Small-scale rural pilot programs in chronic illness management - what next?

In recent years, rural SA has been the recipient of significant funding to support a range of new primary health care initiatives. Much of this funding, additional to normal recurrent budgets in our health system, has facilitated effective change and development through demonstration and research projects across the state. The resultant work involves programs such as: ? coordinated care trials (COAG) ? more allied health services (MAHS) ? Commonwealth regional health service initiatives (CRHS) ? quality use of medicines (QUM) ? community packages for aged care services ? Indigenous chronic disease self-management pilot programs (CDSM) ? chronic disease self-management (CDSM) programs - Sharing Health Care SA ? chronic disease self-management (CDSM) programs in Indigenous communities. In addition to the resources listed above, funding was also provided by the Commonwealth to establish the South Australian Centre for Rural and Remote Health (SACRRH) and develop the University Department of Rural Health in Whyalla. While this new funding has led to substantial developmental work in chronic illness management in particular, one needs to ask whether the time might not be right now for these hitherto small-scale change initiatives to be transformed into ongoing mainstream programs, informed and guided by research outcomes to date. Is it time to move beyond tentative chronic illness programs and into mainstream reform? We have shown that there is much to be gained, both for patients and for the system, from improved coordination of primary care services and initiatives such as self-management programs for patients with chronic conditions. Better management leads to improved patient health outcomes and can reduce demand for unplanned hospital and emergency services. Many admissions to rural hospitals requiring expensive services, in terms of infrastructure and staffing, could be either prevented, or patients could be managed more effectively in the community as part of a wider primary health care program.

Additional weekend therapy may reduce length of rehabilitation stay after stroke: a meta-analysis of individual patient data

QUESTIONS: Among people receiving inpatient rehabilitation after stroke, does additional weekend physiotherapy and/or occupational therapy reduce the length of rehabilitation hospital stay compared to those who receive a weekday-only service, and does this change after controlling for individual factors? Does additional weekend therapy improve the ability to walk and perform activities of daily living, measured at discharge? Does additional weekend therapy improve health-related quality of life, measured 6 months after discharge from rehabilitation? Which individual, clinical and hospital characteristics are associated with shorter length of rehabilitation hospital stay? DESIGN: This study pooled individual data from two randomised, controlled trials (n=350) using an individual patient data meta-analysis and multivariate regression. PARTICIPANTS: People with stroke admitted to inpatient rehabilitation facilities. INTERVENTION: Additional weekend therapy (physiotherapy and/or occupational therapy) compared to usual care (5 days/week therapy). OUTCOME MEASURES: Length of rehabilitation hospital stay, independence in activities of daily living measured with the Functional Independence Measure, walking speed and health-related quality of life. RESULTS: Participants who received weekend therapy had a shorter length of rehabilitation hospital stay. In the un-adjusted analysis, this was not statistically significant (MD -5.7 days, 95% CI -13.0 to 1.5). Controlling for hospital site, age, walking speed and Functional Independence Measure score on admission, receiving weekend therapy was significantly associated with a shorter length of rehabilitation hospital stay (β=7.5, 95% CI 1.7 to 13.4, p=0.001). There were no significant between-group differences in Functional Independence Measure scores (MD 1.9 points, 95% CI -2.8 to 6.6), walking speed (MD 0.06 m/second, 95% CI -0.15 to 0.04) or health-related quality of life (SMD -0.04, 95% CI -0.26 to 0.19) at discharge. DISCUSSION: Modest evidence indicates that additional weekend therapy might reduce rehabilitation hospital length of stay.

