Compliance, normality and the patient on peritoneal dialysis

Monitoring and enhancing patient compliance with peritoneal dialysis (PD) is a recurring and problematic theme in the renal literature. A growing body of literature also argues that a failure to understand the patient's perspective of compliance may be contributing to these problems. The aim of this study was to understand the concept of compliance with PD from the patient's perspective. Using the case study approach recommended by Stake (1995), five patients on PD consented to in-depth interviews that explored the meaning of compliance in the context of PD treatment and lifestyle regimens recommended by health professionals. Participants also discussed factors that influenced their choices to follow, disregard, or refine these regimens. Results indicate that health professionals acting in alignment with individual patient needs and wishes, and demonstrating an awareness of the constraints under which patients operate and the strengths they bring to their treatment, may be the most significant issues to consider with respect to definitions of PD compliance and the development of related compliance interventions. Aspects of compliance that promoted relative normality were also important to the participants in this study and tended to result in greater concordance with health professionals' advice.

Treating an unhealthy organisational culture : the implications of the Bundaberg Hospital inquiry for managerial ethical decision making

This paper explores the interplay between individual values, espoused organisational values and the values of the organisational culture in practice in light of a recent Royal Commission in Queensland, Australia, which highlighted systematic failures in patient care. The lack of congruence among values at these levels impacts upon the ethical decision making of health managers. The presence of institutional ethics regimes such as the Public Sector Ethics Act 1994 (Qld) and agency codes of conduct are not sufficient to counteract the negative influence of informal codes of practice that undermine espoused organisational values and community standards. The ethical decision-making capacity of health care managers remains at the front line in the battle against unethical and unprofessional practice. What is known about the topic? Value congruence theory focusses on the conflicts between individual and organisational values. Congruence between individual values, espoused values and values expressed in everyday practice can only be achieved by ensuring that such shared values are an ever-present factor in managerial decision making. What does this paper add? The importance of value congruence in building and sustaining a healthy organisational culture is confirmed by the evidence presented in the Bundaberg Hospital Inquiry. The presence of strong individual values among staff and strong espoused values in line with community expectations and backed up by legislation and ethics regimes were not, in themselves, sufficient to ensure a healthy organisational culture and prevent unethical, and possibly illegal, behaviour. What are the implications for practitioners? Managers must incorporate ethics in decision making to establish and maintain the nexus between individual and organisational values that is a vital component of a healthy organisational culture.

The provision of patient personal hygiene in the intensive care unit : a descriptive exploratory study of bed-bathing practice

Background/objectives The provision of the patient bed-bath is a fundamental nursing care activity yet few quantitative data and no qualitative data are available on registered nurses’ (RNs) clinical practice in this domain in the intensive care unit (ICU). The aim of this study was to describe ICU RNs current practice with respect to the timing, frequency and duration of the patient bed-bath and the cleansing and emollient agents used. Methods The study utilised a two-phase sequential explanatory mixed method design. Phase one used a questionnaire to survey RNs and phase two employed semi-structured focus group (FG) interviews with RNs. Data was collected over 28 days across four Australian metropolitan ICUs. Ethical approval was granted from the relevant hospital and university human research ethics committees. RNs were asked to complete a questionnaire following each episode of care (i.e. bed-bath) and then to attend one of three FG interviews: RNs with less than 2 years ICU experience; RNs with 2–5 years ICU experience; and RNs with greater than 5 years ICU experience. Results During the 28-day study period the four ICUs had 77.25 beds open. In phase one a total of 539 questionnaires were returned, representing 30.5% of episodes of patient bed-baths (based on 1767 bed occupancy and one bed-bath per patient per day). In 349 bed-bath episodes 54.7% patients were mechanically ventilated. The bed-bath was given between 02.00 and 06.00 h in 161 episodes (30%), took 15–30 min to complete (n = 195, 36.2%) and was completed within the last 8 h in 304 episodes (56.8%). Cleansing agents used were predominantly pH balanced soap or liquid soap and water (n = 379, 71%) in comparison to chlorhexidine impregnated sponges/cloths (n = 86, 16.1%) or other agents such as pre-packaged washcloths (n = 65, 12.2%). In 347 episodes (64.4%) emollients were not applied after the bed-bath. In phase two 12 FGs were conducted (three FGs at each ICU) with a total of 42 RN participants. Thematic analysis of FG transcripts across the three levels of RN ICU experience highlighted a transition of patient hygiene practice philosophy from shades of grey – falling in line for inexperienced clinicians to experienced clinicians concrete beliefs about patient bed-bath needs. Conclusions This study identified variation in process and products used in patient hygiene practices in four ICUs. Further study to improve patient outcomes is required to determine the appropriate timing of patient hygiene activities and cleansing agents used to improve skin integrity.

