A prospective analysis of pain experience, beliefs and attitudes, and pain management in a cohort of Danish surgical patients.

Background: 

Leadership and teamwork in medical emergencies: performance of nursing students and registered nurses in simulated patient scenarios

Aims and objectives: To examine nursing students' and registered nurses' teamwork skills whilst managing simulated deteriorating patients. Background: Studies continue to show the lack of timely recognition of patient deterioration. Management of deteriorating patients can be influenced by education and experience. Design: Mixed methods study conducted in two universities and a rural hospital in Victoria, and one university in Queensland, Australia. Methods: Three simulation scenarios (chest pain, hypovolaemic shock and respiratory distress) were completed in teams of three by 97 nursing students and 44 registered nurses, equating to a total of 32 student and 15 registered nurse teams. Data were obtained from (1) Objective Structured Clinical Examination rating to assess performance; (2) Team Emergency Assessment Measure scores to assess teamwork; (3) simulation video footage; (4) reflective interview during participants' review of video footage. Qualitative thematic analysis of video and interview data was undertaken. Results: Objective structured clinical examination performance was similar across registered nurses and students (mean 54% and 49%); however, Team Emergency Assessment Measure scores differed significantly between the two groups (57% vs 38%, t = 6·841, p < 0·01). In both groups, there was a correlation between technical (Objective Structured Clinical Examination) and nontechnical (Team Emergency Assessment Measure) scores for the respiratory distress scenario (student teams: r = 0·530, p = 0·004, registered nurse teams r = 0·903, p < 0·01) and hypovolaemia scenario (student teams: r = 0·534, p = 0·02, registered nurse teams: r = 0·535, p = 0·049). Themes generated from the analysis of the combined quantitative and qualitative data were as follows: (1) leadership and followership behaviours; (2) help-seeking behaviours; (3) reliance on previous experience; (4) fixation on a single detail; and (5) team support. Conclusions: There is scope to improve leadership, team work and task management skills for registered nurses and nursing students. Simulation appears to be beneficial in enabling less experienced staff to assess their teamwork skills. Relevance to clinical practice: There is a need to encourage less experienced staff to become leaders and for all staff to develop improved teamwork skills for medical emergencies. © 2014 John Wiley & Sons Ltd.

Patient deterioration education: Evaluation of face-to-face simulation and e-simulation approaches

Background: Simulation-based education is one strategy that may be used to teach nursing students to recognize and manage patient deterioration. Method: Final-year preregistration nursing students (n=97) completed three face-to-face laboratory-based team simulations with a simulated patient (actor) and 330 students individually completed a three-scenario Web-based simulation program: FIRST2ACTWeb™. Results: Both groups achieved moderate performance scores (means: face to face, 49%; e-simulation, 69%). Course evaluations were positive, skill gain showing a greater effect size in the face-to-face program than for e-simulation, and higher satisfaction and more positive appraisal. Conclusion: Face-to-face simulation and e-simulation are effective educational strategies with e-simulation offering greater feasibility. Either strategy is likely to add value to the learning experience.

Self-reported access to and quality of healthcare for diabetes : Do the severely obese experience equal access?

Background: Given reported pejorative views that health professionals have about patients who are severely obese, we examined the self-reported views of the quality and availability of diabetes care from the perspective of adults with type 2 diabetes (T2DM), stratified by body mass index (BMI). Methods: 1795 respondents to the Diabetes MILES - Australia national survey had T2DM. Of these, 530 (30%) were severely obese (BMI ≥35 kg/m2) and these participants were matched with 530 controls (BMI <35 kg/m2). Data regarding participants' self-reported interactions with health practitioners and services were compared. Results: Over 70% of participants reported that their general practitioner was the professional they relied on most for diabetes care. There were no betweengroup differences in patient-reported availability of health services, quality of interaction with health practitioners, resources and support for selfmanagement, or access to almost all diabetes services. Discussion: Participants who were severely obese did not generally report greater difficulty in accessing diabetes care.

Symptoms and distress in children with advanced cancer: prospective patient-reported outcomes from the PediQUEST Study

PURPOSE: Thousands of children are living with advanced cancer; yet patient-reported outcomes (PROs) have rarely been used to describe their experiences. We aimed to describe symptom distress in 104 children age 2 years or older with advanced cancer enrolled onto the Pediatric Quality of Life and Evaluation of Symptoms Technology (PediQUEST) Study (multisite clinical trial evaluating an electronic PRO system).

