Using ‘think aloud’ as a strategy for improving clinical reasoning in high fidelity case-based simulation for undergraduate nursing students.

Theme Paper for Curriculum innovation and enhancement theme AIM: This paper reports on a research project that trialled an educational strategy implemented in an undergraduate nursing curriculum. The project aimed to explore the effectiveness of ‘think aloud’ as a strategy for improving clinical reasoning for students in simulated clinical settings. BACKGROUND: Nurses are required to apply and utilise critical thinking skills to enable clinical reasoning and problem solving in the clinical setting (Lasater, 2007). Nursing students are expected to develop and display clinical reasoning skills in practice, but may struggle articulating reasons behind decisions about patient care. The ‘think aloud’ approach is an innovative learning/teaching method which can create an environment suitable for developing clinical reasoning skills in students (Banning, 2008, Lee and Ryan-Wenger, 1997). This project used the ‘think aloud’ strategy within a simulation context to provide a safe learning environment in which third year students were assisted to uncover cognitive approaches to assist in making effective patient care decisions, and improve their confidence, clinical reasoning and active critical reflection about their practice. MEHODS: In semester 2 2011 at QUT, third year nursing students undertook high fidelity simulation (some for the first time), commencing in September of 2011. There were two cohorts for strategy implementation (group 1= used think aloud as a strategy within the simulation, group 2= no specific strategy outside of nursing assessment frameworks used by all students) in relation to problem solving patient needs. The think aloud strategy was described to students in their pre-simulation briefing and allowed time for clarification of this strategy. All other aspects of the simulations remained the same, (resources, suggested nursing assessment frameworks, simulation session duration, size of simulation teams, preparatory materials). Ethics approval has been obtained for this project. RESULTS: Results of a qualitative analysis (in progress- will be completed by March 2012) of student and facilitator reports on students’ ability to meet the learning objectives of solving patient problems using clinical reasoning and experience with the ‘think aloud’ method will be presented. A comparison of clinical reasoning learning outcomes between the two groups will determine the effect on clinical reasoning for students responding to patient problems. CONCLUSIONS: In an environment of increasingly constrained clinical placement opportunities, exploration of alternate strategies to improve critical thinking skills and develop clinical reasoning and problem solving for nursing students is imperative in preparing nurses to respond to changing patient needs.

Can a community pharmacy sleep assessment tool aid the identification of patients at risk of sleep disorders in the community : a pilot study

Background: When experiencing sleep problems for the first time, consumers may often approach community pharmacists for advice as they are easily accessible health care professionals in the community. In Australian community pharmacies there are no specific tools available for use by pharmacists to assist with the assessment and handling of consumers with sleep enquiries. Objective: To assess the feasibility of improving the detection of sleep disorders within the community through the pilot of a newly developed Community Pharmacy Sleep Assessment Tool (COP-SAT). Method: The COP-SAT was designed to incorporate elements from a number of existing, standardized, and validated clinical screening measures. The COP-SAT was trialed in four Australian community pharmacies over a 4-week period. Key findings: A total of 241 community pharmacy consumers were assessed using the COP-SAT. A total of 74 (30.7%) were assessed as being at risk of insomnia, 26 (10.7%) were at risk of daytime sleepiness, 19 (7.9%) were at risk of obstructive sleep apnea, and 121 (50.2%) were regular snorers. A total of 116 (48.1%) participants indicated that they consume caffeine before bedtime, of which 55 (47%) had associated symptoms of sleep onset insomnia. Moreover, 85 (35%) consumed alcohol before bedtime, of which 50 (58%) experienced fragmented sleep, 50 (58%) were regular snorers, and nine (10.6%) had apnea symptoms. The COP-SAT was feasible in the community pharmacy setting. The prevalence of sleep disorders in the sampled population was high, but generally consistent with previous studies on the general population. Conclusion: A large proportion of participants reported sleep disorder symptoms, and a link was found between the consumption of alcohol and caffeine substances at bedtime and associated symptoms. While larger studies are needed to assess the clinical properties of the tool, the results of this feasibility study have demonstrated that the COP-SAT may be a practical tool for the identification of patients at risk of developing sleep disorders in the community.

