Targeted clinical education for staff attitudes towards deliberate self-harm in borderline personality disorder : randomized controlled trial

<b>Objective</b>: The aim of the present study was to assess the impact of attending targeted clinical education on borderline personality disorder on the attitudes of health clinicians towards working with deliberate self-harm behaviours commonly exhibited by patients diagnosed with this complex disorder. Comparisons of clinicians across service settings, occupational fields, and other demographic areas were also made.<br /><br /><b>Method</b>: A purpose-designed demographic questionnaire and the Attitudes Towards Deliberate Self-Harm Questionnaire were used to collect the demographic information and assess the attitudes of 99 mental health and emergency medicine practitioners across two Australian health services and a New Zealand health service, both before and after education attendance.<br /><br /><b>Results</b>: Statistically significant improvements in attitude ratings were found for both emergency medicine clinicians and mental health clinicians in working with deliberate self-harm behaviours in borderline personality disorder, following attendance at the education program with a medium affect size (t(32)=&minus;3.45, p=0.002, d=0.43 and t(65)=&minus;5.12, p=0.000, d=0.42, respectively). Clinicians across occupational areas of nursing, allied health, and medical fields demonstrated equivocal levels of improvement in their attitude ratings.<br /><br /><b>Conclusions</b>: Results are discussed in terms of the necessity of providing regular access to targeted clinical education for health professionals working with patients diagnosed with borderline personality disorder.<br />

Evaluation of advanced breast cancer multidisciplinary team meatings

<b>Background</b>: Multidisciplinary team meetings (MDMs) have become an important decision-making forum in oncology. These meetings bring together expertise from each relevant field to improve continuity of care and health care outcomes for cancer patients. However there is a lack of evidence demonstrating the effectiveness of MDT meetings in improving cancer patient outcomes. The aim of this study was to explore the perceived value and potential usefulness of multidisciplinary team meetings for patients with advanced breast cancer (ABC).<br /><br /><b>Methods</b>: ABC MDMs have been conducted since 2002 at two sites of Eastern Health, the second largest health service in Melbourne. Attendees were invited to complete a confidential questionnaire in November 2007 that comprised seven areas aimed to assess their judgment of how well the MDMs have improved patient management, including medical recommendations, psychosocial care, palliative care, community care, and team development. Average scores were calculated for improvement of each area.<br /><br /><b>Results</b>: A total of 16 (69%) health practitioners participated in the survey, with main representation from nursing (37%), allied health (25%) and medicine (19%). Preliminary results indicate that the broad areas members reported the meeting had improved patient outcomes were in palliative care and medical management. Specific areas of perceived improvement were medical outcomes for patients; early referral to palliative care services; confirmation of diagnosis; referral to supportive care; and appropriateness of palliative care referrals. Conversely, the area that had least improved was community care, as there was no input from GPs or community services other than palliative care. Attendance by GPs and radiologists were considered important for further improving medical outcomes for patients.<br /><br /><b>Conclusions</b>: This study demonstrates the perceived value of the MDT approach in the care of ABC patients, particularly in improving patient outcomes. The next stage of this research is to conduct a survey of ABC patient satisfaction level.<br /><br />

Developing a web-based information resource for palliative care : an action-research inspired approach

<b>Background :</b> General Practitioners and community nurses rely on easily accessible, evidence-based online information to guide practice. To date, the methods that underpin the scoping of user-identified online information needs in palliative care have remained under-explored. This paper describes the benefits and challenges of a collaborative approach involving users and experts that informed the first stage of the development of a palliative care website.<br /><br /><b>Method :</b> The action research-inspired methodology included a panel assessment of an existing palliative care website based in Victoria, Australia; a pre-development survey (n = 197) scoping potential audiences and palliative care information needs; working parties conducting a needs analysis about necessary information content for a redeveloped website targeting health professionals and caregivers/patients; an iterative evaluation process involving users and experts; as well as a final evaluation survey (n = 166).<br /><br /><b>Results : </b>Involving users in the identification of content and links for a palliative care website is time-consuming and requires initial resources, strong networking skills and commitment. However, user participation provided crucial information that led to the widened the scope of the website audience and guided the development and testing of the website. The needs analysis underpinning the project suggests that palliative care peak bodies need to address three distinct audiences (clinicians, allied health professionals as well as patients and their caregivers).<br /><b><br />Conclusion :</b> Web developers should pay close attention to the content, language, and accessibility needs of these groups. Given the substantial cost associated with the maintenance of authoritative health information sites, the paper proposes a more collaborative development in which users can be engaged in the definition of content to ensure relevance and responsiveness, and to eliminate unnecessary detail. Access to volunteer networks forms an integral part of such an approach.<br />

