New Zealand development and trial of mental health nursing clinical indicators - a bicultural study

This paper describes the development and validation of bicultural clinical indicators that measure achievement of mental health nursing practice standards in New Zealand (ANZMCHN, 1995, Standards of practice for mental health nursing in New Zealand. ANZCMHN, Greenacres). A four-stage research design was utilised including focus groups, Delphi surveys, a pilot, and a national field study, with mental health nurses and consumers as participants. During the national field study, consumer files (n=327) from 11 District Health Boards, and registered nurses (n=422) completed an attitude questionnaire regarding the regularity of specific nursing and service activities. Results revealed a variation in the mean occurrence of the clinical indicators in consumer case notes of 18.5–89.9%. Five factors with good internal consistency, encompassing domains of mental health nursing required for best practice, were derived from analysis of the questionnaire. This study presents a research framework for developing culturally and clinically valid, reliable measures of clinical practice.

The use of scoring rubrics to determine clinical performance in the operating suite

Summary : This research evolved out of the need to examine the validity and inter-rater reliability of a set of performance-based scoring rubrics designed to measure competencies within the operating suite.

Method : Both holistic and analytical rubrics were developed aligned to the ACORN Standard [Australian College of Operating Room Nurses Standard NR4, 2004. ACORN Competency Standards for Perioperative Nurses: Standard NR4: The Instrument Nurse in the Perioperative Environment. Australian College of Operating Room Nurses Ltd, Adelaide] and underpinned by the Dreyfus model (1981). Three video clips that captured varying performance of nurses performing as instrument nurses in the operating suite were recorded and used as prompts by expert raters, who judged the performance using the rubrics.

Results : The study found that the holistic rubrics led to more consistent judgments than the analytical rubrics, yet the latter provided more diagnostic information for intervention purposes. Despite less consistency, the Analytical Observation Form had sufficient construct validity to satisfy the requirements of criterion referencing as determined by the Item Separation Index (Rasch, 1960), including high internal consistency and greater inter-rater reliability when average ratings were used.

Conclusion : The study was an empirical investigation of the use of concomitant Analytical and Holistic Rubrics to determine various levels of performance in the operating suite including inter-rater reliability. The methodology chosen was theoretically sound and sufficiently flexible to be used to develop other competencies within the operating suite.

Quality of reporting of randomized clinical trials in abstracts of the 2005 annual meeting of the American College of Rheumatology.

Objective: To determine the quality of abstracts reporting randomized clinical trials (RCT) at the 2005 Annual Scientific Meeting of the American College of Rheumatology.

Methods: All 2005 abstracts including late-breaking abstracts were assessed. An abstract was deemed to be reporting an RCT if it indicated that participants were randomized in the title or body of the abstract. RCT were excluded if they included only pharmacokinetic data. The CONSORT checklist was applied and relevant data extracted. We defined manufacturer support as acknowledgment of industry support or industry employee as co-author.

Results: Of 2146 abstracts, 143 (6.7%) reported RCT. Of these, 78.3% were drug trials, and 63.6% indicated manufacturer support. Only 30.8% of abstracts used "randomized" in the title, 44.1% did not explicitly state whether blinding was undertaken, and only 7.0% clearly stated who was blinded. Thirty percent of studies did not give an explicit definition of eligibility criteria of participants. While 84.6% explicitly described the experimental intervention, only 37.1% explicitly described the comparator intervention. Only 21% explicitly stated that an intention to treat analysis was performed. Baseline demographic and clinical characteristics were reported in 48.3%. While most abstracts reported summary results for each treatment group, only 35.7% reported effect size with its precision.

Conclusion: The quality of reporting is suboptimal in many RCT abstracts. Abstracts reporting RCT would benefit from a structured approach that ensures more detailed reporting of eligibility criteria, active and comparator interventions, flow of participants, and adequate summary and precision of results.

Pilot study of an innovative model for clinical education in dietetics

Aim: To pilot and evaluate a new model of clinical dietetics education to address the sustainability of dietetic placements in the clinical setting.

Methods: Final-year dietetics students (n = 14) completed all nine weeks of clinical placement in the pilot program at two large tertiary referral and teaching health services in metropolitan Melbourne. Staff and students completed surveys about their experience within a week of completing placement. Data collected included paid and unpaid staff working hours, hours in clinical and teaching activity, hours of student attendance and student clinical work hours. Data for the last month of the placement programs in the preceding three years were used for comparison with the pilot program.

