Advance directives, autonomy and the refusal of life-sustaining medical treatment

As Australian society 1s agemg, individuals are increasingly concerned about managing their future, including making decisions about the medical treatment they may wish to receive or refuse if they lose decision-making capacity. To date, there has been relatively little research into the extent to which legal regulation allows competent adults to make advance refusals of life-sustaining medical treatment that will bind health professionals and others when a decision needs to be made at a future time. This thesis aims to fill this gap in the research by presenting the results of research into the legal regulation of advance directives that refuse life-sustaining medical treatment. In the five papers that comprise this thesis, the law that governs this area is examined, and the ethical principle of autonomy is used to critically evaluate that law. The principal finding of this research is that the current scheme of regulation is ineffective to adequately promote the right of a competent adult to make binding advance directives about refusal of medical treatment. The research concludes that legislation should be enacted to enable individuals to complete an advance directive, only imposing restrictions to the extent that this is necessary to promote individual autonomy. The thesis first examines the principle of autonomy upon which the common law (and some statutory law) is expressed to be based, to determine whether that principle is an appropriate one to underpin regulation. 1 The finding of the research is that autonomy can be justified as an organising principle on a number of grounds: it is consistent with the values of a liberal democracy; over recent decades, it is a principle that has been even more prominent within the discipline of medical ethics; and it is the principle which underpins the legal regulation of a related topic, namely the contemporaneous refusal of medical treatment. Next, the thesis reviews the common law to determine whether it effectively achieves the goal of promoting autonomy by allowing a competent adult to make an advance directive refusing treatment that will operate if he or she later loses decision-making capacity. 2 This research finds that conunon law doctrine, as espoused by the judiciary, prioritises individual choice by recognising valid advance directives that refuse treatment as binding. However, the research also concludes that the common law, as applied by the judiciary in some cases, may not be effective to promote individual autonomy, as there have been a number of circumstances where advance directives that refuse treatment have not been followed. The thesis then examines the statutory regimes in Australia that regulate advance directives, with a focus on the regulation of advance refusals of life-sustaining medical treatment.3 This review commences with an examination ofparliamentary debates to establish why legislation was thought to be necessary. It then provides a detailed review of all of the statutory regimes, the extent to which the legislation regulates the form of advance directives, and the circumstances in which they can be completed, will operate and can be ignored by medical professionals. The research finds that legislation was enacted mainly to clarify the common law and bring a level of certainty to the field. Legislative regimes were thought to provide medical professionals with the assurance that compliance with an advance directive that refuses life-sustaining medical treatment will not expose them to legal sanction. However, the research also finds that the legislation places so many restrictions on when an advance directive refusing treatment can be made, or will operate, that they have not been successful in promoting individual autonomy.

Converting theory to practice : university-school collaboration on devising strategies for mentoring pedagogical knowledge

There appears no shortage of theorists for preservice teacher education; however many ideas are abandoned without practical applications. Indeed, it can take years for theories to materialise into practice, if they materialise at all. The quality of preservice teacher education is central for enhancing an education system, and mentors’ roles can assist to shape preservice teachers’ development within the school context. Yet mentoring can be haphazard without being underpinned by a theoretical framework. A mentoring model (personal attributes, system requirements, pedagogical knowledge, modelling, and feedback) has emerged from research and the literature to guide mentors’ practices. This qualitative study investigates mentors’ pedagogical knowledge as one factor crucial to the mentoring process. More specifically, this study involves a questionnaire and audio-recorded focus group meetings with experienced mentors (n=14) who deliberated on devising practical applications for mentoring pedagogical knowledge. Findings revealed that these experienced mentors pinpointed practical applications around a mentor’s role for providing pedagogical knowledge to the mentee. These strategies were varied and demonstrated that any one mentoring practice may be approached from a number of different angles. Nevertheless, there were core mentoring practices in pedagogical knowledge such as showing the mentee how to plan for teaching, articulating classroom management approaches, and talking about how to connect learning to assessment. Mentors may require education on current mentoring practices with practical strategies that are linked to theoretical underpinnings.

