Extending the paramedic role in rural Australia : a story of flexibility and innovation

Introduction: This article identifies trends in the evolving practice of rural paramedics and describes key characteristics, roles and expected outcomes for a Rural Expanded Scope of Practice (RESP) model.

Methods: A multiple case study methodology was employed to examine the evolution of rural paramedic practice. Paramedics, volunteer ambulance officers and other health professionals were interviewed in four rural regions of south-eastern Australia where innovative models of rural paramedic practice were claimed to exist. The research team collected and thematically analysed the data using the filter of a sociological framework throughout 2005 and 2006.

Results: The study found that paramedics are increasingly becoming first line primary healthcare providers in small rural communities and developing additional professional responsibilities throughout the cycle of care.

Conclusions: Adoption of the RESP model would mean that paramedics undertake four broad activities as core components of their new role: (1) rural community engagement; (2) emergency response; (3) situated practice; and (4) primary health care. The model’s key feature is a capacity to integrate existing paramedic models with other health agencies and health professionals to ensure that paramedic care is part of a seamless system that provides patients with well-organized and high quality care. This expansion of paramedics’ scope of practice offers the potential to improve patient care and the general health of rural communities.

The rural and regional ambulance paramedic : moving beyond emergency response - report to the Council of Ambulance Authorities Inc. March 2006

Serious long-term recruitment and retention problems amongst rural health workers in Australiacontribute to inequitable health service access for rural Australians. In response, new healthcaremodels with flexible workforce roles are emerging including expanded-scope paramedic roles.

This research project was born from the view that expanding ambulance paramedics’ scope ofpractice offers the potential to improve patient care and the general health of the community.New healthcare models with flexible workforce roles are clearly needed in rural Australia andexpanded-scope paramedic roles are valuable innovations.

Radiotherapy management of patients diagnosed with glioma in Victoria (1998–2000) : a retrospective cohort study

This study aimed to describe the radiotherapy (RT) management and subsequent outcome in a cohort of patients with newly diagnosed glioma. Treatment details were obtained via a questionnaire completed by neurosurgeons, radiation and medical oncologists who treated patients diagnosed with glioma in Victoria during 1998–2000. Patients were identified by using the population-based Victorian Cancer Registry. Over the study period, data on 828 patients were obtained, of whom 612 (74%) were referred for consideration of RT. Radiotherapy was given to 496 patients as part of their initial treatment and to an additional 10 patients at the time of tumour recurrence or progression. The median age was 72 (16–85) years. Median overall survival (OS) was 9.2 (standard error (SE) 0.6) months for the entire group. Median OS was 29.1 (SE 8.0) and 7.4 (SE 0.4) months for all patients with histological confirmation of World Health Organization Grades III (anaplastic astrocytoma) and IV (glioblastoma multiforme) histology, respectively. A total of 47 different RT dose fractionation schedules were identified. This is the largest survey detailing management of glioma with RT, published to date. A marked variation in dose fractionation schemes was evident. While current best practice involves the use of chemotherapy in conjunction with RT for glioblastoma multiforme, advances in patient care may be undermined by this variation in the use of RT. Clinical trials relevant to an ageing population and evidence-based national clinical guidelines are required to define best practice.

Staff perceptions of risk of assault in psychiatric settings

This thesis examined current perceptions and experiences of staff relating to threatening and assaultive patient behaviours in mental health and forensic settings. The research uncovered the interrelated nature of staff experiences of assault and perceived vulnerability, with the view to optimising patient care and staff wellbeing in psychiatric settings.

Vascular access e-learning : the essentials

Objectives
Form a working group of renal vascular access nurses to develop peer reviewed, accessible, evidence based e-leaning modules related to vascular access principles and practice.

Key messages
Vascular access training and guidelines are often unit specific but the core principles of vascular access care are generally transferable. The vascular access e-learning module aims to utilize resources to minimize wasted time developing and keeping multiple individual vascular access training packages up to date.
Vascular access education is delivered from a variety of resources such as educators, senior staff and vascular access nurses. This e-learning module allows renal units the opportunity to provide a national learning package with general consensus on terminology and up to date evidence based practice.
Recently there has been a rise in the use of ultrasound to assess and perform image guided cannulation in vascular access to improve patient outcomes. There is only a small window of opportunity to provide education in ultrasound use. This module will provide education on this and other aspects of vascular access practices and patient care.

