An evidence-based program to improve analgesic practice and pain outcomes in residential aged care facilities

Pain is common in individuals living in residential aged care facilities (RACFs), and a number of obstacles have been identified as recurring barriers to adequate pain management. To address this, the Australian Pain Society developed 27 recommendations for comprehensive good practice in the identification, assessment, and management of pain. This study reviewed preexisting pain management practice at five Australian RACFs and identified changes needed to implement the recommendations and then implemented an evidence-based program that aimed to facilitate better pain management. The program involved staff training and education and revised in-house pain-management procedures. Reviews occurred before and after the program and included the assessment of 282 residents for analgesic use and pain status. Analgesic use improved after the program (P<.001), with a decrease in residents receiving no analgesics (from 15% to 6%) and an increase in residents receiving around-the-clock plus as-needed analgesics (from 24% to 43%). There were improvements in pain relief for residents with scores indicative of pain, with Abbey pain scale (P=.005), Pain Assessment in Advanced Dementia Scale (P=.001), and Non-communicative Patient's Pain Assessment Instrument scale (P<.001) scores all improving. Although physical function declined as expected, Medical Outcomes Study 36-item Short-Form Survey bodily pain scores also showed improvement (P=.001). Better evidence-based practice and outcomes in RACFs can be achieved with appropriate training and education. Investing resources in the aged care workforce using this program improved analgesic practice and pain relief in participating sites. Further attention to the continued targeted pain management training of aged care staff is likely to improve pain-focused care for residents.

The early years in Irish multigrade classes: trajectories of practice and identity

This study investigates how the experiences of Junior Infants are shaped in multigrade classes. Multigrade classes are composed of two or more grades within the same classroom with one teacher having responsibility for the instruction of all grades in this classroom within a time-tabled period (Little, 2001, Mason and Doepner, 1998). The overall aim of the research is to problematize the issues of early childhood pedagogy in multigrade classes in the context of children negotiating identities, positioning and power relations. A Case Study approach was employed to explore the perspectives of the teachers, children and their parents in eight multigrade schools. Concurrent with this, a nation-wide Questionnaire Survey was also conducted which gave a broader context to the case study findings. Findings from the research study suggest that institutional context is vitally important and finding the space to implement pedagogic practices is a highly complex matter for teachers. While a majority of teachers reported the benefits for younger children being in mixed-age settings alongside older children, only a minority of case study school teachers demonstrated how it is possible to promote classroom climates which were provided multiple opportunities for younger children to engage fully in classrooms. The findings reveal constraints on pedagogical practice which included: time pressures within the job, an increase in diversity in pupil population, meeting special needs, large class sizes, high pupil/teacher ratios, and planning/organisation of tasks which intensified the complexities of addressing the needs of children who differ significantly in age, cognitive, social and emotional levels. An emergent and recurrent theme of this study is the representation of Junior Infants as apprentices in their ‘communities of practice’ who contributed in peripheral ways to the practices of their groups (Lave and Wenger, 1991, Wenger, 1998). Through a continuous process of negotiation of meaning, these pupils learned the knowledge and skills within their communities of practice that empowered some to participate more fully than others. The children in their ‘figured worlds’ (Holland, Lachiotte, Skinner and Caine 1998) occupy identities which are influenced by established arrangements of resources and practices within that community as well as by their own agentive actions. Finally, the findings of the study also demonstrate how the dimension of power is central to the exercise of social relations and pedagogical practices in multigrade classes.

The SPHERE Study: Secondary prevention of heart disease in general practice: protocol of a randomised controlled trial of tailored practice and patient care plans with parallel qualitative, economic and policy analyses. [ISRCTN24081411]

Background: The aim of the SPHERE study is to design, implement and evaluate tailored practice and personal care plans to improve the process of care and objective clinical outcomes for patients with established coronary heart disease (CHD) in general practice across two different health systems on the island of Ireland.CHD is a common cause of death and a significant cause of morbidity in Ireland. Secondary prevention has been recommended as a key strategy for reducing levels of CHD mortality and general practice has been highlighted as an ideal setting for secondary prevention initiatives. Current indications suggest that there is considerable room for improvement in the provision of secondary prevention for patients with established heart disease on the island of Ireland. The review literature recommends structured programmes with continued support and follow-up of patients; the provision of training, tailored to practice needs of access to evidence of effectiveness of secondary prevention; structured recall programmes that also take account of individual practice needs; and patient-centred consultations accompanied by attention to disease management guidelines.

Methods: SPHERE is a cluster randomised controlled trial, with practice-level randomisation to intervention and control groups, recruiting 960 patients from 48 practices in three study centres (Belfast, Dublin and Galway). Primary outcomes are blood pressure, total cholesterol, physical and mental health status (SF-12) and hospital re-admissions. The intervention takes place over two years and data is collected at baseline, one-year and two-year follow-up. Data is obtained from medical charts, consultations with practitioners, and patient postal questionnaires. The SPHERE intervention involves the implementation of a structured systematic programme of care for patients with CHD attending general practice. It is a multi-faceted intervention that has been developed to respond to barriers and solutions to optimal secondary prevention identified in preliminary qualitative research with practitioners and patients. General practitioners and practice nurses attend training sessions in facilitating behaviour change and medication prescribing guidelines for secondary prevention of CHD. Patients are invited to attend regular four-monthly consultations over two years, during which targets and goals for secondary prevention are set and reviewed. The analysis will be strengthened by economic, policy and qualitative components.

