Stressors, mediators, and health care outcomes of home enteral nutrition in family caregivers and their older adult care recipients

Family caregivers manage home enteral nutrition (HEN) for over 77% of an estimated 1 of every 400 Medicare recipients. Increasing usage of HEN in older adults combined with reliance on family caregivers raises concerns for the quality, outcomes, and costs of care. These concerns are relevant in light of Medicare limitations on nursing assistance and non-reimbursement for nutrition services, despite annual costs of over $600 million. This study applied stress process theories to assess stressor, mediator, and outcome variables salient to HEN and caregiving. In-home structured interviews occurred with a multi-ethnic sample of 30 caregiving dyads at 1–3 months after discharge on HEN. Care recipients were aged ≥60 (M = 68.4 years) and did not have dementia. Caregivers were aged ≥21, unpaid, and lived within 45 minutes of care recipients. Caregivers performed an average of 19.7 tasks daily for 61.9 hours weekly. Training needs were identified for 33 functional, care management, technical, and nutritional tasks. Preparedness scores were low (M = 1.73/4.0), and positively correlated with competence, self-rated quality of care and positive feelings, and negatively with overload, role captivity, and negative feelings (Ps < .05). Caregivers had multiple changes in lifestyle and dietary behaviors. Lifestyle changes positively correlated with overload, and negatively with preparedness and positive feelings. Dietary changes positively correlated with number of tasks, overload, role captivity and negative feelings, and negatively with preparedness (Ps < .01). Fifty-seven percent of caregivers aged >50 were at nutrition risk. Care recipients fared worse. Average weight change was −4.35 pounds (P < .001). Physical complications interrupted daily enteral infusions. Water intake was half of fluid need and associated with signs of dehydration (P < .001). Physical and social function was poor, with older subjects more impaired ( P < .04). Those with better prepared or less overloaded caregivers had higher functionality and QOL (P < .002). Complications, type of feeding tube, and caregiver preparedness correlated with frequency of health care utilization (Ps < .05). Efficacy of HEN in older adults requires specialized caregiver training, attention to caregivers' needs, and frequent monitoring from a highly skilled multidisciplinary team including dietitians. ^

Comparative administrative reform: The rhetoric and reality of the Civil Service reform programs in Uganda and Tanzania

Administrative reform is a challenging endeavor for both developed and developing countries alike. For developing countries, the challenge is greater because numerous reforms are implemented concurrently sometimes under conditions of resource scarcity and political instability. So far there is no consensus as to what makes some reforms succeed and others fail. The current study seeks to fill that gap by offering an empirical comparative analysis of the administrative reforms initiated in Uganda and Tanzania since the early 1990s. The purpose of the study is to explain the similarities and differences, and give reasons for the successes and failures of the reform programs in the two countries. It focuses on four major areas; the size of the civil service, pay reform, capacity building, and ethics and accountability. Data were collected via in-depth face to face interviews with 35 key government officials and the content analysis of various documents. The results indicate that the reforms generated initial substantial reduction in the size of the public services in both countries. In Uganda, the traditional civil service was reduced from 140,500 in 1990 to 41,730 in 2004; while in Tanzania Ministries, Departments, and Agencies were reduced by 25%. Pay reform has generated substantial increases in civil servants' salaries in both countries but in Uganda, the government has not been able to abide by the pay strategy while in Tanzania the strategy guides the increments. Civil Service capacity building efforts have focused on enhancing the skills of the personnel. Training needs assessments were undertaken in all ministries in Uganda and a training policy was formulated. In Tanzania, the training needs assessments are still under way and a training policy has not yet been developed. Ethics and accountability are great challenges in both countries, but in Tanzania, there is more political will and commitment to improve the integrity of the civil service. The findings reveal that although Uganda started the reform with much more rigor and initial success, Tanzania has surpassed it and has a more stable, consistent, and promising reform record. This is because Uganda's leadership lacks political legitimacy. The country has since the late 1990s experienced a civil war in the northern and western parts of the country while Tanzania has benefitted from relative peace and high level political legitimacy.

