Nurses' experiences of pain management for people with advanced dementia approaching the end of life: a qualitative study

AIMS AND OBJECTIVES: To explore hospice, acute care and nursing home nurses' experiences of pain management for people with advanced dementia in the final month of life. To identify the challenges, facilitators and practice areas requiring further support.

BACKGROUND: Pain management in end-stage dementia is a fundamental aspect of end of life care; however, it is unclear what challenges and facilitators nurses experience in practice, whether these differ across care settings, and whether training needs to be tailored to the context of care.

DESIGN: A qualitative study using semi-structured interviews and thematic analysis to examine data.

METHODS: 24 registered nurses caring for people dying with advanced dementia were recruited from ten nursing homes, three hospices, and two acute hospitals across a region of the United Kingdom. Interviews were conducted between June 2014 and September 2015.

RESULTS: Three core themes were identified: challenges administering analgesia, the nurse-physician relationship, and interactive learning and practice development. Patient-related challenges to pain management were universal across care settings; nurse- and organisation-related barriers differed between settings. A need for interactive learning and practice development, particularly in pharmacology, was identified.

CONCLUSIONS: Achieving pain management in practice was highly challenging. A number of barriers were identified; however, the manner and extent to which these impacted on nurses differed across hospice, nursing home and acute care settings. Needs-based training to support and promote practice development in pain management in end-stage dementia is required.

RELEVANCE TO CLINICAL PRACTICE: Nurses considered pain management fundamental to end of life care provision; however, nurses working in acute care and nursing home settings may be under-supported and under-resourced to adequately manage pain in people dying with advanced dementia. Nurse-to-nurse mentoring and ongoing needs-assessed interactive case-based learning could help promote practice development in this area. Nurses require continuing professional development in pharmacology. This article is protected by copyright. All rights reserved.

The role of Lean at the interface with between operations management and applied services within a large aerospace organisation: a boundary spanning perspective

Increased complexity in large design and manufacturing organisations requires improvements at the operations management (OM)–applied service (AS) interface areas to improve project effectiveness. The aim of this paper is explore the role of Lean in improving the longitudinal efficiency of the OM–AS interface within a large aerospace organisation using Lean principles and boundary spanning theory. The methodology was an exploratory longitudinal case approach including exploratory interviews (n = 21), focus groups (n = 2), facilitated action-research workshops (n = 2) and two trials or experiments using longitudinal data involving both OM and AS personnel working at the interface. The findings draw upon Lean principles and boundary spanning theory to guide and interpret the findings. It was found that misinterpretation, and forced implementation, of OM-based Lean terminology and practice in the OM–AS interface space led to delays and misplaced resources. Rather both OM and AS staff were challenged to develop a cross boundary understanding of Lean-based boundary (knowledge) objects in interpreting OM requests. The longitudinal findings from the experiments showed that the development of Lean Performance measurements and lean Value Stream constructs was more successful when these Lean constructs were treated as boundary (knowledge) objects requiring transformation over time to orchestrate improved effectiveness and in leading to consistent terminology and understanding between the OM–AS boundary spanning team.

Improving the Utilization of Front-Line Service Delivery System Personnel

There are two types of work typically performed in services which differ in the degree of control management has over when the work must be done. Serving customers, an activity that can occur only when customers are in the system is, by its nature, uncontrollable work. In contrast, the execution of controllable work does not require the presence of customers, and is work over which management has some degree of temporal control. This paper presents two integer programming models for optimally scheduling controllable work simultaneously with shifts. One model explicitly defines variables for the times at which controllable work may be started, while the other uses implicit modeling to reduce the number of variables. In an initial experiment of 864 test problems, the latter model yielded optimal solutions in approximately 81 percent of the time required by the former model. To evaluate the impact on customer service of having front-line employees perform controllable work, a second experiment was conducted simulating 5,832 service delivery systems. The results show that controllable work offers a useful means of improving labor utilization. Perhaps more important, it was found that having front-line employees perform controllable work did not degrade the desired level of customer service.

