Screening and managing cannabis use: comparing GP's and nurses' knowledge, beliefs, and behavior

Background: General practitioners (GPs) and nurses are ideally placed to address the significant unmet demand for the treatment of cannabis-related problems given the numbers of people who regularly seek their care. The aim of this study was to evaluate differences between GPs and nurses’ perceived knowledge, beliefs, and behaviors toward cannabis use and its screening and management. Methods: This study involved 161 nurses and 503 GPs who completed a survey distributed via conference satchels to delegates of Healthed seminars focused on topics relevant to women and children’s health. Differences between GPs and nurses were analyzed using χ2- tests and two-sample t-tests, while logistic regression examined predictors of service provision. Results: GPs were more likely than nurses to have engaged in cannabis-related service provision, but also more frequently reported barriers related to time, interest, and having more important issues to address. Nurses reported less knowledge, skills, and role legitimacy. Perceived screening skills predicted screening and referral to alcohol and other drug (AOD) services, while knowing a regular user increased the likelihood of referrals only. Conclusions: Approaches to increase cannabis-related screening and intervention may be improved by involving nurses, and by leveraging the relationship between nurses and doctors, in primary care.

Ask : a health advocacy program for adolescents with an intellectual disability : a cluster randomised controlled trial

Background Adolescents with intellectual disability often have poor health and healthcare. This is partly as a consequence of poor communication and recall difficulties, and the possible loss of specialised paediatric services. Methods/Design A cluster randomised trial was conducted with adolescents with intellectual disability to investigate a health intervention package to enhance interactions among adolescents with intellectual disability, their parents/carers, and general practitioners (GPs). The trial took place in Queensland, Australia, between February 2007 and September 2010. The intervention package was designed to improve communication with health professionals and families’ organisation of health information, and to increase clinical activities beneficial to improved health outcomes. It consisted of the Comprehensive Health Assessment Program (CHAP), a one-off health check, and the Ask Health Diary, designed for on-going use. Participants were drawn from Special Education Schools and Special Education Units. The education component of the intervention was delivered as part of the school curriculum. Educators were surveyed at baseline and followed-up four months later. Carers were surveyed at baseline and after 26 months. Evidence of health promotion, disease prevention and case-finding activities were extracted from GPs clinical records. Qualitative interviews of educators occurred after completion of the educational component of the intervention and with adolescents and carers after the CHAP. Discussion Adolescents with intellectual disability have difficulty obtaining many health services and often find it difficult to become empowered to improve and protect their health. The health intervention package proposed may aid them by augmenting communication, improving documentation of health encounters, and improving access to, and quality of, GP care. Recruitment strategies to consider for future studies in this population include ensuring potential participants can identify themselves with the individuals used in promotional study material, making direct contact with their families at the start of the study, and closely monitoring the implementation of the educational intervention.

Why we need a population-based approach to clinical indicators for cancer: a case study using microscopic confirmation of lung cancer in Queensland

An important function of clinical cancer registries is to provide feedback to clinicians on various performance measures. To date, most clinical cancer registries in Australia are located in tertiary academic hospitals, where adherence to guidelines is probably already high. Microscopic confirmation is an important process measure for lung cancer care. We found that the proportion of patients with lung cancer without microscopic confirmation was much higher in regional public hospitals (27.1%) than in tertiary hospitals (7.5%), and this disparity remained after adjusting for age, sex and comorbidities. The percentage was also higher in the private than in the public sector. This case study shows that we need a population-based approach to measuring clinical indicators that includes regional public hospitals as a matter of priority and should ideally include the private sector.

The use of CCTV to police public spaces : a case of big brother or big friend?

This paper considers the role of CCTV (closed circuit television) in the surveillance, policing and control of public space in urban and rural locations, specifically in relation to the use of public space by young people. The use of CCTV technology in public spaces is now an established and largely uncontested feature of everyday life in a number of countries and the assertion that they are essentially there for the protection of law abiding and consuming citizens has broadly gone unchallenged. With little or no debate in the U.K. to critique the claims made by the burgeoning security industry that CCTV protects people in the form of a ‘Big Friend’, the state at both central and local levels has endorsed the installation of CCTV apparatus across the nation. Some areas assert in their promotional material that the centre of the shopping and leisure zone is fully surveilled by cameras in order to reassure visitors that their personal safety is a matter of civic concern, with even small towns and villages expending monies on sophisticated and expensive to maintain camera systems. It is within a context of monitoring, recording and control procedures that young people’s use of public space is constructed as a threat to social order, in need of surveillance and exclusion which forms a major and contemporary feature in shaping thinking about urban and rural working class young people in the U.K. As Loader (1996) notes, young people’s claims on public space rarely gain legitimacy if ‘colliding’ with those of local residents, and Davis (1990) describes the increasing ‘militarization and destruction of public space’, while Jacobs (1965) asserts that full participation in the ‘daily life of urban streets’ is essential to the development of young people and beneficial for all who live in an area. This paper challenges the uncritical acceptance of widespread use of CCTV and identifies its oppressive and malevolent potential in forming a ‘surveillance gaze’ over young people (adapting Foucault’s ‘clinical gaze’c. 1973) which can jeopardise mental health and well being in coping with the ‘metropolis’, after Simmel, (1964).

