Using protocols in ICU practice. Engaging the staff.

Aims/Purpose: Protocols are evidenced-based structured guides for directing care to achieve improvements. But translating that evidence into practice is a major challenge. It is not acceptable to simply introduce the protocol and expect it to be adopted and lead to change in practice. Implementation requires effective leadership and management. This presentation describes a strategy for implementation that should promote successful adoption and lead to practice change.
Presentation description: There are many social and behavioural change models to assist and guide practice change. Choosing a model to guide implementation is important for providing a framework for action. The change process requires careful thought, from the protocol itself to the policies and politics within the ICU. In this presentation, I discuss a useful pragmatic guide called the 6SQUID (6 Steps in QUality Intervention Development). This was initially designed for public health interventions, but the model has wider applicability and has similarities with other change process models. Steps requiring consideration include examining the purpose and the need for change; the staff that will be affected and the impact on their workload; and the evidence base supporting the protocol. Subsequent steps in the process that the ICU manager should consider are the change mechanism (widespread multi-disciplinary consultation; adapting the protocol to the local ICU); and identifying how to deliver the change mechanism (educational workshops and preparing staff for the changes are imperative). Recognising the barriers to implementation and change and addressing these locally is also important. Once the protocol has been implemented, there is generally a learning curve before it becomes embedded in practice. Audit and feedback on adherence are useful strategies to monitor and sustain the changes.
Conclusion: Managing change successfully will promote a positive experience for staff. In turn, this will encourage a culture of enthusiasm for translating evidence into practice.

Time-limited home-care reablement services for maintaining and improving the functional independence of older adults

Background: Reablement, also known as restorative care, is one possible approach to home-care services for older adults at risk of functional decline. Unlike traditional home-care services, reablement is frequently time-limited (usually six to 12 weeks) and aims to maximise independence by offering an intensive multidisciplinary, person-centred and goal-directed intervention. Objectives:Objectives To assess the effects of time-limited home-care reablement services (up to 12 weeks) for maintaining and improving the functional independence of older adults (aged 65 years or more) when compared to usual home-care or wait-list control group. Search methods:We searched the following databases with no language restrictions during April to June 2015: the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE (OvidSP); Embase (OvidSP); PsycINFO (OvidSP); ERIC; Sociological Abstracts; ProQuest Dissertations and Theses; CINAHL (EBSCOhost); SIGLE (OpenGrey); AgeLine and Social Care Online. We also searched the reference lists of relevant studies and reviews as well as contacting authors in the field.Selection criteria:We included randomised controlled trials (RCTs), cluster randomised or quasi-randomised trials of time-limited reablement services for older adults (aged 65 years or more) delivered in their home; and incorporated a usual home-care or wait-list control group. Data collection and analysis:Two authors independently assessed studies for inclusion, extracted data, assessed the risk of bias of individual studies and considered quality of the evidence using GRADE. We contacted study authors for additional information where needed.Main results:Two studies, comparing reablement with usual home-care services with 811 participants, met our eligibility criteria for inclusion; we also identified three potentially eligible studies, but findings were not yet available. One included study was conducted in Western Australia with 750 participants (mean age 82.29 years). The second study was conducted in Norway (61 participants; mean age 79 years). We are very uncertain as to the effects of reablement compared with usual care as the evidence was of very low quality for all of the outcomes reported. The main findings were as follows. Functional status: very low quality evidence suggested that reablement may be slightly more effective than usual care in improving function at nine to 12 months (lower scores reflect greater independence; standardised mean difference (SMD) -0.30; 95% confidence interval (CI) -0.53 to -0.06; 2 studies with 249 participants). Adverse events: reablement may make little or no difference to mortality at 12 months’ follow-up (RR 0.97; 95% CI 0.74 to 1.29; 2 studies with 811 participants) or rates of unplanned hospital admission at 24 months (RR 0.94; 95% CI 0.85 to 1.03; 1 study with 750 participants). The very low quality evidence also means we are uncertain whether reablement may influence quality of life (SMD -0.23; 95% CI -0.48 to 0.02; 2 trials with 249 participants) or living arrangements (RR 0.92, 95% CI 0.62 to 1.34; 1 study with 750 participants) at time points up to 12 months. People receiving reablement may be slightly less likely to have been approved for a higher level of personal care than people receiving usual care over the 24 months’ follow-up (RR 0.87; 95% CI 0.77 to 0.98; 1 trial, 750 participants). Similarly, although there may be a small reduction in total aggregated home and healthcare costs over the 24-month follow-up (reablement: AUD 19,888; usual care: AUD 22,757; 1 trial with 750 participants), we are uncertain about the size and importance of these effects as the results were based on very low quality evidence. Neither study reported user satisfaction with the serviceAuthors’ conclusions:There is considerable uncertainty regarding the effects of reablement as the evidence was of very low quality according to our GRADE ratings. Therefore, the effectiveness of reablement services cannot be supported or refuted until more robust evidence becomes available. There is an urgent need for high quality trials across different health and social care systems due to the increasingly high profile of reablement services in policy and practice in several countries. 

