.

The Pirate Bazaar: The Social Life of Copyright Law

This thesis provides a cultural history of Australian copyright law and related artistic controversies. It examines a number of disputes over authorship, collaboration, and appropriation across a variety of cultural fields. It considers legal controversies over the plagiarism of texts, the defacing of paintings, the sampling of musical works, the ownership of plays, the co-operation between film-makers, the sharing of MP3 files on the Internet, and the appropriation of Indigenous culture. Such narratives and stories relate to a broad range of works and subject matter that are protected by copyright law. This study offers an archive of oral histories and narratives of artistic creators about copyright law. It is founded upon interviews with creative artists and activists who have been involved in copyright litigation and policy disputes. This dialogical research provides an insight into the material and social effects of copyright law. This thesis concludes that copyright law is not just a ‘creature of statute’, but it is also a social and imaginative construct. In the lived experience of the law, questions of aesthetics and ethics are extremely important. Industry agreements are quite influential. Contracts play an important part in the operation of copyright law. The media profile of personalities involved in litigation and policy debates is pertinent. This thesis claims that copyright law can be explained by a mix of social factors such as ethical standards, legal regulations, market forces, and computer code. It can also be understood in terms of the personal stories and narratives that people tell about litigation and copyright law reform. Table of Contents Prologue 1 Introduction A Creature of Statute: Copyright Law and Legal Formalism 6 Chapter One The Demidenko Affair: Copyright Law and Literary Works 33 Chapter Two Daubism: Copyright Law and Artistic Works 67 Chapter Three The ABCs of Anarchism: Copyright Law and Musical Works 105 Chapter Four Heretic: Copyright Law and Dramatic Works 146 Chapter Five Shine: Copyright Law and Film 186 Chapter Six Napster: Infinite Digital Jukebox or Pirate Bazaar? Copyright Law and Digital Works 232 Chapter Seven Bangarra Dance Theatre: Copyright Law and Indigenous Culture 275 Chapter Eight The Cathedral and the Bazaar: The Future of Copyright Law 319

A study of governance arrangements for land use and natural resource management planning in Cape York Peninsula

Complex intersecting social, economic and environmental dilemmas in Australia's Cape York Peninsula present a number of challenges for planners seeking to develop and implement land use and natural resource management (NRM) plans. There have been five different attempts at land use and NRM planning in Cape York Peninsula over the last 20 years. These processes have (to greater or lesser extents) failed to deliver community-owned and government-supported plans to guide development and/or the management of the region's natural resources. The region is remote, sparsely populated, and home to a significant Indigenous population. Much of the contestation within the region surrounds the access, use and ownership of the region's internationally valuable natural resources. This paper reviews, from the literature, the relevancy and applicability of criteria for best practice planning and governance. A range of identified best practice governance and planning principles are applied to assess the governance arrangements for planning in the Peninsula. The paper finds that decision-making arrangements for land use and NRM planning in the Peninsula are still in their infancy and are inadequate to support effective outcomes. The paper concludes that broader attention to best practice principles in governance for planning is needed to improve planning outcomes.