As necessidades formativas de professores para o trabalho com a educação integral

In Brazil, since the 1990, the country has been operating an extensive transformation in the education system. This situation is justified, among other reasons, the search for answers to the new demands that modern society gives to school, to new technologies and information and communication systems. To better put the Brazilian school that context, the federal government, through the Ministerial Decree No. 17/2007, created the More Education Program as a measure to combat low levels of development of basic education in the capital cities and metropolitan areas, aiming at the implementation of comprehensive education in schools. After the first year since the implementation of the program, there are advances in the permanence of students within the school. But as for the teachers, there is a gap on ownership and consequent acceptance. Considering the reality of the state system of schools of Basic Education in Natal - RN, this study investigates the training needs of teachers in institutions working with More Education Program, envisioning the educational relationship with Macrocampos contained in this national project. Answering this question allows us to absorb the concept of such needs in teachers, as well as to check priority in relation to the continuing education of teachers for this new pedagogical reality.

Química em cena: uma proposta para formação inicial de professores de química

In educational observed difficulty in train teachers to meet the medium and higher education needs, and one reason for this is the different experiences in the training of educators in relation to those found in the classroom. So often arise criticisms related to relevance and efficiency of degree courses, as regards the performance of its natural mission, which weakens the teacher training. Thus, improving the quality of education is very dependent on the initiatives of teachers, creating teaching alternatives to strengthen their performance in school. From this reflection, it is concluded that teacher training needs new educational proposals that qualify, and so can promote the formation of his students more adequately. Among the educational proposals as alternatives to initial teacher training may use the scientific theater (TC). Considering this possibility, this work has been proposed as investigate and discuss the influence of TC combined with experimentation in the initial training of future teachers in Chemistry who participate in the Groups Fanatics chemistry Theatre (UERN) and Chemistry on Stage (UFRN). Therefore, there was, in a first stage, theatrical essays based on the theater of the oppressed, and written dramaturgical scripts, a collaborative proposal. To incorporate experimentation in chemistry to theater rehearsals, there was a systematic literature search and after content analysis, were selected categories, materials and reagents easily accessible, easy procedures and implementation with low risk of accidents and easy care chemical waste. In the second part we identified: a) the beliefs of student teachers in the use of TC ally trial for initial training of chemistry teachers; b) the influence of TC ally to trial on learning of chemical concepts of high school students who attended the shows; c) the reasons for using or not TC ally to trial by chemistry teachers who participated in the TC group and currently work in the classroom. In this study, questionnaires and interviews were used, compounds, respectively, by a Likert scale and open questions. Quantitative data were analyzed by classical statistics the media, using as centrality measures the average, the concordance argument and the average deviation. Qualitative data were discussed according to content analysis, with categories that emerged from reading the answers. These analyzes concluded that the licensees have a positive view on the use of scientific theater for disclosure of the chemical for use in the learning of chemical concepts, pedagogical and disciplinary knowledge, and to form promotion strategy for research and extension at the University. They credit improvements in their initial training on the use of scientific theater combined with experimentation. The TC provides motivation for the construction of conceptual thinking in an informal way of chemical communication, allowing the student to expand their knowledge, not only favoring the phenomenological approach, but also the construction of chemical knowledge and the internalization of scientific concepts.

Necessidades formativas em Matemática representadas nas vozes de um grupo de professoras dos anos iniciais da rede pública de ensino