Recruitment and results of a pilot trial of vitamin D supplementation in the general population of Australia

Context: The benefits of high serum levels of 25-hydroxyvitamin D [25(OH)D] are unclear. Trials are needed to establish an appropriate evidence base. Objective: We plan to conduct a large-scale trial of vitamin D supplementation for the reduction of cancer incidence and overall mortality and report here the methods and results of a pilot trial established to inform its design. Design: Pilot D-Health was a randomized trial carried out in a general community setting with 12 months intervention and follow-up. Participants: Participants were 60- to 84-yr-old residents of one of the four eastern Australian states who did not have any vitamin D-related disorders and who were not taking more than 400 IU supplementary vitamin D per day. A total of 644 participants were randomized, and 615 completed the study (two persons withdrew because of nonserious adverse events). Interventions: The interventions were monthly doses of placebo or 30,000 or 60,000 IU vitamin D3. Main Outcomes: The main outcomes were the recruitment rate and changes in serum 25(OH)D. Results: Ten percent of those approached were recruited. At baseline, the mean 25(OH)D was 42 nmol/liter in all three study arms. The mean change in 25(OH)D in the placebo group was 0.12 nmol/liter, compared with changes of 22 and 36 nmol/liter in the 30,000- and 60,000-IU groups, respectively. Conclusions: The D-Health pilot has shown that a large trial is feasible in Australia and that a dose of 2000 IU/d will be needed to ensure that a large proportion of the population reaches the target serum 25(OH)D level. Copyright © 2012 by The Endocrine Society.

Symposium - How effective are brief motivational interviewing interventions : Are they necessary? Do they require enhancement? Can they be translated into routine clinical practice?

Brief interventions are effective for problem drinking and reductions are known to occur in association with screening and assessment. Design and methods: This study aimed to determine how much change occurred between baseline assessment and a one-session brief intervention (S1), and the predictors of early change among adults with comorbid depression and alcohol misuse (n=202) participating in a clinical trial. The primary focus was on changes in Beck Depression Inventory fastscreen scores and alcohol consumption (standard drinks per week) prior to random allocation to nine further sessions addressing either depression, alcohol, or both problems. Results: There were large and clinically significant reductions between baseline and S1, with the strongest predictors being baseline scores in the relevant domain and change in the other domain. Client engagement was also predictive of early depression changes. Discussion and Conclusion: Monitoring progress in both domains from first contact, and provision of empathic care, followed by brief intervention appear to be useful for this high prevalence comorbidity...

Representation of assertions in clinical free-­text using SNOMED CT

Information retrieval (IR) by clinicians in the healthcare setting is critical for informing clinical decision-making. However, a large part of this information is in the form of free-text and inhibits clinical decision support and effective healthcare services. This makes meaningful use of clinical free-­text in electronic health records (EHRs) for patient care a difficult task. Within the context of IR, given a repository of free-­text clinical reports, one might want to retrieve and analyse data for patients who have a known clinical finding.

Development of clinical competencies for emergency nurse practitioners : a pilot study

Background: Nurse practitioner education and practice has been guided by generic competency standards in Australia since 2006. Development of specialist competencies has been less structured and there are no formal standards to guide education and continuing professional development for specialty fields. There is limited international research and no Australian research into development of specialist nurse practitioner competencies. This pilot study aimed to test data collection methods, tools and processes in preparation for a larger national study to investigate specialist competency standards for emergency nurse practitioners. Research into specialist emergency nurse practitioner competencies has not been conducted in Australia. Methods: Mixed methods research was conducted with a sample of experienced emergency nurse practitioners. Deductive analysis of data from a focus group workshop informed development of a draft specialty competency framework. The framework was subsequently subjected to systematic scrutiny for consensus validation through a two round Delphi Study. Results: The Delphi study first round had a 100% response rate; the second round 75% response rate. The scoring for all items in both rounds was above the 80% cut off mark with the lowest mean score being 4.1 (82%) from the first round. Conclusion: The authors collaborated with emergency nurse practitioners to produce preliminary data on the formation of specialty competencies as a first step in developing an Australian framework.

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.

Histological and morphometric lesions in the pre-clinical, developmental phase of insulin-induced laminitis in Standardbred horses

Lamellar pathology in experimentally-induced equine laminitis associated with euglycaemic hyperinsulinaemia is substantial by the acute, clinical phase (∼48 h post-induction). However, lamellar pathology of the developmental, pre-clinical phase requires evaluation. The aim of this study was to analyse lamellar lesions both qualitatively and quantitatively, 6, 12 and 24 h after the commencement of hyperinsulinaemia. Histological and histomorphometrical analyses of lamellar pathology at each time-point included assessment of lamellar length and width, epidermal cell proliferation and death, basement membrane (BM) pathology and leucocyte infiltration. Archived lamellar tissue from control horses and those with acute, insulin-induced laminitis (48 h) was also assessed for cellular proliferative activity by counting the number of cells showing positive nuclear immuno labelling for TPX2. Decreased secondary epidermal lamellar (SEL) width and increased histomorphological evidence of SEL epidermal basal (and supra-basal) cell death occurred early in disease progression (6 h). Increased cellular proliferation in SELs, infiltration of the dermis with small numbers of leucocytes and BM damage occurred later (24 and 48 h). Some lesions, such as narrowing of the SELs, were progressive over this time period (6–48 h). Cellular pathology preceded leucocyte infiltration and BM pathology, indicating that the latter changes may be secondary or downstream events in hyperinsulinaemic laminitis.