Lateral positioning for critically ill adult patients

BACKGROUND: Critically ill patients require regular body position changes to minimize the adverse effects of bed rest, inactivity and immobilization. However, uncertainty surrounds the effectiveness of lateral positioning for improving pulmonary gas exchange, aiding drainage of tracheobronchial secretions and preventing morbidity. In addition, it is unclear whether the perceived risk levied by respiratory and haemodynamic instability upon turning critically ill patients outweighs the respiratory benefits of side-to-side rotation. Thus, lack of certainty may contribute to variation in positioning practice and equivocal patient outcomes. OBJECTIVES: To evaluate effects of the lateral position compared with other body positions on patient outcomes (mortality, morbidity and clinical adverse events) in critically ill adult patients. (Clinical adverse events include hypoxaemia, hypotension, low oxygen delivery and global indicators of impaired tissue oxygenation.) We examined single use of the lateral position (i.e. on the right or left side) and repeat use of the lateral position (i.e. lateral positioning) within a positioning schedule. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 5), MEDLINE (1950 to 23 May 2015), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1937 to 23 May 2015), the Allied and Complementary Medicine Database (AMED) (1984 to 23 May 2015), Latin American Caribbean Health Sciences Literature (LILACS) (1901 to 23 May 2015), Web of Science (1945 to 23 May 2015), Index to Theses in Great Britain and Ireland (1950 to 23 May 2015), Trove (2009 to 23 May 2015; previously Australasian Digital Theses Program (1997 to December 2008)) and Proquest Dissertations and Theses (2009 to 23 May 2015; previously Proquest Digital Dissertations (1980 to 23 May 2015)). We handsearched the reference lists of potentially relevant reports and two nursing journals. SELECTION CRITERIA: We included randomized and quasi-randomized trials examining effects of lateral positioning in critically ill adults. We included manual or automated turns but limited eligibility to studies that included duration of body position of 10 minutes or longer. We examined each lateral position versus at least one comparator (opposite lateral position and/or another body position) for single therapy effects, and the lateral positioning schedule (repeated lateral turning) versus other positioning schedules for repetitive therapy effects. DATA COLLECTION AND ANALYSIS: We pre-specified methods to be used for data collection, risk of bias assessment and analysis. Two independent review authors carried out each stage of selection and data extraction and settled differences in opinion by consensus, or by third party adjudication when disagreements remained unresolved. We planned analysis of pair-wise comparisons under composite time intervals with the aim of considering recommendations based on meta-analyses of studies with low risk of bias. MAIN RESULTS: We included 24 studies of critically ill adults. No study reported mortality as an outcome of interest. Two randomized controlled trials (RCTs) examined lateral positioning for pulmonary morbidity outcomes but provided insufficient information for meta-analysis. A total of 22 randomized trials examined effects of lateral positioning (four parallel-group and 18 cross-over designs) by measuring various continuous data outcomes commonly used to detect adverse cardiopulmonary events within critical care areas. However, parallel-group studies were not comparable, and cross-over studies provided limited data as the result of unit of analysis errors. Eight studies provided some data; most of these were single studies with small effects that were imprecise. We pooled partial pressure of arterial oxygen (PaO2) as a measure to detect hypoxaemia from two small studies of participants with unilateral lung disease (n = 19). The mean difference (MD) between lateral positions (bad lung down versus good lung down) was approximately 50 mmHg (MD -49.26 mmHg, 95% confidence interval (CI) -67.33 to -31.18; P value < 0.00001). Despite a lower mean PaO2 for bad lung down, hypoxaemia (mean PaO2 < 60 mmHg) was not consistently reported. Furthermore, pooled data had methodological shortcomings with unclear risk of bias. We had similar doubts regarding internal validity for other studies included in the review. AUTHORS' CONCLUSIONS: Review authors could provide no clinical practice recommendations based on the findings of included studies. Available research could not eliminate the uncertainty surrounding benefits and/or risks associated with lateral positioning of critically ill adult patients. Research gaps include the effectiveness of lateral positioning compared with semi recumbent positioning for mechanically ventilated patients, lateral positioning compared with prone positioning for acute respiratory distress syndrome (ARDS) and less frequent changes in body position. We recommend that future research be undertaken to address whether the routine practice of repositioning patients on their side benefits all, some or few critically ill patients.

Understanding the bereavement care roles of nurses within acute care: a systematic review

AIM AND OBJECTIVES: To investigate nurses' roles and responsibilities in providing bereavement care during the care of dying patients within acute care hospitals.

BACKGROUND: Bereavement within acute care hospitals is often sudden, unexpected and managed by nurses who may have limited access to experts. Nurses' roles and experience in the provision of bereavement care can have a significant influence on the subsequent bereavement process for families. Identifying the roles and responsibilities nurses have in bereavement care will enhance bereavement supports within acute care environments.

DESIGN: Methods: A mixed-methods systematic review was conducted utilising the databases Cumulative Index Nursing and Allied Health Literature (CINAHL Plus), Embase, Ovid MEDLINE, PsychINFO, CareSearch and Google Scholar. Included studies published between 2006 to 2015, identified nurse participants, and the studies were conducted in acute care hospitals. Seven studies met the inclusion criteria and the research results were extracted and subjected to thematic synthesis.

RESULTS: Nurses' role in bereavement care included patient-centred care, family-centred care, advocacy and professional development. Concerns about bereavement roles included competing clinical workload demands, limitations of physical environments in acute care hospitals and, the need for further education in bereavement care.

CONCLUSIONS: Further research is needed to enable more detailed clarification of the roles nurse undertake in bereavement care in acute care hospitals. There is also a need to evaluate the effectiveness of these nursing roles and how these provisions impact on the bereavement process of patients and families. 

Training a system-literate care coordination workforce.

People with chronic complex conditions continue to experience increasing health system fragmentation and poor coordination. To reverse these trends, one solution has been an investment in effective models of care coordination that use a care coordinator workforce. Care coordinators are not a homogenous workforce - but an applied professional role, providing direct and indirect care, and is often undertaken by nurses, allied health professionals, social workers or general practitioners. In Australia, there is no training curriculum nor courses, nor nationally recognised professional quality standards for the care coordinator workforce. With the growing complexity and fragmentation of the health care system, health system literacy - shared understanding of the roles and contributions of the different workforce professions, organisations and systems, among patients and indeed the health workforce is required. Efforts to improve health system literacy among the health workforce are increasing at a policy, practice and research level. However, insufficient evidence exists about what are the health system literacy needs of care coordinators, and what is required for them to be most effective. Key areas to build a health system literate care coordination workforce are presented. Care coordination is more than an optional extra, but one of the only ways we are going to be able to provide equitable health services for people with chronic complex conditions. People with low health literacy require more support with the coordination of their care, therefore we need to build a high performing care coordinator workforce that upholds professional quality standards, and is health literacy responsive.

