Chaotic soul - messy heart : the phenomenon of experiencing auditory hallucinations

Globally, it is estimated that 24 million people live with schizophrenia (WHO, 2008), while 1.2 million people have been diagnosed with schizophrenia in Indonesia. Auditory hallucinations are a key symptom of schizophrenia according to the DSM IV-TR (Frances, First, & Pincus, 2002). It is estimated that the prevalence of auditory hallucinations in people with schizophrenia range from 64.3% to 83.4% (Thomas et al., 2007). Until recently, the majority of studies were conducted in Western societies the primary focus of which, has been on the causes and treatments of auditory hallucinations (Walton, 1999) and on the biological and cognitive aspects of the phenomenon (Changas, Garcia-Montes, de Lemus & Olivencia, 2003). While a few studies have explored the lived experience of people with schizophrenia, there is little research about the experience of auditory hallucinations. Therefore, the focus of this study was on an exploration of the experience of auditory hallucinations as described by Indonesian people living with schizophrenia. Based on the available literature, there have been no published qualitative studies relating to the lived experience of auditory hallucinations as described by Indonesian people diagnosed with schizophrenia. Husserlian descriptive phenomenological approach was applied in explicating the phenomenon of auditory hallucinations in this study. In-depth audio-taped interviews were conducted with 13 participants. Analysis of participant transcripts was undertaken using Colaizzi.s (1973) approach. Eight major themes were explicated: Feeling more like a robot than a human being - feeling compelled to respond to auditory hallucinations; voices of contradiction - a point of confusion; a frightening experience, the voices emerged at times of loss and grief; disruption to daily living; tattered relationships and family disarray; finding a personal path to living with auditory hallucinations; seeking relief in Allah through prayer and ritual. Experiencing auditory hallucinations for people diagnosed with schizophrenia is a journey of challenges as each individual struggles to understand their now changed life-world, reconstruct a sense of meaning within their illness experience, and to carve out a pathway to wellness. The challenge for practitioners is to learn from those who have experienced auditory hallucinations, to be with them in their journey of recovery and wellness, and to apply a person-centered approach to care within the context of a multidisciplinary team.

Risk factors for impaired respiratory function during nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory : a matched case-control study

Background: Side effects of the medications used for procedural sedation and analgesia in the cardiac catheterisation laboratory are known to cause impaired respiratory function. Impaired respiratory function poses considerable risk to patient safety as it can lead to inadequate oxygenation. Having knowledge about the conditions that predict impaired respiratory function prior to the procedure would enable nurses to identify at-risk patients and selectively implement intensive respiratory monitoring. This would reduce the possibility of inadequate oxygenation occurring. Aim: To identify pre-procedure risk factors for impaired respiratory function during nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory. Design: Retrospective matched case–control. Methods: 21 cases of impaired respiratory function were identified and matched to 113 controls from a consecutive cohort of patients over 18 years of age. Conditional logistic regression was used to identify risk factors for impaired respiratory function. Results: With each additional indicator of acute illness, case patients were nearly two times more likely than their controls to experience impaired respiratory function (OR 1.78; 95% CI 1.19–2.67; p = 0.005). Indicators of acute illness included emergency admission, being transferred from a critical care unit for the procedure or requiring respiratory or haemodynamic support in the lead up to the procedure. Conclusion: Several factors that predict the likelihood of impaired respiratory function were identified. The results from this study could be used to inform prospective studies investigating the effectiveness of interventions for impaired respiratory function during nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory.

Nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory : a mixed methods study