Hospital Administrative Characteristics and Volunteer Resource Management Practices

Purpose – The purpose of this paper is to explore the links between various characteristics of hospital administration and the utilization of classes of volunteer resource management (VRM) practices. Design/methodology/approach – This paper uses original data collected via surveys of volunteer directors in 122 hospitals in five Northeastern and Southern US states. Findings – Structural equation modeling results suggest that number of paid volunteer management staff, scope of responsibility of the primary volunteer administrator, and hospital size are positively associated with increased usage of certain VRM practices. Research limitations/implications – First, the authors begin the exploration of VRM antecedents, and encourage others to continue this line of inquiry; and second, the authors assess dimensionality of practices, allowing future researchers to consider whether specific dimensions have a differential impact on key individual and organizational outcomes. Practical implications – Based on the findings of a relationship between administrative characteristics and the on-the-ground execution of VRM practice, a baseline audit comparing current practices to those VRM practices presented here might be useful in determining what next steps may be taken to focus investments in VRM that can ultimately drive practice utilization. Originality/value – The exploration of the dimensionality of volunteer management adds a novel perspective to both the academic study, and practice, of volunteer management. To the authors’ knowledge, this is the first empirical categorization of VRM practices.

IoT Based Pain Management using Physiological Parameters

The continuous technology evaluation is benefiting our lives to a great extent. The evolution of Internet of things and deployment of wireless sensor networks is making it possible to have more connectivity between people and devices used extensively in our daily lives. Almost every discipline of daily life including health sector, transportation, agriculture etc. is benefiting from these technologies. There is a great potential of research and refinement of health sector as the current system is very often dependent on manual evaluations conducted by the clinicians. There is no automatic system for patient health monitoring and assessment which results to incomplete and less reliable heath information. Internet of things has a great potential to benefit health care applications by automated and remote assessment, monitoring and identification of diseases. Acute pain is the main cause of people visiting to hospitals. An automatic pain detection system based on internet of things with wireless devices can make the assessment and redemption significantly more efficient. The contribution of this research work is proposing pain assessment method based on physiological parameters. The physiological parameters chosen for this study are heart rate, electrocardiography, breathing rate and galvanic skin response. As a first step, the relation between these physiological parameters and acute pain experienced by the test persons is evaluated. The electrocardiography data collected from the test persons is analyzed to extract interbeat intervals. This evaluation clearly demonstrates specific patterns and trends in these parameters as a consequence of pain. This parametric behavior is then used to assess and identify the pain intensity by implementing machine learning algorithms. Support vector machines are used for classifying these parameters influenced by different pain intensities and classification results are achieved. The classification results with good accuracy rates between two and three levels of pain intensities shows clear indication of pain and the feasibility of this pain assessment method. An improved approach on the basis of this research work can be implemented by using both physiological parameters and electromyography data of facial muscles for classification.

Towars a chemical reagents and residues management at the teaching laboratories of the Chemistry School of the Universidad Nacional

The academic activities carried out at the School of Chemistry make indispensable to develop actions oriented toward the consolidation of a reagent and residue management system, especially in the teaching laboratories. The project “Management of reagents and residues in the teaching laboratories of the School of Chemistry” works under the Green Chemistry values which designs products and chemical processes that reduce or eliminate the use and production of dangerous substances, to benefit the environment. With a preventive vision, a change from the  laboratory practices is looked to select those with less environmental impact. Additionally, residue quantification is made and its management protocols are developed for each practice. The project has several stages: diagnose, action implementation, student, teacher and administration personnel training and evaluation during the process and at the end of it. The article describes methodological aspects of the project operation emphasizing on reagent and residue quantification through flow diagrams.

