Implementation of clinical practice guidelines using simulation in education

Background: Underpinning the Department of Human Services (DHS) “Future directions for Victoria’s maternity services” strategy in Victoria, are the principles of achieving the right balance between primary level care and access to appropriate levels of medical care by making the best use of the complementary skills of midwives, GPs and obstetricians. Planning new models of care have exposed a need to upskill many clinicians in providing evidence based pregnancy care. A statewide education program conducts 1 day workshops to multidisciplinary forums in Victoria. The program content is developed with each service and simulation activities are incorporated in the workshop to provide a realistic environment for practising skills related to the implementation of clinical practice guidelines.

Method: Post workshop surveys are completed anonymously by participants using a five point Likert scale to evaluate their experiences in peer learning, the use of simulation, reflective practice and communication skills training. Open ended responses were analysed thematically.

Results: In 2007, 14 workshops were conducted with 254 clinicians attending. The survey response rate was 80%. Participants responded ‘strongly agree’ or ‘agree’ that the workshop: enhanced their ability to access current pregnancy care research and information 193/ 204(95%), challenged them to think more broadly 192/204(94%), provided an opportunity to reflect on their communication skills during the simulation actives 197/201 (96%) and provided a valuable opportunity for observing the communication skills of their peers 197/ 201(98%).

Conclusion: Providing opportunities for peer learning in pregnancy education is valuable and the use of simulation can play an important role in overcoming barriers to implementing guidelines.

To what extent do nurses use research in clinical practice? A systematic review

Background : In the past forty years, many gains have been made in our understanding of the concept of research utilization. While numerous studies exist on professional nurses' use of research in practice, no attempt has been made to systematically evaluate and synthesize this body of literature with respect to the extent to which nurses use research in their clinical practice. The objective of this study was to systematically identify and analyze the available evidence related to the extent to which nurses use research findings in practice.

Methods : This study was a systematic review of published and grey literature. The search strategy included 13 online bibliographic databases: Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, MEDLINE, CINAHL, EMBASE, HAPI, Web of Science, SCOPUS, OCLC Papers First, OCLC WorldCat, ABI Inform, Sociological Abstracts, and Dissertation Abstracts. The inclusion criteria consisted of primary research reports that assess professional nurses' use of research in practice, written in the English or Scandinavian languages. Extent of research use was determined by assigning research use scores reported in each article to one of four quartiles: low, moderate-low, moderate-high, or high.

Results : Following removal of duplicate citations, a total of 12,418 titles were identified through database searches, of which 133 articles were retrieved. Of the articles retrieved, 55 satisfied the inclusion criteria. The 55 final reports included cross-sectional/survey (n = 51) and quasi-experimental (n = 4) designs. A sensitivity analysis, comparing findings from all reports with those rated moderate (moderate-weak and moderate-strong) and strong quality, did not show significant differences. In a majority of the articles identified (n = 38, 69%), nurses reported moderate-high research use.

Conclusions : According to this review, nurses' reported use of research is moderate-high and has remained relatively consistent over time until the early 2000's. This finding, however, may paint an overly optimistic picture of the extent to which nurses use research in their practice given the methodological problems inherent in the majority of studies. There is a clear need for the development of standard measures of research use and robust well-designed studies examining nurses' use of research and its impact on patient outcomes. The relatively unchanged self-reports of moderate-high research use by nurses is troubling given that over 40 years have elapsed since the first studies in this review were conducted and the increasing emphasis in the past 15 years on evidence-based practice. More troubling is the absence of studies in which attempts are made to assess the effects of varying levels of research use on patient outcomes.

Human rights and correctional clinical practice

The formulation of human rights theory and policies represents an ethical advance and promises to supply a framework for resolving ethnic, social, and individual conflicts. Ethics is essentially a means for coordinating the conflicting interests of peoples and nations and human rights provide a strong foundation to do this in multiple domains. Our aim in this paper is to apply a human rights perspective, in association with a justifying theory and set of goods, to the correctional arena. First, we discuss the definition of human rights, their proper analysis and justification. We then apply the results of our discussion to the assessment, treatment, and monitoring of offenders. Finally, we consider the policy, research, and intervention implications of a human rights perspective for correctional practitioners.

A role for glutathione in the pathophysiology of bipolar disorder and schizophrenia? Animal models and relevance to clinical practice.

