The TrueBlue study : is practice nurse-led collaborative care effective in the management of depression for patients with heart disease or diabetes?

Background: In the presence of type 2 diabetes (T2DM) or coronary heart disease (CHD), depression is under diagnosed and under treated despite being associated with worse clinical outcomes. Our earlier pilot study demonstrated that it was feasible, acceptable and affordable for practice nurses to extend their role to include screening for and monitoring of depression alongside biological and lifestyle risk factors. The current study will compare the clinical outcomes of our model of practice nurse-led collaborative care with usual care for patients with depression and T2DM or CHD.

Methods: This is a cluster-randomised intervention trial. Eighteen general practices from regional and metropolitan areas agreed to join this study, and were allocated randomly to an intervention or control group. We aim to recruit 50 patients with co-morbid depression and diabetes or heart disease from each of these practices. In the intervention group, practice nurses (PNs) will be trained for their enhanced roles in this nurse-led collaborative care study. Patients will be invited to attend a practice nurse consultation every 3 months prior to seeing their usual general practitioner. The PN will assess psychological, physiological and lifestyle parameters then work with the patient to set management goals. The outcome of this assessment will form the basis of a GP Management Plan document. In the control group, the patients will continue to receive their usual care for the first six months of the study before the PNs undergo the training and switch to the intervention protocol. The primary clinical outcome will be a reduction in the depression score. The study will also measure the impact on physiological measures, quality of life and on patient attitude to health care delivered by practice nurses.

Conclusion: The strength of this programme is that it provides a sustainable model of chronic disease management with monitoring and self-management assistance for physiological, lifestyle and psychological risk factors for high-risk patients with co-morbid depression, diabetes or heart disease. The study will demonstrate whether nurse-led collaborative care achieves better outcomes than usual care.

Investigation of overweight and obesity management in a rural primary health care setting

Background : The rural region of interest has one main central medical clinic and several smaller outlying clinics. The services available for weight management include dietetic services, community-based groups and bariatric surgery. At present, no formal area specific referral pathway exists for the treatment of overweight and obesity.
Aims & rationale/Objectives : To investigate general practitioners':
- assessment practices and experiences with overweight and obese clients
- experience of different treatment options for overweight and obesity
- perceived barriers to overweight and obesity management.
Methods : A self-administered survey will be sent to general practitioners within the region of interest. The survey was designed to investigate current methods of assessing overweight and obesity; treatment options; and perceived barriers to successful weight management. Participants will also be offered a brief interview to discuss the following topics; Usefulness of NHMRC's Overweight and Obesity Guidelines; barriers and frustrations of weight management, GP's and dietitian's roles in overweight and obesity treatment.
Principal findings : It is expected the principal findings will include details about methods used to determine overweight and obesity; factors considered when selecting patients for treatment; favoured treatment options of GPs; perceived barriers and frustrations of managing overweight and obese patients.
Discussion : Overweight and obesity are significant health issues in Australia, with recent data indicating more than 60% of Australian adults are affected (NHMRC, 2003). Studies have also suggested that the prevalence of overweight and obesity is higher in rural populations (Coulson, 2005). GPs have been recognised as an important contributor in the treatment of overweight and obesity (Campbell, 2000). There have been guidelines produced to assist GPs, however the extent to which guidelines are utilised or their perceived effectiveness have not yet been investigated.
Implications : It is thought that an investigation into current methods of assessing overweight and obesity; treatment options; and perceived barriers to successful weight management will provide valuable information to inform primary health care service provision and future quality improvement directions.
Presentation type : Poster
Session theme : Primary health care delivery

Adults with arthritic conditions and care-seeking in an attachment framework

This thesis investigated the role of care-seeking amongst adults with arthritis, using an attachment framework to help explain the inconsistent results of previous studies in regard to psychological adjustment to a chronic illness. The results highlight the importance of attachment processes in partially influencing care-seeking and coping strategies that shape psychological adjustment. The portfolio addresses the frequent co-occurence of depression with chronic medical disorders. This impacts the ability for chronic, medically ill adults to engage in self-management strategies. Four case studies are presented.