A snapshot of radiation therapy techniques and technology in Queensland : an aid to mapping undergraduate curriculum

Introduction: Undergraduate students studying the Bachelor of Radiation Therapy at Queensland University of Technology (QUT) attend clinical placements in a number of department sites across Queensland. To ensure that the curriculum prepares students for the most common treatments and current techniques in use in these departments, a curriculum matching exercise was performed. Methods: A cross-sectional census was performed on a pre-determined “Snapshot” date in 2012. This was undertaken by the clinical education staff in each department who used a standardized proforma to count the number of patients as well as prescription, equipment, and technique data for a list of tumour site categories. This information was combined into aggregate anonymized data. Results: All 12 Queensland radiation therapy clinical sites participated in the Snapshot data collection exercise to produce a comprehensive overview of clinical practice on the chosen day. A total of 59 different tumour sites were treated on the chosen day and as expected the most common treatment sites were prostate and breast, comprising 46% of patients treated. Data analysis also indicated that intensity-modulated radiotherapy (IMRT) use is relatively high with 19.6% of patients receiving IMRT treatment on the chosen day. Both IMRT and image-guided radiotherapy (IGRT) indications matched recommendations from the evidence. Conclusion: The Snapshot method proved to be a feasible and efficient method of gathering useful

Creative intersections : supervision, practice and the space between

Supervision in the creative arts is a topic of growing significance since the increase in creative practice PhDs across universities in Australasia. This presentation will provide context of existing discussions in creative practice and supervision. Creative practice – encompassing practice-based or practice-led research – has now a rich history of research surrounding it. Although it is a comparatively new area of knowledge, great advances have been made in terms of how practice can influence, generate, and become research. The practice of supervision is also a topic of interest, perhaps unsurprisingly considering its necessity within the university environment. Many scholars have written much about supervision practices and the importance of the supervisory role, both in academic and more informal forms. However, there is an obvious space in between: there is very little research on supervision practices within creative practice higher degrees, especially at PhD or doctorate level. Despite the existence of creative practice PhD programs, and thus the inherent necessity for successful supervisors, there remain minimal publications and limited resources available. Creative Intersections explores the existing publications and resources, and illustrates that a space for new published knowledge and tools exists.

Compounding practices in Queensland : experiences and perceptions of pharmacists and pharmacy students

Background: Changes in the roles of the contemporary pharmacist has seen a decline in the number and variety of extemporaneously compounded dosage forms. Pharmacy curricula reflect this change with a reduction in the emphasis on extemporaneous compounding practice. Aim: To elicit information about extemporaneously compounded dosage forms and perceptions of compounding practice from pharmacists and pharmacy students. Method: Self-administered surveys were mailed to 1063 pharmacists and offered online to 896 pharmacy undergraduates across the 4 years of a Bachelor of Pharmacy program in Queensland. Results: 382 (36%) pharmacists and 455 (51%) students completed the survey. Most pharmacists (96%) reported compounding a product in the 12 months prior to the survey, particularly semi-solids (89%) and liquids (64%) for external use. Most pharmacies (> 96%) owned basic compounding equipment, such as a slab and spatula, mortar and pestle, and cylindrical/conical measures. Half of the pharmacies used mechanical rather than electronic balances. Students expressed greater confidence in their ability to use basic compounding equipment and to perform basic compounding tasks as they progressed through the 4-year degree course. Pharmacists’ views on students’ ability to compound basic products at the end of their degree were generally similar to the proportion of final-year students who reported they could confidently complete the task. Conclusion: Despite a decline in extemporaneously compounded products in community pharmacy, pharmacy graduates need to be competent in compounding techniques.