Expectations, obligations or promises? A conceptual review and revision of the beliefs comprising the psychological contract

The psychological contract is a frequently deployed construct to examine the dynamics of the employee-employer exchange relationship. While there is consensus that the contract comprises employee and employer beliefs regarding this relationship, the various belief types are not conceptually well-defined and understood. Over time, the contract has been conceptualised as comprising expectations, obligations, promises or some combination therein. While most contemporary researchers focus solely upon promises, the justifications for this position are unpersuasive. This paper theoretically describes the various belief types, identifies their interrelationships and proposes a reconceptualisation of the beliefs constituting the contract. Specifically, it is demonstrated that the extant promise-based belief framework provides too restrictive a theoretical base for a comprehensive understanding of individuals’ psychological contracts.

The Early Prevention of Obesity in CHildren (EPOCH) collaboration : an individual patient data prospective meta-analysis

Background: Efforts to prevent the development of overweight and obesity have increasingly focused early in the life course as we recognise that both metabolic and behavioural patterns are often established within the first few years of life. Randomised controlled trials (RCTs) of interventions are even more powerful when, with forethought, they are synthesised into an individual patient data (IPD) prospective meta-analysis (PMA). An IPD PMA is a unique research design where several trials are identified for inclusion in an analysis before any of the individual trial results become known and the data are provided for each randomised patient. This methodology minimises the publication and selection bias often associated with a retrospective meta-analysis by allowing hypotheses, analysis methods and selection criteria to be specified a priori. Methods/Design: The Early Prevention of Obesity in CHildren (EPOCH) Collaboration was formed in 2009. The main objective of the EPOCH Collaboration is to determine if early intervention for childhood obesity impacts on body mass index (BMI) z scores at age 18-24 months. Additional research questions will focus on whether early intervention has an impact on children’s dietary quality, TV viewing time, duration of breastfeeding and parenting styles. This protocol includes the hypotheses, inclusion criteria and outcome measures to be used in the IPD PMA. The sample size of the combined dataset at final outcome assessment (approximately 1800 infants) will allow greater precision when exploring differences in the effect of early intervention with respect to pre-specified participant- and intervention-level characteristics. Discussion: Finalisation of the data collection procedures and analysis plans will be complete by the end of 2010. Data collection and analysis will occur during 2011-2012 and results should be available by 2013. Trial registration number: ACTRN12610000789066

Patient education to prevent falls among older hospital inpatients : a randomized controlled trial

Background Falls are a common adverse event during hospitalization of older adults, and few interventions have been shown to prevent then. Methods This study was a 3-group randomized trial to evaluate the efficacy of 2 forms of multimedia patient education compared with usual care for the prevention of in-hospital falls. Older hospital patients (n = 1206) admitted to a mixture of acute (orthopedic, respiratory, and medical) and subacute (geriatric and neurorehabilitation) hospital wards at 2 Australian hospitals were recruited between January 2008 and April 2009. The interventions were a multimedia patient education program based on the health-belief model combined with trained health professional follow-up (complete program), multi-media patient education materials alone (materials only), and usual care (control). Falls data were collected by blinded research assistants by reviewing hospital incident reports, hand searching medical records, and conducting weekly patient interviews. Results Rates of falls per 1000 patient-days did not differ significantly between groups (control, 9.27; materials only, 8.61; and complete program, 7.63). However, there was a significant interaction between the intervention and presence of cognitive impairment. Falls were less frequent among cognitively intact patients in the complete program group (4.01 per 1000 patient-days) than among cognitively intact patients in the materials-only group (8.18 per 1000 patient-days) (adjusted hazard ratio, 0.51; 95% confidence interval, 0.28-0.93]) and control group (8.72 per 1000 patient-days) (adjusted hazard ratio, 0.43; 95% confidence interval, 0.24-0.78). Conclusion Multimedia patient education with trained health professional follow-up reduced falls among patients with intact cognitive function admitted to a range of hospital wards.

Evidence of disagreement between patient-perceived change and conventional longitudinal evaluation of change in health-related quality of life among older adults

Objective: To identify agreement levels between conventional longitudinal evaluation of change (post–pre) and patient-perceived change (post–then test) in health-related quality of life. Design: A prospective cohort investigation with two assessment points (baseline and six-month follow-up) was implemented. Setting: Community rehabilitation setting. Subjects: Frail older adults accessing community-based rehabilitation services. Intervention: Nil as part of this investigation. Main measures: Conventional longitudinal change in health-related quality of life was considered the difference between standard EQ-5D assessments completed at baseline and follow-up. To evaluate patient-perceived change a ‘then test’ was also completed at the follow-up assessment. This required participants to report (from their current perspective) how they believe their health-related quality of life was at baseline (using the EQ-5D). Patient-perceived change was considered the difference between ‘then test’ and standard follow-up EQ-5D assessments. Results: The mean (SD) age of participants was 78.8 (7.3). Of the 70 participants 62 (89%) of data sets were complete and included in analysis. Agreement between conventional (post–pre) and patient-perceived (post–then test) change was low to moderate (EQ-5D utility intraclass correlation coefficient (ICC)¼0.41, EQ-5D visual analogue scale (VAS) ICC¼0.21). Neither approach inferred greater change than the other (utility P¼0.925, VAS P¼0.506). Mean (95% confidence interval (CI)) conventional change in EQ-5D utility and VAS were 0.140 (0.045,0.236) and 8.8 (3.3,14.3) respectively, while patient-perceived change was 0.147 (0.055,0.238) and 6.4 (1.7,11.1) respectively. Conclusions: Substantial disagreement exists between conventional longitudinal evaluation of change in health-related quality of life and patient-perceived change in health-related quality of life (as measured using a then test) within individuals.