Results: Combined data for the two providers showed that the model reduced the amount of supervision hours per student hour on placement by 16% while maintaining quality indicators during the pilot compared with previous years. Students in the pilot program were more positive about their experience compared with students in the existing program. The overall trend of responses in the staff surveys was positive for the pilot program, but the trend was not as marked as that of student responses.

Conclusion: The new model of clinical dietetics education was successfully piloted and demonstrated the potential to increase student training capacity without a negative impact on student achievement or major resource demands. Refinements to the model and opportunities to enhance integration into the dietetics degree program were identified during the project. The learning needs of non-English-speaking background students require further scrutiny.

Typology of adolescent sexual offenders : millon adolescent clinical inventory profiles, developmental factors, and offence characteristics

The Millon Adolescent Clinical Inventory (MACI) profiles of 82 adolescent male sexual offenders aged 13-19 in a community-based treatment sample were analysed to identify different subtypes of offender based on personality variables. Four groups were identified by cluster analysis: a withdrawn, socially inadequate type (n = 25); an antisocial and externalising type (n = 11); a conforming type (n = 20); and a passive-aggressive type (n = 26). Between-group comparisons showed that the proportion of adolescents reporting physical abuse by their parents was significantly different across the four groups. Subgroup membership was unrelated to victim age, victim gender, and offender history of sexual victimisation. Adolescents who had been victims of sexual abuse were significantly more likely to have had a male victim than those offenders without a history of sexual victimisation. The results of this study provide evidence for the heterogeneity of adolescent sexual offenders in terms of personality characteristics and psychopathology, while also suggesting potentially different aetiological pathways and different treatment needs.

Innovative model for clinical education in dietetics

Aim: Professional practice placement programs in dietetics face a number of challenges in respect of quantity, quality and sustainability. The aim of the present study is to report on the development of an innovative placement model based on a variety of training and supervision approaches to address these aforementioned challenges.

Methods: The model was developed following an investigation of existing practice and the literature with approaches that were identified as important to the requirements and constraints of dietetics clinical training incorporated into the model.

Results: Although one-on-one supervision is the predominant approach in Australian dietetic education, the educational literature and the authors' experience showed that a variety of approaches are represented in some form. The model developed involves the pairing of two students with one supervisor with students changing peer partners and supervisors every three weeks during the nine-week placement to diversify exposure to working and learning styles. The model integrates four customised approaches: incremental exposure to tasks; use of a clinical reasoning framework to help structure student understanding of the methods and judgements involved in patient care; structured enquiry in group discussions; and peer observation and feedback.

Conclusions: The model has potential to achieve efficiencies in supervisors' involvement by coordinating the skill development activities of students as a group and promoting peer-assisted learning.

Mother–infant psychotherapy and perinatal psychiatry: current clinical practice and future directions

Objective: To explore trends in the practice of mother-infant psychotherapy among perinatal psychiatry clinicians based in Melbourne.Methods: A cross-sectional survey with a purpose designed self-report questionnaire was used to assess the attitudes and practices of 47 perinatal and infant psychiatry clinicians in their use and understanding of mother-infant psychotherapy.Results: Seventy per cent of clinicians in this field of psychotherapy who responded to the questionnaire subscribe to a psychodynamic model, although cognitive behavioural models are also used. The interventions were mostly used in conjunction with other interventions, would be more accurately described as 'parent-infant psychotherapy', and non-psychiatrists in the area tended to be more likely to be formally trained in psychotherapy, but only 4% were formally trained in specific mother-infant psychotherapy. There was a unanimous request for further clinical training in this area.Conclusions: The emerging field of perinatal psychiatry needs to develop coherent therapeutic models and conduct outcome trials on specific interventions. Specific trainings in these models, in assessment and in diagnostic frameworks are required to enhance clinical efficacy, for research and service development purposes.

Developing Clinical Practice Guidelines for violence risk assessment in mental health triage : a systematic review

Background : On a global level, there is a growing trend to utilise mental health triage service systems as a way of providing consumers with access to 24 hour mental health care. At present, violence risk assessment in mental health triage lacks a suitable evidence base and clear guidelines. This presentation provides an overview of a Clinical Practice Guideline for violence risk assessment at point of entry to health services.
Aims : The objective of this study was to develop Clinical Practice Guidelines for violence risk assessment in mental health triage, and to pilot test the Clinical Guidelines in two major hospitals in Melbourne.
Method : The method employed in the study was a systematic review, as per the Australian National Health and Medical Research Council’s methodology for developing Clinical Guidelines. Research was conducted at the Royal Melbourne Hospital and the Alfred Hospital to establish the utility of the Guideline in practice.
Results : The systematic review established the highest level of evidence for violence risk assessment. Clinical Practice Guidelines for mental health triage were developed from these findings.
Conclusions : Evidence based Clinical Guidelines maximise the potential for creating safer outcomes for consumers, families/carers, and health care workers.

