Development of the palliative care needs assessment tool (PC-NAT) for use by multi-disciplinary health professionals

Needs assessment strategies can facilitate prioritisation of resources. To develop a needs assessment tool for use with advanced cancer patients and caregivers, to prompt early intervation. A convenience sample of 103 health professionals viewed three videotaped consultations involving a simulated patient, his/her caregiver and a health professional, completed the Palliative Care Needs Assessment Tool (PC-NAT) and provided feedback on clarity, content and acceptability of the PC-NAT. Face and content validity, acceptability and feasibility of the PC-NAT were confirmed. Kappa scores indicated adequate inter-rater reliability for the majority of domains; the patient spirituality domain and the caregiver physical and family and relationship domains had low reliability. The PC-NAT can be used by health professionals with a range of clinical expertise to identify individuals' needs, thereby enabling early intervention. Further psychometric testing and an evaluation to assess the impact of the systematic use of the PC-NAT on quality of life, unmet needs and service utilisation of patients and caregivers are underway.

What should I say?: Qualitative findings on dilemmas in palliative care nursing

The nursing literature suggests that talking and listening to patients about issues associated with death and dying, is both important and difficult, and may be improved with training. This discussion presents the results of recent nursing research to confirm, and elaborate on, this theme. In this research participants touched on many central issues in communicating with patients that included articulating a sense of discomfort and inadequacy about the whole process, detailing the innumerable blocks to open communication [e.g., interference, denial, unrealistic optimism, resistance, collusion and anger] and sharing their sense of success and failure. The insights of nurses who participated in this research testify to the ongoing need to prioritize the development of nursing skills and support in this challenging but important area.

Mediating conflict and control : practice challenges for nurses working in palliative care

A work-based professional development program was offered to a group of registered nurses working in palliative care. The goal of the program was to improve skills in psychosocial care (Yates et al., 1996). Participants were encouraged to reflect critically on their practice experience within a group setting. The focus of the group discussion and reflection were shared practice incidents. Each participant was given the opportunity to identify and describe an incident from their professional practice that presented a challenging issue within palliative nursing. This paper explores the themes of conflict and control, evident within the collection of fifteen practice incidents and discusses the nurses role as mediator. The concepts of patient advocacy and professional autonomy are challenged through the nurses experience of providing care within a hierarchical and bureaucratic health service. The outcome of reflection for the organization is most effective when shared experience and collective action (rather than individual practice) are the focus.

Exploring empathy as a variable in the evaluation of professional development programmes for palliative care nurses

Research indicates that empathy, a quality regarded as fundamentally important to nursing practice, is a teachable skill. Because empathic nurse-patient relationships are particularly important in the care of the terminally ill, this has direct relevance to the professional development of palliative care nurses. This article discusses the place of empathy as a criterion variable in the evaluation of a professional development program for palliative care nurses introduced at the Centre for Mental Health Nursing Research at Queensland University of Technology, Brisbane, Australia. A modified version of the Staff-Patient Interaction Response Scale (SPIRS) was used as a pre- and postintervention measure to assess the expressed empathy of the participating nurses. The modifications to SPIR and its coding system to make it suitable for palliative care nursing, and the mechanisms for improving and evaluating the reliability of this instrument will be discussed. The full description of this particular modification of SPIRS for palliative care research is provided as an example of how this instrument could be used in projects for which nurses undertake the difficult task of providing compassionate care to the terminally ill.

Design of a professional development programme for palliative care nurses (Part Two)

Yates et al (1996) provided a review of the literature on educational approaches to improving psychosocial care of terminally ill patients and their families and suggested that there was an urgent need for innovation in this area. A programme of professional development currently being offered to 181 palliative care nurses in Queensland, Australia, was also described. This paper presents research in progress evaluating this programme which involves use of a quasi-experimental pre-post test design. It also includes process and outcome measures to assess effectiveness in improving the participant's ability to provide psychosocial care to patients and families. Research examining the effectiveness of various educational programmes on care of the dying has offered equivocal results (Yates et al 1996). Degner and Gow (1988a) noted that the inconsistencies found in research into death education result from inadequate study designs, variations in the conceptualisation and measurement of the outcomes of the programmes and flaws in data analysis. Such studies have often lacked a theoretical basis, few have employed well-controlled experimental designs, and the programme outcomes have generally been limited to the participant's 'death anxiety', or other death attitudes which have been variously defined and measured. Whilst Degner and Gow (1988b) have reported that undergraduate nursing students who participated in a care of the dying educational programme demonstrated more 'approach caring' behaviours than a control group, the impact of education programmes on patient care has rarely been examined. Failure to link education to nursing practice and subsequent clinical outcomes has, however, been seen as a major limitation of nursing knowledge in this area (Degner et al 1991). This paper describes an approach to researching the effectiveness of professional development programmes for palliative care nurses.