Implications for clinical practice
Implications include access to standardized learning packages based on current evidence based practice, eencouraging the utilization of new technology (e.g. Ultrasound observation and interpretation of results), reinforcing the underpinning knowledge of anatomy and physiology of vascular access, standardizing practice benefits to patients and nurses moving between dialysis units, improving accessibility by transitioning learning to smart phones and tablets and providing an opportunity for international collaboration related to vascular access e-learning concepts.

Emergency department mental health triage scales improve outcomes.

The assessment and management of clients with mental illness is an important facet of providing emergency care. In Australian emergency departments, it is usually the generalist registered nurses* without adequate preparation in the assessment and care for clients with mental illness who conduct the initial assessment at triage. A search of the literature revealed a limited number of publications addressing the provision of triage and management guidelines to assist nurses to make objective clinical decisions to ensure appropriate care for clients with mental illness. This paper examines the need for such guidelines and reviews a number of mental health triage scales that have been evaluated for use in emergency departments. Findings show that these triage scales have led to improvements in staff confidence and attitudes when dealing with clients with mental health problems, resulting in improved outcomes for clients. Strengths and limitations of the evaluations have also been explored. Highlighted is the need for consideration of the inclusion of clients' reactions to the impact of this change to service delivery in future evaluations.

Evidence-based psychiatric practice: doctrine or trap?

Medical practice has rapidly shifted towards an 'evidence-based' approach. While there are acknowledged clear benefits to this, a number of pitfalls are frequently not appreciated. Perhaps the most important limitation is the extent to which the current body of data is inadequate for many common clinical decisions. Algorithms risk being developed, frequently by third parties, without acknowledgement of these limitations and with substantial implications for clinical independence and the quality of patient care. This paper discusses potential problems of the evidence-based approach and suggests possible guidelines for the management of clinical decisions given the limitations of data-based guidelines.

Accepting risk in the acceleration of drug development for rare cancers.

Rare cancers collectively contribute a disproportionate fraction of the total burden of cancer. The oncology community is increasingly facing small numbers of patients with each cancer subtype, requiring cooperation and collaboration to complete multicentre trials that advance knowledge and patient care. At the same time, new insights into the biology of rare cancers have led to an explosion in knowledge and development of targeted agents. These insights and techniques are set to revolutionise the care of patients with cancer. However, drug development strategies and the availability of new agents for rare cancers are at risk of stalling owing to the ever-increasing complexity and costs of clinical trials. Finding solutions to these problems is imperative to the future of cancer care. We propose that a greater degree of risk sharing is needed than is currently accepted to enable the use of new methods with confidence, and to keep pace with scientific advancement.

Actor-Network Theory (ANT) based visualisation of socio-technical facets of RFID technology translation: an Australian hospital scenario

In the early 2000s, Information Systems researchers in Australia had begun to emphasise socio-technical approaches in innovation adoption of technologies. The ‘essentialist' approaches to adoption (for example, Innovation Diffusion or TAM), suggest an essence is largely responsible for rate of adoption (Tatnall, 2011) or a new technology introduced may spark innovation. The socio-technical factors in implementing an innovation are largely flouted by researchers and hospitals. Innovation Translation is an approach that purports that any innovation needs to be customised and translated in to context before it can be adopted. Equally, Actor-Network Theory (ANT) is an approach that embraces the differences in technical and human factors and socio-professional aspects in a non-deterministic manner. The research reported in this paper is an attempt to combined the two approaches in an effective manner, to visualise the socio-technical factors in RFID technology adoption in an Australian hospital. This research investigation demonstrates RFID technology translation in an Australian hospital using a case approach (Yin, 2009). Data was collected using a process of focus groups and interviews, analysed with document analysis and concept mapping techniques. The data was then reconstructed in a ‘movie script' format, with Acts and Scenes funnelled to ANT informed abstraction at the end of each Act. The information visualisation at the end of each Act using ANT informed Lens reveal the re-negotiation and improvement of network relationships between the people (factors) involved including nurses, patient care orderlies, management staff and non-human participants such as equipment and technology. The paper augments the current gaps in literature regarding socio-technical approaches in technology adoption within Australian healthcare context, which is transitioning from non-integrated nearly technophobic hospitals in the last decade to a tech-savvy integrated era. More importantly, the ANT visualisation addresses one of the criticisms of ANT i.e. its insufficiency to explain relationship formations between participants and over changes of events in relationship networks (Greenhalgh & Stones, 2010).