COPD results in a reduction in UCP3 long mRNA and UCP3 protein content in types I and IIa skeletal muscle fibers.

Purpose: Findings recently have shown coupling protein-3 (UCP3) content to be decreased in the skeletal muscle of patients with chronic obstructive pulmonary disease (COPD). Uncoupling protein-3 mRNA exists as two isoforms: long (UCP3L) and short (UCP3S). The UCP3 protein is expressed the least in oxidative and the most in glycolytic muscle fibers. Levels of UCP3 have been associated positively with intramyocellular triglyceride (IMTG) contents in conditions of altered fatty acid metabolism. As a source for muscle free fatty acid metabolism, IMTG is decreased in COPD. The current study completely characterized all the parameters of UCP3 expression (ie, UCP3L and UCP3S mRNA expression in whole muscle samples) and UCP3 protein content as well as IMTG content in the different fiber types in patients with COPD and healthy control subjects.

Methods: Using real-time polymerase chain reaction, UCP3 gene expression was quantified. Skeletal muscle fiber type and UCP3 protein and IMTG content were measured using immunofluorescence and Oil red oil staining, respectively.

Results: The findings showed that UCP3L mRNA expression was 44% lower (P < .005) in the patients with COPD than in the control subjects, whereas the UCP3S mRNA content was similar in the two groups. As compared with control subjects, UCP3 protein content was decreased by 89% and 83% and the IMTG content by 64% and 54%, respectively, in types I and IIa fibers (P < .0167) of patients with COPD, whereas they were unchanged in IIx fibers.

Conclusions: The reduced UCP3 and IMTG content in the more oxidative fibers may be linked to the altered muscle fatty acid metabolism associated with COPD. Further studies are required to determine the exact role and clinical relevance of the reduced UCP3 content in patients with COPD.

Processes influencing the development of graduate nurse capabilities in clinical risk management : an Australian study

Objectives: To explore and describe key processes influencing the development of graduate nurse capabilities in clinical risk management (CRM).

Methods: This study was undertaken using an exploratory descriptive case study method. Four sample units of analysis were used, notably: 2 cohorts of graduate nurses (n = 11) undertaking a 12-month graduate nurse transition program; key stakeholders (n = 34), that is, nurse unit managers, clinical teachers, preceptors, a quality manager, a librarian, and senior nurse administratiors employed by the participating health service; patient outcome data; and pertinent literature.

Results: Data strongly suggested that graduate nurse capabilities in CRM were most influenced not by their supposed lack of clinical knowledge and skills but by their lack of corporate knowledge. The failure to provide new graduate nurses with pertinent information on CRM at the beginning of their employment and thereafter at pertinent intervals during the graduate nurse year program aslo hindered the development of their capabilities to manage clinical risk.

Conclusions: Management and educational processes pertinent to informing and involving new graduate nurses in a hospital's local CRM program (including information about the organization's local policies and procedures) need to be implemented systematically at the very beginning of a new graduate's employment and thereafter throughout the remainder of the graduate nurse year.

Cystic fibrosis in children of the eastern Arabian peninsula : a clinical, spatial and genetic study