Seeking the views of health professionals on translating chronic disease self-management models into practice

Abstract
Few studies have investigated the views of health professionals with respect to their use of chronic disease self-management (CDSM) in the workplace.
Objective
This qualitative study, conducted in an Australian health care setting, examined health professional's formal self-management (SM) training and their views and experiences on the use of SM techniques when working with people living with a chronic illness.
Methods
Purposive sample of 31 health care professionals from a range of service types participated in semi-structured interviews.
Results
The majority of participants (65%) had received no formal training in SM techniques. Participants reported a preference for an eclectic approach to SM, relying primarily on five elements: collaborative care, self-responsibility, client's individual situation, structured support and linking with community agencies. Problems with CDSM centred on medication management, complex measuring devices and limited efficacy with some patient groups.
Conclusion
This study provides valuable information with respect to the use of CDSM within the workplace from the unique perspective of a range of healthcare providers within an Australian health care setting.
Practice implications
Training implications, with respect to CDSM and patient care, are discussed, together with how these findings contribute to the debate concerning how SM principles are translated into healthcare settings.

A question of self-preservation : immunopathology in influenza virus infection

Influenza A viruses that circulate normally in the human population cause a debilitating, though generally transient, illness that is sometimes fatal, particularly in the elderly. Severe complications arising from pandemic influenza or the highly pathogenic avian H5N1 viruses are often associated with rapid, massive inflammatory cell infiltration, acute respiratory distress, reactive hemophagocytosis and multiple organ involvement. Histological and pathological indicators strongly suggest a key role for an excessive host response in mediating at least some of this pathology. Here, we review the current literature on how various effector arms of the immune system can act deleteriously to initiate or exacerbate pathological damage in this viral pneumonia. Generally, the same immunological factors mediating tissue damage during the anti-influenza immune response are also critical for efficient elimination of virus, thereby posing a significant challenge in the design of harmless yet effective therapeutic strategies for tackling influenza virus.

The resident assessment instrument-minimum data set 2.0 quality indicators : a systematic review

Background
The Resident Assessment Instrument-Minimum Data Set (RAI-MDS) 2.0 is designed to collect the minimum amount of data to guide care planning and monitoring for residents in long-term care settings. These data have been used to compute indicators of care quality. Use of the quality indicators to inform quality improvement initiatives is contingent upon the validity and reliability of the indicators. The purpose of this review was to systematically examine published and grey research reports in order to assess the state of the science regarding the validity and reliability of the RAI-MDS 2.0 Quality Indicators (QIs).

Methods
We systematically reviewed the evidence for the validity and reliability of the RAI-MDS 2.0 QIs. A comprehensive literature search identified relevant original research published, in English, prior to December 2008. Fourteen articles and one report examining the validity and/or reliability of the RAI-MDS 2.0 QIs were included.

Results
The studies fell into two broad categories, those that examined individual quality indicators and those that examined multiple indicators. All studies were conducted in the United States and included from one to a total of 209 facilities. The number of residents included in the studies ranged from 109 to 5758. One study conducted under research conditions examined 38 chronic care QIs, of which strong evidence for the validity of 12 of the QIs was found. In response to these findings, the 12 QIs were recommended for public reporting purposes. However, a number of observational studies (n=13), conducted in "real world" conditions, have tested the validity and/or reliability of individual QIs, with mixed results. Ten QIs have been studied in this manner, including falls, depression, depression without treatment, urinary incontinence, urinary tract infections, weight loss, bedfast, restraint, pressure ulcer, and pain. These studies have revealed the potential for systematic bias in reporting, with under-reporting of some indicators and over-reporting of others.

Conclusion
Evidence for the reliability and validity of the RAI-MDS QIs remains inconclusive. The QIs provide a useful tool for quality monitoring and to inform quality improvement programs and initiatives. However, caution should be exercised when interpreting the QI results and other sources of evidence of the quality of care processes should be considered in conjunction with QI results.

Improving the coordination of care for low back pain patients by creating better links between acute and community services

This paper reports on the development of a care-pathway to improve service linkages between the acute setting and community health services in the treatment of low back pain. The pathway was informed by two processes: (1) a literature review based on best-practice guidelines in the assessment, treatment and continuity of care for low back pain patients; and (2) consultation with staff and key stakeholders. Stakeholders from both the acute and community sectors comprised the Working Group, who identified central areas of concern to be addressed in the care-pathway, with the goal of preventing chronicity of low back pain and reducing emergency department presentations. The main outcomes achieved include: the development of a new care-coordinator role, which would support a greater focus on integration between acute and community sectors for low back pain patients; identifying the need to screen at-risk patients; implementation of the SCTT (Service Coordination Tool Templates) tool as a system of referral across the acute and community settings; and agreement on the need to develop an evidence-based self-management program to be offered to low back pain patients. The benefits and challenges of implementing this care pathway are discussed.

