Empowerment in nursing : paternalism or maternalism?

The aim of this article is to explore whether patient empowerment flourishes in the wake of current health reforms or if there is a power struggle between nursing and medicine as to what is in the patients' best interest. Shifting the balance of power from healthcare professionals to patients has become a key element of healthcare policy in England. The RCN's definition of nursing places patient empowerment as a central remit of nurses. However, achieving genuine patient empowerment is not easy and requires individuals and organizations to alter their beliefs, values and behaviours. To empower patients nurses must be in a position to share power and this may require a realignment of the traditional power base within health care. Although empowerment is often viewed on a one-to-one level between professionals and patients, for true patient empowerment to occur, issues of power and control must also be addressed at a national and political level.

Good practice report : clinical teaching

Clinical experience, or experience in the ‘real world’ of practice, is a fundamental component of many health professional courses. It often involves students undertaking practical experience in clinical workplace settings, typically referred to as clinical placements, under the supervision of health professionals. Broadly speaking, the role of clinical supervisors, or teachers, is aimed at assisting students to integrate the theoretical and skills based components of the curriculum within the context of patient/client care (Erstzen et al 2009). Clinical experience also provides students with the opportunity to assimilate the attitudes, values and skills which they require to become appropriately skilled professionals in the environments in which they will eventually practise. However, clinical settings are particularly challenging learning environments for students. Unlike classroom learning, students in the clinical setting frequently find themselves involved in unplanned and often complex activities with patients and other health care providers, being supervised by a variety of clinical staff who have very different methods and styles of teaching, and negotiating bureaucratic or hierarchical structures in busy clinical workplaces where they may only be spending a limited amount of time. Kilminster et al (2007) also draw attention to tensions that may exist between the learning needs of students and the provision of quality care or need to prevent harm to the patient (e.g. Elkind et al 2007). All of these factors complicate the realisation of clinical education goals and underscore the need for effective clinical teaching practices that maximise student learning in clinical environments. This report provides a summary of work that has been achieved in relation to ALTC projects and fellowships associated with clinical teaching, and a review of scholarly publications relevant to this field. The report also makes recommendations based on issues identified and/or where further work is indicated. The projects and fellowships reviewed cover a range of discipline areas including Biology, Paramedic Practice, Clinical Exercise Physiology, Occupational Therapy, Speech Pathology, Physiotherapy, Pharmacy, Nursing and Veterinary Science. The main areas of focus cover issues related to curriculum, particularly in relation to industry expectations of ‘work-ready’ graduates and the implications for theoretical and practical, or clinical preparation; development of competency assessment tools that are nationally applicable across discipline-specific courses; and improvement of clinical learning through strategies targeting the clinical learning environment, building the teaching capacity of clinical supervisors and/or enhancing the clinical learning/teaching process.

Becoming a pharmacist : students' perceptions of their curricular experience and professional identity formation

Introduction Student professional identity formation is important for enabling the successful transition between academic education and professional practice. Recognition of this has resulted in significant changes in professional education (e.g., the inclusion of experiential placements and authentic learning experiences). There is limited research that examines how the curricular experience influences pharmacy studentsʼ professional identity formation. Methods Using focus groups, comprising 82 students from all levels of a four-year Australian undergraduate pharmacy course, this study examined studentsʼ perceptions of their overall curricular experience and examined how these experiences influenced the construction of their professional identities. Results Our analysis found that the pharmacy students struggled with their professional identity formation. Many were entering the degree with little understanding of what being a pharmacist entailed. Once in the educational context, the nature of the role became both apparent and idealistic but not enacted. Students experienced dissonance between the idealistic notion of pharmacy practice and the realities of placements, and this may have been enhanced by a lack of patient-centered care role models. This struggle left them concluding that the role of the pharmacist was constrained and limited. Conclusions We argue that professional identity formation needs to be in the foreground from commencement of the degree and throughout the curriculum.