Understanding context in knowledge translation: a concept analysis study protocol.

AIM: To conduct a concept analysis of clinical practice contexts (work environments) that facilitate or militate against the uptake of research evidence by healthcare professionals in clinical practice. This will involve developing a clear definition of context by describing its features, domains and defining characteristics. BACKGROUND: The context where clinical care is delivered influences that care. While research shows that context is important to knowledge translation (implementation), we lack conceptual clarity on what is context, which contextual factors probably modify the effect of knowledge translation interventions (and hence should be considered when designing interventions) and which contextual factors themselves could be targeted as part of a knowledge translation intervention (context modification). DESIGN: Concept analysis. METHODS: The Walker and Avant concept analysis method, comprised of eight systematic steps, will be used: (1) concept selection; (2) determination of aims; (3) identification of uses of context; (4) determination of defining attributes of context; (5) identification/construction of a model case of context; (6) identification/construction of additional cases of context; (7) identification/construction of antecedents and consequences of context; and (8) definition of empirical referents of context. This study is funded by the Canadian Institutes of Health Research (January 2014). DISCUSSION: This study will result in a much needed framework of context for knowledge translation, which identifies specific elements that, if assessed and used to tailor knowledge translation activities, will result in increased research use by nurses and other healthcare professionals in clinical practice, ultimately leading to better patient care.

Abortion and conscientious objection: the new battleground

This paper examines the vexed issue of conscientious objection and abortion. It begins by outlining the increasing claims to conscientious objection invoked by physicians in reproductive health services. After an examination of developments overseas, the paper turns to the acrimonious debate in Victoria concerning the conscience clause and the 'obligation to refer' contained in the Abortion Law Reform Act 2008 (Vic) ('ALRA'). This paper questions the interpretation by the Catholic Church that the clause breaches its right to freedom of conscience and freedom of religion. We argue that the unregulated use of conscientious objection impedes women's rights to access safe lawful medical procedures. As such, we contend that a physician's withdrawal from patient care on the basis of conscience must be limited to certain circumstances. The paper then examines international and national guidelines, international treaties and recommendations of treaty monitoring bodies, laws in other jurisdictions, and trends in case law. The purpose of this examination is to show that the conscientious objection clause and the 'obligation to refer' in ALRA is consistent with international practice and laws in other jurisdictions. Finally, the paper turns to the problematic interpretation of conscience and moral responsibility in the context of abortion. We believe that narrow interpretations of conscience must be challenged, in order to incorporate patients' rights to include the choice of abortion and other lawful treatments according to their conscience. We conclude that the conscientious objection provisions in ALRA have achieved the right balance and that there is no justifiable legal reason upon which opponents can challenge the law.

Psychosocial aspects in home hemodialysis: A review

Psychosocial aspects related to home hemodialysis (HD) play an important role in the success of home HD programs. Once patients commence HD at home, unique psychosocial issues related to patient and care partner burden can emerge. Proactive professional support, peer support, respite care, travel support, and financial support from the home HD health care team must be a priority for patient care. If the psychosocial aspects are not proactively addressed, patients receiving HD at home may return to in-center HD and the program may struggle as a result. This review provides a psychosocial guide for new start-up home HD programs.