Teacher training processes, initial and continuing, and professional practice of teachers who teach Mathematics in the early years are highlighted in the literature as complex, but also are regarded as the way to overcome many difficulties in teaching this component curriculum in the school stage in question. The aim of the study was to investigate how the training needs in Mathematics are represented by a group of teachers in the early years of elementary school of public health system of the city of Uberlândia, State of Minas Gerais. The research, qualitative approach, had as object of study the training needs, in Mathematics, of teachers in the early years. The research involved 16 teachers from two schools in the municipal public schools of that city. Data were collected through questionnaires, non-participant observations, semi-structured interviews followed by group and individual. Analyses were performed by means of thematic categories, founded by content analysis. Data interpretation allowed to understand training needs in mathematics that are presented to the collaborating group from their professional practice, considering the knowledge and skills necessary to teaching. It is understood that the teachers of the study group have major limitations in relation to the specific content and didactic knowledge of Mathematics content, however, the concern is that demonstrated not always being aware of it. Moreover, the difficulties experienced in teaching practice proven to be overcome by sources and non-formal training activities, primarily through more experienced colleagues in the profession. Thus, it becomes difficult to think the initial and continuing training courses for teachers without the training needs of the teaching practice is appreciated as an object of study.

Comparative Administrative Reform: The Rhetoric and Reality of the Civil Service Reform Programs in Uganda and Tanzania

Administrative reform is a challenging endeavor for both developed and developing countries alike. For developing countries, the challenge is greater because numerous reforms are implemented concurrently sometimes under conditions of resource scarcity and political instability. So far there is no consensus as to what makes some reforms succeed and others fail. The current study seeks to fill that gap by offering an empirical comparative analysis of the administrative reforms initiated in Uganda and Tanzania since the early 1990s. The purpose of the study is to explain the similarities and differences, and give reasons for the successes and failures of the reform programs in the two countries. It focuses on four major areas; the size of the civil service, pay reform, capacity building, and ethics and accountability. Data were collected via in-depth face to face interviews with 35 key government officials and the content analysis of various documents. The results indicate that the reforms generated initial substantial reduction in the size of the public services in both countries. In Uganda, the traditional civil service was reduced from 140,500 in 1990 to 41,730 in 2004; while in Tanzania Ministries, Departments, and Agencies were reduced by 25%. Pay reform has generated substantial increases in civil servants’ salaries in both countries but in Uganda, the government has not been able to abide by the pay strategy while in Tanzania the strategy guides the increments. Civil Service capacity building efforts have focused on enhancing the skills of the personnel. Training needs assessments were undertaken in all ministries in Uganda and a training policy was formulated. In Tanzania, the training needs assessments are still under way and a training policy has not yet been developed. Ethics and accountability are great challenges in both countries, but in Tanzania, there is more political will and commitment to improve the integrity of the civil service. The findings reveal that although Uganda started the reform with much more rigor and initial success, Tanzania has surpassed it and has a more stable, consistent, and promising reform record. This is because Uganda’s leadership lacks political legitimacy. The country has since the late 1990s experienced a civil war in the northern and western parts of the country while Tanzania has benefitted from relative peace and high level political legitimacy.

Working with people affected by cancer – Phase 1 of a mixed methods exploration of practitioner perspectives in nutritional therapy