Applications of medical image processing in the diagnosis and treatment of spinal deformity

In Chapter 10, Adam and Dougherty describe the application of medical image processing to the assessment and treatment of spinal deformity, with a focus on the surgical treatment of idiopathic scoliosis. The natural history of spinal deformity and current approaches to surgical and non-surgical treatment are briefly described, followed by an overview of current clinically used imaging modalities. The key metrics currently used to assess the severity and progression of spinal deformities from medical images are presented, followed by a discussion of the errors and uncertainties involved in manual measurements. This provides the context for an analysis of automated and semi-automated image processing approaches to measure spinal curve shape and severity in two and three dimensions.

Managing large collections of business process models - Current techniques and challenges

Nowadays, business process management is an important approach for managing organizations from an operational perspective. As a consequence, it is common to see organizations develop collections of hundreds or even thousands of business process models. Such large collections of process models bring new challenges and provide new opportunities, as the knowledge that they encapsulate requires to be properly managed. Therefore, a variety of techniques for managing large collections of business process models is being developed. The goal of this paper is to provide an overview of the management techniques that currently exist, as well as the open research challenges that they pose.

Knowledge management and Dublin Core

This paper is concerned with investigating existing and potential scope of Dublin Core metadata in Knowledge Management contexts. Modelling knowledge is identified as a conceptual prerequisite in this investigation, principally for the purpose of clarifying scope prior to identifying the range of tasks associated with organising knowledge. A variety of models is presented and relationships between data, information, and knowledge discussed. It is argued that the two most common modes of organisation, hierarchies and networks, influence the effectiveness and flow of knowledge. Practical perspective is provided by reference to implementations and projects providing evidence of how DC metadata is applied in such contexts. A sense-making model is introduced that can be used as a shorthand reference for identifying useful facets of knowledge that might be described using metadata. Discussion is aimed at presenting this model in a way that both validates current applications and points to potential novel applications.

Classifying external causes of injury : history, current approaches, and future directions

The International Classification of Diseases (ICD) is used to categorise diseases, injuries and external causes, and is a key epidemiological tool enabling the storage and retrieval of data from health and vital records to produce core international mortality and morbidity statistics. The ICD is updated periodically to ensure the classification remains current and work is now underway to develop the next revision, ICD-11. There have been almost 20 years since the last ICD edition was published and over 60 years since the last substantial structural revision of the external causes chapter. Revision of such a critical tool requires transparency and documentation to ensure that changes made to the classification system are recorded comprehensively for future reference. In this paper, the authors provide a history of external causes classification development and outline the external cause structure. Approaches to manage ICD-10 deficiencies are discussed and the ICD-11 revision approach regarding the development of, rationale for and implications of proposed changes to the chapter are outlined. Through improved capture of external cause concepts in ICD-11, a stronger evidence base will be available to inform injury prevention, treatment, rehabilitation and policy initiatives to ultimately contribute to a reduction in injury morbidity and mortality.

Discovering novel knowledge using granule mining

This paper presents an extended granule mining based methodology, to effectively describe the relationships between granules not only by traditional support and confidence, but by diversity and condition diversity as well. Diversity measures how diverse of a granule associated with the other granules, it provides a kind of novel knowledge in databases. We also provide an algorithm to implement the proposed methodology. The experiments conducted to characterize a real network traffic data collection show that the proposed concepts and algorithm are promising.