Prescribing practices of Australian dispensing doctors

Background: In response to health workforce shortages policymakers have considered expanding the roles that a health professional may perform. A more traditional combination of health professional roles is that of a dispensing doctor (DD) who routinely prescribes and dispenses pharmaceuticals. A systematic review conducted on mainly overseas DDs’ practices found that DDs tended to prescribe more items per patients, less often generically, and showed poorer adherence to best practice. Convenience for patients was cited by both patients and DDs as the main reason for dispensing. In Australia, rural doctors are allowed to dispense Pharmaceutical Benefit Scheme (PBS) subsidised pharmaceutical benefits if there is no reasonable pharmacy coverage. Little was known about the practices of these Australian DDs. Objectives: To examine the PBS prescribing patterns of dispensing with matched non-dispensing doctors and identify factors that influence prescribing behaviour. Method: A sequential explanatory (QUAN-->qual) mixed methodology was utilised. Firstly, rurality-matched DDs’ and non-DDs’ PBS data for fiscal years 2005-7 were analysed against criteria distilled from a systematic review and stakeholder consultations. Secondly, structured interviews were conducted with a purposive sample of DDs to examine the quantitative findings. Key findings: DDs prescribed significantly fewer PBS prescriptions per patients but used Regulation 24 significantly more than non-DDs. Regulation 24 biased the prescribing data. DDs prescribed proportionally more penicillin type antibiotics, adrenergic inhalants and non-steroidal anti-inflammatories as compared to non-DDs. Reasons offered by DD-respondents highlighted that prescribing was influenced by an awareness of cost to the patients, peer pressure and confidential prescriber feedback provided on a regular basis. Implications: This innovative census study does not support international data that DDs are less judicious in their prescribing. There is some evidence that DDs might reduce health inequity between rural and urban Australian, and that the DD health model is valuable to patients in isolated communities.

Footprint-based estimates of arch structure are confounded by body composition in adults

Previous research employing indirect measures of arch structure, such as those derived from footprints, have indicated that obesity results in a “flatter” foot type. In the absence of radiographic measures, however, definitive conclusions regarding the osseous alignment of the foot cannot be made. We determined the effect of body mass index (BMI) on radiographic and footprint‐based measures of arch structure. The research was a cross‐sectional study in which radiographic and footprint‐based measures of foot structure were made in 30 subjects (10 males, 20 female) in addition to standard anthropometric measures of height, weight, and BMI. Multiple (univariate) regression analysis demonstrated that both BMI ( β  = 0.39, t 26  = 2.12, p  = 0.04) and radiographic arch alignment ( β  = 0.51, t 26  = 3.32, p  < 0.01) were significant predictors of footprint‐based measures of arch height after controlling for all variables in the model ( R 2  = 0.59, F 3,26  = 12.3, p  < 0.01). In contrast, radiographic arch alignment was not significantly associated with BMI ( β  = −0.03, t 26  = −0.13, p  = 0.89) when Arch Index and age were held constant ( R 2  = 0.52, F 3,26  = 9.3, p  < 0.01). Adult obesity does not influence osseous alignment of the medial longitudinal arch, but selectively distorts footprint‐based measures of arch structure. Footprint‐based measures of arch structure should be interpreted with caution when comparing groups of varying body composition.

A systematic review of the literature comparing the practices of dispensing and non-dispensing doctors

Objectives: Some doctors perform the dual roles of prescribing and dispensing pharmaceuticals. The dispensing doctors (DDs) role may give rise to prescribing behaviours that vary from those of non-DDs. The aim of this review was to systematically and comparatively appraise the research evidence related to the practices of DDs. Methods: A systematic search of bibliographic databases and reference lists from selected papers were the sources of the data. Inclusion criteria were papers published in English, between 1970 and 2008 that provided quantitative data comparing the practices of DDs and non-DDs. At least two of the authors abstracted data from all eligible papers using a purpose-made data extraction form. Results: Twenty-one papers were included in this review. Evidence indicated that DDs prescribed more pharmaceutical items and less often generically than non-DDs. There was limited evidence to suggest that DDs prescribed less judiciously and were associated with poor dispensing standards. Patient convenience and access to pharmaceuticals were main reasons for doctors to dispense. Conclusion: DDs can fill an important gap in the provision of pharmaceuticals for their patients especially where health workforce shortages exist. There was evidence the dispensing role influenced prescribing. Patient convenience should be balanced against scarce medical resources, being utilised for dispensing.

Can testosterone replacement decrease the memory problem of old age?

The world is rapidly ageing. It is against this backdrop that there are increasing incidences of dementia reported worldwide, with Alzheimer's disease (AD) being the most common form of dementia in the elderly. It is estimated that AD affects almost 4 million people in the US, and costs the US economy more than 65 million dollars annually. There is currently no cure for AD but various therapeutic agents have been employed in attempting to slow down the progression of the illness, one of which is oestrogen. Over the last decades, scientists have focused mainly on the roles of oestrogen in the prevention and treatment of AD. Newer evidences suggested that testosterone might also be involved in the pathogenesis of AD. Although the exact mechanisms on how androgen might affect AD are still largely unknown, it is known that testosterone can act directly via androgen receptor-dependent mechanisms or indirectly by converting to oestrogen to exert this effect. Clinical trials need to be conducted to ascertain the putative role of androgen replacement in Alzheimer's disease.