A Relação entre Mindfulness, Auto-Compaixão, Vergonha e Psicopatologia em Praticantes e Não Praticantes de Meditação/Yoga

O estudo do mindfulness tem sido alvo de um crescente interesse no domínio da Psicologia, pela sua importância no aumento de bem-estar e redução de sintomatologia psicopatológica. Os estudos realizados acerca da forma como o mindfulness assume um papel preponderante no bem-estar psicológico dos indivíduos, tendo por base um conjunto de competências ou aptidões que podem ser aprendidas e praticadas, favorece uma melhoria da saúde e do bem-estar dos indivíduos. Deste modo, com o objectivo de contribuir para o conhecimento da relação entre mindfulness, auto-compaixão, vergonha e psicopatologia em praticantes e não praticantes de meditação/yoga, realizou-se um conjunto de estudos numa amostra constituída por 121 sujeitos, em que 53 integram uma população praticante de meditação/yoga e 68 pertencem à população geral não praticante de meditação/yoga. Os resultados revelam que indivíduos praticantes de meditação/yoga registam valores significativamente mais elevados nas facetas observar e não reagir da escala de mindfulness. Por sua vez, sujeitos com maiores índices de traço de mindfulness apresentam níveis mais baixos de vergonha externa e interna. Para além disto, indivíduos com elevado traço de mindfulness distinguem-se significativamente dos indivíduos com baixo traço de mindfulness ao apresentarem níveis mais elevados de auto-compaixão e níveis mais baixos de depressão, ansiedade e stress. / The study of mindfulness has been the target of a growing interest in the field of psychology because of its importance in increasing welfare and lessening of psychopathological symptoms. Studies on how mindfulness plays a central role in psychological well-being of individuals, based on a set of competencies or skills that can be learned and practiced, promotes improved health and well-being of individuals. Thus, in order to contribute to the knowledge of the relationship between mindfulness, self-pity, shame and psychopathology in non-practitioners and practitioners of meditation / yoga, it was held a series of studies on a sample of 121 subjects, in which 53 were part of a population practicing meditation / yoga and 68 belong to the general population not practicing meditation / yoga. The results show that individuals who practice meditation / yoga recorded significantly higher values in the watch and not react aspects of mindfulness scale. In turn, subjects with higher trait mindfulness have lower levels of external and internal shame. In addition, individuals with higher trait mindfulness differ significantly from individuals with low trait mindfulness of the present higher levels of self-pity and lower levels of depression, anxiety and stress.

“Medical bag for General Practice” Just in Case: redesigning the doctor’s bag (2012)

This research addressed practice related problems from a medico-legal perspective and aims to provide a working tool that aids GPs to comply with best practice protocols. The resulting bag was developed in collaboration with General Practitioners, clinicians and members of the Medical Defense Union. Using proven methods developed within the Healthcare & Patient Safety Lab (e.g. DOME, Ambulance) to establish an evidence-based brief, this research used task, equipment and consumables analysis to determine minimum requirements and preferred layouts for task optimisation. The research established that clinicians require three distinct functions in their workspace: laying out, organisation and information retrieval. Feedback from clinicians indicates that this working tool allows them to access information and equipment wherever they may be and suggests an improvement from current practice. The research is now into a second year where the design of the bag will be refined and tested. Lifestyle and demographic changes such as the ageing population and increased prevalence of chronic diseases require more consistent standards of primary care, and care that is well coordinated and integrated (Imison, et al., 2011). Many guidelines exist relating to general practice and the doctor’s bag (NSLMC, 2008, RACGP, 2010, RCGP, 2008 and Hiramanek, 2004), however there is no standard in the UK that regulates the shape and materials of the bag or its contents. Doctors may use any sort of vessel to transport their equipment and consumables to a patient’s location. Furthermore, treating a patient in their own home, outside an ideal clinical environment, presents its own complications. A looks-like, works-like bag prototype and information system that will be used in clinical trials, the results of which will determine the manufacturing of a new, standardised bag for clinical treatment used by members of the Medical Defence Union.