A tan in a test tube -in vitro models for investigating ultraviolet radiation-induced damage in skin

Presently, global rates of skin cancers induced by ultraviolet radiation (UVR) exposure are on the rise. In view of this, current knowledge gaps in the biology of photocarcinogenesis and skin cancer progression urgently need to be addressed. One factor that has limited skin cancer research has been the need for a reproducible and physiologically-relevant model able to represent the complexity of human skin. This review outlines the main currently-used in vitro models of UVR-induced skin damage. This includes the use of conventional two-dimensional cell culture techniques and the major animal models that have been employed in photobiology and photocarcinogenesis research. Additionally, the progression towards the use of cultured skin explants and tissue-engineered skin constructs, and their utility as models of native skin's responses to UVR are described. The inherent advantages and disadvantages of these in vitro systems are also discussed.

Multisensory integration weightings underlying haptic feedback laparoscopic surgery

"This letter aims to highlight the multisensory integration weighting mechanisms that may account for the results in studies investigating haptic feedback in laparoscopic surgery. The current lack of multisensory theoretical knowledge in laparoscopy is evident, and “a much better understanding of how multimodal displays in virtual environments influence human performance is required” ...publisher website

Middle school social sciences : exploring teachers’ conceptions of essential knowledge

This study examines teachers’ conceptions of essential knowledge in the humanities and social sciences, commonly referred to as "social education", in the middle years of schooling. Social education has long been a highly contested area of the curriculum in Australia. In Queensland, social education comprises the integrated learning area of Studies of Society and Environment (SOSE). However, the new Australian Curriculum marks a return to discipline-based study of history and geography. This phenomenographic study addresses a perceived lack of understanding in the current research literature in Australia of the nature of middle school teachers’ professional knowledge for teaching the social sciences. Teachers are conceptualised in this study as curriculum makers in the classroom and, as such, their conceptions of essential knowledge are significant. Shulman’s (1986, 1987) theory of teachers’ knowledge forms the theoretical foundation of the study, which is contextualised in Federal and State education policies and the literature on the middle phase of schooling. Transcripts of interviews conducted with a group of thirty-one Queensland middle school teachers of SOSE were subjected to phenomenographic analysis, revealing seven qualitatively different categories of description. Essential aspects of knowledge for social education emerging from the study were: (1) discipline-based knowledge; (2) curriculum knowledge; (3) knowledge derived from teaching experience; (4) knowledge of middle years learners; (5) knowledge of integration; (6) knowledge of current affairs; and (7) knowledge invested in teacher identity. The three dimensions of variation that linked and differentiated the categories were: (1) content; (2) inquiry learning; and (3) teacher autonomy. These findings are presented as an outcome space where the categories are grouped as knowledge of the learning area, knowledge of contexts and knowledge of self as teacher. The results of the study suggest that social education teachers’ identity and knowledge of self are critical aspects of their knowledge as curriculum makers. The results illustrate that the professional and personal domains intersect, extending Shulman’s (1986, 1987) original theorisation of teachers’ knowledge into the personal arena. Further, middle years teachers’ conceptions of essential knowledge reveal a practice-based theorisation of knowledge for social education that fits the goals of middle schooling. The research concludes that attention to teacher identity in teacher education and in-service professional development has considerable potential to grow teachers’ knowledge in the social sciences and enhance their capacity for school-based curriculum leadership.

Achieving quality improvement in the mask manufacturing industry by using Six Sigma technique