Effect of tailored practice and patient care plans on secondary prevention of heart disease in general practice: cluster randomised controlled trial

Objective: To test the effectiveness of a complex intervention designed, within a theoretical framework, to improve outcomes for patients with coronary heart disease. Design: Cluster randomised controlled multicentre trial. Setting: General practices in Northern Ireland and the Republic of Ireland, regions with different healthcare systems. Participants: 903 patients with established coronary heart disease registered with one of 48 practices. Intervention: Tailored care plans for practices (practice based training in prescribing and behaviour change, administrative support, quarterly newsletter), and tailored care plans for patients (motivational interviewing, goal identification, and target setting for lifestyle change) with reviews every four months at the practices. Control practices provided usual care. Main outcome measures: The proportion of patients at 18 month follow-up above target levels for blood pressure and total cholesterol concentration, and those admitted to hospital, and changes in physical and mental health status (SF-12). Results: At baseline the numbers (proportions) of patients above the recommended limits were: systolic blood pressure greater than 140 mm Hg (305/899; 33.9%, 95% confidence interval 30.8% to 33.9%), diastolic blood pressure greater than 90 mm Hg (111/901; 12.3%, 10.2% to 14.5%), and total cholesterol concentration greater than 5 mmol/l (188/860; 20.8%, 19.1% to 24.6%). At the 18 month follow-up there were no significant differences between intervention and control groups in the numbers (proportions) of patients above the recommended limits: systolic blood pressure, intervention 98/360 (27.2%) v control, 133/405 (32.8%), odds ratio 1.51 (95% confidence interval 0.99 to 2.30; P=0.06); diastolic blood pressure, intervention 32/360 (8.9%) v control, 40/405 (9.9%), 1.40 (0.75 to 2.64; P=0.29); and total cholesterol concentration, intervention 52/342 (15.2%) v control, 64/391 (16.4%), 1.13 (0.63 to 2.03; P=0.65). The number of patients admitted to hospital over the 18 month study period significantly decreased in the intervention group compared with the control group: 107/415 (25.8%) v 148/435 (34.0%), 1.56 (1.53 to 2.60; P=0.03). Conclusions: Admissions to hospital were significantly reduced after an intensive 18 month intervention to improve outcomes for patients with coronary heart disease, but no other clinical benefits were shown, possibly because of a ceiling effect related to improved management of the disease. Trial registration: Current Controlled Trials ISRCTN24081411.

Cluster randomised controlled trial of an infection control education and training intervention programme focusing on meticillin-resistant Staphylococcus aureus in nursing homes for older people

The aim of this cluster randomised controlled trial was to test the impact of an infection control education and training programme on meticillin-resistant Staphylococcus aureus (MRSA) prevalence in nursing homes. Nursing homes were randomised to intervention (infection control education and training programme; N¼16) or control (usual practice continued; N¼16). Staff in intervention homes were educated and trained (0, 3 and 6 months) in the principles and implementation of good infection control practice with infection control audits conducted in all sites (0, 3, 6 and 12 months) to assess compliance with good practice. Audit scores were fed back to nursing home managers in intervention homes, together with a written report indicating where practice could be improved. Nasal swabs were taken from all consenting residents and staff at 0, 3, 6 and 12 months. The primary outcome was MRSA prevalence in residents and staff, and the secondary outcome was a change in infection control audit scores. In all, 793 residents and 338 staff were recruited at baseline. MRSA prevalence did not change during the study in residents or staff. The relative risk of a resident being colonised with MRSA in an intervention home compared with a control home at 12 months was 0.99 (95% con?dence interval: 0.69, 1.42) after adjustment for clustering. Mean infection control audit scores were signi?cantly higher in the intervention homes (82%) compared with the control homes (64%) at 12 months (P<0.0001). Consideration should be given to other approaches which may help to reduce MRSA in this setting.

Masks as self-study. Challenging and sustaining teachers’ personal and professional personae in early–mid career life phases

Drawing on previous research identifying how teachers’ capacities to sustain their effectiveness in different phases of their professional lives are affected positively and/or negatively by their sense of identity, this paper illuminates three early–mid career teachers’ self-study inquiries, centring on mask work. The creative development of individual masks discloses teachers’ complex, occasionally
dislocated narratives of personal/professional identity. Subsequent improvisation with their masks is shown to engage teachers emotionally with tensions and dissonances within and between their various personae and personal, professional and political contexts at each of their respective career life phases. Storylines ultimately become reframed and, in a number of instances, lay claim to reinvigorated commitment, self-determination and initiatives for change.