Caring for Children Dying from Cancer at Home: a Qualitative Study of the Experience of Primary Care Practitioners

Background. The rarity of childhood cancers makes providing palliative care in the community an unusual event for primary care practitioners. Providing this care requires effective interprofessional collaboration with the team that forms to provide the care often working together for the first and only time. Objective. To explore the experiences of primary care practitioners following their involvement in the palliative care of a child with cancer at home. Methods. The study design was a community-based qualitative study. The study location was the West Midlands region. Purposeful sample of GPs and community nurses involved in providing palliative care to 12 children. One-to-one in-depth interviews with 47 primary care professionals (10 GPs and 37 community nurses) and 5 facilitated case discussions were undertaken. Field notes were documented and grounded theory data analysis undertaken: chronological comparative data analysis identifying generated themes. Results. GPs had minimal input into the preceding care of children undergoing treatment for cancer but sought to re-establish their role at the child’s transition to palliative care. GPs felt they had a role to play and could add value to this phase of care, highlighted their continuing role with the child’s family and acknowledged that they had gained from the experience of contributing. However, lack of specialist knowledge and uncertainty about their role within the team made this more challenging. In contrast, community nurses were routinely involved in both active treatment and palliation care phases. There was little evidence of collaboration between the specialist and primary care professionals involved. There was considerable variation in out of hours provision across cases. Conclusions. Engaging primary care practitioners needs to be more actively anticipated and negotiated at the transition to palliation. Variation in out of hours care is another cause for concern. Enhancing inter-professional collaboration and planning during both active and palliative care phases may help. Keywords. Cancer, family medicine, palliative care, paediatric.

Values and Beliefs Held About Parenting and Education by School Staff and Parents of Pupils with Special Educational Needs in the Context of Home- School Collaboration

Effective collaboration between school staff and parents of children identified as having special educational needs is considered to be an essential component of the child’s successful education. Differences in beliefs and perspectives adopted by the school staff and parents play an important role in the process of collaboration. However, little is known about the precise relationship between the beliefs and the process of collaboration. The purpose of this study was to explore the values and beliefs held by the school staff and parents in the areas of parenting and education. The study also explored the link between these beliefs and the process of collaboration within four parent-teacher dyads from mainstream primary schools. Focus groups and semi-structured interviews based on repertory grid technique were used. The findings highlighted an overall similarity in the participants’ views on collaboration and in their important beliefs about parenting and education. At the same time, differences in perspectives adopted by parents and teachers were also identified. The author discusses how these differences in perspectives are manifested in the process of collaboration from the point of Cultural Capital Theory. The factors such as power differentials, trust between parents and teachers, and limited resources and constraints of educational system are highlighted. Implication for practice for teachers and educational psychologists are discussed.

The impact of mindfulness on the wellbeing and performance of educators: A systematic review of the empirical literature

Given the potentially demanding nature of teaching, efforts are underway to develop practices that can improve the wellbeing of educators, including interventions based on mindfulness meditation. We performed systematic review of empirical studies featuring analyses of mindfulness in teaching contexts. Databases were reviewed from the start of records to January 2016. Eligibility criteria included empirical analyses of mindfulness and wellbeing outcomes acquired in relation to practice. A total of 19 papers met the eligibility criteria and were included in the systematic review, consisting of a total 1,981 participants. Studies were principally examined for outcomes such as burnout, anxiety, depression and stress, as well as more positive wellbeing measures (e.g., life satisfaction). The systematic review revealed that mindfulness was generally associated with positive outcomes in relation to most measures. However, the quality of the studies was inconsistent, and so further research is needed, particularly involving high-quality randomised control trials.

Co-creation and co-destruction: : A practice-theory based study of interactive value formation

Drawing on an empirical study of public transport, this paper studies interactive value formation at the provider—customer interface, from a practice—theory perspective. In contrast to the bulk of previous research, it argues that interactive value formation is not only associated with value co-creation but also with value co-destruction. In addition, the paper also identifies five interaction value practices — informing, greeting, delivering, charging, and helping — and theorizes how interactive value formation takes place as well as how value is intersubjectively assessed by actors at the provider—customer interface. Furthermore, the paper also distinguishes between four types of interactive value formation praxis corresponding with four subject positions which practitioners step into when engaging in interactive value formation.