METHODS: Symptom data were collected using age- and respondent-adapted versions of the PediQUEST Memorial Symptom Assessment Scale (PQ-MSAS) at most once per week. Clinical and treatment data were obtained from medical records. Individual symptom scores were dichotomized into high/low distress. Determinants of PQ-MSAS scores were explored using linear mixed-effects models.

RESULTS: During 9 months of follow-up, PQ-MSAS was administered 920 times: 459 times in teens (99% self-report), 249 times in children ages 7 to 12 years (96% child/parent report), and 212 times in those ages 2 to 6 years (parent reports). Common symptoms included pain (48%), fatigue (46%), drowsiness (39%), and irritability (37%); most scores indicated high distress. Among the 73 PQ-MSAS surveys administered in the last 12 weeks of life, pain was highly prevalent (62%; 58% with high distress). Being female, having a brain tumor, experiencing recent disease progression, and receiving moderate- or high-intensity cancer-directed therapy in the prior 10 days were associated with worse PQ-MSAS scores. In the final 12 weeks of life, receiving mild cancer-directed therapy was associated with improved psychological PQ-MSAS scores.

CONCLUSION: Children with advanced cancer experience high symptom distress. Strategies to promote intensive symptom management are indicated, especially with disease progression or administration of intensive treatments.

Cross-cultural examination of the structure of the Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R)

This study investigated the cross-cultural factor stability and internal consistency of the Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R); a measure of the quality of postoperative pain management employed internationally. We conducted exploratory factor analysis (EFA) of APS-POQ-R data from two point-prevalence studies comprising 268 and 311 surveys of Danish and Australian medical-surgical patients. Parallel analysis indicated four and three factor solutions for Danish and Australian patients respectively, which accounted for 58.1% and 52.9% of variance. Internal consistency was unsatisfactory among both Danish (Cronbach α=.54) and Australian (Cronbach α=.63) cohorts. There was a high degree of between-group similarity in item-factor loadings of variables coded as "pain experience", but not "pain management". This reflected cross-cultural differences in ratings of treatment satisfaction. For Danish patients, satisfaction was associated with the degree of pain severity and activity interference whereas for Australian patients, satisfaction was associated with their perceived ability to participate in treatment. To facilitate further cross-cultural comparison, we compared our findings to past research conducted in the U.S. and Iceland. EFA supported the construct validity of the APS-POQ-R as a measure of "pain experience", but indicated that items measuring "pain management" may vary cross-culturally. Findings highlighted the need for further validation of the APS-POQ-R internationally. PERSPECTIVE: This study revealed the APS-POQ-R as a valid measure of postoperative pain experience for Danish and Australian patients. Measures of patients' perception of pain management were not robust to group differences in treatment expectations and demonstrated cross-cultural instability. Results highlighted difficulties in establishing stable cross-cultural, cross-population subscales for the APS-POQ-R.

Leadership and teamwork in medical emergencies: Performance of nursing students and registered nurses in simulated patient scenarios

Aims and objectives: To examine nursing students' and registered nurses' teamwork skills whilst managing simulated deteriorating patients. Background: Studies continue to show the lack of timely recognition of patient deterioration. Management of deteriorating patients can be influenced by education and experience. Design: Mixed methods study conducted in two universities and a rural hospital in Victoria, and one university in Queensland, Australia. Methods: Three simulation scenarios (chest pain, hypovolaemic shock and respiratory distress) were completed in teams of three by 97 nursing students and 44 registered nurses, equating to a total of 32 student and 15 registered nurse teams. Data were obtained from (1) Objective Structured Clinical Examination rating to assess performance; (2) Team Emergency Assessment Measure scores to assess teamwork; (3) simulation video footage; (4) reflective interview during participants' review of video footage. Qualitative thematic analysis of video and interview data was undertaken. Results: Objective structured clinical examination performance was similar across registered nurses and students (mean 54% and 49%); however, Team Emergency Assessment Measure scores differed significantly between the two groups (57% vs 38%, t = 6·841, p < 0·01). In both groups, there was a correlation between technical (Objective Structured Clinical Examination) and nontechnical (Team Emergency Assessment Measure) scores for the respiratory distress scenario (student teams: r = 0·530, p = 0·004, registered nurse teams r = 0·903, p < 0·01) and hypovolaemia scenario (student teams: r = 0·534, p = 0·02, registered nurse teams: r = 0·535, p = 0·049). Themes generated from the analysis of the combined quantitative and qualitative data were as follows: (1) leadership and followership behaviours; (2) help-seeking behaviours; (3) reliance on previous experience; (4) fixation on a single detail; and (5) team support. Conclusions: There is scope to improve leadership, team work and task management skills for registered nurses and nursing students. Simulation appears to be beneficial in enabling less experienced staff to assess their teamwork skills. Relevance to clinical practice: There is a need to encourage less experienced staff to become leaders and for all staff to develop improved teamwork skills for medical emergencies.