A collaborative rapid persona-building workshop : creating design personas with health researchers

In the HealthMap project for People With HIV, (PWHIV) designers employed a collaborative rapid ‘persona-building' workshop with health researchers to develop patient personas that embodied patient-centred design goals and contextual awareness from a variety of qualitative and quantitative data. On reflection, this collaborative rapid workshop was a process for drawing together the divergent user research insights and expertise of stakeholders into focus for a chronic disease self-management design. This paper discusses, (i) an analysis of the transcript of the workshop and, (ii) interviews with five practising senior designers, in order to reflect on how the persona-building process was enacted and its role in the HealthMap design evolution. The collaborative rapid persona-building methodology supported: embedding user research insights, eliciting domain expertise, introducing design thinking, facilitating stakeholder collaboration and defining early design requirements. The contribution of this paper is to model the process of collaborative rapid persona-building and to introduce the collaborative rapid persona-building framework as a method to generate design priorities from domain expertise and user research data.

What keeps nurses busy in the mental health setting?

The foundation of mental health nursing has historically been grounded in an interpersonal, person-centred process of health care, yet recent evidence suggests that the interactional work of mental health nursing is being eroded. Literature emphasizes the importance of person-centred care on consumer outcomes, a model reliant upon the intimate engagement of nurses and consumers. Yet, the arrival of medical interventions in psychiatry has diverted nursing work from the therapeutic nursing role to task-based roles delegated by medicine, distancing nurses from consumers. This study used work sampling methodology to observe the proportion of time nurses working in an inpatient mental health setting spend in the activities of direct care, indirect care and service-related activities. Nurses spent 32 of their time in direct care, 52% in indirect care and 17% in service-related activities. Mental health nurses need to re-establish their therapeutic availability to maximize consumer experiences and outcomes.

Cultural safety and diversity: Refocusing our energies in mental health nursing practice, education and research

INTRODUCTION AND BACKGROUND: This presentation draws on a body of work assessing cultural safety's potential to generate change in mental health nursing research (Cox and Simpson 2015), in education and in clinical practice (Cox and Taua 2013, 2016; Happell, Cowin, Roper, Lakeman & Cox 2013). It presents evidence to suggest that cultural safety could resolve the conceptual confusion surrounding culture and diversity in nursing curricular, in clinical and in research practice. The history and nature of mental health work recommend cultural safety to focus attention on diversity, power imbalance, racism, cultural dominance, and structural inequality, identified as barriers and tensions in clinical practice and in service user participation. Cultural safety gives mental health nursing a well theorized and articulated model, which is evolving to improve practice into the future. DESCRIPTION: This work involved an immersion in the literature on cultural safety and the Service User Research movement. It draws on 5 months' work with a service users' research group in the UK and reflections on 9 years of cultural safety teaching. POLICY/PRACTICE CHANGE: This work provokes a crucial change of emphasis from locating the source of issues in the diversity of people to locating it in how society responds to diversity: a change from individualistic to systemic concerns. IMPLICATIONS FOR MENTAL HEALTH NURSING: Cultural safety in clinical practice, education, and research is specifically concerned with awareness of the impact of systemic workplace cultures and with staff cultural self-awareness to bring about cultural change and person-centred care of individuals' unique needs and aspirations within their life context.

IWGDF guidance on the prevention of foot ulcers in at-risk patients with diabetes