The Six Sigma technique is one of the quality management strategies and is utilised for improving the quality and productivity in the manufacturing process. It is inspired by the two major project methodologies of Deming’s "Plan – Do – Check – Act (PDCA)" Cycle which consists of DMAIC and DMADV. Those two methodologies are comprised of five phases. The DMAIC project methodology will be comprehensively used in this research. In brief, DMAIC is utilised for improving the existing manufacturing process and it involves the phases Define, Measure, Analyse, Improve, and Control. Mask industry has become a significant industry in today’s society since the outbreak of some serious diseases such as the Severe Acute Respiratory Syndrome (SARS), bird flu, influenza, swine flu and hay fever. Protecting the respiratory system, then, has become the fundamental requirement for preventing respiratory deceases. Mask is the most appropriate and protective product inasmuch as it is effective in protecting the respiratory tract and resisting the virus infection through air. In order to satisfy various customers’ requirements, thousands of mask products are designed in the market. Moreover, masks are also widely used in industries including medical industries, semi-conductor industries, food industries, traditional manufacturing, and metal industries. Notwithstanding the quality of masks have become the prioritisations since they are used to prevent dangerous diseases and safeguard people, the quality improvement technique are of very high significance in mask industry. The purpose of this research project is firstly to investigate the current quality control practices in a mask industry, then, to explore the feasibility of using Six Sigma technique in that industry, and finally, to implement the Six Sigma technique in the case company to develop and evaluate the product quality process. This research mainly investigates the quality problems of musk industry and effectiveness of six sigma technique in musk industry with the United Excel Enterprise Corporation (UEE) Company as a case company. The DMAIC project methodology in the Six Sigma technique is adopted and developed in this research. This research makes significant contribution to knowledge. The main results contribute to the discovering the root causes of quality problems in a mask industry. Secondly, the company was able to increase not only acceptance rate but quality level by utilising the Six Sigma technique. Hence, utilising the Six Sigma technique could increase the production capacity of the company. Third, the Six Sigma technique is necessary to be extensively modified to improve the quality control in the mask industry. The impact of the Six Sigma technique on the overall performance in the business organisation should be further explored in future research.

Hospital outpatient responses to potential driving impairment due to prescribed medications