Aim: The aim of this thesis is to describe the process by which the inherited disease, cystic fibrosis, (CF) was recognised as an important clinical entity in the United Arab Emirates (UAE) and the Sultanate of Oman (Oman). It examines the clinical presentation of the first patients and assesses their degree of severity. Further, it describes the first studies carried out to determine the underlying CF mutations associated with the disease in the UAE and Oman. An estimate is offered of the birth frequency of the condition. Overall, the cultural, geographical and historical aspect of the societies in which the disease occurs is stressed. Methods: An initial literature search was carried out using Medline of any literature pertaining to the Arab World and CF. this was read and classified into the relevance to Arabs in general, the Middle East and then specifically the Arab (Persian) Gulf societies. Thereafter, a clinic was established at Tawam Hospital, Al Ain, UAE, for children presenting With chronic respiratory disease that could serve as a national referral centre. It was run by the Author as a service of the Paediatric Department of the UAE University Medical School. I sent a letter to every Paediatrician working in the UAE informing them of our clinic and offering our services for the diagnosis and management of chronic respiratory disease in children. This was based on the author's experience as a respiratory paediatrician in Australia and New Zealand and as the Professor of Paediatrics in the UAE. No such service then existed in the UAE. Funding was sought to establish a research programme and develop a molecular genetics laboratory in the UAE Medical School. A series of successful research applications provided the grants to commence the investigations. Once a small number of children had been identified as having CF from those referred to the respiratory clinic, the initial project was to assess and report their clinical presentation. Following this an early start was made on the identification of the mutations responsible. Once these were established an attempt was made to estimate the frequency of the condition at birth. Additional clinical studies revolved around assessing the severity of the condition that was associated with the main mutations that were identified. A clinical comparison was made with those with the mutation AF508 and the other main mutation, despite the obvious limitation of small numbers then available. Radiological assessment was made to evaluate the progression of the disease. The final aspect of the study was to assess patients from Oman and compare their findings and mutations with the neighbouring UAE. Based on information gained hypotheses are proposed regarding the spread of the gene mutation by population drift. Thesis outline: A literature review is presented in the form of a critique on the disease and a resume of the relevant aspects of the genetics of CF. Additionally, facts about the two countries' geography and history are presented. Finally, knowledge about CF mutations and population origins from other areas is presented. The second main section deals with the clinical features of the disorder as it presents in the UAE. Molecular findings are then presented and details of the common mutation found in Bedouin Arabs. Hypotheses are then presented based on the information gathered. Results: CF is not a rare disease in the Arab children of the UAE and Oman. These findings refute previous reports of CF being a rare or non-existent disease in Arabs. The condition presents with a severe clinical picture, with early colonisation of the respiratory tract with staphylococcus, haemophilus and pseudomonas organisms, even with conventional CF management practices in place. The CF mutation S549R is prevalent in Arabs of Bedouin stock, while AF508 is found in those of Baluch origin. The former may be descendants of Arabs who left southern Arabia and travelled to the Trucial Coast at the time of the destruction of the great dam at Marib. The origins of this mutation may lie in the area that corresponds to the modern Republic of Yemen. The latter groups are descendants of those who came originally from Baluchistan. It is hypothesised also that the ancestral home of the AF508 mutation may be in the geographical area now known as Baluchistan, that spans three separate modern political territories. The evidence presented supports the concept that the S549R mutation may be associated with a severe, if not the severest, clinical pattern recognised. It equates with that seen with the homozygous AF508 genotype. The absence of an additional mutation in the promoter region accounts for the different clinical pattern seen in previously described patients. Conclusions: There needs to be a major awareness of the presence of CF as a severe clinical disease in the children of the Gulf States. The clinical presentation and findings support the concept of under recognition of the disease. Climatic conditions put the children at special risk of hyponatraemia and electrolyte imbalance. The absence of surviving adults with the disease suggests premature deaths have occurred, but the high fertility rates have maintained the gene pool for this recessive disorder.

Cross-cultural adaptation of a tobacco questionnaire for Punjabi, Cantonese, Urdu and Sylheti speakers: qualitative research for better clinical practice, cessation services and research.Â

Objective : To develop cross‐culturally valid and comparable questionnaires for use in clinical practice, tobacco cessation services and multiethnic surveys on tobacco use.
Methods : Key questions in Urdu, Cantonese, Punjabi and Sylheti on tobacco use were compiled from the best existing surveys. Additional items were translated by bilingual coworkers. In one‐to‐one and group consultations, lay members of the Pakistani, Chinese, Indian Sikh and Bangladeshi communities assessed the appropriateness of questions. Questionnaires were developed and field tested. Cross‐cultural comparability was judged in a discussion between the researchers and coworkers, and questionnaires were finalised. Questionnaires in Cantonese (written and verbal forms differ) and Sylheti (no script in contemporary use) were written as spoken to avoid spot translations by interviewers.
Results : The Chinese did not use bidis, hookahs or smokeless tobacco, so these topics were excluded for them. It was unacceptable for Punjabi Sikhs to use tobacco. For the Urdu speakers and Sylheti speakers there was no outright taboo, particularly for men, but it was not encouraged. Use of paan was common among women and men. Many changes to existing questions were necessary to enhance cultural and linguistic appropriateness—for example, using less formal language, or rephrasing to clarify meaning. Questions were modified to ensure comparability across languages, including English.
Conclusion : Using theoretically recommended approaches, a tobacco‐related questionnaire with face and content validity was constructed for Urdu, Punjabi, Cantonese and Sylheti speakers, paving the way for practitioners to collect more valid data to underpin services, for sounder research and ultimately better tobacco control. The methods and lessons are applicable internationally.