Improving psychosocial care: a professional development programme

Despite the numerous reports of difficulties experienced by health care providers in providing psychosocial care to terminally ill patients and their families, few studies have yet been undertaken to examine the effectiveness of different educational approaches to addressing these issues. The aim of this paper is to describe a programme of professional development for palliative care nurses, which is currently being offered to 181 registered nurses in Queensland, Australia. The programme is based on an action learning model and is designed to facilitate processes of reflection and peer consultation. In Part One of this paper, a review of this literature is presented to provide the background and rationale for the programme design. Details of the research programme developed to evaluate the programme will be presented in Part Two of this paper, which is to be published in the next issue of this Journal. Surveys of health professionals suggest that the demands of working with terminally ill patients are associated with a great deal of stress (Beaton and Degner 1990, Seale 1992, Vachon 1995), and emotional burden, as they are confronted with their patients' physical and emotional suffering over extended periods of time (Ullrich and Fitzgerald 1990). Key areas of concern (Lyons 1988, Bramwell 1989, Seale 1992, Copp and Dunn 1993, Wilkinson 1995) include: * Handling questions and conversations with dying patients. * Dealing with ethical and moral issues. * Handling emotions. * Giving hope. * Providing spiritual care and bereavement support. * Confronting team communication problems.

Pain : the views of elderly people living in long term residential care settings

While an individual's beliefs and attitudes have long been considered important factors in how people respond to pain, few studies have attempted to provide in-depth descriptions of the nature of such pain beliefs and attitudes The aim of this research was to investigate the views of pain and pain management practices held by elderly people living in long-term residential care settings Ten 60–90 minute focus group interviews, each involving around five elderly people, were conducted in four large, long-term residential care settings in Brisbane, Australia Categories of beliefs and attitudes regarding pain were identified following analysis of the verbatim transcripts of these interviews Findings suggest that many elderly people living in long-term residential care settings may have become resigned to pain, that they are ambivalent about the benefit of any action for their pain and that they may be reluctant to express their pain Implications of these beliefs and attitudes are discussed

Constructions of children's needs in informal kinship care in rural China

Kinship care is the oldest form of alternative child care in the world. Recent years have witnessed a significant increase in the number of children being placed in kinship care across Western countries. However, in contrast to rapid knowledge advances about formal kinship care, far less is known about the needs of children in informal kinship care, especially in Asian contexts. This thesis and the study upon which it is formed sought to redress this knowledge gap. Qualitative approach was adopted to explore social constructions of children in informal kinship care in rural China. Parents in China seeking work in cities have left behind around 58 million rural children, mostly with relatives and without the involvement of the state. The present study examined caregivers’ and school personnel’s understandings of these school-age children’s needs through semi-structured interviews with 23 kin caregivers and five school personnel in Shijiapu Town, Jilin Province, China. The central question that guided the whole study is: What are the needs of children in informal kinship care in rural Jilin Province, China? Interpretative Phenomenological Analysis was used to categorise and interpret the qualitative data. Based on participants’ constructions, this study developed a need model with eight themes. They are: (1) emotional needs and mental health, (2) relationships, (3) empowerment and agency, (4) safety, (5) education, (6) basic care, (7) physical health, and (8) personal development. These needs are grounded in the Chinese context, and therefore a good understanding of Chinese culture is essential to address them. The first four needs particularly capture children’s separations from their parents, and the rest are more general, and can be applied to most Chinese children. To meet the most important need for children left behind, namely education, these caregivers determined that others needs sometimes have to be compromised. Children left behind are a vulnerable group in contemporary rural China, and their diverse needs are attended to by several groups. This study found that as children’s closest kin while their parents are away, caregivers play a vital role in salving the children’s emotional loss. Caregivers’ love and familial obligations strongly motivate them to care for these children, and sensitivity to social stigma makes them strive to show their love and care to compensate for perceived differences between these children and their peers. Caregivers’ efforts to make children happy, however, were sometimes criticised by some school personnel, who see this as spoiling. The conflicting viewpoint between caregivers and school personnel indicate their different roles and perceptions in children’s lives, and the latter influence these children in a more authoritative way. Informal kinship care has several advantages of addressing children’s needs, especially their needs for emotional bonds with family. Community-based kin networks provide children with both emotional and material support. However, these advantages sometimes are restricted by caregivers’ child rearing capacity. Having developed a model of the needs of children left behind in China, this study suggests that caregivers, school personnel and government social services work in harmony to be child-centred and meet these children’s diverse needs. The unmet needs of children left behind mainly result from unbalanced development between urban and rural China, therefore, it is imperative to enhance state policies and programs that improve wellbeing for this growing part of China’s people.