Driving and using prescription medicines that have the potential to impair driving is an emerging research area. To date it is characterised by a limited (although growing) number of studies and methodological complexities that make generalisations about impairment due to medications difficult. Consistent evidence has been found for the impairing effects of hypnotics, sedative antidepressants and antihistamines, and narcotic analgesics, although it has been estimated that as many as nine medication classes have the potential to impair driving (Alvarez & del Rio, 2000; Walsh, de Gier, Christopherson, & Verstraete, 2004). There is also evidence for increased negative effects related to concomitant use of other medications and alcohol (Movig et al., 2004; Pringle, Ahern, Heller, Gold, & Brown, 2005). Statistics on the high levels of Australian prescription medication use suggest that consumer awareness of driving impairment due to medicines should be examined. One web-based study has found a low level of awareness, knowledge and risk perceptions among Australian drivers about the impairing effects of various medications on driving (Mallick, Johnston, Goren, & Kennedy, 2007). The lack of awareness and knowledge brings into question the effectiveness of the existing countermeasures. In Australia these consist of the use of ancillary warning labels administered under mandatory regulation and professional guidelines, advice to patients, and the use of Consumer Medicines Information (CMI) with medications that are known to cause impairment. The responsibility for the use of the warnings and related counsel to patients primarily lies with the pharmacist when dispensing relevant medication. A review by the Therapeutic Goods Administration (TGA) noted that in practice, advice to patients may not occur and that CMI is not always available (TGA, 2002). Researchers have also found that patients' recall of verbal counsel is very low (Houts, Bachrach, Witmer, Tringali, Bucher, & Localio, 1998). With healthcare observed as increasingly being provided in outpatient conditions (Davis et al., 2006; Vingilis & MacDonald, 2000), establishing the effectiveness of the warning labels as a countermeasure is especially important. There have been recent international developments in medication categorisation systems and associated medication warning labels. In 2005, France implemented a four-tier medication categorisation and warning system to improve patients' and health professionals' awareness and knowledge of related road safety issues (AFSSAPS, 2005). This warning system uses a pictogram and indicates the level of potential impairment in relation to driving performance through the use of colour and advice on the recommended behaviour to adopt towards driving. The comparable Australian system does not indicate the severity level of potential effects, and does not provide specific guidelines on the attitude or actions that the individual should adopt towards driving. It is reliant upon the patient to be vigilant in self-monitoring effects, to understand the potential ways in which they may be affected and how serious these effects may be, and to adopt the appropriate protective actions. This thesis investigates the responses of a sample of Australian hospital outpatients who receive appropriate labelling and counselling advice about potential driving impairment due to prescribed medicines. It aims to provide baseline data on the understanding and use of relevant medications by a Queensland public hospital outpatient sample recruited through the hospital pharmacy. It includes an exploration and comparison of the effect of the Australian and French medication warning systems on medication user knowledge, attitudes, beliefs and behaviour, and explores whether there are areas in which the Australian system may be improved by including any beneficial elements of the French system. A total of 358 outpatients were surveyed, and a follow-up telephone survey was conducted with a subgroup of consenting participants who were taking at least one medication that required an ancillary warning label about driving impairment. A complementary study of 75 French hospital outpatients was also conducted to further investigate the performance of the warnings. Not surprisingly, medication use among the Australian outpatient sample was high. The ancillary warning labels required to appear on medications that can impair driving were prevalent. A subgroup of participants was identified as being potentially at-risk of driving impaired, based on their reported recent use of medications requiring an ancillary warning label and level of driving activity. The sample reported previous behaviour and held future intentions that were consistent with warning label advice and health protective action. Participants did not express a particular need for being advised by a health professional regarding fitness to drive in relation to their medication. However, it was also apparent from the analysis that the participants would be significantly more likely to follow advice from a doctor than a pharmacist. High levels of knowledge in terms of general principles about effects of alcohol, illicit drugs and combinations of substances, and related health and crash risks were revealed. This may reflect a sample specific effect. Emphasis is placed in the professional guidelines for hospital pharmacists that make it essential that advisory labels are applied to medicines where applicable and that warning advice is given to all patients on medication which may affect driving (SHPA, 2006, p. 221). The research program applied selected theoretical constructs from Schwarzer's (1992) Health Action Process Approach, which has extended constructs from existing health theories such as the Theory of Planned Behavior (Ajzen, 1991) to better account for the intention-behaviour gap often observed when predicting behaviour. This was undertaken to explore the utility of the constructs in understanding and predicting compliance intentions and behaviour with the mandatory medication warning about driving impairment. This investigation revealed that the theoretical constructs related to intention and planning to avoid driving if an effect from the medication was noticed were useful. Not all the theoretical model constructs that had been demonstrated to be significant predictors in previous research on different health behaviours were significant in the present analyses. Positive outcome expectancies from avoiding driving were found to be important influences on forming the intention to avoid driving if an effect due to medication was noticed. In turn, intention was found to be a significant predictor of planning. Other selected theoretical constructs failed to predict compliance with the Australian warning label advice. It is possible that the limited predictive power of a number of constructs including risk perceptions is due to the small sample size obtained at follow up on which the evaluation is based. Alternately, it is possible that the theoretical constructs failed to sufficiently account for issues of particular relevance to the driving situation. The responses of the Australian hospital outpatient sample towards the Australian and French medication warning labels, which differed according to visual characteristics and warning message, were examined. In addition, a complementary study with a sample of French hospital outpatients was undertaken in order to allow general comparisons concerning the performance of the warnings. While a large amount of research exists concerning warning effectiveness, there is little research that has specifically investigated medication warnings relating to driving impairment. General established principles concerning factors that have been demonstrated to enhance warning noticeability and behavioural compliance have been extrapolated and investigated in the present study. The extent to which there is a need for education and improved health messages on this issue was a core issue of investigation in this thesis. Among the Australian sample, the size of the warning label and text, and red colour were the most visually important characteristics. The pictogram used in the French labels was also rated highly, and was salient for a large proportion of the sample. According to the study of French hospital outpatients, the pictogram was perceived to be the most important visual characteristic. Overall, the findings suggest that the Australian approach of using a combination of visual characteristics was important for the majority of the sample but that the use of a pictogram could enhance effects. A high rate of warning recall was found overall and a further important finding was that higher warning label recall was associated with increased number of medication classes taken. These results suggest that increased vigilance and care are associated with the number of medications taken and the associated repetition of the warning message. Significantly higher levels of risk perception were found for the French Level 3 (highest severity) label compared with the comparable mandatory Australian ancillary Label 1 warning. Participants' intentions related to the warning labels indicated that they would be more cautious while taking potentially impairing medication displaying the French Level 3 label compared with the Australian Label 1. These are potentially important findings for the Australian context regarding the current driving impairment warnings about displayed on medication. The findings raise other important implications for the Australian labelling context. An underlying factor may be the differences in the wording of the warning messages that appear on the Australian and French labels. The French label explicitly states "do not drive" while the Australian label states "if affected, do not drive", and the difference in responses may reflect that less severity is perceived where the situation involves the consumer's self-assessment of their impairment. The differences in the assignment of responsibility by the Australian (the consumer assesses and decides) and French (the doctor assesses and decides) approaches for the decision to drive while taking medication raises the core question of who is most able to assess driving impairment due to medication: the consumer, or the health professional? There are pros and cons related to knowledge, expertise and practicalities with either option. However, if the safety of the consumer is the primary aim, then the trend towards stronger risk perceptions and more consistent and cautious behavioural intentions in relation to the French label suggests that this approach may be more beneficial for consumer safety. The observations from the follow-up survey, although based on a small sample size and descriptive in nature, revealed that just over half of the sample recalled seeing a warning label about driving impairment on at least one of their medications. The majority of these respondents reported compliance with the warning advice. However, the results indicated variation in responses concerning alcohol intake and modifying the dose of medication or driving habits so that they could continue to drive, which suggests that the warning advice may not be having the desired impact. The findings of this research have implications for current countermeasures in this area. These have included enhancing the role that prescribing doctors have in providing warnings and advice to patients about the impact that their medication can have on driving, increasing consumer perceptions of the authority of pharmacists on this issue, and the reinforcement of the warning message. More broadly, it is suggested that there would be benefit in a wider dissemination of research-based information on increased crash risk and systematic monitoring and publicity about the representation of medications in crashes resulting in injuries and fatalities. Suggestions for future research concern the continued investigation of the effects of medications and interactions with existing medical conditions and other substances on driving skills, effects of variations in warning label design, individual behaviours and characteristics (particularly among those groups who are dependent upon prescription medication) and validation of consumer self-assessment of impairment.