The cardiac catheterisation laboratory (CCL) is a specialised medical radiology facility where both chronic-stable and life-threatening cardiovascular illness is evaluated and treated. Although there are many potential sources of discomfort and distress associated with procedures performed in the CCL, a general anaesthetic is not usually required. For this reason, an anaesthetist is not routinely assigned to the CCL. Instead, to manage pain, discomfort and anxiety during the procedure, nurses administer a combination of sedative and analgesic medications according to direction from the cardiologist performing the procedure. This practice is referred to as nurse-administered procedural sedation and analgesia (PSA). While anecdotal evidence suggested that nurse-administered PSA was commonly used in the CCL, it was clear from the limited information available that current nurse-led PSA administration and monitoring practices varied and that there was contention around some aspects of practice including the type of medications that were suitable to be used and the depth of sedation that could be safely induced without an anaesthetist present. The overall aim of the program of research presented in this thesis was to establish an evidence base for nurse-led sedation practices in the CCL context. A sequential mixed methods design was used over three phases. The objective of the first phase was to appraise the existing evidence for nurse-administered PSA in the CCL. Two studies were conducted. The first study was an integrative review of empirical research studies and clinical practice guidelines focused on nurse-administered PSA in the CCL as well as in other similar procedural settings. This was the first review to systematically appraise the available evidence supporting the use of nurse-administered PSA in the CCL. A major finding was that, overall, nurse-administered PSA in the CCL was generally deemed to be safe. However, it was concluded from the analysis of the studies and the guidelines that were included in the review, that the management of sedation in the CCL was impacted by a variety of contextual factors including local hospital policy, workforce constraints and cardiologists’ preferences for the type of sedation used. The second study in the first phase was conducted to identify a sedation scale that could be used to monitor level of sedation during nurse-administered PSA in the CCL. It involved a structured literature review and psychometric analysis of scale properties. However, only one scale was found that was developed specifically for the CCL, which had not undergone psychometric testing. Several weaknesses were identified in its item structure. Other sedation scales that were identified were developed for the ICU. Although these scales have demonstrated validity and reliability in the ICU, weaknesses in their item structure precluded their use in the CCL. As findings indicated that no existing sedation scale should be applied to practice in the CCL, recommendations for the development and psychometric testing of a new sedation scale were developed. The objective of the second phase of the program of research was to explore current practice. Three studies were conducted in this phase using both quantitative and qualitative research methods. The first was a qualitative explorative study of nurses’ perceptions of the issues and challenges associated with nurse-administered PSA in the CCL. Major themes emerged from analysis of the qualitative data regarding the lack of access to anaesthetists, the limitations of sedative medications, the barriers to effective patient monitoring and the impact that the increasing complexity of procedures has on patients' sedation requirements. The second study in Phase Two was a cross-sectional survey of nurse-administered PSA practice in Australian and New Zealand CCLs. This was the first study to quantify the frequency that nurse-administered PSA was used in the CCL setting and to characterise associated nursing practices. It was found that nearly all CCLs utilise nurse-administered PSA (94%). Of note, by characterising nurse-administered PSA in Australian and New Zealand CCLs, several strategies to improve practice, such as setting up protocols for patient monitoring and establishing comprehensive PSA education for CCL nurses, were identified. The third study in Phase Two was a matched case-control study of risk factors for impaired respiratory function during nurse-administered PSA in the CCL setting. Patients with acute illness were found to be nearly twice as likely to experience impaired respiratory function during nurse-administered PSA (OR=1.78; 95%CI=1.19-2.67; p=0.005). These significant findings can now be used to inform prospective studies investigating the effectiveness of interventions for impaired respiratory function during nurse-administered PSA in the CCL. The objective of the third and final phase of the program of research was to develop recommendations for practice. To achieve this objective, a synthesis of findings from the previous phases of the program of research informed a modified Delphi study, which was conducted to develop a set of clinical practice guidelines for nurse-administered PSA in the CCL. The clinical practice guidelines that were developed set current best practice standards for pre-procedural patient assessment and risk screening practices as well as the intra and post-procedural patient monitoring practices that nurses who administer PSA in the CCL should undertake in order to deliver safe, evidence-based and consistent care to the many patients who undergo procedures in this setting. In summary, the mixed methods approach that was used clearly enabled the research objectives to be comprehensively addressed in an informed sequential manner, and, as a consequence, this thesis has generated a substantial amount of new knowledge to inform and support nurse-led sedation practice in the CCL context. However, a limitation of the research to note is that the comprehensive appraisal of the evidence conducted, combined with the guideline development process, highlighted that there were numerous deficiencies in the evidence base. As such, rather than being based on high-level evidence, many of the recommendations for practice were produced by consensus. For this reason, further research is required in order to ascertain which specific practices result in the most optimal patient and health service outcomes. Therefore, along with necessary guideline implementation and evaluation projects, post-doctoral research is planned to follow up on the research gaps identified, which are planned to form part of a continuing program of research in this field.

