Ethical challenges associated with providing continence care in residential aged care facilities : findings from a grounded theory study

A person-centred approach to care in residential aged care facilities should uphold residents’ rights to independence, choice, decision-making, participation, and control over their lifestyle. Little is known about how nurses and personal care assistants working in these facilities uphold these ideals when assisting residents maintain continence and manage incontinence. The overall aim of the study was to develop a grounded theory to describe and explain how Australian residents of aged care facilities have their continence care needs determined, delivered and communicated. This paper presents and discusses a subset of the findings about the ethical challenges nurses and personal care assistants encountered whilst providing continence care. Grounded theory methodology was used for in-depth interviews with 18 nurses and personal care assistants who had experience of providing, supervising or assessing continence care in any Australian residential aged care facility, and to analyse 88 hours of field observations in two facilities. Data generation and analysis occurred simultaneously using open coding, theoretical coding, and selective coding, until data were saturated. While addressing the day-to-day needs of residents who needed help to maintain continence and/or manage incontinence, nurses and personal care assistants struggled to enable residents to exercise choice and autonomy. The main factor that contributed to this problem was that the fact that nurses and personal care assistants had to respond to multiple, competing, and conflicting expectations about residents’ care needs. This situation was compounded by workforce constraints, inadequate information about residents’ care needs, and an unpredictable work environment. Providing continence care accentuated the ethical tensions associated with caregiving. Nurses’ and personal care assistants’ responses were mainly characterised by highly protective behaviours towards residents. Underlying structural factors that hinder high quality continence care to residents of aged care facilities should be urgently addressed.

Differences in health behaviours between immigrant and non-immigrant groups: a protocol for a systematic review

Health behaviours are important determinants of health and adoption of unhealthy behaviour is considered as one of the mechanisms through which immigrants' health changes over time in the host country. The change in health behaviours over time can contribute either to improving or worsening the overall health status of immigrants. Despite being the important mediators for the change in overall health status and chronic health conditions, no previous review (either general or systematic) has examined differences in key health behaviours simultaneously between immigrants and non-immigrants. This study aims to provide a systematic overview of the current global literature on differences in key health behaviours (that is, tobacco smoking, physical activity and alcohol drinking) between immigrant and non-immigrant groups.

Type 2 diabetes care in North Karelia Finland: do area-level socio-economic factors affect processes and outcomes?

This research assessed the impact of area-level socio-economic factors on the prevalence and outcomes of type 2 diabetes in North Karelia, Finland.

Patterns of care in adult medulloblastoma: results of an international online survey

The literature on medulloblastoma in adults is generally limited to case reports and retrospective series, and there is no accepted standard of care. The Cooperative Trials Group for Neuro-Oncology (COGNO) sought to determine the range and consistency of clinicians’ approaches to management as a basis for future trials. We aimed to identify current treatment strategies for adult medulloblastoma through an online survey launched at the 2012 Society of Neuro-Oncology meeting and by email invitation. Clinicians who had treated at least one adult patient with medulloblastoma, primitive neuroectodermal tumor (PNET), or pineoblastoma in the preceding year were asked about their most recent patient and invited to discuss their approach to a typical clinical scenario. Between November 2012 and January 2013, 45 clinicians (11 medical oncologists, 8 radiation oncologists, 5 pediatric oncologists, and 21 others) from Australia (24), United States (3), Europe (4) and other countries (14) completed the survey. Responding clinicians had treated 54 cases in the past 12 months. The most common histological type was medulloblastoma (64 %), then PNET (20 %). Most patients were male (68 %), and had high-risk disease (65 %). Complete surgical resection in 56 and 32 % had molecular testing. Radiotherapy was predominantly cranio-spinal (92 %) and given mostly post-resection (80 %). Combination chemotherapy was more common than single-agent chemotherapy. The choice of chemotherapy varied considerably. There is substantial variation in the treatment of adult medulloblastoma, most pronounced in the choice of chemotherapeutic agents, highlighting the need for further collaborative research to guide evidence-based treatment strategies.

Qualitative synthesis and systematic review in health professions education

Context  Formal qualitative synthesis is the process of pooling qualitative and mixed-method research data, and then drawing conclusions regarding the collective meaning of the research. Qualitative synthesis is regularly used within systematic reviews in the health professions literature, although such use has been heavily debated in the general literature. This controversy arises in part from the inherent tensions found when generalisations are derived from in-depth studies that are heavily context-dependent.Methods  We explore three representative qualitative synthesis methodologies: thematic analysis; meta-ethnography, and realist synthesis. These can be understood across two dimensions: integrative to interpretative, and idealist to realist. Three examples are used to illustrate the relative strengths and limitations of these approaches.Discussion  Against a backdrop of controversy and diverse methodologies, readers must take a critical stand when reading literature reviews that use qualitative synthesis to derive their findings. We argue that notions of qualitative rigour such as transparency and acknowledgment of the researchers’ stance should be applied to qualitative synthesis.