Entrepreneurship education in non-business schools : best practice for Australian contexts of knowledge and innovation communities (Final Report)

In the current era of global economic instability, business and industry have already identified a widening gap between graduate skills and employability. An important element of this is the lack of entrepreneurial skills in graduates. This Teaching Fellowship investigated two sides of a story about entrepreneurial skills and their teaching. Senior players in the innovation commercialisation industry, a high profile entrepreneurial sector, were surveyed to gauge their needs and experiences of graduates they employ. International contexts of entrepreneurship education were investigated to explore how their teaching programs impart the skills of entrepreneurship. Such knowledge is an essential for the design of education programs that can deliver the entrepreneurial skills deemed important by industry for future sustainability. Two programs of entrepreneurship education are being implemented at QUT that draw on the best practice exemplars investigated during this Fellowship. The QUT Innovation Space (QIS) focuses on capturing the innovation and creativity of students, staff and others. The QIS is a physical and virtual meeting and networking space; a connected community enhancing the engagement of participants. The Q_Hatchery is still embryonic; but it is intended to be an innovation community that brings together nascent entrepreneurial businesses to collaborate, train and support each other. There is a niche between concept product and business incubator where an experiential learning environment for otherwise isolated ‘garage-at-home’ businesses could improve success rates. The QIS and the Q_Hatchery serve as living research laboratories to trial the concepts emerging from the skills survey. The survey of skills requirements of the innovation commercialisation industry has produced a large and high quality data set still being explored. Work experience as an employability factor has already emerged as an industry requirement that provides employee maturity. Exploratory factor analysis of the skills topics surveyed has led to a process-based conceptual model for teaching and learning higher-order entrepreneurial skills. Two foundational skills domains (Knowledge, Awareness) are proposed as prerequisites which allow individuals with a suite of early stage entrepreneurial and behavioural skills (Pre-leadership) to further leverage their careers into a leadership role in industry with development of skills around higher order elements of entrepreneurship, management in new business ventures and progressing winning technologies to market. The next stage of the analysis is to test the proposed model through structured equation modelling. Another factor that emerged quickly from the survey analysis broadens the generic concept of team skills currently voiced in Australian policy documents discussing the employability agenda. While there was recognition of the role of sharing, creating and using knowledge in a team-based interdisciplinary context, the adoption and adaptation of behaviours and attitudes of other team members of different disciplinary backgrounds (interprofessionalism) featured as an issue. Most undergraduates are taught and undertake teamwork in silos and, thus, seldom experience a true real-world interdisciplinary environment. Enhancing the entrepreneurial capacity of Australian industry is essential for the economic health of the country and can only be achieved by addressing the lack of entrepreneurial skills in graduates from the higher education system. This Fellowship has attempted to address this deficiency by identifying the skills requirements and providing frameworks for their teaching.