Maximising the benefits of radio frequency identification technology (RFID) integration in clinical contexts : a linear conduit

Radio Frequency Identification Technology (RFIO) has been explored for various process enhancements in clinical contexts, particularly hospitals, for asset tracking. The technology has been accepted in such environments, as it is inexpensive and, in principle, uncomplicated to integrate with other clinical support systems. It is perceived to offer many benefits to currently resource critical/strained clinical environments. This research investigation focuses on the exploitation of the potential of the technology, to enhance processes in clinical environments. In this paper, the researchers aimed to uncover if the technology, as presently deployed, has been able to achieve its potential and, in particular, if it has been fully integrated into processes in a way that maximises the benefits that were perceived. This research is part of a larger investigation that aims to develop a meta-model for integration of RFIO into processes in a form that will maximise benefits that may be achievable in clinical environments. As the first phase of the investigation, the key learning from a clinical context (hospital), which has deployed RFIO and attempted to integrate it into the processes, to enable better efficiencies, is presented in this paper. The case method has been used as a methodological framework. Two clinical contexts (hospitals) are involved in the larger project, which constitutes two phases. In Phase 1, semi structured interviews were conducted with a selected number of participants involved with the RFIO deployment project, before and after, in clinical context 1 (hereinafter named as CCl). The results were then synthesised drawing a set of key learning, from different viewpoints (implementers and users), as reported in this paper. These results outline a linear conduit for a new proposed implementation (CC2). On completion of the phase II, the researchers aim to construct a meta-model for maximising the potential of RFIO in clinical contexts. This paper is limited to the first phase that aims to draw key learning to inform the linear conduit.

An observational study of health professionals’ use of evidence to inform the development of clinical management tools

Aim. This observational study sought to investigate the process of evidence use by health professionals during development of evidence-based clinical management tools.

Background. Studies conducted to explore the process of research use are scarce and knowledge of this process is essential for our understanding of the influences on research use in practice.

Design. A qualitative, non-participant, observational design.

Methods. Behaviour and actions of two separate multidisciplinary teams were observed and audio-recorded during a combined total of seven meetings for the development of clinical management tools. Semi-structured, one-to-one interviews were conducted approximately half-way through the development process and following completion of the clinical management tools.

Results. Three major themes emerged from this research. First, the process of clinical management tool development and evidence use. Nurses assumed responsibility for coordination of development which focused on describing current practice. Second, the forms of evidence employed during the development process included the use of experiential knowledge, opinions and knowledge of the context, in addition to research evidence. However, reference to research evidence was limited and its incorporation into the instrument was infrequently observed. Third, the use of research evidence emerged with respect to how such evidence was employed.

Conclusion. This study focused on real-life discussion and decision-making that occurred between health professionals when developing evidence-based clinical management tools. Health professionals may have a tendency to rely on their professional experience and current practice in preference to seeking and applying relevant research evidence.

Relevance to clinical practice. Nurses have an important role to play in the development of multidisciplinary evidence-based clinical management tools, but to actively participate in this process they need to be familiar with the relevant research evidence and have the skills and confidence to integrate the evidence into practice.

Nurses' perceived barriers to the implementation of a Fall Prevention Clinical Practice Guideline in Singapore hospitals

Background

Theories of behavior change indicate that an analysis of barriers to change is helpful when trying to influence professional practice. The aim of this study was to assess the perceived barriers to practice change by eliciting nurses' opinions with regard to barriers to, and facilitators of, implementation of a Fall Prevention clinical practice guideline in five acute care hospitals in Singapore.
Methods

Nurses were surveyed to identify their perceptions regarding barriers to implementation of clinical practice guidelines in their practice setting. The validated questionnaire, 'Barriers and facilitators assessment instrument', was administered to nurses (n = 1830) working in the medical, surgical, geriatric units, at five acute care hospitals in Singapore.
Results

An 80.2% response rate was achieved. The greatest barriers to implementation of clinical practice guidelines reported included: knowledge and motivation, availability of support staff, access to facilities, health status of patients, and, education of staff and patients.
Conclusion

Numerous barriers to the use of the Fall Prevention Clinical Practice Guideline have been identified. This study has laid the foundation for further research into implementation of clinical practice guidelines in Singapore by identifying barriers to change in acute care settings.