Ansatzpunkte für das Change-Management beim Aufbau einer Notebook-Universität

Die Einführung von Notebooks an einer Universität bringt zunächst keine grundlegende Innovation mit sich. Die Potenziale, die mit dem Einsatz von Notebooks in der Präsenzlehre verbunden sind, sind vielfältig. Der Beitrag zeigt auf, welche Vorteile der Notebook-Einsatz auf den unterschiedlichen Ebenen Individuum, Gruppe und Organisation beinhaltet. Am Beispiel des eCampus-Projektes der Universität Duisburg-Essen zeigt sich, dass dieser Mehrwert sich jedoch nicht von selbst einstellt, sondern an bestimmte Bedingungen auf den verschiedenen Ebenen geknüpft ist. Es sind Maßnahmen notwendig, um die intendierten Veränderungsprozesse in Gang zu setzen, damit Notebooks im Alltag von Lehre und Forschung verankert werden können. Dazu sind Maßnahmen in den Bereichen Infrastruktur, didaktische Reform, Personal- und Organisationsentwicklung sowie Medienproduktion und -distribution zu ergreifen und in einem angemessenen Gleichgewicht umzusetzen. (DIPF/Orig.)

Pressure ulcer management in Oman: nurses’ knowledge and views

Background: Pressure ulcers (PrUs) have a significant impact on health system expenditure and patient’s quality of life. It is a global problem. Many studies were undertaken in regard to PrU prevention and management. In Oman, no studies have been conducted to investigate nurses’ knowledge on prevention and management of PrUs. The purpose of this descriptive sequential explanatory mixed-method study was to explore the nurses’ level of knowledge in relation to prevention and management of PrUs in Oman. Methods: A mixed method design was used and the study was conducted over two Phases. In Phase I, a questionnaire was developed to explore nurses’ knowledge on PrU, policy, and resources. The main section of the questionnaire was the Pieper-Zulkowski Pressure Ulcer knowledge test (PZ-PUKT) which tests the knowledge on PrU. Another two sections were developed including questions about wound policy and resources available for PrU prevention and management in Oman. The questionnaire was distributed to nurses who were working in surgical, medical, orthopaedic, CCU, and ICU wards/units in seven hospitals. In Phase II study, semi-structured qualitative interviews were conducted with 16 of the questionnaire respondents. Interviews took approximately 30 minutes, were recorded and transcribed verbatim. Qualitative data were analysed using the Knowledge, Attitudes and Practice (KAP) model as the a priori framework. Results: In Phase I, 478 questionnaires were analysed. The knowledge test results showed the overall mean percent score for correctly answered questions was 51% suggesting a low level of knowledge. There was a significant relationship between nurses’ knowledge and age (P=0.001) and between knowledge and years of experience (P=0.001) with knowledge increasing with age and years of experience. In Phase II, four themes were identified from the interviews: knowledge, attitude, and practice (framework themes) and perception of role. Findings indicated positive and negative attitudes towards the care of PrUs. Some nurses stated feeling rewarded when they see wounds improving while others said they could not work with patients independently because they lacked the knowledge and the skills needed. There was variation in the management of PrU between hospitals. Both studies indicated that the wound management policy did not include enough information to guide nurses. Conclusion: Overall the nurses’ level of knowledge on PrU was relatively low. Most nurses were not familiar with wound management policy or different PrU prevention and management strategies. Nurses are aware of the risk of PrUs and try their best to manage them with the available resources however more training is required.

Exit ventriculoperitoneal shunt; enter endoscopic third ventriculostomy (ETV): contemporary views on hydrocephalus and their implications on management

Hydrocephalus has been known to affect humans since the birth of human medicine as it is described by Hippocrates. The management of this condition is however still dodged by challenges due to a poor understanding of its pathophysiology. The ventriculoperitoneal shunt presents considerable problems especially with respect to infection and shunt malfunction. Low income countries, that currently face the greater burden of paediatric hydrocephalus. experience an increased challenge with ventriculoperitoneal shunts due to a shortage of qualified personnel to handle shunt complications. Recent advances in neuro-endoscopic surgery have presented opportunities for alternative treatment options for hydrocephalus such as endoscopic third ventriculostomy (ETV). This paper explores the alternative views in the pathophysiology of hydrocephalus and how they explain the effectiveness of ETV in treating hydrocephalus arising from a variety of causes.