Barriers to care for depressed older people : perceptions of aged care among medical professionals

The current study evaluated barriers to detection of depression among older people. Focus groups were conducted with 21 professional carers, 4 nurses, 10 general practitioners, and 7 aged care managers. The results demonstrated that care for older people is primarily focused on physical care. Further, staff resources, a lack of continuity of care, multiple co-morbidities, reluctance by older people to discuss depression, negative attitudes among carers, as well as a lack of skills all contributed to a failure to detect and treat depression. The implications of these findings for training programs for professional carers are discussed.<br />

Responding to rural skills shortages : innovations using vocational education and training

Aims &amp; Rationale/Objectives<br />To locate, analyse and make accessible innovative models of health training and service delivery that have been developed in response to a shortage of skills.<br /><br />Methods<br />Drawing on a synthesis of Australian and international literature on innovative and effective models for addressing health skill shortages, 50 models were selected for further study. Models were also identified from nominations by key health sector stakeholders. Selected models represent diversity in terms of the nature of skill shortage addressed, barriers overcome in developing the model, health care specialisations, and customer groups.<br /><br />Principal Findings<br />Rural and remote areas have become home to a set of innovative service delivery models. Models identified encompass local, regional and state/national responses. Local responses are usually single health service-training provider partnerships. Regional responses, the most numerous, tend to have a specific focus, such as training young people. A small number of holistic state or national responses, eg the skills ecosystem approach, address multiple barriers to health service provision. Typical barriers include unwillingness to risk-take, stakeholder differences, and entrenched workplace cultures. Enhancers include stakeholder commitment, community acceptance, and cultural fit.<br /><br />Discussion<br />Of particular interest is increasing numbers of therapy assistants to help address shortages of allied health professionals, and work to formalise their training, and develop standards of practice and policy. Other models likely to help address skill shortage amongst VET health workers focus on recruiting, supporting and training employees from a range of disadvantaged target groups, and on providing career paths with opportunities for staff to expand their skills. Such models are underpinned by nationally recognised qualifications, but each solution is targeted to a particular context in terms of the potential workforce and local need.<br />

Factors affecting the offer of pulmonary rehabilitation to patients with chronic obstructive pulmonary disease by primary care professionals : a qualitative study

<b>Aim</b>: To explore health professionals&rsquo; experiences of barriers and facilitators to referring patients for pulmonary rehabilitation in a primary care setting. <br /><br /><b>Background</b>: Pulmonary rehabilitation involves a multidisciplinary teamwork approach to improving<br />the quality of life for people with chronic obstructive pulmonary disease. This study aimed to find out about health care professionals&rsquo; experiences when referring patients. Reports suggest that a health care professional&rsquo;s attitude towards a treatment affects the willingness of patients to accept advice. <br /><br /><b>Methods</b>: Five focus group interviews were undertaken with 21 health professionals from North Midlands, UK. Data were analysed using a thematic analysis drawing on the techniques of grounded theory.<br /><br /><b>Findings</b>: Chronic disease management has been delegated to Practice Nurses in many cases leaving some nurses feeling unsupported and some General Practitioners feeling deskilled. Problems with communication, a lack of adequate and timely local service provision, a difficult referral process, time pressures and lack of information were barriers to health care professionals making an offer of pulmonary rehabilitation. An explanatory model is proposed to describe how addressing barriers to referral may improve health care professionals views about pulmonary rehabilitation and therefore may mean that they present it in a more positive manner.<br />

Responding to the ageing profile of emergency department patients

<b>Background</b><br />Older people with acute superimposed on chronic health problems are becoming a core aspect of emergency department (ED) caseload. This project explored the ED experience from the perspective of older patients and their carers.<br /><br /><b>Method</b><br />A convenience sample of thirty participants was recruited across three participating EDs: tw o metropolitan and one regional. The project utilised two approaches to data collection: 1) an observation approach where a project officer observed participants from the time of ED presentation until discharge, or for up to six hours; and 2) a subsequent interview was conducted with the participant and their carer within a week of the ED presentation. Data from both sources were integrated, and independently thematically analysed by two members of the team.<br /><br /><b>Results</b><br />Thirty participants aged over 65 were recruited. Their average age was 77.1 (sd=6.7) years, 59% w ere female, and 74% were triage category 1- 3 (indicating moderate/high acuity). Participants spent on average 7 hours 47 minutes in the ED, with 50% discharged home, 43% admitted to general wards or MAPU, and 7% discharged to residential care/hospice. Key themes in the factors influencing the patient experience and examples of quality care were identified, along with opportunities to improve the capacity for EDs to be &ldquo;older person friendly&rdquo;, and &ldquo;person-centred.&rdquo; Challenges include improving the effectiveness of communication between staff and patients/carers (including issues around people from culturally and linguistically diverse backgrounds), availability of allied health professionals to assist with discharge planning, and a tendency for older people not to seek ED care until the health problem was severe. Patient exemplars highlight key themes.<br /><b><br />Discussion and implications</b><br />Results of the project highlight positive aspects of emergency department care for older people and inform targets for improvement strategies. These can be used to drive ongoing improvements in care for older people presenting to EDs.<br />

Leaving the bush : why did they do it?