Recommendations - 1 To identify a person with diabetes at risk for foot ulceration, examine the feet annually to seek evidence for signs or symptoms of peripheral neuropathy and peripheral artery disease. (GRADE strength of recommendation: strong; Quality of evidence: low) - 2 In a person with diabetes who has peripheral neuropathy, screen for a history of foot ulceration or lower-extremity amputation, peripheral artery disease, foot deformity, pre-ulcerative signs on the foot, poor foot hygiene and ill-fitting or inadequate footwear. (Strong; Low) - 3 Treat any pre-ulcerative sign on the foot of a patient with diabetes. This includes removing callus, protecting blisters and draining when necessary, treating ingrown or thickened toe nails, treating haemorrhage when necessary and prescribing antifungal treatment for fungal infections. (Strong; Low) - 4 To protect their feet, instruct an at-risk patient with diabetes not to walk barefoot, in socks only, or in thin-soled standard slippers, whether at home or when outside. (Strong; Low) - 5 Instruct an at-risk patient with diabetes to daily inspect their feet and the inside of their shoes, daily wash their feet (with careful drying particularly between the toes), avoid using chemical agents or plasters to remove callus or corns, use emollients to lubricate dry skin and cut toe nails straight across. (Weak; Low) - 6 Instruct an at-risk patient with diabetes to wear properly fitting footwear to prevent a first foot ulcer, either plantar or non-plantar, or a recurrent non-plantar foot ulcer. When a foot deformity or a pre-ulcerative sign is present, consider prescribing therapeutic shoes, custom-made insoles or toe orthosis. (Strong; Low) - 7 To prevent a recurrent plantar foot ulcer in an at-risk patient with diabetes, prescribe therapeutic footwear that has a demonstrated plantar pressure-relieving effect during walking (i.e. 30% relief compared with plantar pressure in standard of care therapeutic footwear) and encourage the patient to wear this footwear. (Strong; Moderate) - 8 To prevent a first foot ulcer in an at-risk patient with diabetes, provide education aimed at improving foot care knowledge and behaviour, as well as encouraging the patient to adhere to this foot care advice. (Weak; Low) - 9 To prevent a recurrent foot ulcer in an at-risk patient with diabetes, provide integrated foot care, which includes professional foot treatment, adequate footwear and education. This should be repeated or re-evaluated once every 1 to 3 months as necessary. (Strong; Low) - 10 Instruct a high-risk patient with diabetes to monitor foot skin temperature at home to prevent a first or recurrent plantar foot ulcer. This aims at identifying the early signs of inflammation, followed by action taken by the patient and care provider to resolve the cause of inflammation. (Weak; Moderate) - 11 Consider digital flexor tenotomy to prevent a toe ulcer when conservative treatment fails in a high-risk patient with diabetes, hammertoes and either a pre-ulcerative sign or an ulcer on the distal toe. (Weak; Low) - 12 Consider Achilles tendon lengthening, joint arthroplasty, single or pan metatarsal head resection, or osteotomy to prevent a recurrent foot ulcer when conservative treatment fails in a high-risk patient with diabetes and a plantar forefoot ulcer. (Weak; Low) - 13 Do not use a nerve decompression procedure in an effort to prevent a foot ulcer in an at-risk patient with diabetes, in preference to accepted standards of good quality care. (Weak; Low)

Agente Comunitário de Saúde (ACS): construção do percurso identitário a partir da história de vida

Esta pesquisa busca compreender a construção do percurso identitário do Agente Comunitário de Saúde (ACS) a partir da história de vida. Os objetivos colocados neste estudo foram analisar as formas como se constituíram os princípios e valores que orientam as práticas de cuidado do ACS e de construir uma narrativa que contemplasse como as contingências e os acasos produziram os sentidos para o seu percurso identitário. Para isto, utilizou-se a metodologia qualitativa heterogênea através da abordagem da História de Vida e da Análise de Conteúdo. A primeira - História de Vida, segundo Becker (1994) é a expressão de uma forma de vida, de conhecer crenças, valores e desejos de uma população estudada dentro do contexto da vida destes sujeitos. Para tanto, foram realizadas entrevistas com seis ACS que atuam há pelo menos dois anos no município do Rio de Janeiro. As entrevistas foram gravadas e, parcialmente, transcritas após o aceite e a assinatura do termo de consentimento. Acredito que os agentes podem operar entre si diferentes modos de fazer, uma vez que afetam e sofrem afetamentos, atravessam e ao mesmo tempo são atravessados por diferentes micro redes que geram solidariedade ou individualismo, humanidade ou animosidade nas inter-relações. Neste contexto, o estudo conclui que ainda que a maioria dos entrevistados não escolhesse a carreira de ACS, houve uma disponibilidade para aprender o ofício e um compromisso com as atribuições definidas para o exercício profissional. Aliado a isso, constatou-se também, que a inserção na profissão foi uma forma de conseguir um emprego formal que garanta uma renda fixa mensal. Não há o desejo de permanecer por muito tempo nesta profissão pelo desgaste físico e emocional que é fortemente sentido já no primeiro ano de trabalho. Em relação à construção dos sentidos para o percurso identitário dos ACS, os depoimentos apresentam uma identificação com as ações de ajuda e solidariedade presentes na vida dos sujeitos. E, dentre os valores ou princípios que constituíram a formação de um caráter ou identidade pessoal, que são determinantes para a atuação no cuidado à saúde das pessoas, destacam-se a sensibilidade, a escuta, o afeto, o acolhimento, a ética, a amizade e alteridade. Na discussão sobre a necessidade deste profissional ser morador da área que vai atuar, observou-se, a partir das narrativas, que esta exigência pode facilitar a abordagem. Contudo, a qualidade do cuidado não está diretamente relacionada a este critério que pode gerar distanciamento e desconfiança dos outros moradores. Logo, estudos como este se justificam para que se possa reafirmar a importância de trabalhadores do SUS, em especial, o ACS. Estes representam hoje mais de 200 mil trabalhadores da saúde pública e se espera que sejam profissionais responsáveis por um cuidado em saúde que respeitem as diferenças entre as pessoas, que não sobreponham a doença ao sujeito e não minimizem o sofrimento em função do cumprimento de metas e produção de dados a serem planilhados. Lutem, acima de tudo, pela defesa de qualquer vida.

