Creating a therapeutic environment : a non-randomised controlled trial of a quiet time intervention for patients in acute care

Background: Noise is a significant barrier to sleep for acute care hospital patients, and sleep has been shown to be therapeutic for health, healing and recovery. Scheduled quiet time interventions to promote inpatient rest and sleep have been successfully trialled in critical care but not in acute care settings. Objectives: The study aim was to evaluate as cheduled quiet time intervention in an acute care setting. The study measured the effect of a scheduled quiet time on noise levels, inpatients’ rest and sleep behaviour, and wellbeing. The study also examined the impact of the intervention on patients’, visitors’ and health professionals’ satisfaction, and organisational functioning. Design: The study was a multi-centred non-randomised parallel group trial. Settings: The research was conducted in the acute orthopaedic wards of two major urban public hospitals in Brisbane, Australia. Participants: All patientsadmitted to the two wards in the5-month period of the study were invited to participate, withafinalsample of 299 participants recruited. This sample produced an effect size of 0.89 for an increase in the number of patients asleep during the quiet time. Methods: Demographic data were collected to enable comparison between groups. Data for noise level, sleep status, sleepiness and well being were collected using previously validated instruments: a Castle Model 824 digital sound level indicator; a three point sleep status scale; the Epworth Sleepiness Scale; and the SF12 V2 questionnaire. The staff, patient and visitor surveys on the experimental ward were adapted from published instruments. Results: Significant differences were found between the two groups in mean decibel level and numbers of patients awake and asleep. The difference in mean measured noise levels between the two environments corresponded to a ‘perceived’ difference of 2 to 1. There were significant correlations between average decibel level and number of patients awake and asleep in the experimental group, and between average decibel level and number of patients awake in the control group. Overall, patients, visitors and health professionals were satisfied with the quiet time intervention. Conclusions: The findings show that a quiet time intervention on an acute care hospital ward can affect noise level and patient sleep/wake patterns during the intervention period. The overall strongly positive response from surveys suggests that scheduled quiet time would be a positively perceived intervention with therapeutic benefit.

General practitioners’ experiences of the psychological aspects in the care of a dying patient

Objective: General practitioners (GPs) play an integral role in addressing the psychological needs of palliative care patients and their families. This qualitative study investigated psychosocial issues faced by GPs in the management of patients receiving palliative care and investigated the themes relevant to the psychosocial care of dying patients. Method: Fifteen general practitioners whose patient had been recently referred to the Mt. Olivet Palliative Home Care Services in Brisbane participated in an individual case review discussions guided by key questions within a semistructured format. These interviews focused on the psychosocial aspects of care and management of the referred patient, including aspects of the doctor/patient relationship, experience of delivering diagnosis and prognosis, addressing the psychological concerns of the patients' family, and the doctors' personal experiences, reactions, and responses. Qualitative analysis was conducted on the transcripts of these interviews. Results: The significant themes that emerged related to perceived barriers to exploration of emotional concerns, including spiritual issues, and the discussion of prognosis and dying, the perception of patients' responses/coping styles, and the GP's personal experience of the care (usually expressed in terms of identification with patient). Significance of results: The findings indicate the significant challenges facing clinicians in discussions with patients and families about death, to exploring the patient's emotional responses to terminal illness and spiritual concerns for the patient and family. These qualitative date indicate important tasks in the training and clinical support for doctors providing palliative care.

Not like my mother : truth and the author in creative nonfiction

This exegesis examines how a writer can effectively negotiate the relationship between author, character, fact and truth, in a work of Creative Nonfiction. It was found that individual truths, in a work of Creative Nonfiction, are not necessarily universal truths due to individual, cultural, historical and religious circumstances. What was also identified, through the examination of published Creative Nonfiction, is a necessity to ensure there are clear demarcation lines between authorial truth and fiction. The Creative Nonfiction works examined, which established this framework for the reader, ensured an ethical relationship between author and audience. These strategies and frameworks were then applied to my own Creative Nonfiction.