The demand for allied health professionals (AHPs) in rural areas is increasing due to changes in lifestyle, disease and disability of the population. Recruitment and retention of AHPs in rural Australia is an issue that continues to challenge policy makers. However, recent initiatives from the Commonwealth Government have focused on boosting the rural health workforce through grants that support education and training, expand health services and increase the number of rural and remote clinical placements. In addition to this funding, suggested restructure of the current allied health service delivery model is gaining much attention. Although this funding and organisational reform is much needed and welcomed, the changing nature of allied health work, increasing demand, and shortages across most rural areas highlight the need for research to address the complexities associated with recruitment and retention of these professionals.<br /><br />Gaining insight into the experiences of rural AHPs can assist with enhancing government funded recruitment and retention programs and developing sustainable and efficient workforce policies. This study hopes to build on our previous research that implies recruitment is enhanced when retention is optimal, since AHPs are willing to recommend their workplace. Therefore, the factors that influence retention are just as valid and important as the factors that influence recruitment, but many of the existing workforce models have solely focused on recruitment.4 Additionally, these models do not adequately address issues regarding rural employment, they are difficult to implement, and costly to sustain.<br /><br />In order to make policy recommendations on recruitment and retention in Australia, this paper aims to explore the experiences of AHPs who resigned from rural employment<br />

Opting in and opting out: a grounded theory of nursings contribution to inpatient rehabilitation

<b>Aim:</b> To develop a grounded theory of nursing&rsquo;s contribution to patient rehabilitation from the perspective of nurses working in inpatient rehabilitation.<br /><b><br />Design:</b> Grounded theory method, informed by the theoretical perspective of symbolic interactionism, was used to guide data collection and analysis, and the development of a grounded theory.<br /><b><br />Setting:</b> Five inpatient rehabilitation units in Australia.<br /><b><br />Participants:</b> Thirty-five registered and 18 enrolled nurses participated in audio-taped interviews and/or were observed during periods of their everyday practice.<br /><b><br />Findings:</b> The analysis revealed a situation whereby nurses made decisions about when to &lsquo;opt in&rsquo; and when to &lsquo;opt out&rsquo; of inpatient rehabilitation. This occurred on two levels: with their interaction with patients and allied health professionals, and when faced with negative system issues that impacted on their ability to contribute to patient rehabilitation. The primary contribution nurses made to inpatient rehabilitation was working directly with patients, enabling them to self-care. Nurses coached patients when their decisions about &lsquo;opting in&rsquo; and &lsquo;opting out&rsquo; were based on assessment of the person in their particular context. In contrast, the nurses mostly distanced themselves from system-based problems, &lsquo;opting out&rsquo; of addressing them. They did this not to make their working lives easier, but more manageable.<br /><b><br />Conclusion:</b> System-based problems impacted negatively on the nurses&rsquo; ability to deliver comprehensive rehabilitation care. As a consequence, some nurses felt unable to influence the care and they withdrew professionally to make their work lives more manageable.<br />

Preventing falls among older people : current practice and attitudes among community pharmacists

Objective: Falls among older people are a major cause of injury and death in Australia Urgent action is required if we are to stem the .epidemic' increase in falls as our population ages. This paper describes current practice and attitudes of community pharmacists in Northern Rivers, New South Wales, in relation to preventing falls. .. Method: Comm~typhannacists in the Northern Rivers area ofNew South Wales were surveyed to detennine their current activities to reduce the risk of falls in older clients and to gauge awareness of the successful 1992-96 falls prevention program- 'Stay on Your Feet'. Results: Response rate was 79% (53/67). Seventy-two per cent reported that they urge 'most' or 'almost all' older clients to bring in out-of-date medications for disposal, 66% give them falls prevention advice at least 'sometimes', 57% refer at least 'some' older clients to allied health practitioners for assessment or treatment of falls risk. and 92% are interested in receiving more written information regarding falls prevention. Conclusion: The fmdings suggest that while community pharmacists are both ready and keen to play a role in future falls prevention initiatives. their current involvement varies considerably. Specific ways in which they might further help to reduce falls are: regularly checking the potential of client. medications to connibute to falls. giving more verbal or written advice, promoting 'falls safe' products, referring older clients to allied health practitioners for assessment or treatment of falls risk, and training staff [Q provide falls prevention advice

Falls prevention in rural general practice: what stands the test of time and where to from here?