Introduction - Nutritional therapy (NT) is a bioscience-based branch of complementary and alternative medicine (CAM) with National Occupational Standards (NOS) and accredited training courses which include compulsory clinical training. Approximately 900 practitioners are registered with the voluntary regulator, the Complementary and Natural Healthcare Council (CNHC), but the number of unregulated practitioners is unknown. Cancer is a leading cause of death worldwide; nutrition and lifestyle factors may affect recurrence and survival rates. Many cancer patients and survivors seek individualised advice on diet and use of supplements and appropriately skilled nutritional therapy practitioners (NTP) may be well-placed to safely provide this advice. Little is known of NTPs’ perspectives on working with people affected by cancer; this study seeks to explore their views on training, use of evidence and other resources, to support the development of safe evidence-based practice in this important clinical area. Methods – An on-line anonymised questionnaire collected data from participants recruited from all UK registered NTPs. Recruitment was facilitated by the British Association for Applied Nutrition and Nutritional Therapy (BANT). Quantitative data on practitioner characteristics, years in practice, other therapies practiced and work with cancer clients were collected. Qualitative data on types of evidence used, barriers to practice and perceived training and support needs when working with clients with cancer, were collected and analysed. SPSS was used to produce descriptive statistics. Preliminary Results – 274/888 (31%) of registered NTPs participated. 61% respondents had accredited NT qualifications of which 46% were at degree or post-graduate level. 73% (202) participants indicated they also had other higher education qualifications, including 153 (56%) at degree or above. When asked to describe their position on cancer work, 17% respondents (40/238) indicated no interest, and 35% (84/238) respondents already work with cancer clients (cancer practitioners - CP). A further 48% (114/238) respondents expressed interest in starting cancer work, and typically requested specialist training and practice guidelines to support this area of clinical practice. Cancer practitioners (CP) rated searches of peer-reviewed literature as most useful for information to support practice, whereas commercial product information was rated least useful. CPs requested engagement with mainstream medicine, more access to research evidence and professional recognition to facilitate and support work with cancer clients. A need for professional networking, mentorship and/or supervision was noted by CP and non-CP respondents, which is of interest since 81% all participants worked as sole practitioners exclusively or as part of their practice, <1% worked within the NHS. Discussion & Conclusions – This is the first detailed documentation of NTP perspectives on cancer work. A number of areas have been identified for further detailed evidence to be collected using focus groups and interviews, including detailed training needs, communication with mainstream cancer professionals, access to research evidence, and professional recognition. This work will inform and support the development of professional practice guidelines for NT and inform the development of specialist training and other resources.

Los conocimientos acerca del maltrato infantil de los futuros profesionales de la educación: un estudio exploratorio

Los profesionales de la educación se encuentran, en su ejercicio profesional, en una posición privilegiada para realizar una detección precoz del maltrato infantil y para identificar posibles casos de riesgo. Sin embargo, en ocasiones, maestros y educadores en general aducen falta de conocimiento y formación para realizar dichas tareas. Es por ello que, en este trabajo deseamos insistir en la necesidad de analizar la formación de los futuros profesionales de la educación en torno al maltrato infantil, tanto en el seno de la familia como fuera de ella, y ya sea ejercido por un adulto o por otros menores. No olvidemos que la identificación temprana de comportamientos violentos y, por supuesto, la puesta en marcha de estrategias sólidas para su prevención requieren disponer de una buena capacitación. Por esta razón, hemos realizado un estudio piloto que nos permitiera conocer la formación que los estudiantes del Grado de Pedagogía tienen sobre el maltrato infantil, utilizando un cuestionario que hemos diseñado específicamente para alcanzar tal propósito. En la realización de un estudio piloto contamos con una muestra de 24 alumnos y alumnas del 4º curso del Grado de Pedagogía. Entre las conclusiones alcanzadas destacamos que, tras analizar los datos derivados del pase piloto, podemos concluir que los futuros pedagogos consideran necesario tener formación específica al respecto, una preparación que, mayoritariamente, consideran insuficiente y muy limitada para poder afrontar sus responsabilidades profesionales en el futuro.

Nurses' experiences of pain management for people with advanced dementia approaching the end of life: a qualitative study

AIMS AND OBJECTIVES: To explore hospice, acute care and nursing home nurses' experiences of pain management for people with advanced dementia in the final month of life. To identify the challenges, facilitators and practice areas requiring further support.

BACKGROUND: Pain management in end-stage dementia is a fundamental aspect of end of life care; however, it is unclear what challenges and facilitators nurses experience in practice, whether these differ across care settings, and whether training needs to be tailored to the context of care.

DESIGN: A qualitative study using semi-structured interviews and thematic analysis to examine data.

METHODS: 24 registered nurses caring for people dying with advanced dementia were recruited from ten nursing homes, three hospices, and two acute hospitals across a region of the United Kingdom. Interviews were conducted between June 2014 and September 2015.

RESULTS: Three core themes were identified: challenges administering analgesia, the nurse-physician relationship, and interactive learning and practice development. Patient-related challenges to pain management were universal across care settings; nurse- and organisation-related barriers differed between settings. A need for interactive learning and practice development, particularly in pharmacology, was identified.

