'How can we go on caring when nobody here cares about us?' Australian public maternity units as contested care sites

BACKGROUND: Provision of personalised, continuous care focused on 'well women' is now central to midwifery identity and work ideals, but it remains difficult in hospital contexts shaped by increased demand and by neoliberal policies. Previous accounts of occupational and work-family conflicts in midwifery and nursing have pointed to the 'moral distress' associated with managing conflicting expectations in health workplaces. QUESTION: This paper examines these issues in the Australian context and considers further the ethical implications of midwives not feeling 'cared for' themselves in health care organisations. METHODS: Qualitative research in several Victorian maternity units included use of interviews and observational methods to explore staff experiences of organisational and professional change. Data were coded and analysed using NVivo. FINDINGS: Midwives reported frequent contestation as they sought to practice their ideal of themselves as caregivers in what they reported as often 'uncaring' workplaces. To interpret this data, we argue for seeing midwifery caring as embodied social practice taking place within 'organisation carescapes'. CONCLUSION: Theoretical analysis of the moral and ethical dimensions of the contemporary organisational structure of maternity care suggests that a practice-based and dialogical ethic should form the core principle of care both for women in childbirth and for their carers.

Readmission to an acute psychiatric unit within 28 days of discharge : identifying those at risk

Objective. To examine factors that could help identify those most at risk of readmission to an acute psychiatric in-patient unit within 28 days of a discharge.

Method. A detailed file audit was conducted comparing 54 consecutive patients who had been readmitted within 28 days of discharge with 61 patients, chosen at random, who had not been readmitted during the same period.

Results. Readmission within 28-days of discharge was associated with having been admitted in the previous year (P = 0.004), receiving the Disability Support Pension (P = 0.015), not having a discharge plan sent to the patient’s GP on discharge from the index admission (P = 0.05), receiving follow-up by the mental health team within 7 days of discharge (P = 0.007) and being unemployed (P = 0.015).

Conclusions. Targeting those with previous admissions for focussed discharge planning may help organisations reduce the numbers of unnecessary early readmissions.

What is known about the topic? Readmission within 28-days of discharge is being increasingly used by service funders and organisations as an indicator of the effectiveness of community care and of the organisation’s ability to provide continuous care across programs. Previous studies, mainly conducted in the US in the mid-90s, often reach contradictory conclusions and their relevance to the Australian setting is limited.

What does this paper add? This paper uses data from an Australia mental health service. It identifies patient and service characteristics associated with rapid re-admission and provides a baseline to evaluate strategies to reduce the readmission rate.

What are the implications for practitioners? This paper highlights the importance of careful discharge planning and communication with general practitioners particularly in relation to patients who have had previous admissions.

Obesity prevention interventions in early childhood education and care settings with parental involvement: a systematic review

Partnering early childhood education and care (ECEC) and the home together may be more effective in combating obesogenic risk factors in preschool children. Thus, an evaluation of ECEC obesity prevention interventions with a parental component was conducted, exploring parental engagement and its effect on obesity and healthy lifestyle outcomes. A search revealed 15 peer-reviewed papers. Some studies demonstrated positive weight changes, and secondary outcomes of changes in physical activity and healthy eating were reported in most studies; study quality ranged from fair to good. Four findings were linked to weight changes: (1) when educational material is consistent across settings; (2) capacity building of parents; (3) parents encouraging their children to drink water and (4) parental satisfaction and participation. A partnership between parents and ECEC may be a powerful force in the prevention of paediatric obesity. A better understanding of collaborative parental engagement is needed.

Evaluation of the Counterweight Programme for obesity management in primary care: a starting point for continuous improvement

Background Evaluation for obesity management in primary care is limited, and successful outcomes are from intensive clinical trials in hospital settings.

Aim To determine to what extent measures of success seen in intensive clinical trials can be achieved in routine primary care. Primary outcome measures were weight change and percentage of patients achieving ≤5% loss at 12 and 24 months.

Design of study Prospective evaluation of a new continuous improvement model for weight management in primary care.

Setting Primary care, UK.

Method Primary care practice nurses from 65 UK general practices delivered interventions to 1906 patients with body mass index (BMI) ≥30 kg/m2 or ≥28 kg/m2 with obesity-related comorbidities.

Results Mean baseline weight was 101.2 kg (BMI 37.1 kg/m2); 25% of patients had BMI ≥40 kg/m2 and 74% had ≥1 major obesity-related comorbidity. At final data capture 1419 patients were in the programme for ≥12 months, and 825 for ≥24 months. Mean weight change in those who attended and had data at 12 months (n = 642) was −3.0 kg (95% CI = −3.5 to −2.4 kg) and at 24 months (n = 357) was −2.3 kg (95% CI = −3.2 to −1.4 kg). Among attenders at specific time-points, 30.7% had maintained weight loss of ≥5% at 12 months, and 31.9% at 24 months. A total of 761 (54%) of all 1419 patients who had been enrolled in the programme for >12 months provided data at or beyond 12 months.