Chemosensory science in the context of cancer treatment: implications for patient care

Introduction: This collaborative commentary brings together both clinical and sensory science perspectives in an effort to explain the mechanisms of cancer treatment and the ensuing implications for the sensorium. Strategy: This paper makes the distinction between food hedonics and true chemosensory effects in the cancer context and describes the adverse effects cancer and its treatment have on the eating and drinking experience, including gastronomic, nutritional and emotional implications. Results from a prospective breast cancer cohort study, conducted by an interdisciplinary team of nurses, medical oncologists, dietitians and sensory science researchers shed new light on specific sensory symptomatology associated with chemotherapy treatment and the implications this has for informing reliable pre-treatment patient education. Findings: Two conceptual models are posed as frameworks for better understanding the determinants and consequences of altered eating and drinking experiences during chemotherapy, as well as the link between patient-reported symptoms and chemosensory or hedonic disturbances. Discussion: Application of evidence of cancer treatment and its sensory effects in the patient treatment context continues to be a challenge for cancer clinicians, especially where standardised testing of taste and smell function are not able to be practically administered. Conclusions: Recommendations are made for further research and practice pursuits to underpin improved food enjoyment and dietary quality throughout the cancer trajectory. Clinician education of sensory science is also encouraged.

The experience of family carers of people with dementia who are hospitalised

Hospital admission of a person with dementia can have a significant impact on the family carer, who temporarily relinquishes caring to health professionals. A descriptive qualitative design using in-depth interviews with a conversational approach was used to elicit data. Adjusting to the change in the carer’s role can be challenging and result in feelings of helplessness, loneliness, loss of control and being undervalued. Family support can assist with the transition but family conflict increases anxiety. Good communication between clinicians and the carer is vital. The carer should be included in decision-making as the ‘expert' in the care of the person with dementia. This article discusses findings of a larger study specifically related to the emotional support required for the carers of people with dementia, who are admitted to hospital. The carer and the patient must be considered as a dyad in relation to discharge planning.

The role of IT governance in generating business value from IT investments in healthcare: lessons from an Australian experience

Digitizing the core processes of healthcare delivery is looked at as a solution to control the escalating costs without compromising quality or patient outcomes. However, to date the business value of such IT solutions remains elusive, especially in view of the high failure rate of many solutions coupled with the high user resistance. The uniqueness of the healthcare industry makes measuring the business value of IT a complex missions, yet it is the thesis of this research that such an activity is an essential first step if we are to realise the full potential of IT in healthcare. The role IT governance can play is of high importance to generate business value from IT investments in healthcare. This is investigated using an integrative model that is proffered to conceptualise the business value of IT in healthcare. This conceptual model is then used to guide an exploratory case study based at a leading private healthcare provider in Melbourne-Australia.

A trial of e-simulation of sudden patient deterioration (FIRST2ACT WEB) on student learning

BACKGROUND: High-fidelity simulation pedagogy is of increasing importance in health professional education; however, face-to-face simulation programs are resource intensive and impractical to implement across large numbers of students. OBJECTIVES: To investigate undergraduate nursing students' theoretical and applied learning in response to the e-simulation program-FIRST2ACT WEBTM, and explore predictors of virtual clinical performance. DESIGN AND SETTING: Multi-center trial of FIRST2ACT WEBTM accessible to students in five Australian universities and colleges, across 8 campuses. PARTICIPANTS: A population of 489 final-year nursing students in programs of study leading to license to practice. METHODS: Participants proceeded through three phases: (i) pre-simulation-briefing and assessment of clinical knowledge and experience; (ii) e-simulation-three interactive e-simulation clinical scenarios which included video recordings of patients with deteriorating conditions, interactive clinical tasks, pop up responses to tasks, and timed performance; and (iii) post-simulation feedback and evaluation. Descriptive statistics were followed by bivariate analysis to detect any associations, which were further tested using standard regression analysis. RESULTS: Of 409 students who commenced the program (83% response rate), 367 undergraduate nursing students completed the web-based program in its entirety, yielding a completion rate of 89.7%; 38.1% of students achieved passing clinical performance across three scenarios, and the proportion achieving passing clinical knowledge increased from 78.15% pre-simulation to 91.6% post-simulation. Knowledge was the main independent predictor of clinical performance in responding to a virtual deteriorating patient R(2)=0.090, F(7, 352)=4.962, p<0.001. DISCUSSION: The use of web-based technology allows simulation activities to be accessible to a large number of participants and completion rates indicate that 'Net Generation' nursing students were highly engaged with this mode of learning. CONCLUSION: The web-based e-simulation program FIRST2ACTTM effectively enhanced knowledge, virtual clinical performance, and self-assessed knowledge, skills, confidence, and competence in final-year nursing students.