Avaliação da disnatremia em pacientes com indicação de suporte renal em unidades de terapia intensiva

As disnatremias são os distúrbios hidroeletrolíticos mais comuns, sendo relatados em cerca de 30-40% dos pacientes hospitalizados. Quando presentes na admissão em Unidade de Tratamento Intensivo (UTI) são fatores de risco independentes de pior prognóstico, estando associadas à maior letalidade hospitalar. Mesmo disnatremias limítrofes (130 135 mEq/l na hiponatremia e 145 a 150 mEq/L na hipernatremia) têm sido associadas a um maior tempo de internação na UTI e a um aumento de letalidade hospitalar, independente da gravidade da doença de base. A concentração sérica do sódio é mantida por um fino controle, por meio da regulação renal do sal e da água. Pacientes com doença renal crônica (DRC) em tratamento conservador ou em terapia renal substitutiva, apresentam maior prevalência de disnatremia. Embora a hiponatremia seja mais frequente nessa população, o diagnóstico de hipo- ou hipernatremia tem sido associado a uma maior mortalidade. Não há relato claro na literatura da prevalência de disnatremias na injúria renal aguda (IRA), em especial nos casos mais graves, em que há indicação de suporte dialítico. O presente estudo teve como objetivos avaliar a prevalência da disnatremia e o seu impacto no prognóstico de pacientes gravemente enfermos com IRA e necessidade de suporte renal (SR) na UTI.Em um período de 44 meses (de dezembro de 2004 a julho 2008) foram incluídos de forma prospectiva todos os pacientes que iniciaram SR em 14 UTIs de 3 hospitais terciários do Rio de Janeiro. Dados clínicos e laboratoriais foram coletados prospectivamente e lançados em uma planilha eletrônica para posterior análise com o software R. Os desfechos de interesse foram letalidade na UTI e no hospital. As variáveis que, além do sódio, apresentavam associação com os desfechos de interesse na análise bivariada, foram selecionadas e incluídas no modelo de regressão logística múltipla.Um total de 772 pacientes foram incluídos no estudo. A mediana da idade foi de 75 [IIQ: 61-82 anos]; 81,5% (IC: 78,4%-84%) foram admitidos na UTI por complicações clínicas. A presença de pelo menos uma comorbidade (hipertensão, diabetes, doença coronariana, insuficiência cardíaca, doença pulmonar obstrutiva crônica ou cirrose) esteve presente em 84% dos pacientes. A maior parte dos pacientes (72,5%, IC: 69,2%-75,7%) apresentava o diagnóstico de sepse. Os principais fatores contribuinte para IRA foram sepse (72%) e isquemia/choque (66%). A mortalidade na UTI foi de 64,6% (IC: 61,1%-68%) e a hospitalar foi de 69,7% (IC: 66,3%-72,9%). O diagnóstico de disnatremia foi frequente, estando presente em 47,3% (IC: 43,7%-50,9%) dos pacientes. A hipernatremia foi significantemente mais frequente do que a hiponatremia (33,7% X 13,6%, p=0.001) na população estudada. Na análise multivariada, os pacientes mais idosos, a admissão clínica, o número de comorbidades e o número de disfunções orgânicas estiveram associados a uma maior letalidade hospitalar. Os paciente com hipernatremia grave (>155 mEq/l) apresentaram maior associação com o óbito na UTI e no hospital [odds ratio (OR) ajustado de 3.39 (1,48-7,8) e 2,87 (1,2-6,89), respectivamente], apesar de todos terem sido submetidos ao SR durante a internação na UTI. O estudo demonstrou que as disnatremias são altamente prevalentes em pacientes com IRA e necessidade de diálise na UTI. Diferente do que tem sido demonstrado na população de UTI e na com DRC, a hipernatremia é o distúrbio do sódio mais frequentemente observado na população estudada. A idade mais avançada, a admissão clínica, o número de comorbidades e o número de disfunções orgânicas e a hipernatremia grave estão associados a um pior desfecho na IRA com necessidade de SR na UTI.