Cost effectiveness of patient education for the prevention of falls in hospital : economic evaluation from a randomized controlled trial

Background Falls are one of the most frequently occurring adverse events that impact upon the recovery of older hospital inpatients. Falls can threaten both immediate and longer-term health and independence. There is need to identify cost-effective means for preventing falls in hospitals. Hospital-based falls prevention interventions tested in randomized trials have not yet been subjected to economic evaluation. Methods Incremental cost-effectiveness analysis was undertaken from the health service provider perspective, over the period of hospitalization (time horizon) using the Australian Dollar (A$) at 2008 values. Analyses were based on data from a randomized trial among n = 1,206 acute and rehabilitation inpatients. Decision tree modeling with three-way sensitivity analyses were conducted using burden of disease estimates developed from trial data and previous research. The intervention was a multimedia patient education program provided with trained health professional follow-up shown to reduce falls among cognitively intact hospital patients. Results The short-term cost to a health service of one cognitively intact patient being a faller could be as high as A$14,591 (2008). The education program cost A$526 (2008) to prevent one cognitively intact patient becoming a faller and A$294 (2008) to prevent one fall based on primary trial data. These estimates were unstable due to high variability in the hospital costs accrued by individual patients involved in the trial. There was a 52% probability the complete program was both more effective and less costly (from the health service perspective) than providing usual care alone. Decision tree modeling sensitivity analyses identified that when provided in real life contexts, the program would be both more effective in preventing falls among cognitively intact inpatients and cost saving where the proportion of these patients who would otherwise fall under usual care conditions is at least 4.0%. Conclusions This economic evaluation was designed to assist health care providers decide in what circumstances this intervention should be provided. If the proportion of cognitively intact patients falling on a ward under usual care conditions is 4% or greater, then provision of the complete program in addition to usual care will likely both prevent falls and reduce costs for a health service.

Exercise-based cardiac rehabilitation for the 21st century

Exercise-based cardiac rehabilitation (CR) is efficacious in reducing mortality and hospital admissions; however it remains inaccessible to large proportions of the patient population. Removal of attendance barriers for hospital or centre-based CR has seen the promotion of home-based CR. Delivery of safe and appropriately prescribed exercise in the home was first documented 25 years ago, with the utilisation of fixed land-line telecommunications to monitor ECG. The advent of miniature ECG sensors, in conjunction with smartphones, now enables CR to be delivered with greater flexibility with regard to location, time and format, while retaining the capacity for real-time patient monitoring. A range of new systems allow other signals including speed, location, pulse oximetry, and respiration to be monitored and these may have application in CR. There is compelling evidence that telemonitored-based CR is an effective alternative to traditional CR practice. The long-standing barrier of access to centre-based CR, combined with new delivery platforms, raises the question of when telemonitored-based CR could replace conventional approaches as the standard practice.

The acute response of tendon to loading: implications for rehabilitation

Achilles tendinopathy is a common disorder involving physically active and sedentary individuals alike. Although the processes underlying its development are poorly understood, tendinopathy is widely regarded as an ‘overuse’ injury in which the tendon fails to adapt to prevalent loading conditions. Paradoxically, there is emerging evidence that heavy eccentric loading of the Achilles tendon may be an effective conservative approach for treatment of tendinopathy, with success rates of 60–80% reported. Interestingly, loading exercises involving other forms of muscle action, such as concentric activation, have been shown to be less effective treatment options. However, little is known about the acute response of tendon to exercise at present, and there are few plausible explanatory mechanisms for the observed beneficial effects of eccentric exercise, as opposed to other forms of strain stimuli. This paper presents the findings from a series of experiments undertaken to evaluate the effect of various strain stimuli on the time-dependent response of human Achilles tendon in vivo. It was shown for the first time, that heavy resistive ankle plantarflexion/ dorsiflexion exercises induced an immediate and significant decrease in Achilles tendon thickness (~15%). While thickness returned to pre-exercise levels within 24 hours, the recovery was exponential, with primary recovery occurring in less than 6 hours post-exercise. We proposed that such a diametral strain response with tensile loading reflects collagen realignment, Poison’s effects and radial extrusion of water from the tendon core. With unloading, the recovery of tendon dimensions likely reflects the re-diffusion of water via osmotic and/or inflammatory driven processes. Interestingly, prolonged walking was found to induce a similar diametral strain response. In subsequent studies, we demonstrated that eccentric exercise resulted in a greater reduction (-21%) in Achilles tendon thickness than isolated concentric exercise alone (-5%), despite a similar loading impulse. These novel findings, coupled with observations of a reduced diametral strain response with tendon pathology, highlight the importance of fluid movement to tendon function, nutrition and health. They also provide new insights into potential mechanisms underlying Achilles tendinopathy that impact rehabilitation strategies.