Conclusion This intervention achieves and maintains clinically valuable weight loss within routine primary care.

Vocal negotiation over parental care? Acoustic communication at the nest predicts partners' incubation share

In species with biparental care, individuals adjust their workload to that of their partner to either compensate or match its investment. Communication within a pair might be crucial for achieving this adjustment. Zebra finches, Taeniopygia guttata, form life-long monogamous pair bonds, in which partners are highly coordinated and both incubate the eggs. When relieving each other during incubation, partners perform a structured call duet at the nest. If this duet functions to coordinate incubation workload, disrupting the pair's usual nest-relief pattern by delaying the male's return to the nest should affect the structure of the duet. Using domesticated birds breeding in a large aviary, we found that delaying the male's return induced shorter duets with higher call rates. In addition, we tracked the location of individuals with a transponder at the nest and the feeder, and showed that these accelerated duets were associated with an increased haste of the partners to take turns incubating and foraging. Females also spent less time incubating during their subsequent shift, and females' time off-nest was best predicted by their mate's calling behaviour in the previous duet. Taken together, these results suggest that duets may function as 'vocal negotiation' over parental care.

Parental decision-making surrounding complicated births: the impact on parent-infant and infant-marital relationships

This paper reviews current research regarding the impact of birth complications on parental decisionmaking, and the resulting effects on parent-infant and infant-marital relationships. It discusses the importance of informed decision-making on parental satisfaction of the birthing experience, and the benefits of certain strategies, such as kangaroo care, in the facilitation of greater levels of attachment and improved relationships. The paper concludes with suggestions for future research areas to focus on finding better ways to prepare and support parents in these situations, thus improving the quality of relationships between parents and with their child.

Pain assessment in critical care: what have we learnt from research

Despite an ongoing acknowledgement in the literature that pain is a significant problem within the critical care environment, this issue has not been adequately addressed by critical care nurses. This paper examines strategies for changing pain management practices in critical care, including reviewing documentation practices, the utilisation of guidelines and algorithms to augment clinical decision making, and increasing educational opportunities available to critical care nurses. It is recommended that pain assessment be given a higher priority within the clinical context, particularly as inadequate pain assessment and management has been linked to increased morbidity and mortality within critical care. Importantly, critical care nurses need to not only be aware of research-based pain management practices, but also lead the way in implementation and continuous evaluation as a measure of decreasing patient pain in the future.

Television time and continuous metabolic risk in physically active adults

Purpose: Among Australian adults who met the public health guideline for the minimum health-enhancing levels of physical activity, we examined the dose-response associations of television-viewing time with continuous metabolic risk variables.

Methods: Data were analyzed on 2031 men and 2033 women aged >= 25 yr from the 1999-2000 Australian Diabetes, Obesity and Lifestyle study without clinically diagnosed diabetes or heart disease, who reported at least 2.5 h·wk-1 of moderate- to vigorous-intensity physical activity. Waist circumference, resting blood pressure, and fasting and 2-h plasma glucose, triglycerides, and high-density-lipoprotein cholesterol (HDL-C) were measured. The cross-sectional associations of these metabolic variables with quartiles and hours per day of self-reported television-viewing time were examined separately for men and for women. Analyses were adjusted for age, education, income, smoking, diet quality, alcohol intake, parental history of diabetes, and total physical activity time, as well as menopausal status and current use of postmenopausal hormones for women.

Results: Significant, detrimental dose-response associations of television-viewing time were observed with waist circumference, systolic blood pressure, and 2-h plasma glucose in men and women, and with fasting plasma glucose, triglycerides, and HDL-C in women. The associations were stronger in women than in men, with significant gender interactions observed for triglycerides and HDL-C. Though waist circumference attenuated the associations, they remained statistically significant for 2-h plasma glucose in men and women, and for triglycerides and HDL-C in women.

Conclusions: In a population of healthy Australian adults who met the public health guideline for physical activity, television-viewing time was positively associated with a number of metabolic risk variables. These findings support the case for a concurrent sedentary behavior and health guideline for adults, which is in addition to the public health guideline on physical activity.

A critical review of daily sedation interruption in the intensive care unit

Background. Daily sedation interruption (DSI) has been proposed as a method of improving sedation management of critically ill patients by reducing the adverse effects of continuous sedation infusions.

Aim. To critique the research regarding daily sedation interruption, to inform education, research and practice in this area of intensive care practice.

Design. Literature review.

Method. Medline, CINAHL and Web of Science were searched for relevant key terms. Eight research-based studies, published in the English language between 1995–December 2006 and three conference abstracts were retrieved.