Radiographic projections for acute shoulder trauma: A review of current practice

A review of radiographers was undertaken to determine the specific projections currently performed for patients with acute presentation for shoulder trauma. Radiographers were asked to indicate projections they would perform for specific patient presentations. This poster presents a snapshot of the diversity of projections performed and a review of the current evidence of the most appropriate projections

The development of Monte Carlo techniques for the verification of radiotherapy treatments

Introduction: Recent advances in the planning and delivery of radiotherapy treatments have resulted in improvements in the accuracy and precision with which therapeutic radiation can be administered. As the complexity of the treatments increases it becomes more difficult to predict the dose distribution in the patient accurately. Monte Carlo (MC) methods have the potential to improve the accuracy of the dose calculations and are increasingly being recognised as the ‘gold standard’ for predicting dose deposition in the patient [1]. This project has three main aims: 1. To develop tools that enable the transfer of treatment plan information from the treatment planning system (TPS) to a MC dose calculation engine. 2. To develop tools for comparing the 3D dose distributions calculated by the TPS and the MC dose engine. 3. To investigate the radiobiological significance of any errors between the TPS patient dose distribution and the MC dose distribution in terms of Tumour Control Probability (TCP) and Normal Tissue Complication Probabilities (NTCP). The work presented here addresses the first two aims. Methods: (1a) Plan Importing: A database of commissioned accelerator models (Elekta Precise and Varian 2100CD) has been developed for treatment simulations in the MC system (EGSnrc/BEAMnrc). Beam descriptions can be exported from the TPS using the widespread DICOM framework, and the resultant files are parsed with the assistance of a software library (PixelMed Java DICOM Toolkit). The information in these files (such as the monitor units, the jaw positions and gantry orientation) is used to construct a plan-specific accelerator model which allows an accurate simulation of the patient treatment field. (1b) Dose Simulation: The calculation of a dose distribution requires patient CT images which are prepared for the MC simulation using a tool (CTCREATE) packaged with the system. Beam simulation results are converted to absolute dose per- MU using calibration factors recorded during the commissioning process and treatment simulation. These distributions are combined according to the MU meter settings stored in the exported plan to produce an accurate description of the prescribed dose to the patient. (2) Dose Comparison: TPS dose calculations can be obtained using either a DICOM export or by direct retrieval of binary dose files from the file system. Dose difference, gamma evaluation and normalised dose difference algorithms [2] were employed for the comparison of the TPS dose distribution and the MC dose distribution. These implementations are spatial resolution independent and able to interpolate for comparisons. Results and Discussion: The tools successfully produced Monte Carlo input files for a variety of plans exported from the Eclipse (Varian Medical Systems) and Pinnacle (Philips Medical Systems) planning systems: ranging in complexity from a single uniform square field to a five-field step and shoot IMRT treatment. The simulation of collimated beams has been verified geometrically, and validation of dose distributions in a simple body phantom (QUASAR) will follow. The developed dose comparison algorithms have also been tested with controlled dose distribution changes. Conclusion: The capability of the developed code to independently process treatment plans has been demonstrated. A number of limitations exist: only static fields are currently supported (dynamic wedges and dynamic IMRT will require further development), and the process has not been tested for planning systems other than Eclipse and Pinnacle. The tools will be used to independently assess the accuracy of the current treatment planning system dose calculation algorithms for complex treatment deliveries such as IMRT in treatment sites where patient inhomogeneities are expected to be significant. Acknowledgements: Computational resources and services used in this work were provided by the HPC and Research Support Group, Queensland University of Technology, Brisbane, Australia. Pinnacle dose parsing made possible with the help of Paul Reich, North Coast Cancer Institute, North Coast, New South Wales.