O Lean Management e os desafios da gestão de recursos humanos na FAP

O estudo que se apresenta teve como objetivo analisar a implementação do modelo de Serviços Partilhados, com recurso à metodologia lean, nos serviços de apoio de pessoal do Complexo de Alfragide que decorreu no contexto da sua implementação na Força Aérea Portuguesa, determinada pelo Despacho do CEMFA n.º 59/2015, de 31 de julho. Para desenvolver este trabalho foi utilizada uma estratégia de investigação mista (quantitativa e qualitativa), seguindo o raciocínio hipotético-dedutivo. O desenho de pesquisa utilizado foi o estudo de caso, recorrendo a entrevistas, à análise documental e a um questionário para recolha de dados. Os resultados apurados através das entrevistas e do inquérito permitem concluir que a implementação do novo modelo alcançou alguns dos objetivos a que se propunha, nomeadamente, a melhoria dos serviços de apoio de pessoal prestados aos militares e civis. Apesar de se antever um elevado potencial ao nível da racionalização de Recursos Humanos, de momento, esse objetivo ainda não foi inteiramente alcançado. Conclui-se a presente investigação sugerindo a reavaliação numa fase mais adiantada da implementação do modelo de Serviços Partilhados no Complexo de Alfragide e o alargamento a outras Unidades de modo a obter uma visão mais abrangente da realidade na Força Aérea. Abstract: The study aimed to analyze the implementation of the Shared Services model, using the lean methodology, in the personnel support services in Complexo de Alfragide. This process took place in the context of implementation of this model in the Portuguese Air Force, determined by CEMFA Order No. 59/2015 of 31 July. To develop this work was used a mixed research strategy (quantitative and qualitative), following the hypothetical-deductive reasoning. The research design used was the case study, interviews, document analysis and a questionnaire. By the results obtained through the views expressed in the interviews and in the investigation, it can be concluded that the implementation of the Shared Services model has achieved some of the goals that it proposed like the improvement in personnel support services. Although foreseen great potential in terms of gains of Human Resources rationalization and due to several factors, has not yet been possible to achieve this goal. This research is concluded suggesting a reevaluation at a later stage of the implementation of the Shared Services model in the Complexo de Alfragide and extension to other Units for a more comprehensive view of reality in the Air Force.

Errors in preparation and medication management in nursing professionals

The preparation and administration of medications is one of the most common and relevant functions of nurses, demanding great responsibility. Incorrect administration of medication, currently constitutes a serious problem in health services, and is considered one of the main adverse effects suffered by hospitalized patients. Objectives: Identify the major errors in the preparation and administration of medication by nurses in hospitals and know what factors lead to the error occurred in the preparation and administration of medication. Methods: A systematic review of the literature. Deined as inclusion criteria: original scientiic papers, complete, published in the period 2011 to May 2016, the SciELO and LILACS databases, performed in a hospital environment, addressing errors in preparation and administration of medication by nurses and in Portuguese language. After application of the inclusion criteria obtained a sample of 7 articles. Results: The main errors identiied in the pr eparation and administration of medication were wrong dose 71.4%, wrong time 71.4%, 57.2% dilution inadequate, incorrect selection of the patient 42.8% and 42.8% via inadequate. The factors that were most commonly reported by the nursing staff, as the cause of the error was the lack of human appeal 57.2%, inappropriate locations for the preparation of medication 57.2%, the presence of noise and low brightness in preparation location 57, 2%, professionals untrained 42.8%, fatigue and stress 42.8% and inattention 42.8%. Conclusions: The literature shows a high error rate in the preparation and administration of medication for various reasons, making it important that preventive measures of this occurrence are implemented.