The experience of anxiety in colonoscopy outpatients: a mixed-method study.

Colonoscopy is commonly used to investigate gastrointestinal symptoms such as pain or changes in bowel habits and may either induce patient anxiety or assist in patient reassurance. Currently, 2 studies investigating negative colonoscopy, reassurance, and anxiety came to conflicting conclusions on this issue. Furthermore, it is possible that differences in coping styles may influence patient anxiety. A mixed-methods study was conducted with 26 precolonoscopy and 24 postcolonoscopy patients to address the conflicting, limited literature regarding colonoscopy, coping, and anxiety. Participants completed postal surveys and interviews were conducted with 16 participants. There was no significant difference between pre- and postcolonoscopy groups on any anxiety measures; however, this was possibly because of individual differences. Significant positive correlations were found between maladaptive coping and state anxiety indicating that healthcare professionals should consider screening for maladaptive coping in patients needing invasive procedures. Neither problem- nor emotion-focused coping showed any significant relationship with state anxiety. Interviews revealed that clinicians and endoscopy nurses should be aware that some patients are not absorbing correct information about colonoscopy, specifically that they may be conscious or experience pain during the procedure. Because of this, clinicians should ensure that patients understand standard practice at their hospital. In addition, interview data suggested that more attention should be given to pain management as it currently may not be adequate during conscious sedation.

Patient-controlled intranasal fentanyl analgesia: a pilot study to assess practicality and tolerability during childbirth

Background: Intranasal administration of fentanyl is a non-invasive method of analgesic delivery which has been shown to be effective. This pilot study aimed to assess the practicality and tolerability of patient-controlled intranasal fentanyl for relieving pain during childbirth. Methods: This prospective, non-randomised, clinical trial recruited women with a singleton pregnancy during November 2009 to October 2011. Exclusion criteria included respiratory disease, gestation <37 weeks and pregnancy complications. The device administered fentanyl 54 lg per spray, incorporating a 3-min lock-out. Data collected included demographics, dose, additional analgesia, adverse events, pain relief and delivery outcomes. Follow-up data were obtained within 48 h regarding tolerability of the device. Results: The final sample included 32 women: mean age was 28.7 years and gestation 39.8 weeks. Mean fentanyl dose was 734 lg and duration of use was 3.5 h. Most women (78.2%) reported satisfactory to excellent pain relief using the nasal device. Four neonates (12.5%) required bag-mask ventilation at birth: three had adequate respiration within 5 min and one required short-term observation in the special-care nursery. For all items, there was a trend towards an adverse outcome, including neonatal respiratory support, as the dose of fentanyl increased. On follow-up, 84.4% reported they would use intranasal fentanyl for their next childbirth experience. Conclusions: Patient-controlled intranasal fentanyl provides an acceptable level of analgesia during childbirth. It may, however, increase the risk of neonatal respiratory depression. Future, randomised studies should evaluate the safety and efficacy of patient-controlled intranasal fentanyl compared with existing analgesia options.

"It's a tube up your bottom; it makes people nervous": the experience of anxiety in initial colonoscopy patients.

This study aimed to prospectively consider the effect of colonoscopy on patients' experiences of anxiety at 4 time points related to an initial colonoscopy, using a qualitative approach. The study involved a sample of 13 patients undergoing an initial colonoscopy at a public hospital and followed for 12 months. Four exploratory interviews were conducted with each participant: before the procedure, 1 week, 2 weeks, and 12 months after the procedure. Thematic analysis was conducted to summarize patients' responses. In these participants, colonoscopy was associated with stigma. The discussion of the procedure was perceived as stressful and embarrassing and led to anxiety. Irrational expectations regarding the procedure were also contributing to anxiety, as was a doctor-patient relationship based on unequal powers and lack of control. Before the procedure, fear of a serious diagnosis contributed to anxiety; however, postprocedure, an unclear or functional diagnosis also appeared to increase anxiety. Anticipating the preparation for the procedure was also reported as an important factor in preprocedure anxiety. A shift toward a biopsychosocial approach to healthcare, such as providing patients with a greater sense of control by participating in decision making, should be recommended as it may reduce anxiety.