Using videotelephony to support paediatric oncology-related palliative care in the home : from abandoned RCT to acceptability study

Videotelephony (real-time audio-visual communication) has been used successfully in adult palliative home care. This paper describes two attempts to complete an RCT (both of which were abandoned following difficulties with family recruitment), designed to investigate the use of videotelephony with families receiving palliative care from a tertiary paediatric oncology service in Brisbane, Australia. To investigate whether providing videotelephone-based support was acceptable to these families, a 12-month non-randomised acceptability trial was completed. Seventeen palliative care families were offered access to a videotelephone support service in addition to the 24 hours ‘on-call’ service already offered. A 92% participation rate in this study provided some reassurance that the use of videotelephones themselves was not a factor in poor RCT participation rates. The next phase of research is to investigate the integration of videotelephone-based support from the time of diagnosis, through outpatient care and support, and for palliative care rather than for palliative care in isolation

The S.T.A.B. Trial - Standardised Testing of Artificial Blood. A comparative study of various products that may be used as artificial blood for high fidelity simulation training in the critical care setting

Aim: In the current climate of medical education, there is an ever-increasing demand for and emphasis on simulation as both a teaching and training tool. The objective of our study was to compare the realism and practicality of a number of artificial blood products that could be used for high-fidelity simulation. Method: A literature and internet search was performed and 15 artificial blood products were identified from a variety of sources. One product was excluded due to its potential toxicity risks. Five observers, blinded to the products, performed two assessments on each product using an evaluation tool with 14 predefined criteria including color, consistency, clotting, and staining potential to manikin skin and clothing. Each criterion was rated using a five-point Likert scale. The products were left for 24 hours, both refrigerated and at room temperature, and then reassessed. Statistical analysis was performed to identify the most suitable products, and both inter- and intra-rater variability were examined. Results: Three products scored consistently well with all five assessors, with one product in particular scoring well in almost every criterion. This highest-rated product had a mean rating of 3.6 of 5.0 (95% posterior Interval 3.4-3.7). Inter-rater variability was minor with average ratings varying from 3.0 to 3.4 between the highest and lowest scorer. Intrarater variability was negligible with good agreement between first and second rating as per weighted kappa scores (K = 0.67). Conclusion: The most realistic and practical form of artificial blood identified was a commercial product called KD151 Flowing Blood Syrup. It was found to be not only realistic in appearance but practical in terms of storage and stain removal.

Re-invent yourself: from London intensive care nursing and the Nigerian oil fields to an an academic library in Brisbane; a career change worth making.

A complete change of career forces a seismic shift in every aspect of your life. From day one, you have to face the loss of long held beliefs, behaviours, the known world of self, and security. We came from professions that themselves are poles apart, and many of the challenges we faced entering the profession were the same: juggling full-time work, part time study, and family commitmemts, taking a pay cut, and loss of social life. But over a short period of time we both transitioned to our new profession successfully. so what make our successful transition possible?

The Impact of Experiential Learning in Enhancing Palliative Care Knowledge and Skills among Nurses

Nurses working in community settings are increasingly required to care for people with chronic, life limiting conditions. Innovative educational programs are required to ensure nurses are equipped to deal with this challenging area of practice. The Program of Experience in the Palliative Approach (PEPA) started in 2003 as an initiative of the Australian Government, Department of Health and Ageing. The overall aim of PEPA is to improve the quality, availability and access to palliative care for people who are dying, and their families, by improving the skills and expertise of health practitioners, and enhancing collaboration between primary and specialist palliative care services. PEPA provides nurses with an opportunity to develop knowledge and skills in the palliative approach to care through funded clinical workforce placements or workshops.