Context-aware real-time assistant architecture for pervasive healthcare

The aging population in many countries brings into focus rising healthcare costs and pressure on conventional healthcare services. Pervasive healthcare has emerged as a viable solution capable of providing a technology-driven approach to alleviate such problems by allowing healthcare to move from the hospital-centred care to self-care, mobile care, and at-home care. The state-of-the-art studies in this field, however, lack a systematic approach for providing comprehensive pervasive healthcare solutions from data collection to data interpretation and from data analysis to data delivery. In this thesis we introduce a Context-aware Real-time Assistant (CARA) architecture that integrates novel approaches with state-of-the-art technology solutions to provide a full-scale pervasive healthcare solution with the emphasis on context awareness to help maintaining the well-being of elderly people. CARA collects information about and around the individual in a home environment, and enables accurately recognition and continuously monitoring activities of daily living. It employs an innovative reasoning engine to provide accurate real-time interpretation of the context and current situation assessment. Being mindful of the use of the system for sensitive personal applications, CARA includes several mechanisms to make the sophisticated intelligent components as transparent and accountable as possible, it also includes a novel cloud-based component for more effective data analysis. To deliver the automated real-time services, CARA supports interactive video and medical sensor based remote consultation. Our proposal has been validated in three application domains that are rich in pervasive contexts and real-time scenarios: (i) Mobile-based Activity Recognition, (ii) Intelligent Healthcare Decision Support Systems and (iii) Home-based Remote Monitoring Systems.

Visual functioning and quality of life in the subfoveal radiotherapy study (SFRADS): SFRADS report 2

Aims: To determine whether or not self reported visual functioning and quality of life in patients with choroidal neovascularisation caused by age related macular degeneration (AMD) is better in those treated with 12 Gy external beam radiotherapy in comparison with untreated subjects. Methods: A multicentre single masked randomised controlled trial of 12 Gy of external beam radiation therapy (EBRT) delivered as 6x2 Gy fractions to the macula of an affected eye versus observation. Patients with AMD, aged 60 years or over, in three UK hospital units, who had subfoveal CNV and a visual acuity equal to or better than 6/60 (logMAR 1.0). Methods: Data from 199 eligible participants who were randomly assigned to 12 Gy teletherapy or observation were available for analysis. Visual function assessment, ophthalmic examination, and fundus fluorescein angiography were undertaken at baseline and at 3, 6, 12, and 24 months after study entry. To assess patient centred outcomes, subjects were asked to complete the Daily Living Tasks Dependent on Vision (DLTV) and the SF-36 questionnaires at baseline, 6, 12, and 24 months after enrolment to the study. Cross sectional and longitudinal analyses were conducted using arm of study as grouping variable. Regression analysis was employed to adjust for the effect of baseline co-variates on outcome at 12 months and 24 months. Results: Both control and treated subjects had significant losses in visual functioning as seen by a progressive decline in mean scores in the four dimensions of the DLTV. There were no statistically significant differences between treatment and control subjects in any of dimensions of the DLTV at 12 months or 24 months after study entry. Regression analysis confirmed that treatment status had no effect on the change in DLTV dimensional scores. Conclusions: The small benefits noted in clinical measures of vision in treated eyes did not translate into better self reported visual functioning in patients who received treatment when compared with the control arm. These findings have implications for the design of future clinical trials and studies.