An evaluation of the beyondblue depression training program for aged care workers

Background: The prevalence of depression among older people receiving care is high, yet the rate of treatment of this disorder is low. One way to improve the pathway to care is to train care staff to recognize the symptoms of depression and raise their confidence in responding to them. In this study we evaluated the efficacy of the beyondblue Depression Training Program to achieve this aim.
Methods: Staff (N=148) from low level care facilities and community care facilities in metropolitan Melbourne completed the beyondblue Depression Training Program, while staff in other facilities (N = 96) acted as controls. Pre-program, post-program and follow-up questionnaire data were collected and referrals for depression by staff were recorded.
Results: Training improved carers’ knowledge about depression, their self-efficacy in responding to signs of depression and their attitudes towards working with depressed aged care recipients. In addition, training increased the number of referrals for depression made by carers.
Conclusion: Training aged care staff in depression can improve the pathways to care for depressed care recipients, and has the potential to improve the quality of life of older people.

Quality nephrology nursing care : beyond Kt/V

Ask nephrology nurses about the care in their hemodialysis units and they will probably say that high quality care is provided. This perception may reflect a genuine pride in their own and their colleagues' hemodialysis services, however, the meaning of high quality dialysis care remains unclear. Quality is often framed in terms of the high percentage of patients receiving a Kt/V of greater than 1.2 or 1.4. The unfortunate inference here is that high quality hemodialysis care is defined as the waste clearing service of the urea molecule. Defining quality in this narrow way conflicts with the caring and compassionate nursing ethic. Furthermore, it places a high value on a single mathematically derived formula that ignores many other indicators of quality dialysis care. In this article, the authors examine some historical, political, and technical features of Kt/V and use the metaphor of a hangover to illustrate the overuse of Kt/V, arguing that nurses have embraced Kt/V at the expense of other core elements of dialysis nursing care.

Environmental mastery and depression in older adults in residential care

This study investigated the association between environmental mastery and depression in a sample of 96 older adults (aged 64–98 years) in residential care. The participants completed a scale that assessed depression along with measures for risk factors for depression such as functional capacity, self-evaluated physical health, bereavement experiences and environmental mastery. The results showed that 49 per cent of the variance in participants’ scores in depression could be attributed to their self-reported level of environmental mastery. Given the complexity of depression and the likelihood of reduced environmental mastery among older adults in residential care, the construct was further assessed as a mediating variable between the risk factors and depression. With environmental mastery taken as such, the explained variance in depression increased to 56 per cent. It was concluded that environmental mastery may be one of the more important factors affecting the mental health of older adults living in residential care and that strategies for increasing the residents’ environmental mastery are important to their psychological wellbeing. The discussion notes that among the questions needing further investigation are whether older adults who experience high environmental mastery make the transition from community living to residential nursing home care more successfully than others, and whether perceived mastery diminishes over time or occurs at the point of transition from community independent living to dependent supported living.

A pilot program of physical activity promotion among clients receiving home and community care

Three Victorian local governments cooperated in a pilot study of physical activity promotion as part of home and community care (HACC) service delivery. Thirty-one people receiving HACC volunteered to participate, including completing the Transtheoretical Stages of Change Exercise Questionnaire and the short-form Stanford Health Assessment Questionnaire (HAQ) just before and at 3 months and 6 months after starting regular self-selected physical activity. Twenty-one participants returned questionnaires at 3 months, and 17 participants returned questionnaires at 6 months. Data were analysed using paired t tests and effect sizes were calculated as mean differences. At 3 months, mean improvements were identified on 6 of the 8 HAQDI (disability index) subscales, and in the overall HAQ-DI score. Improvement in dressing and grooming was preserved at 6 months. At either 3 or 6 months, improvements in dressing and grooming, reach, hygiene, and daily activities, and overall HAQ-DI score exceeded the minimum clinically important difference. No improvements were statistically significant, as is likely in a pilot study with a small sample, however, these results suggest that even very small increases in physical activity may afford clinically meaningful improvements in some areas of physical function required for independent living.