Practical considerations in the management of proton-pump inhibitors

Proton-pump inhibitors (PPIs) are one of the most active ingredients prescribed in Spain. In recent decades there has been an overuse of these drugs in both outpatient clinics and hospitals that has lead to a significant increase in healthcare spending and to an increase in the risk of possible side effects. It is important for health professionals to know the accepted indications and the correct doses for the use of these drugs. On the market there are different types of PPI: omeprazole, pantoprazole, lansoprazole, rabeprazole and esomeprazole. Omeprazole is the oldest and most used PPI, being also the cheapest. Although there are no important differences between PPIs in curing diseases, esomeprazole, a new-generation PPI, has proved to be more effective in eradicating H. pylori and in healing severe esophagitis compared to other PPIs. In recent years the use of generic drugs has spread; these drugs have the same bioavailability than the original drugs. In the case of PPIs, the few comparative studies available in the literature between original and generic drugs have shown no significant differences in clinical efficacy.

Performance analysis of brazilian public and philanthropic hospitals

This paper presents the results of a research that aimed at identifying optimal performance standards of Brazilian public and philanthropic hospitals. In order to carry out the analysis, a model based on Data Envelopment Analysis (DEA) was developed. We collected financial data from hospitals’ financial statements available on the internet, as well as operational data from the Information Technology Department of the Brazilian Public Health Care System – SUS (DATASUS). Data from 18 hospitals from 2007 to 2011 were analyzed. Our DEA model used both operational and financial indicators (variables). In order to develop this model, two indicators were considered inputs: Values (in Brazilian Reais) of Fixed Assets and Planned Capacity. On the other hand, the following indicators were considered outputs: Net Margin, Return on Assets and Institutional Mortality Rate. As regards the proposed model, there were five hospitals with optimal performance and four hospitals were considered inefficient, upon the analysis of the variables, considering the analyzed period. Analysis of the weights indicated the most relevant variables for determining efficiency and scale variable values, which is an important tool to aid the decision-making by hospital managers. Finally, the scale variables determined the returns on production, indicating that 14 hospitals work with scale diseconomies. This may indicate inefficiency in the resource management of the Brazilian public health-care system, by analyzing this set of proposed variables.

Talking about quality: exploring how ‘quality’ is conceptualized in European hospitals and healthcare systems

BACKGROUND: Conceptualization of quality of care - in terms of what individuals, groups and organizations include in their meaning of quality, is an unexplored research area. It is important to understand how quality is conceptualised as a means to successfully implement improvement efforts and bridge potential disconnect in language about quality between system levels, professions, and clinical services. The aim is therefore to explore and compare conceptualization of quality among national bodies (macro level), senior hospital managers (meso level), and professional groups within clinical micro systems (micro level) in a cross-national study. METHODS: This cross-national multi-level case study combines analysis of national policy documents and regulations at the macro level with semi-structured interviews (383) and non-participant observation (803 hours) of key meetings and shadowing of staff at the meso and micro levels in ten purposively sampled European hospitals (England, the Netherlands, Portugal, Sweden, and Norway). Fieldwork at the meso and micro levels was undertaken over a 12-month period (2011-2012) and different types of micro systems were included (maternity, oncology, orthopaedics, elderly care, intensive care, and geriatrics). RESULTS: The three quality dimensions clinical effectiveness, patient safety, and patient experience were incorporated in macro level policies in all countries. Senior hospital managers adopted a similar conceptualization, but also included efficiency and costs in their conceptualization of quality. 'Quality' in the forms of measuring indicators and performance management were dominant among senior hospital managers (with clinical and non-clinical background). The differential emphasis on the three quality dimensions was strongly linked to professional roles, personal ideas, and beliefs at the micro level. Clinical effectiveness was dominant among physicians (evidence-based approach), while patient experience was dominant among nurses (patient-centered care, enough time to talk with patients). Conceptualization varied between micro systems depending on the type of services provided. CONCLUSION: The quality conceptualization differed across system levels (macro-meso-micro), among professional groups (nurses, doctors, managers), and between the studied micro systems in our ten sampled European hospitals. This entails a managerial alignment challenge translating macro level quality definitions into different local contexts.