The tripeptide, glutathione (glutamylcysteinylglycine) is the primary endogenous free radical scavenger in the human body. When glutathione (GSH) levels are reduced there is an increased potential for cellular oxidative stress, characterised by an increase and accruement of reactive oxygen species (ROS). Oxidative stress has been implicated in the pathology of schizophrenia and bipolar disorder. This could partly be caused by alterations in dopaminergic and glutamatergic activity that are implicated in these illnesses. Glutamate and dopamine are highly redox reactive molecules and produce ROS during normal neurotransmission. Alterations to these neurotransmitter pathways may therefore increase the oxidative burden in the brain. Furthermore, mitochondrial dysfunction, as a source of oxidative stress, has been documented in both schizophrenia and bipolar disorder. The combination of altered neurotransmission and this mitochondrial dysfunction leading to oxidative damage may ultimately contribute to illness symptoms. Animal models have been established to investigate the involvement of glutathione depletion in aspects of schizophrenia and bipolar disorder to further characterise the role of oxidative stress in psychopathology. Stemming from preclinical evidence, clinical studies have recently shown antioxidant precursor treatment to be effective in schizophrenia and bipolar disorder, providing a novel clinical angle to augment often suboptimal conventional treatments.

The management of individuals with bipolar disorder : a review of the evidence and its integration into clinical practice

Bipolar disorder is a common, debilitating, chronic illness that emerges early in life and has serious consequences such as long-term unemployment and suicide. It confers considerable functional disability to the individual, their family and society as a whole and yet it is often undetected, misdiagnosed and treated poorly. In the past decade, many new treatment strategies have been trialled in the management of bipolar disorder with variable success. The emerging evidence, for pharmacological agents in particular, is promising but when considered alone does not directly translate to real-world clinical populations of bipolar disorder. Data from drug trials are largely based on findings that identify difterences between groups determined in a time-limited manner, whereas clinical management concerns the treatment of individuals over the life-long course of the illness. Considering the findings in the context of the individual and their particular needs perhaps besl bridges the gap between the evidence from research studies and their application in clinical practice. Specifically, only lithium and valproate have moderate or strong evidence for use across all three phases of bipolar disorder, Anticonvulsants, such as lamotrigine. have strong evidence in maintenance; whereas antipsychotics largely have strong evidence in acute mania, with the exception of quetiapine, which has strong evidence in bipolar depression. Maintenance data for antipsychotics is emerging but at present remains weak. Combinations have strong evidence in acute phases of illness but maintenance data is urgently needed. Conventional antidepressants only have weak evidence in bipolar depression and do not have a role in maintenance therapy. Therefore, this paper summarizes the efficacy data for treating bipolar disorder and also applies clinical considerations to these data when

How is the diagnosis of asthma in older people established in clinical practice?

What we need to know
• How is breathlessness perceived and defined in older people?
• What impact does breathlessness have on quality of life?
• Can history taking and physical examination be tailored to efficiently cover all the organ systems associated with
breathlessness?
• Can a self- or carer-rated questionnaire be used to identify asthma in patients with breathlessness?
What we need to do
• Develop self- and carer-rated questionnaires that measure change in function and quality of life before and after
treatment.
• Validate objective measures of physical function and airflow that are sufficiently sensitive to measure change with
treatment.
• Develop a diagnostic guideline in general practice that includes measures of mood and cognitive function and
involves carers where necessary.
• Provide rehabilitation and restorative care services.

Treatment and outcomes of an Australian cohort of outpatients with bipolar 1 or schizoaffective disorder over twenty-four months : implications for clinical practice

Background The Bipolar Comprehensive Outcomes Study (BCOS) is a 2-year, prospective, non-interventional, observational study designed to explore the clinical and functional outcomes associated with ‘real-world’ treatment of participants with bipolar I or schizoaffective disorder. All participants received treatment as usual. There was no study medication.

Methods Participants prescribed either conventional mood stabilizers (CMS; n = 155) alone, or olanzapine with, or without, CMS (olanzapine ± CMS; n = 84) were assessed every 3 months using several measures, including the Young Mania Rating Scale, 21-item Hamilton Depression Rating Scale, Clinical Global Impressions Scale – Bipolar Version, and the EuroQol Instrument. This paper reports 24-month longitudinal clinical, pharmacological, functional, and socioeconomic data.

Results On average, participants were 42 (range 18 to 79) years of age, 58%; were female, and 73%; had a diagnosis of bipolar I. Polypharmacy was the usual approach to pharmacological treatment; participants took a median of 5 different psychotropic medications over the course of the study, and spent a median proportion of time of 100%; of the study on mood stabilizers, 90%; on antipsychotics, 9%; on antidepressants, and 5%; on benzodiazepines/hypnotics. By 24 months, the majority of participants had achieved both symptomatic and syndromal remission of both mania and depression. Symptomatic relapse rates were similar for both the CMS alone (65%;) and the olanzapine ± CMS (61%;) cohorts.

Conclusions Participants with bipolar I or schizoaffective disorder in this study were receiving complex medication treatments that were often discordant with recommendations made in contemporary major treatment guidelines. The majority of study participants demonstrated some clinical and functional improvements, but not all achieved remission of symptoms or syndrome.