CONCLUSIONS: Achieving pain management in practice was highly challenging. A number of barriers were identified; however, the manner and extent to which these impacted on nurses differed across hospice, nursing home and acute care settings. Needs-based training to support and promote practice development in pain management in end-stage dementia is required.

RELEVANCE TO CLINICAL PRACTICE: Nurses considered pain management fundamental to end of life care provision; however, nurses working in acute care and nursing home settings may be under-supported and under-resourced to adequately manage pain in people dying with advanced dementia. Nurse-to-nurse mentoring and ongoing needs-assessed interactive case-based learning could help promote practice development in this area. Nurses require continuing professional development in pharmacology. This article is protected by copyright. All rights reserved.

IMPLEMENTING BACK PAIN TREATMENT PATHWAYS IN CLINICAL PRACTICE: QUALITATATIVE ANALYSIS OF STAKEHOLDER PERCEPTIONS

Background
Evidence-based practice advocates utilising best current research evidence, while reflecting patient preference and clinical expertise in decision making. Successfully incorporating this evidence into practice is a complex process. Based on recommendations of existing guidelines and systematic evidence reviews conducted using the GRADE approach, treatment pathways for common spinal pain disorders were developed.

Aims
The aim of this study was to identify important potential facilitators to the integration of these pathways into routine clinical practice.

Methods
A 22 person stakeholder group consisting of patient representatives, clinicians, researchers and members of relevant clinical interest groups took part in a series of moderated focus groups, followed up with individual, semi-structured interviews. Data were analysed using content analysis.

Results
Participants identified a number of issues which were categorized into broad themes. Common facilitators to implementation included continual education and synthesis of research evidence which is reflective of everyday practice; as well as the use of clear, unambiguous messages in recommendations. Meeting additional training needs in new or extended areas of practice was also recognized as an important factor. Different stakeholders identified specific areas which could be associated with successful uptake. Patients frequently defined early involvement in a shared decision making process as important. Clinicians identified case based examples and information on important prognostic indicators as useful tools to aiding decisions.

Conclusion
A number of potential implementation strategies were identified. Further work will examine the impact of these and other important factors on the integration of evidence-based treatment recommendations into clinical practice.

“There’s a Catch-22”. The complexities of pain management for people with advanced dementia nearing the end of life: a qualitative exploration of physicians’ perspectives

Background: Pain management is a cornerstone of palliative care. The clinical issues encountered by physicians when managing pain in patients dying with advanced dementia, and how these may impact on prescribing and treatment, are unknown. Aim: To explore physicians’ experiences of pain management for patients nearing the end of life, the impact of these on prescribing and treatment approaches, and the methods employed to overcome these challenges. Design: Qualitative, semi-structured interview study exploring: barriers to and facilitators of pain management, prescribing and treatment decisions, and training needs. Thematic analysis was used to elicit key themes. Settings/Participants: Twenty-three physicians, responsible for treating patients with advanced dementia approaching the end of life, were recruited from primary care (n=9), psychiatry (n=7) and hospice care (n=7). Results: Six themes emerged: diagnosing pain, complex prescribing and treatment approaches, side-effects and adverse events, route of administration, importance of sharing knowledge and training needs. Knowledge exchange was often practised through liaison with physicians from other specialties. Cross-specialty mentoring, and the creation of knowledge networks were believed to improve pain management in this patient population. Conclusions: Pain management in end-stage dementia is complex, requiring cross-population of knowledge between palliative care specialists and non-specialists, in addition to collateral information provided by other health professionals and patients’ families. Regular, cost- and time-effective mentoring and ongoing professional development are perceived to be essential in empowering physicians to meet clinical challenges in this area.