Screening in early childhood for risk of later mental health problems : a longitudinal study

Depression in childhood or adolescence is associated with increased rates of depression in adulthood. Does this justify efforts to detect (and treat) those with symptoms of depression in early childhood or adolescence? The aim of this study was to determine how well symptoms of anxiety/depression (A-D) in early childhood and adolescence predict adult mental health. The study sample is taken from a population-based prospective birth cohort study. Of the 8556 mothers initially approached to participate 8458 agreed, of whom 7223 mothers gave birth to a live singleton baby. Children were screened using modified Child Behaviour Checklist (CBCL) scales for internalizing and total problems (T-P) at age 5 and the CBCL and Youth Self Report (YSR) A-D subscale and T-P scale at age 14. At age 21, a sub-sample of 2563 young adults in this cohort were administered the CIDI-Auto. Results indicated that screening at age 5 would detect few later cases of significant mental ill-health. Using a cut-point of 20% for internalizing at child age 5 years the CBCL had sensitivities of only 25% and 18% for major depression and anxiety disorders at 21 years, respectively. At age 14, the YSR generally performed a little better than the CBCL as a screening instrument, but neither performed at a satisfactory level. Of the children who were categorised as having YSR A-D at 14 years 30% and 37% met DSM-IV criteria for major depression and anxiety disorders, respectively, at age 21. Our findings challenge an existing movement encouraging the detection and treatment of those with symptoms of mental illness in early childhood.

Management of chronic pain

When you have completed this chapter you will be able to: • recognise the scope and impact of chronic pain in Australia • discuss the relevance of a biopsychosocial model of chronic pain for persons with chronic illness and disability • identify key components of pain assessment • acknowledge the central role the person with chronic pain takes in the management of their health • identify a range of therapies available for the management of chronic pain

A study of post diagnosis breast cancer concerns for women living in rural and remote Queensland. Part I : Personal concerns

The findings presented in this paper are part of a research project designed to provide a preliminary indication of the support needs of postdiagnosis women with breast cancer in remote and isolated areas in Queensland. This discussion will present data that focuses on the women’s expressed personal concerns. For participants in this research a diagnosis of breast cancer involves a confrontation with their own mortality and the possibility of a reduced life span. This is a definite life crisis, creating shock and needing considerable adjustment. Along with these generic issues the participants also articulated significant issues in relation to their experience as women in a rural setting. These concerns centred around worries about how their partner and families cope during their absences for treatment, the additional burden on the family of having to cope with running the property or farm during the participant’s absence or illness, added financial strain brought about by the cost of travel for treatment, maintenance of properties during absences, and problems created by time off from properties or self-employment. These findings accord with other reports of health and welfare services for rural Australian and the generic literature on psycho-oncology studies of breast cancer.

Patients with terminal cancer who use alternative therapies: their beliefs and practices

This paper examines the extent to which patients who have been diagnosed as having terminal cancer choose to use non-medical therapies. In particular it is concerned with the illness behaviour of patients who are receiving conventional cytotoxic drug and radiation treatments, who also decide to use a wide range of ‘alternative’ medications and therapies. The paper discusses the findings of a study of 152 patients with metastatic cancer that examined the extent to which they used alternative cancer therapies, as well as the beliefs and attitudes they have about their cancer, its treatment, and the practitioners providing that treatment. Four groups of users of alternative therapies, who differ according to their commitment to and the type of therapies they use, were identified. Results of logistic regression analyses indicate that those using alternative therapies were different in range of social attitudes. These differences were primarily their greater reported ‘will to live’ and desire for control over treatment decisions, and the differing beliefs they hold about their disease.

The Large Allen Cognitive Level Screen as an indicator for medication adherence among adults accessing community mental health services

Background: Medication remains the cornerstone treatment for mental illness. Cognition is one of the strongest predictors of non-adherence. The aim of this preliminary investigation was to examine the association between the Large Allen Cognitive Level Screen (LACLS) and medication adherence among a small sample of mental health service users to determine whether the LACLS has potential as a screening tool for capacity to manage medication regimens. Method: Demographic and clinical information was collected from a small sample of people who had recently accessed community mental health services. Participants then completed the LACLS and the Medication Adherence Rating Scale (MARS) at a single time point. The strength of association between the LACLS and MARS was examined using Spearman rank-order correlation. Results: A strong positive correlation between the LACLS and medication adherence (r = 0.71, p = 0.01) was evident. No participants reported the use of medication aids despite evidence of impaired cognitive functioning. Conclusion: This investigation has provided the first empirical evidence indicating that the LACLS may have utility as a screening instrument for capacity to manage medication adherence among this population. While promising, this finding should be interpreted with caveats given its preliminary nature.