40 years of cancer nursing in Australia : the emergence of a specialty

Over the past 40 years, the nature and scope of cancer nursing practice has been shaped to a large extent by scientific and medical advances, as well as by social, economic and political factors. Nurses’ role in cancer care has evolved from being predominantly functional and dependent in its approach to being a specialty with clearly defined standards of practice underpinned by a growing evidence base and an agreed set of professional performance capabilities. The unique contribution that nurses make to minimising the effects of cancer on a person’s life and improving the patient experience is now well established and Australian cancer nurses are recognised as leaders in the field internationally. Nurses have achieved improved outcomes for people affected by cancer as part of a multidisciplinary team. By being active participants in the Clinical Oncological Society of Australia for at least 30 of the organisation’s 40 year history, Australian cancer nurses have been provided unique opportunities for professional development and inter-professional collaboration. To meet future challenges in delivering quality cancer care, cancer nurses will need to be full partners with consumers and with other health professionals in redesigning health care systems that are more responsive to changes in social, demographic, scientific and technological contexts.

Segmentation of cone-beam CT using a hidden Markov random field with informative priors

Purpose: Flat-detector, cone-beam computed tomography (CBCT) has enormous potential to improve the accuracy of treatment delivery in image-guided radiotherapy (IGRT). To assist radiotherapists in interpreting these images, we use a Bayesian statistical model to label each voxel according to its tissue type. Methods: The rich sources of prior information in IGRT are incorporated into a hidden Markov random field (MRF) model of the 3D image lattice. Tissue densities in the reference CT scan are estimated using inverse regression and then rescaled to approximate the corresponding CBCT intensity values. The treatment planning contours are combined with published studies of physiological variability to produce a spatial prior distribution for changes in the size, shape and position of the tumour volume and organs at risk (OAR). The voxel labels are estimated using the iterated conditional modes (ICM) algorithm. Results: The accuracy of the method has been evaluated using 27 CBCT scans of an electron density phantom (CIRS, Inc. model 062). The mean voxel-wise misclassification rate was 6.2%, with Dice similarity coefficient of 0.73 for liver, muscle, breast and adipose tissue. Conclusions: By incorporating prior information, we are able to successfully segment CBCT images. This could be a viable approach for automated, online image analysis in radiotherapy.

The concept of congruent patient-centred care for hepatitis C management

Patient-centred care has been touted as the cornerstone of an effective and efficient primary health care system. However, primary care by its nature is a fragmented system. The system co-evolves in response to needs rather than being planned. In recent years, Medicare Locals were formed in Australia with the intention to tap into this pragmatic nature of primary care and foster health services delivery which is responsive to community and individual patient needs i.e. ‘patient-centred care’. However, it remains to be seen what and how theoretical framework/s can inform this work. For this presentation we aim to illustrate with a case study how hepatitis C is currently managed in primary care and hypothesise what a congruent model of patient-centred care for hepatitis C management could look like.

Relationship of moderate and low isometric lumbar extension through architectural and muscular activity variables: a cross sectional study

Background No study relating the changes obtained in the architecture of erector spinae (ES) muscle were registered with ultrasound and different intensities of muscle contraction recorded by surface EMG (electromyography) on the ES muscle was found. The aim of this study was analyse the relationship in the response of the ES muscle during isometric moderate and light lumbar isometric extension considering architecture and functional muscle variables. Methods Cross-sectional study. 46 subjects (52% men) with a group mean age of 30.4 (±7.78). The participants developed isometric lumbar extension while performing moderate and low isometric trunk and hip extension in a sitting position with hips flexed 90 degrees and the lumbar spine in neutral position. During these measurements, electromyography recordings and ultrasound images were taken bilaterally. Bilaterally pennation angle, muscle thickness, torque and muscle activation were measured. This study was developed at the human movement analysis laboratory of the Health Science Faculty of the University of Malaga (Spain). Results Strong and moderate correlations were found at moderate and low intensities contraction between the variable of the same intensity, with correlation values ranging from 0.726 (Torque Moderate – EMG Left Moderate) to 0.923 (Angle Left Light – Angle Right Light) (p < 0.001). This correlation is observed between the variables that describe the same intensity of contraction, showing a poor correlation between variables of different intensities. Conclusion There is a strong relationship between architecture and function variables of ES muscle when describe an isometric lumbar extension at light or moderate intensity. Keywords: Ultrasonography; Surface electromyography; Thickness; Pennation angle; Erector spinae