Teaching research and epidemiology to undergraduate students in the health sciences

Objective: To identify and address particular challenges in the teaching of epidemiological concepts to undergraduate students in non-clinical health disciplines. Methods and Results: Relevant pedagogical literature was reviewed to identify a range of evidence-based teaching approaches. The authors also drew on their experience in curriculum development and teaching in this field to provide guidelines for teaching epidemiology in a way that is engaging to students and likely to promote deep, rather than surface, learning. Discussion of a range of practical strategies is included along with applied examples of teaching epidemiological content. Conclusions and Implications: Increasingly, there is a greater emphasis on improved learning outcomes in higher education. Graduates from non-clinical health courses are required to have a core understanding of epidemiology and teachers of epidemiology need to be able to access resources that are relevant and useful for these students. A theoretically grounded framework for effective teaching of epidemiological principles to non-clinical undergraduates is provided, together with a range of useful teaching resources (both paper and web-based). Implementation of the strategies discussed will help ensure graduates are able to appropriately apply epidemiological skills in their professional practice.

Enhancing the health of medical students : outcomes of an integrated mindfulness and lifestyle program

Medical students experience various stresses and many poor health behaviours. Previous studies consistently show that student wellbeing is at its lowest pre-exam. Little core-curriculum is traditionally dedicated to providing self-care skills for medical students. This paper describes the development, implementation and outcomes of the Health Enhancement Program (HEP) at Monash University. It comprises mindfulness and ESSENCE lifestyle programs, is experientially-based, and integrates with biomedical sciences, clinical skills and assessment. This study measured the program’s impact on medical student psychological distress and quality of life. A cohort study performed on the 2006 first-year intake measured effects of the HEP on various markers of wellbeing. Instruments used were the depression, anxiety and hostility subscales of the Symptom Checklist-90-R incorporating the Global Severity Index (GSI) and the WHO Quality of Life (WHOQOL) questionnaire. Pre-course data (T1) was gathered mid-semester and post-course data (T2) corresponded with pre-exam week. To examine differences between T1 and T2 repeated measures ANOVA was used for the GSI and two separate repeated measures MANOVAs were used to examine changes in the subscales of the SCL-90-R and the WHOQOL-BREF. Follow-up t-tests were conducted to examine differences between individual subscales. A total of 148 of an eligible 270 students returned data at T1 and T2 giving a response rate of 55%. 90.5% of students reported personally applying the mindfulness practices. Improved student wellbeing was noted on all measures and reached statistical significance for the depression (mean T1 = 0.91, T2 = 0.78; p = 0.01) and hostility (0.62, 0.49; 0.03) subscales and the GSI (0.73, 0.64; 0.02) of the SCL-90, but not the anxiety subscale (0.62, 0.54; 0.11). Statistically significant results were also found for the psychological domain (62.42, 65.62; p < 0.001) but not the physical domain (69.11, 70.90; p = 0.07) of the WHOQOL. This study is the first to demonstrate an overall improvement in medical student wellbeing during the pre-exam period suggesting that the common decline in wellbeing is avoidable. Although the findings of this study indicate the potential for improving student wellbeing at the same time as meeting important learning objectives, the limitations in study design due to the current duration of follow-up and lack of a control group means that the data should be interpreted with caution. Future research should be directed at determining the contribution of individual program components, long-term outcomes, and impacts on future attitudes and clinical practice.

This is public health : Australian students’ understanding of public health

This is Public Health Campaign,Young adults are a frequent target of health promotion campaigns in Australia yet there is evidence to suggest that this cohort has little understanding of the nature and intent of Public Health initiatives in their own environment. This paper describes the results of a study that evaluated the knowledge and understanding of public health of a sample of 333 first year health science students at an Australian University. Students were asked to submit photographs depicting their ideas about public health and accompany these with a written rationale for their choices. The results of the study suggest that the students at this level have a narrow interpretation of public health and do not understand the organized nature of public health efforts or the aims of such initiatives. This study provides important insight into the thinking of this cohort of young Australians, both in the context of preparing them for future careers in public health as well as in relation to their response to health promotion campaigns targeting them.

Graduate students lend their voices : reflections on the 10th seminar in health and environmental education research

Graduate students were invited by their faculty advisors to attend the 10
th Seminar in Health and Environmental Education Research. Afterward, they were encouraged to comment on their experiences, involvement, and positioning. Two main authors developed survey questions and retrieved, analyzed, and synthesized the responses of four other graduate students. The overall experience of attending an invitational research seminar evoked various ideas about graduate students’ present and future roles in research communities.