Towards determining soft tissue properties for modelling spine surgery : current progress and challenges

Current complication rates for adolescent scoliosis surgery necessitate the development of better surgical planning tools to improve outcomes. Here we present our approach to developing finite element models of the thoracolumbar spine for deformity surgery simulation, with patient-specific model anatomy based on low-dose pre-operative computed tomography scans. In a first step towards defining patient-specific tissue properties, an initial 'benchmark' set of properties were used to simulate a clinically performed pre-operative spinal flexibility assessment, the fulcrum bending radiograph. Clinical data for ten patients were compared with the simulated results for this assessment and in cases where these data differed by more than 10%, soft tissue properties for the costo-vertebral joint (CVJt) were altered to achieve better agreement. Results from these analyses showed that changing the CVJt stiffness resulted in acceptable agreement between clinical and simulated flexibility in two of the six cases. In light of these results and those of our previous studies in this area, it is suggested that spinal flexibility in the fulcrum bending test is not governed by any single soft tissue structure acting in isolation. More detailed biomechanical characterisation of the fulcrum bending test is required to provide better data for determination of patient-specific soft tissue properties.

Everyone's problem but nobody's job : staff perceptions and explanations for poor nutritional intake in older medical patients

Aim: Up to 60% of older medical patients are malnourished with further decline during hospital stay. There is limited evidence for effective nutrition intervention. Staff focus groups were conducted to improve understanding of potential contextual and cultural barriers to feeding older adults in hospital. Methods: Three focus groups involved 22 staff working on the acute medical wards of a large tertiary teaching hospital. Staff disciplines were nursing, dietetics, speech pathology, occupational therapy, physiotherapy, pharmacy. A semistructured topic guide was used by the same facilitator to prompt discussions on hospital nutrition care including barriers. Focus groups were tape-recorded, transcribed and analysed thematically. Results: All staff recognised malnutrition to be an important problem in older patients during hospital stay and identified patient-level barriers to nutrition care such as non-compliance to feeding plans and hospital-level barriers including nursing staff shortages. Differences between disciplines revealed a lack of a coordinated approach, including poor knowledge of nutrition care processes, poor interdisciplinary communication, and a lack of a sense of shared responsibility/coordinated approach to nutrition care. All staff talked about competing activities at meal times and felt disempowered to prioritise nutrition in the acute medical setting. Staff agreed education and ‘extra hands’ would address most barriers but did not consider organisational change. Conclusions: Redesigning the model of care to reprioritise meal-time activities and redefine multidisciplinary roles and responsibilities would support coordinated nutrition care. However, effectiveness may also depend on hospitalwide leadership and support to empower staff and increase accountability within a team-led approach.