General Practice after the Introduction of the QOF

While the Quality and Outcomes Framework (QOF) is reported to improve performance, its impact on some aspects of organisations need to be explored given the increased reliance on such schemes. Organisational culture can be seen as providing a sense of common values, belief, and norms, which may act as guidelines for behaviour in organisational settings. This research employs a competing value framework depictures different types of culture based on specific focuses and processes. The study is based on interviews with 2 GP practices in the north of England involving 19 participants. Healthcare professionals were aware that there is a dominant value held and shared strongly among members of the organisations-to provide high quality patient-centred services. This study found that while clan culture is still strong in both practices, changes occured in respondents' culture after the implementation of the QOF.

Preferences for a third-trimester ultrasound scan in a low-risk obstetric population: a discrete choice experiment

Objective: Establish maternal preferences for a third-trimester ultrasound scan in a healthy, low-risk pregnant population.

Design: Cross-sectional study incorporating a discrete choice experiment.

Setting: A large, urban maternity hospital in Northern Ireland.

Participants: One hundred and forty-six women in their second trimester of pregnancy.

Methods: A discrete choice experiment was designed to elicit preferences for four attributes of a third-trimester ultrasound scan: health-care professional conducting the scan, detection rate for abnormal foetal growth, provision of non-medical information, cost. Additional data collected included age, marital status, socio-economic status, obstetric history, pregnancy-specific stress levels, perceived health and whether pregnancy was planned. Analysis was undertaken using a mixed logit model with interaction effects.

Main outcome measures: Women's preferences for, and trade-offs between, the attributes of a hypothetical scan and indirect willingness-to-pay estimates.

Results: Women had significant positive preference for higher rate of detection, lower cost and provision of non-medical information, with no significant value placed on scan operator. Interaction effects revealed subgroups that valued the scan most: women experiencing their first pregnancy, women reporting higher levels of stress, an adverse obstetric history and older women.

Conclusions: Women were able to trade on aspects of care and place relative importance on clinical, non-clinical outcomes and processes of service delivery, thus highlighting the potential of using health utilities in the development of services from a clinical, economic and social perspective. Specifically, maternal preferences exhibited provide valuable information for designing a randomized trial of effectiveness and insight for clinical and policy decision makers to inform woman-centred care.

Organization specific predictors of job satisfaction: findings from a Canadian multi-site quality of work life cross-sectional survey

Background: Organizational features can affect how staff view their quality of work life. Determining staff perceptions about quality of work life is an important consideration for employers interested in improving employee job satisfaction. The purpose of this study was to identify organization specific predictors of job satisfaction within a health care system that consisted of six independent health care organizations.

Methods: 5,486 full, part and causal time (non-physician) staff on active payroll within six organizations (2 community hospitals, 1 community hospital/long-term care facility, 1 long-term care facility, 1 tertiary care/community health centre, and 1 visiting nursing agency) located in five communities in Central West Ontario, Canada were asked to complete a 65-item quality of work life survey. The self-administered questionnaires collected staff perceptions of: co-worker and supervisor support; teamwork and communication; job demands and decision authority; organization characteristics; patient/resident care; compensation and benefits; staff training and development; and impressions of the organization. Socio-demographic data were also collected.

Results: Depending on the organization, between 15 and 30 (of the 40 potential predictor) variables were found to be statistically associated with job satisfaction (univariate analyses). Logistic regression analyses identified the best predictors of job satisfaction and these are presented for each of the six organizations and for all organizations combined.

Conclusions: The findings indicate that job satisfaction is a multidimensional construct and although there appear to be some commonalities across organizations, some predictors of job satisfaction appear to be organization and context specific.