Management of sharps in ambulance care : a state-wide survey of paramedic knowledge and reported practice

Paramedics are at high risk of exposure to infectious diseases because they frequently undertake procedures such as the use and disposal of sharps as components of everyday practice. While the literature demonstrates that the management of sharps is problematic across all health disciplines, there is a paucity of research examining sharps management practices in the Australian pre-hospital paramedic context. This study examines knowledge and practices of sharps control among paramedics in Queensland, Australia. A mail survey focusing on infection control knowledge and practices was sent to all clinical personnel of the Queensland Ambulance Service (QAS) (N = 2274). A total of 1258 surveys were returned, a response rate of 55.3%. Participants responded to 12 true/false statements on the management of sharps and three questions about recapping practices. Most respondents were knowledgeable about the correct management of sharps, with a mean of 11.28 (out of 12, SD = 1.32). When gauging reported practices, more than half (59.1%, n = 736) of participants reported recapping a needle, and 38.5% (n = 479) reported never having done so. These results reflect good knowledge of general management of sharps among respondents, but suggest deficits regarding reported practices. The results suggest that a comprehensive ambulance in-service education programme focusing particularly on sharps management is required. The study highlights the need for further research on sharps management practices in the field, identification of barriers to safe sharps practices in pre-hospital settings, and 'best practice' for translating good sharps management knowledge into practice.

Determinants of pre-hospital care non-usage for patients with emergency care needs [including commentary by Snooks H.]

Objective-To establish the demographic, health status and insurance determinants of pre-hospital ambulance non-usage for patients with emergency medical needs. Methods-Triage category, date of birth, sex, marital status, country of origin, method and time of arrival, ambulance insurance status, diagnosis, and disposal were collected for all patients who presented over a four month period (n=10 229) to the emergency department of a major provincial hospital. Data for patients with urgent (n=678) or critical care needs (n=332) who did not use pre-hospital care were analysed using Poisson regression. Results-Only a small percentage (6.6%) of the total sample were triaged as having urgent medical needs or critical care needs (3.2%). Predictors of usage for those with urgent care needs included age greater than 65 years (prevalence ratio (PR)=0.54; 95% confidence interval (CI)= 0.35 to 0.83), being admitted to intensive care or transferred to another hospital (PR=0.62; 95% CI=0.44 to 0.89) or ward (PR=0.72; 95% CI=0.56 to 0.93) and ambulance insurance status (PR=0.67; 95% CI=052 to 0.86). Sex, marital status, time of day and country of origin were not predictive of usage and non-usage. Predictors of usage for those with critical care needs included age 65 years or greater (PR=0.45; 95% CI=0.25 to 0.81) and a diagnosis of trauma (PR=0.49; 95% CI=0.26 to 0.92). A non-English speaking background was predictive of non-usage (PR=1.98; 95% CI=1.06 to 3.70). Sex, marital status, time of day, triage and ambulance insurance status were not predictive of non-usage. Conclusions-Socioeconomic and medical factors variously influence ambulance usage depending on the severity or urgency of the medical condition. Ambulance insurance status was less of an influence as severity of condition increased suggesting that, at a critical level of urgency, patients without insurance are willing to pay for a pre-hospital ambulance service.

Towards self-authorship in child care students : implications for working with children and their families

Using self authorship as a theoretical framework, this chapter examines the relationship between personal epistemology and beliefs about children’s learning for students studying to be child care workers in Australia. Scenario-based interviews were used to investigate how students’ views of knowledge, identity and relationships with others were related to beliefs about how children learn. Implications for vocational education are discussed.

The NOURISH randomised control trial : positive feeding practices and food preferences in early childhood - a primary prevention program for childhood obesity

Background Primary prevention of childhood overweight is an international priority. In Australia 20-25% of 2-8 year olds are already overweight. These children are at substantially increased the risk of becoming overweight adults, with attendant increased risk of morbidity and mortality. Early feeding practices determine infant exposure to food (type, amount, frequency) and include responses (eg coercion) to infant feeding behaviour (eg. food refusal). There is correlational evidence linking parenting style and early feeding practices to child eating behaviour and weight status. A focus on early feeding is consistent with the national focus on early childhood as the foundation for life-long health and well being. The NOURISH trial aims to implement and evaluate a community-based intervention to promote early feeding practices that will foster healthy food preferences and intake and preserve the innate capacity to self-regulate food intake in young children. Methods/Design This randomised controlled trial (RCT) aims to recruit 820 first-time mothers and their healthy term infants. A consecutive sample of eligible mothers will be approached postnatally at major maternity hospitals in Brisbane and Adelaide. Initial consent will be for re-contact for full enrolment when the infants are 4-7 months old. Individual mother- infant dyads will be randomised to usual care or the intervention. The intervention will provide anticipatory guidance via two modules of six fortnightly parent education and peer support group sessions, each followed by six months of regular maintenance contact. The modules will commence when the infants are aged 4-7 and 13-16 months to coincide with establishment of solid feeding, and autonomy and independence, respectively. Outcome measures will be assessed at baseline, with follow up at nine and 18 months. These will include infant intake (type and amount of foods), food preferences, feeding behaviour and growth and self-reported maternal feeding practices and parenting practices and efficacy. Covariates will include sociodemographics, infant feeding mode and temperament, maternal weight status and weight concern and child care exposure. Discussion Despite the strong rationale to focus on parents’ early feeding practices as a key determinant of child food preferences, intake and self-regulatory capacity, prospective longitudinal and intervention studies are rare. This trial will be amongst to provide Level II evidence regarding the impact of an intervention (commencing prior to age 12 months) on children’s eating patterns and behaviours. Trial Registration: ACTRN12608000056392