Results. Of the eight articles and three conference abstracts reviewed, five originated from one intensive care unit (ICU) in the USA. The research indicates that DSI reduces ventilation time, length of stay in ICU, complications of critical illness, incidence of post-traumatic stress disorder and is reportedly used by 15–62% of ICU clinicians in Australia, Europe, USA and Canada.

Conclusions. DSI improves patients' physiological and psychological outcomes when compared with routine sedation management. However, research relating to these findings has methodological limitations, such as the use of homogenous samples, single-centre trials and retrospective design, thus limiting their generalisability.

Relevance to clinical practice. DSI may provide clinicians with a simple, cost-effective method of reducing some adverse effects of sedation on ICU patients. However, the evidence supporting DSI is limited and cannot be generalised to heterogeneous ICU populations internationally. More robust research is required to assess the potential impact of DSI on the physical and mental health of ICU survivors.

Addressing online information needs in palliative care : an action research-inspired approach

Whereas user participation has been embraced worldwide as a means to provide better patient outcomes, the implementation of formative, action research approaches in online health information has remained under-explored. The purpose of this study is to present an action research-based methodology that allows the scoping of health information and design needs in complex, multi-user online environments. The project's four main stages were informed by an iterative, formative approach involving continuous expert and user evaluation. The study suggests that an action research-inspired formative approach can be successfully employed to generate user-participation. Moreover, sustained user-participation effectively addresses most quality issues regarding content, language, and accessibility raised in the recent literature. The paper concludes that an action research approach geared to develop online health resources deserves more attention.

Capacity building for integrated health care at the local level

Aims & Rationale/Objectives
Taking a capacity building approach to research and evaluation within the context of a federally funded national program challenges the traditional paradigms of both research and evaluation. The objective of this approach was to foster attitudes and behaviours of reflection, critical inquiry and collaborative action amongst participants responsible for health care integration activities.

Methods
A series of workshops focusing on different elements of health care integration was conducted. Each workshop offered skill development in research and evaluation methods relevant to the participants' clinical practise. The workshops were multidisciplinary and cross-sectoral in order to promote discussion about shared patient care issues.

Principal Findings
Participatory action research facilitated by external agents can build the capacity of participants to identify and make changes that improve health care integration at local levels. A capacity building approach to research and evaluation can mediate tensions between top-down initiatives and on-the-ground practitioners.

Discussion
A capacity building approach was crucial to the success of this project particularly as the project proposal was developed at the corporate level. The workshops played an important role in engaging the participants and fostering the development of solutions for locally identified clinical issues. The opportunities for discussion with other health care service providers were both readily embraced and appreciated by the participants. The networks formed during the workshops are likely to be vital in sustaining integration efforts.

Implications
Education sessions such as the workshops held within this project ensure that health care integration remains on the agenda of the relevant organisations. These workshops fostered a continuous quality improvement approach whilst focusing on the skills required and the systemic barriers to achieving health care integration. The success of these workshops is evidence that the need and desire for shared education opportunities exists and the interdisciplinary focus is a powerful tool for developing an appreciation of the cultures within disciplines as well as linkages.

Using project evaluation to build capacity for integrated health care at local levels

Capacity-building evaluation featuring multidisciplinary cross-agency workshops fostered continuous quality improvement, while focusing on skills required and systemic barriers to health care integration between GPs and a regional hospital.

Providing sporting experiences for children in Out of School Hours Care (OSHC) environments : sport and physical activity participation and intentions

The Out of School Hours Sports Program (OSHSP) aimed to provide structured sporting experiences and community links to local clubs for children in Out of School Hours Care (OSHC). The OSHSP involved 17 State Sporting Associations (SSAs), 71 OSHC Services and local club representatives. This study explored children's participation in sport in and outside the OSHSP and parental intention for participation in sport in and outside the OSHSP. Surveys were received from 211 children (76 girls and 125 boys; mean age = 7.9 years, S.D. = 1.7) and their parents/guardians (37.9% response rate). OSHC is characterised by freedom of choice of participation in activities by children. The OSHSP was used to provide an opportunity to choose to participate in a sport while attending OSHC. At the OSHC Services surveyed, between 7.1 and 100% of the children attending OSHC chose to participate in the OSHSP. Of those children who chose to participate, 85% were participating in a sport, usually a different sport to the one offered in the OSHSP. This participation was largely club-based (49.8%), most often once a week for training and competition (55.2%). Parental intentions for children's participation in the OSHSP sports varied with respect to the number of years attending the OSHSP, where children played and trained in their main sport, and how many times a week a child played and trained in their main sport. Older children tended to play and train for sport more times per week and had been attending the OSHC for more years than younger children.