Structured type 1 diabetes education delivered in routine care in Australia reduces diabetes-related emergencies and severe diabetes-related distress: the OzDAFNE program

AIMS: To evaluate structured type 1 diabetes education delivered in routine practice throughout Australia.

METHODS: Participants attended a five-day training program in insulin dose adjustment and carbohydrate counting between April 2007 and February 2012. Using an uncontrolled before-and-after study design, we investigated: HbA1c (% and mmol/mol); severe hypoglycaemia; diabetes ketoacidosis (DKA) requiring hospitalisation, and diabetes-related distress (Problem Areas in Diabetes scale; PAID), weight (kg); body mass index. Data were collected pre-training and 6-18 months post-training. Change in outcome scores were examined overall as well as between groups stratified by baseline HbA1c quartiles. Data are mean±SD or % (n).

RESULTS: 506 participants had data eligible for analysis. From baseline to follow-up, significant reductions were observed in the proportion of participants reporting at least one severe hypoglycaemic event (24.7% (n=123) vs 12.1% (n=59), p<0.001); and severe diabetes-related distress (29.3% (n=145) vs 12.6% (n=60), p<0.001). DKA requiring hospitalisation in the past year reduced from 4.1% (n=20) to 1.2% (n=6). For those with above target baseline HbA1c there was a small, statistically significant improvement (n=418, 8.4±1.1% (69±12mmol/mol) to 8.2±1.1% (66±12mmol/mol). HbA1c improvement was clinically significant among those in the highest baseline quartile (n=122, 9.7±1.1% (82±11mmol/mol) to 9.0±1.2% (75±13mmol/mol), p<0.001).

CONCLUSIONS: The proportion of participants reporting severe hypoglycaemia, DKA and severe diabetes-related distress was at least halved, and HbA1c reduced by 0.7% (7mmol/mol) among those with highest baseline levels. Structured type 1 diabetes education delivered in routine practice offers clinically important benefits for those with greatest clinical need.

Quality continence care in residential aged care facilities - what should we measure?

The article presents an abstract of a study that uses qualitative research methods to explore key stakeholder perspectives on quality continence care in residential aged care facilities.

Validation of the 12-item partners in health scale to measure patient self-management behaviour and knowledge in Dutch patients with COPD

The 12-item Partner in Health (PIH) scale was developed in Australia to measure self-management behaviour and knowledge in patients with chronic diseases. The scale has undergone several changes since first published. Our study aim was to validate the latest PIH in Dutch COPD patients.The 12 items of the PIH are scored on a self-rated 9-point Likert scale (range: 0-8; higher scores indicate better self-management), providing total and subscale scores (knowledge, coping, recognition and management of functions, adherence to treatment).We used forward-backward translation of the latest version of the Australian PIH. Dimensionality and reliability analyses were performed to investigate the psychometric properties, and to determine whether the Dutch PIH replicated the same four subscales of self-management as the original PIH.Reanalysis of the original PIH validation study (186 Australian patients with chronic diseases) showed a single scale. Two scales (1. knowledge and coping; 2. recognition and management of symptoms, adherence to treatment) were found for the Dutch PIH (118 Dutch COPD patients). The correlation between the two Dutch scales was 0.43. The lower-bound of the reliability of the total scale was 0.81 (Australian PIH) and 0.84 (Dutch PIH).Different scale structures were found for the original Australian and the Dutch PIH. Our results did not support the 4-scale structure reported previously. To increase comparability and generalisability of our findings, the scale structure of the revised Australian PIH needs to be investigated further. Meanwhile, we advise using the PIH total score or two subscale scores when assessing COPD patients.

Inequity in health: older rural driving and dementia

Introduction The number of drivers with dementia is expected to increase exponentially over the coming decades. Most individuals with moderate-to-severe dementia (table 1) are unfit to drive.1 Drivers with moderate-to-severe dementia have higher rates of MVCs than age-matched controls.2 Identifying and preventing these individuals from driving is crucial, particularly in urban areas. The density of cars and pedestrians, and the complexity of traffic typically place greater demands on drivers in urban areas, and, therefore, require greater reactivity and forward planning than in rural environments.3 ,4 The ability to drive is a critical means of maintaining one's social inclusion, and is commonly a practical necessity. Therefore, decisions about the entitlement to drive should not unfairly restrict mobility or unnecessarily compound the disadvantages experienced by older people with mild cognitive impairment and early dementia (table 1), particularly as diagnoses are now being made earlier.1 This paper describes the difficulties inherent in addressing the question of when and in what circumstances a diagnosis of dementia might render a person unfit to drive and focuses on those who live in rural areas. We examine the consequences of dementia diagnosis on driving, driver testing requirements and licensing procedures, and the impacts of driving cessation. We then discuss how living in rural areas may alter the level of risk of drivers with dementia and practical implications for licensing policies.