Suicide and community psychiatric care

A preliminary survey of 34 suicides among patients attending community services for the chronically mentally ill revealed a rate of 520 per 100,000 admitted. In contrast to earlier hospital surveys, no risk variables were identified for patients dying by suicide. Thirty-four percent of suicides occurred within one week of the last treatment and 59% within 3 months of service entry. It appears that early and intensive follow-up may be necessary to prevent suicide among patients receiving community psychiatric care.

The relationship between clinical outcomes and quality of life for residents of aged care facilities

Objectives It is widely assumed improving care in residential facilities will improve quality of life (QoL), but little research has explored this relationship. The Clinical Care Indicators (CCI) Tool was developed to fill an existing gap in quality assessment within Australian residential aged care facilities and it was used to explore potential links between clinical outcomes and QoL. Design and Setting Clinical outcome and QoL data were collected within four residential facilities from the same aged care provider. Subjects Subjects were 82 residents of four facilities. Outcome Measures Clinical outcomes were measured using the CCI Tool and QoL data was obtained using the Australian WHOQOL‑100. Results Independent t‑test analyses were calculated to compare individual CCIs with each domain of the WHOQOL‑100, while Pearson’s product moment coefficients (r) were calculated between the total number of problem indicators and QoL scores. Significant results suggested poorer clinical outcomes adversely affected QoL. Social and spiritual QoL were particularly affected by clinical outcomes and poorer status in hydration, falls and depression were most strongly associated with lower QoL scores. Poorer clinical status as a whole was also significantly correlated with poorer QoL. Conclusions Hydration, falls and depression were most often associated with poorer resident QoL and as such appear to be key areas for clinical management in residential aged care. However, poor clinical outcomes overall also adversely affected QoL, which suggests maintaining optimum clinical status through high quality nursing care, would not only be important for resident health but also for enhancing general life quality.

Using a longitudinal model to estimate the effect of methicillin-resistant staphylococcus aureus infection on length of stay in an intensive care unit

Healthcare-associated methicillin-resistant Staphylococcus aureus(MRSA) infection may cause increased hospital stay or, sometimes, death. Quantifying this effect is complicated because it is a time-dependent exposure: infection may prolong hospital stay, while longer stays increase the risk of infection. We overcome these problems by using a multinomial longitudinal model for estimating the daily probability of death and discharge. We then extend the basic model to estimate how the effect of MRSA infection varies over time, and to quantify the number of excess ICU days due to infection. We find that infection decreases the relative risk of discharge (relative risk ratio = 0.68, 95% credible interval: 0.54, 0.82), but is only indirectly associated with increased mortality. An infection on the first day of admission resulted in a mean extra stay of 0.3 days (95% CI: 0.1, 0.5) for a patient with an APACHE II score of 10, and 1.2 days (95% CI: 0.5, 2.0) for a patient with an APACHE II score of 30. The decrease in the relative risk of discharge remained fairly constant with day of MRSA infection, but was slightly stronger closer to the start of infection. These results confirm the importance of MRSA infection in increasing ICU stay, but suggest that previous work may have systematically overestimated the effect size.