Continuity of midwifery care and gestational weight gain in obese women : a randomised controlled trial

Background: The increased prevalence of obesity in pregnant women in Australia and other developed countries is a significant public health concern. Obese women are at increased risk of serious perinatal complications and guidelines recommend weight gain restriction and additional care. There is limited evidence to support the effectiveness of dietary and physical activity lifestyle interventions in preventing adverse perinatal outcomes and new strategies need to be evaluated. The primary aim of this project is to evaluate the effect of continuity of midwifery care on restricting gestational weight gain in obese women to the recommended range. The secondary aims of the study are to assess the impact of continuity of midwifery care on: women’s experience of pregnancy care; women’s satisfaction with care and a range of psychological factors.
Methods/Design: A two arm randomised controlled trial (RCT) will be conducted with primigravid women recruited from maternity services in Victoria, Australia. Participants will be primigravid women, with a BMI≥30 who are less than 17 weeks gestation. Women allocated to the intervention arm will be cared for in a midwifery continuity of care model and receive an informational leaflet on managing weight gain in pregnancy. Women allocated to the control group will receive routine care in addition to the same informational leaflet. Weight gain during pregnancy, standards of care, medical and obstetric information will be extracted from medical records. Data collected at recruitment (self administered survey) and at 36 weeks by postal survey will include sociodemographic information and the use of validated scales to measure secondary outcomes.
Discussion: Continuity of midwifery care models are well aligned with current Victorian, Australian and many international government policies on maternity care. Increasingly, midwifery continuity models of care are being introduced in low risk maternity care, and information on their application in high risk populations is required. There is an identified need to trial alternative antenatal interventions to reduce perinatal risk factors for women who are obese and the findings from this project may have application in other maternity services. In addition this study will inform a larger trial that will focus on birth and postnatal outcomes.

The professionalisation of stress management : health and wellbeing as a professional duty of care?

Workplace stress associated with ongoing processes of organizational change is a major occupational and public health concern. It is also a costly economic issue—both public and private. In this paper a framework will be used that draws on Michel Foucault’s genealogies of the Self to suggest that the management of stress by professionals—in a workplace environment increasingly characterized by the practices of risk management—emerges as a key element of the choices and responsibilities that frame what it means to be professional. To be (a) professional means to be a person capable of making choices and accepting responsibilities that are framed by a duty of care to manage one’s health and well-being to maximize organizational performance and effectiveness. The article will examine the ways in which transformations in the organization and practice of teachers’ work have witnessed large numbers of teachers being seen, and seeing themselves, as stressed. These understandings of teacher stress have provoked a number of strategies designed to encourage individuals to take care of themselves—and to take care of themselves in ways that will make schools more effective. The authors are concerned with understanding the processes that are at work which make it possible to imagine that it is a professional duty of care to manage one’s life in such a way as to be both balanced and effective in contexts of uncertainty and risk.

Intervention for depression among palliative care patients and their families : a study protocol for evaluation of a training program for professional care staff

Background: Clinical depression is highly prevalent yet under-detected and under-treated in palliative care settings and is associated with a number of adverse medical and psychological outcomes for patients and their family members. This article presents a study protocol to evaluate a training intervention for non-physician palliative care staff to improve the recognition of depression and provide support for depressed patients and their family members. Details of the hypotheses and expected outcomes, study design, training program development and evaluation measures are described.
Methods and Design: A randomised controlled trial will be implemented across two palliative care services to evaluate the “Training program for professional carers to recognise and manage depression in palliative care settings”. Pre-, post- and three-month follow-up data will be collected to assess: the impact of the training on the knowledge, attitudes, self-efficacy and perceived barriers of palliative care staff when working with depression; referral rates for depression; and changes to staff practices. Quantitative and qualitative methods, in the form of self-report questionnaires and interviews with staff and family members, will be used to evaluate the effectiveness of the intervention.
Discussion: This study will determine the effectiveness of an intervention that aims to respond to the urgent need for innovative programs to target depression in the palliative care setting. The expected outcome of this study is the validation of an evidence-based training program to improve staff recognition and appropriate referrals for depression, as well as improve psychosocial support for depressed patients and their family members.

Building equity in chronic disease management in Thailand : a whole-system provincial trial of systematic, pro-active chronic illness care

Thailand has a history of implementing innovative and proactive policies to address the health needs of its population. Since 1962 Thailand has implemented initiatives that led to it having a health system characterized by a primary care focus, decentralization and mechanisms to maximize equity and universal access to basic care at the local level. Thai health structures initially evolved to meet challenges including infectious and developmental diseases and later HIV. Early in the 21st century chronic illness rapidly became the greatest cause of morbidity and mortality and the question has arisen how Thailand can adapt its strong health system to deal with the new epidemics. This article describes an effort to reorient provincial health services to meet the needs of the increasing number of people with diabetes and heart disease. It describes measures taken to build on the equity-promoting elements of the Thai health system. The project included; a situational analysis, development and implementation of a chronic disease self-management intervention implemented by nurses and alignment of provincial health services. The self-management intervention is currently being evaluated within a clustered randomized control trial. The evaluation has been developed to fit with the focus on equity in relation to both selection criteria and the outcomes that are being assessed.