Patient preference for falls prevention in hospitals revealed through willingness-to-pay, contingent valuation survey

Rationale, aims and objectives: Patient preference for interventions aimed at preventing in-hospital falls has not previously been investigated. This study aims to contrast the amount patients are willing to pay to prevent falls through six intervention approaches. ----- ----- Methods: This was a cross-sectional willingness-to-pay (WTP), contingent valuation survey conducted among hospital inpatients (n = 125) during their first week on a geriatric rehabilitation unit in Queensland, Australia. Contingent valuation scenarios were constructed for six falls prevention interventions: a falls consultation, an exercise programme, a face-to-face education programme, a booklet and video education programme, hip protectors and a targeted, multifactorial intervention programme. The benefit to participants in terms of reduction in risk of falls was held constant (30% risk reduction) within each scenario. ----- ----- Results: Participants valued the targeted, multifactorial intervention programme the highest [mean WTP (95% CI): $(AUD)268 ($240, $296)], followed by the falls consultation [$215 ($196, $234)], exercise [$174 ($156, $191)], face-to-face education [$164 ($146, $182)], hip protector [$74 ($62, $87)] and booklet and video education interventions [$68 ($57, $80)]. A ‘cost of provision’ bias was identified, which adversely affected the valuation of the booklet and video education intervention. ----- ----- Conclusion: There may be considerable indirect and intangible costs associated with interventions to prevent falls in hospitals that can substantially affect patient preferences. These costs could substantially influence the ability of these interventions to generate a net benefit in a cost–benefit analysis.

International students in Australian universities : gap between student expectations and realities

Australian Universities are very successful in attracting large number of international students. A large proportion of University revenue comes from the full fee paying international students. However, there have been many reports that international students face numerous problems when they arrive in Australia. The common management practice is to provide support staff services to deal with the orientation and welfare of international students. Such service units act as intermediaries between the students and the teaching and learning community of the university. However, the actual experience of international students may be difficult for support staff, counsellors, advisers and academic staff to anticipate. There is little information on the actual experience of students relative to their expectations. This study aimed at securing a deeper understanding of the contextually relevant issues facing by international students in Australian universities in order to develop management strategies aimed at improved teaching and learning outcomes for international students. Using a highly reliable survey questionnaire, a questionnaire survey was conducted among the international students at Queensland University of Technology (QUT), Brisbane, Australia. About 180 engineering students responded in the survey resulting in a response rate of 81%. Results indicate that international students face many difficulties including understanding colloquial language, Australian accent, cost of tuition, feelin isolation, safety, security, health services, accommodation and part time jobs. They also face difficulty in coping with learning methods in Australia, particularly in research report writing. However, they are happy with their lecturers and find them very helpful. Many of the students lacked the information regarding various community groups, recreational and sports facilities in Australia before arriving. Findings of the study show that there is a significant gap between the expectation of the students before coming to Australia and actual experience they experience here. Importantly, there is a lack of coordination between international students, international student services (ISS) and university management and as a consequence there have been little improvement in conditions. There is no direct link between student experience and University management. Many important suggestions arisen from this study and most important suggestion is that the student information system should be integrated with the University enterprise resource planning (ERP) to reduce the huge gap between international student expectation and actual experiences.

Patient-specific computational biomechanics for simulating adolescent scoliosis surgery : predicted vs clinical correction for a preliminary series of six patients

Scoliosis is a spinal deformity that requires surgical correction in progressive cases. In order to optimize surgical outcomes, patient-specific finite element models are being developed by our group. In this paper, a single rod anterior correction procedure is simulated for a group of six scoliosis patients. For each patient, personalised model geometry was derived from low-dose CT scans, and clinically measured intra-operative corrective forces were applied. However, tissue material properties were not patient-specific, being derived from existing literature. Clinically, the patient group had a mean initial Cobb angle of 47.3 degrees, which was corrected to 17.5 degrees after surgery. The mean simulated post-operative Cobb angle for the group was 18.1 degrees. Although this represents good agreement between clinical and simulated corrections, the discrepancy between clinical and simulated Cobb angle for individual patients varied between -10.3 and +8.6 degrees, with only three of the six patients matching the clinical result to within accepted Cobb measurement error of +-5 degrees. The results of this study suggest that spinal tissue material properties play an important role in governing the correction obtained during surgery, and that patient-specific modelling approaches must address the question of how to prescribe patient-specific soft tissue properties for spine surgery simulation.