An exploratory study of specialist and generalist teachers: predicting self efficacy in delivering primary physical education.

We aimed to determine whether primary school teachers’ motivational regulations to exercise and self efficacy in delivering a physical education (PE) lesson are different based on prior PE training. Two groups of qualified primary school teachers were recruited; PE specialists and a group of generalist primary school teachers who also teach PE. All teachers completed the Behavioural Regulation in Exercise Questionnaire-2, International Physical Activity Questionnaire and the Teachers’ Sense of Efficacy Scale. PE specialists demonstrated significantly higher levels of intrinsic motivation towards exercise participation and took part in more physical activity in comparison to the generalist teachers. Regression analysis showed that being a PE specialist predicted higher scores in instructional strategies and classroom management in PE. Our findings support the useof Self Determination Theory concepts in understanding teacher’s exercise participation motivations. These findings have implications for the modelling role of teachers in encouraging children to be physically active.

Voices of the Undereducated in Adult Education and Training in Ontario: A Phenomenographic Approach

This doctoral study was an exploration of the qualitatively different ways in which undereducated adults (at or below a high school level of formal education) reported their experiences of participation in adult education and training (AET) programmes offered by publicly funded school boards or their arms-length affiliate in the province of Ontario. In light of a low participation rate in the Canadian AET system by undereducated adults, the rationale was to examine whether or not AET programmes are meeting the needs of undereducated adults beyond a narrow focus on an instrumental approach associated with human capital development. This study was located in a theoretical framework consisting of (a) learning theory, (b) motivations for participation, (c) general barriers to participation, (d) structural barriers to participation, and (e) transformative learning. The purposive sample consisted of 11 participants between the ages of 18-58 who were drawn from service providers in 4 geographic regions of Ontario. Data collection consisted of (a) demographics, (b) voice recordings from face-to-face participant interviews, (c) participant weekly critical incident reports, and (d) researcher reflexive journal notes. Data were analyzed in accordance with a phenomenographic approach within a constructivist/interpretivist research paradigm. Findings revealed 4 qualitatively different ways in which undereducated adult learners reported their experiences of participation in AET and were reported as the voice of (a) security, (b) engagement, (c) relationship, and (d) competency. Implications to theory and practice and to further inquiry were outlined.

Vocational Higher Secondary Education in Kerala: A Status Study of Students, Pass Outs and Training Components

This study analyses the socio-economic backgrounds and entrepreneurial profiles of the students and pass outs of the Vocational Higher Secondary Education in Kerala and the academic achievements of the Vocational Higher Secondary students and pass outs in Kerala in terms of their performance in the examinations. The study also analyses the quality and availability of the various training and support facilities of the Vocational Higher Secondary Schools in Kerala, nature and rate of employment and higher studies among the pass outs of the Vocational Higher Secondary Education in Kerala and the awareness of students, pass outs, teachers and principals regarding the goals and objectives, mode of implementation, apprenticeship training and higher study and employment opportunities of the programme of the Vocational Higher Secondary Education in Kerala.

Linking the UK Professional Standards Framework to reflective practice and action research

This is a part of a collection of materials developed by the HEAcademy Subject Centre for Languages, linguistics and area studies. The materials provide reflective activities designed to engage teachers with some of the key issues in working with international students and practical ideas for ways in which these can be addressed. They will be of particular interest to new staff or anyone new to working with international students.

Shaping literacy in the secondary school: policy, practice and agency in the age of the national literacy strategy

This article examines the definitions of literacy in operation in secondary schools, and the relationship between official literacy policy and the practices of the agents responsible for implementing this policy. We trace the history of national policy back to the Language Across the Curriculum movement of the 1970s as it provides an illustrative point of comparison with the first five years of the National Literacy Strategy. Drawing on empirical data which illuminate the views, perceptions and practices of key agents on a number of levels, we critically review the concept of 'school literacy' promoted in government policy, defining it as 'school-centric literacy' and question its ability to facilitate participation in the practices associated with the media and technological literacies which are increasingly a feature of school life. There is evidence of some unplanned effects of the current national policy but also that levels of agency, for literacy teachers in particular, may be rapidly diminishing.

Ethnographic methodologies for construction research: knowing, practice and interventions

Ethnographic methodologies developed in social anthropology and sociology hold considerable promise for addressing practical, problem-based research concerned with the construction site. The extended researcher-engagement characteristic of ethnography reveals rich insights, yet is infrequently used to understand how workplace realities are lived out on construction sites. Moreover, studies that do employ these methods are rarely reported within construction research journals. This paper argues that recent innovations in ethnographic methodologies offer new routes to: posing questions; understanding workplace socialities (i.e. the qualities of the social relationships that develop on construction sites); learning about forms, uses and communication of knowledge on construction sites; and turning these into meaningful recommendations. This argument is supported by examples from an interdisciplinary ethnography concerning migrant workers and communications on UK construction sites. The presented research seeks to understand how construction workers communicate with managers and each other and how they stay safe on site, with the objective of informing site health-and-safety strategies and the production and evaluation of training and other materials.