Medication communication during handover interactions in specialty practice settings

AIMS AND OBJECTIVES: To investigate what and how medication information is communicated during handover interactions in specialty hospital settings. BACKGROUND: Effective communication about patients' medications between health professionals and nurses at handover is vital for the delivery of safe continuity of care. DESIGN: An exploratory qualitative design and observational study. METHODS: Participant observation was undertaken at a metropolitan Australian public hospital in four specialty settings: cardiothoracic care, intensive care, emergency care and oncology care. A medication communication model was applied to the data and thematic analysis was performed. RESULTS: Over 130 hours of observational data were collected. In total, 185 (predominately nursing) handovers were observed across the four specialty settings involving 37 nurse participants. Health professionals communicated partial details of patients' medication regimens, by focusing on auditing the medication administration record, and through the handover approach employed. Gaps in medication information at handover were evident as shown by lack of communication about detailed and specific medication content. Incoming nurses rarely posed questions about medications at handover. CONCLUSIONS: Handover interactions contained restricted and incomplete medication information. Improving the transparency, completeness and accuracy of medication communication is vital for optimising patient safety and quality of care in specialty practice settings. RELEVANCE TO CLINICAL PRACTICE: For nurses to make informed and rapid decisions regarding appropriate patient care, information about all types of prescribed medications is essential, which is communicated in an explicit and clear way. Jargon and assumptions related to medication details should be minimised to reduce the risk of misunderstandings. Disclosure of structured medication information supports nurses to perform accurate patient assessments, make knowledgeable decisions about the appropriateness of medications and their doses, and anticipate possible adverse events associated with medications. In addition, benefits of patient and family member contributions in communicating about medications at handover should also be considered.

Nutrition competencies in health professionals' education and training: a new paradigm

Most health care professionals are not adequately trained to address diet and nutrition-related issues with their patients, thus missing important opportunities to ameliorate chronic diseases and improve outcomes in acute illness. In this symposium, the speakers reviewed the status of nutrition education for health care professionals in the United States, United Kingdom, and Australia. Nutrition education is not required for educating and training physicians in many countries. Nutrition education for the spectrum of health care professionals is uncoordinated, which runs contrary to the current theme of interprofessional education. The central role of competencies in guiding medical education was emphasized and the urgent need to establish competencies in nutrition-related patient care was presented. The importance of additional strategies to improve nutrition education of health care professionals was highlighted. Public health legislation such as the Patient Protection and Affordable Care Act recognizes the role of nutrition, however, to capitalize on this increasing momentum, health care professionals must be trained to deliver needed services. Thus, there is a pressing need to garner support from stakeholders to achieve this goal. Promoting a research agenda that provides outcome-based evidence on individual and public health levels is needed to improve and sustain effective interprofessional nutrition education.

Evolving epidemiology of injecting drug use-associated infective endocarditis: a regional centre experience

INTRODUCTION AND AIMS: Injecting drug use (IDU) is a major risk factor for infective endocarditis (IE). An understanding of the epidemiology of IE and IDU is vital for delivery of health care for this disease. Our aim was to examine the rates of IDU-associated IE (IDU-IE) in a single centre over the last 12 years. DESIGN AND METHODS: Retrospective analysis of two cohorts of consecutive patients (n = 226) admitted with IE from 2002 to 2013. Numbers of cases and rates of IE were compared between two cohorts (2002-2006 and 2009-2013). Rate ratios were calculated using Poisson distributions. Poisson regression was used to examine relationship over time. RESULTS: One hundred thirty cases of endocarditis were seen in the first observation period (6 IDU-IE) and 96 in the second observation period (15 IDU-IE). The estimated incidence rate of IE had fallen from 10.1 to 6.45 per 100, 000 person-years [rate ratio 0.64, 95% confidence interval (CI) 0.48, 0.85]. In contrast, the estimated incidence rate of IDU-E has risen from 0.48 to 0.79 per 100, 000 person-years (rate ratio 1.65, 95% CI 0.59, 4.57). Incidence rate regression suggests that the number of IDU-IE cases is expected to increase by a factor of 1.25 (95%CI 1.09-1.44) for each increase of 1 year. DISCUSSION AND CONCLUSIONS: Over the last decade, there has been a decrease in incidence rate and total number of cases of IE but a rise in rate and number of cases of IDU-IE. This may indicate increasing IDU or increased rates of endocarditis in intravenous drug users in this region. This finding may inform health-care planning in the area.