<b>Objective</b>: General practitioner recall of the 1992&ndash;96 'Stay on Your Feet' (SOYF) program and its influence on practice were surveyed five years post-intervention to gauge sustainability of the SOYF General Practice (GP) component.<br /><br /><b>Methods</b>: A survey assessed which SOYF components were still in existence, current practice related to falls prevention, and interest in professional development. All general practitioners (GPs) situated within the boundaries of a rural Area Health Service were mailed a survey in late 2001.<br /><br /><b>Results</b>: Response rate was 66.5% (139/209). Of 117 GPs in practice at the time of SOYF, 80.2% reported having heard of SOYF and 74.4% of those felt it had influenced practice. Half (50.9%) still had a copy of the SOYF GP resource and of those, 58.6% used it at least 'occasionally'. Three-quarters of GPs surveyed (75.2%) checked medications 'most/almost all' of the time with patients over 60 years; 46.7% assessed falls risk factors; 41.3% gave advice; and 22.6% referred to allied health practitioners. GPs indicated a strong interest in falls prevention-related professional development. There was no significant association between use of the SOYF resource package and any of the current falls prevention practices (all &chi;² &gt;0.05).<br /><b><br />Conclusions and implications</b>: There was high recall of SOYF and a general belief that it influenced practice. There was little indication that use of the resource had any lasting influence on GPs' practices. In future, careful thought needs to go into designing a program that has potential to affect long-term change in GPs' falls prevention practice.<br />

Grounded theory of nursing's contribution to inpatient rehabilitation

There is growing awareness of the benefits of rehabilitation both in Australia and overseas. While the provision of rehabilitation services is not new, recognition of this type of health service as an integral part of health care has been linked to changes in the provision of acute care services, advances in medical technology, improvements in the management of trauma and an ageing population. Despite this, little attention has been paid to nursing's contribution to patient rehabilitation in Australia. The aim of this grounded theory study, therefore, was to collect and analyse nurses' reports of their contributions to patient rehabilitation and to describe and analyse contextual factors influencing that contribution. Data were collected during interviews with registered and enrolled nurses working in five inpatient rehabilitation units in New South Wales and during observation of the nurses' everyday practice. A total of 53 nurses participated in the study, 35 registered nurses and 18 enrolled nurses. Grounded theory, informed by the theoretical perspective of symbolic interactionism, was used to guide data analysis, the ongoing collection of data and the generation of a substantive theory. The findings revealed six major categories. One was an everyday problem labelled incongruence between nurses' and patients' understandings and expectations of rehabilitation. Another category, labelled coaching patients to self-care, described how nurses independently negotiated the everyday problem of incongruence. The remaining four categories captured conditions in the inpatient context which influenced how nurses could contribute to patient rehabilitation. Two categories, labelled segregation: divided and dividing work practices between nursing and allied health and role ambiguity, were powerful in shaping nursing's contribution as they acted individually and synergistically to constrain nursing's contribution to patient rehabilitation. The other two categories, labelled distancing to manage systemic constraints and grasping the nettle to realise nursing's potential, represent the mutually exclusive strategies nurses used in response to segregation and role ambiguity. From exploration of the relationship between the six categories, the core category and an interactive grounded theory called opting in and opting out emerged. In turn, this grounded theory reveals nursing's contribution to inpatient rehabilitation as well as contextual conditions constraining that contribution. The significance of these findings is made manifest through their contribution to the advancement of nursing knowledge and through implications for nursing practice and education, rehabilitation service delivery and research.

Population monitoring of language and cognitive development in Australia : the Australian early development index

The Australian Early Development Index (AEDI) is a population measure of child development. The AEDI measures Language and Cognitive Development, Social Competence, Emotional Maturity, Physical Health and Wellbeing, and Communication Skills and General Knowledge. In Australia these data are collected by teachers for children in their first full time year of schooling. The aim of this paper is to aid people's understanding and interpretation of population measures such as the AEDI. With a greater awareness of the merits and complexities of population data clinicians and allied health professionals can play a vital role in aiding communities and policy makers to interpret and act upon the data in an intelligent way. This paper is primarily descriptive providing background information on the development and use of the instrument utilizing one of the 5 developmental domains (Language and Cognitive Development) as an example. The results show a complex relationship between children residing in differing socio-economic regions, children with English as their primary or secondary language and children who are able or not able to effectively communicate in English.<br />