Nursing research : the Australian College of Nursing position statement

Background Nursing perspectives play an important role in addressing the health priorities of today’s society. The Australian College of Nursing (ACN) acknowledges the significant contribution that nursing research has made since the first nurse researcher, Florence Nightingale, documented the factors that affected the morbidity and mortality of soldiers wounded in the Crimean war in the 1800s. The nursing profession continues to celebrate the significant contribution nursing research made to improving nursing practice and health outcomes. These significant contributions over recent years include, but are not limited to: 1. Health services research that has demonstrated the importance of nursing services and how such services are designed/organised to ensure safety and quality of care (Duffield, et al., 2011; Fernandez, et al., 2012; Middleton, et al., 2011); 2. Clinical research that has demonstrated the value of specific nursing interventions to improved health outcomes, including enhanced survival, reduced morbidity, and improved quality of life and consumer engagement (Cancer Australia and Cancer Voices Australia, 2011; Kitson, et al., 2013; Middleton, et al., 2012; Rickard, et al., 2012; Zeitz, et al., 2011); 3. Basic science research that has advanced discoveries in terms of understanding the biological mechanisms underpinning nursing interventions (Illi, et al., 2012; Kim, et al., 2012; Miaskowski, et al., 2010; Simonova, et al., 2012); 4. Epidemiological research that has advanced understanding about how individuals and populations respond to health problems (Carrington, et al., 2012); 5. Qualitative research that has advanced understanding about experiences of and responses to health and illness and the processes of care that are important to optimal outcomes (Schulman-Green, et al., 2012; Scott, et al., 2011).

Double standards in special medical research : questioning the discrepancy between requirements for medical research involving incompetent adults and medical research involving children

Medical research represents a substantial departure from conventional medical care. Medical care is patient-orientated, with decisions based on the best interests and/or wishes of the person receiving the care. In contrast, medical research is future-directed. Primarily it aims to contribute new knowledge about illness or disease, or new knowledge about interventions, such as drugs, that impact upon some human condition. Current State and Territory laws and research ethics guidelines in Australia relating to the review of medical research appropriately acknowledge that the functions of medical care and medical research differ. Prior to a medical research project commencing, the study must be reviewed and approved by a Human Research Ethics Committee (HREC). For medical research involving incompetent adults, some jurisdictions require an additional, independent safeguard by way of tribunal or court approval of medical research protocols. This extra review process reflects the uncertainty of medical research involvement, and the difficulties surrogate decision-makers of incompetent adults face in making decisions about others, and deliberating about the risks and benefits of research involvement. Parents of children also face the same difficulties when making decisions about their child’s research involvement. However, unlike the position concerning incompetent adults, there are no similar safeguards under Australian law in relation to the approval of medical research involving children. This column questions why this discrepancy exists with a view to generating further dialogue on the topic.

Culture in and culture of health promotion: tensions at the interface of Australian Indigenous health promotion

With persisting health inequalities across and between diverse populations, health promotion must consider its engagement with the culture concept in achieving better health for all. By way of a conversation between an Indigenous and non-Indigenous health promotion practitioner, this unique presentation will critically examine the cultural practice of health promotion for Indigenous Australians. Culture becomes the central tenant of this conversation – but not culture in the sense of something to “fix” to improve Indigenous health, or import to make mainstream practices “culturally appropriate”. Rather, the somewhat invisible culture of Australian health promotion practice itself is highlighted. The enthusiasm of mainstream health promotion practice for risk and reductionism supplants biological determinism with a cultural determinism that constructs culture as illness-producing. This is in contrast to Indigenous perspectives of culture in which it is described as integral to individual and community health and well-being. Whilst empowerment features strongly within global health promotion discourses, the preoccupation of health promotion with the inherent deficit/behavioural change approach is an all too convenient distraction from the broader structural factors impacting on the health of Indigenous Australians. That Indigenous Australians have not benefitted from successful public health policy interventions in the same way as the general population is in itself revealing of the culture of health promotion practice in Australia and it is somewhat ironic that the health promotion fraternity seems not to have questioned its own practice. This conversation aims to encourage health promotion practitioners, researchers and policy makers to interrogate the cultural assumptions of their own practice and of the public health system they are part of and consider how to embed and empower the voices and experiences of those who are ‘culturally othered’ within health promotion practice.