Mental health nurses’ attitudes, behaviour, experience and knowledge regarding adults with a diagnosis of borderline personality disorder: systematic, integrative literature review

Aims and objectives To establish whether mental health nurses responses to people with borderline personality disorder are problematic and, if so, to inform solutions to support change. Background There is some evidence that people diagnosed with borderline personality disorder are unpopular among mental health nurses who respond to them in ways which could be counter-therapeutic. Interventions to improve nurses’ attitudes have had limited success. Design Systematic, integrative literature review. Methods Computerised databases were searched from inception to April 2015 for papers describing primary research focused on mental health nurses’ attitudes, behaviour, experience, and knowledge regarding adults diagnosed with borderline personality disorder. Analysis of qualitative studies employed metasynthesis; analysis of quantitative studies was informed by the theory of planned behaviour. Results Forty studies were included. Only one used direct observation of clinical practice. Nurses’ knowledge and experiences vary widely. They find the group very challenging to work with, report having many training needs, and, objectively, their attitudes are poorer than other professionals’ and poorer than towards other diagnostic groups. Nurses say they need a coherent therapeutic framework to guide their practice, and their experience of caregiving seems improved where this exists. Conclusions Mental health nurses’ responses to people with borderline personality disorder are sometimes counter-therapeutic. As interventions to change them have had limited success there is a need for fresh thinking. Observational research to better understand the link between attitudes and clinical practice is required. Evidence-based education about borderline personality disorder is necessary, but developing nurses to lead in the design, implementation and teaching of coherent therapeutic frameworks may have greater benefits. Relevance to clinical practice There should be greater focus on development and implementation of a team-wide approach, with nurses as equal partners, when working with patients with borderline personality disorder.

Intervenção Precoce com Jovens Mães

A Formação Parental poderá ser a chave para o sucesso de muitas famílias, principalmente para aquelas que se encontram menos preparadas para este novo papel, que é ser mãe ou pai, sobretudo quando ainda são jovens. Desta forma, o presente estudo tem como objetivos identificar quais as necessidades de formação de mães com filhos com idades compreendidas entre os 3 e 6 anos apoiadas pelo Centro da Mãe do Funchal; aplicar um programa de formação parental adequado às necessidades das mães; avaliar a evolução das competências e estilos parentais e comparar os resultados com outros estudos. Como já supramencionado, este estudo desenvolveu-se no Centro de Mãe do Funchal, Instituição Particular de Solidariedade Social, que tem como objetivo apoiar e/ou acolher grávidas adolescentes e jovens mães, com os seus filhos, em situação de risco. As participantes do estudo foram três assistentes sociais, uma psicóloga e seis jovens mães de crianças em idade pré-escolar, apoiadas pelo Centro de Mãe. A identificação das necessidades de formação das mães foi concretizada recorrendo a entrevistas semiestruturadas. Posteriormente, procedemos à adaptação de um programa de formação parental, baseando-o no programa “Escola de Mães” do estudo de Bernardo (2013). Após as alterações necessárias ao programa de formação parental, este foi aplicado às mães. Com o objetivo de avaliar a evolução das competências e estilos parentais, foi efetuada também uma entrevista antes e após a frequência da formação parental. De forma a consubstanciar esta avaliação foram utilizados três instrumentos validados para a população portuguesa, designadamente o Questionário de Estilos Parentais – Pais adaptado de Parental Authority Questionnaire PAQ, de Buri (1991, cit in Pires et al.,2011), a Escala de Estima de Si - S.E.R.T.H.U.A.L. adaptado de Tap et al., (2009) e a Escala de Autoeficácia Parental de Brites (2010). As alterações do estilo parental praticado antes e após a frequência do programa indicam que o Programa de formação parental teve um impacto positivo junto da maioria das participantes neste estudo. É de realçar ainda a evolução das competências parentais das mães, manifestadas na sua autoestima e na relação com os seus filhos.

A história da ciência como subsídio para a construção do conhecimento do conceito da dupla hélice

Acompanha: Dupla-hélice: a construção de um conhecimento

A operacionalização do programa de matemática em vigor no 1.º Ciclo do Ensino Básico pelos professores do concelho de Machico

Trabalho de projeto apresentado à Escola Superior de Educação de Paula Frassinetti para obtenção do grau de Mestre em Ciências da Educação Especialização em Supervisão Pedagógica