Communicating personal amnesty : a model for health promotion in an Australian disability context

Currently pathological and illness-centric policy surrounds the evaluation of the health status of a person experiencing disability. In this research partnerships were built between disability service providers, community development organizations and disability arts organizations to build a translational evaluative methodology prior to implementation of an arts-based workshop that was embedded in a strengths-based approach to health and well-being. The model consisted of three foci: participation in a pre-designed drama-based workshop program; individualized assessment and evaluation of changing health status; and longitudinal analysis of participants changing health status in their public lives following the culmination of the workshop series. Participants (n = 15) were recruited through disability service providers and disability arts organizations to complete a 13-week workshop series and public performance. The study developed accumulative qualitative analysis tools and member-checking methods specific to the communication systems used by individual participants. Principle findings included increased confidence for verbal and non-verbal communicators; increased personal drive, ambition and goal-setting; increased arts-based skills including professional engagements as artists; demonstrated skills in communicating perceptions of health status to private and public spheres. Tangential positive observations were evident in the changing recreational, vocational and educational activities participants engaged with pre- and post- the workshop series; participants advocating for autonomous accommodation and health provision and changes in the disability service staff's culture. The research is an example of translational health methodologies in disability studies.

Predictors of mental health in post-menopausal women : results from the Australian healthy aging of women study

Objective: To examine the extent to which socio-demographics, modifiable lifestyle, and physical health status influence the mental health of post-menopausal Australian women. Methods: Cross-sectional data on health status, chronic disease and modifiable lifestyle factors were collected from a random cross-section of 340 women aged 60-70 years, residing in Queensland, Australia. Structural equation modelling (SEM) was used to measure the effect of a range of socio-demographic characteristics, modifiable lifestyle factors, and health markers (self-reported physical health, history of chronic illness) on the latent construct of mental health status. Mental health was evaluated using the Medical Outcomes Study Short Form 12 (SF-12®) which examined and Center for Epidemiologic Studies Depression Scale (CES-D). Results: The model was a good fit for the data (χ2=4.582, df=3, p=0.205) suggesting that mental health is negatively correlated with sleep disturbance (β = -0.612, p <0.001), and a history of depression (β = -0.141, p = 0.024).While mental health was associated with poor sleep, it was not correlated with most lifestyle factors (BMI, alcohol consumption, or cigarette smoking) or socio-demographics like age, income or employment category and they were removed from the final model. Conclusion: Research suggests that it is important to engage in a range of health promoting behaviours to preserve good health. We found that predictors of current mental health status included sleep disturbance, and past mental health problems, while socio-demographics and modifiable lifestyle had little impact. It may be however, that these factors influenced other variables associated with the mental health of post-menopausal women, and these relationships warrant further investigation.

Prevalence and correlates of sleep disturbance in post-menopausal Australian women : the Healthy Aging of Women (HOW) study

Background: Sleep disturbance in midlife women has been studied extensively, although less is known about sleep after menopause. This study examined the relative impact of socio-demographics, modifiable lifestyle factors, and health status on sleep disturbance in post-menopausal women from Queensland, Australia. Methods: The longitudinal Healthy Aging of Women (HOW) study examines health-related quality of life (HRQOL measured by SF-12©), chronic illness, modifiable lifestyle factors such as physical activity, alcohol consumption, smoking, and sleep disturbance (General Sleep Disturbance Scale, GSDS ≥ 43 represent poor sleep) in midlife and older women from low and high socio-economic, rural and urban areas of South-East Queensland, Australia. This paper presents cross-sectional data from the 322 women, aged 60-70 years, participating in the HOW study in 2011. Results: For women in this study, sleep disturbance was relatively common, with 23% (n = 83) reporting poor sleeping (GSDS ≥ 43). Sleep disturbance scores were strongly correlated with being unemployed or on a disability support pension (β = 18.69, P < 0.01), sedentary lifestyle (β = 23.84, P < 0.01), and lower mental (β = -0.60, P <0.01) and physical health-related quality of life scores (β = -0.32, P = 0.01), and these variables explained almost one third of variance in sleep disturbance scores (ηρ² = 29%). Conclusions: Multivariable analysis revealed that sleep disturbance was correlated with physical and mental health-related quality of life, disability, and sedentary lifestyle, but not other lifestyle and socio-demographic characteristics. It may be however, that modifiable lifestyle factors may indirectly impact on sleep by influencing health status.