Improving the operational skills of the health personnel working in the emergency departments

Key messages

There is a huge difference regarding the way in which the emergency system is organized within single countries around Europe. Comparing high-level organisations we have benefited in terms of ideas, projects and potential objectives to be set in order to improve our work and to improve results for patients.

Attachment security and existential distress among patients with advanced cancer

BACKGROUND

Felt security in close relationships may affect individual adaptation responses to existential threat in severe illness. We examined the contribution of attachment security to demoralization, a state of existential distress involving perceived pointlessness and meaninglessness in advanced cancer.

METHOD

A mixed cross-sectional sample of 382 patients with advanced cancer (mean age 59, 60% female) was recruited from outpatient oncology clinics. Participants completed self-report measures of attachment security, demoralization, depression, and physical symptom burden. We used multiple linear regression to analyze the association between attachment security and demoralization, controlling for demographic factors and symptom burden and tested whether attachment security moderated the association of symptom burden with demoralization. Separate analyses compared the contribution of the dimensions of attachment anxiety and attachment avoidance.

RESULTS

The prevalence of clinically relevant demoralization was 35%. Demoralization was associated with lower attachment security (β = -0.54, 95%CI: -0.62 to 0.46). This effect was empirically stronger for attachment anxiety (β = 0.52, 95%CI: 0.44 to 0.60) compared to attachment avoidance (β = 0.36, 95%CI: 0.27 to 0.45). Attachment security also significantly moderated the association of physical symptom burden with demoralization, such that with less attachment security, there was a stronger association between symptom burden and demoralization.

CONCLUSION

Attachment security may protect from demoralization in advanced cancer. Its relative lack, particularly on the dimension of attachment anxiety, may limit adaptive capacities to deal with illness burden and to sustain morale and purpose in life. An understanding of individual differences in attachment needs can inform existential interventions for severely ill individuals.

Pregabalin prescriptions in the United Kingdom: a drug utilisation study of The Health Improvement Network (THIN) primary care database

AIM

In Europe, pregabalin is approved for treatment of neuropathic pain, general anxiety disorder (GAD) and as adjunctive therapy for epilepsy. The purpose of this study was to assess utilisation of pregabalin in the UK, including patients with a recorded history of substance abuse, from a large general practice database.

METHODS

This observational drug utilisation study (DUS) analysed pregabalin prescription data from the UK Health Improvement Network primary care database between September 2004 and July 2009. Patient demographics, diagnoses (by READ codes) and pregabalin dosing data were collected. Diagnosis codes were used as proxy for approved indication for pregabalin.

RESULT

A cohort of 18,951 patients was prescribed pregabalin; dosing information was available for 13,480 (71.1%). Median age of patients was 58 years, and majority were female (60.1%). Median (interquartile range) prescribed average daily dose (ADD) of pregabalin for all patients was 150.0 (162.5) mg/day; this was highest in patients with epilepsy (191.9 mg/day), followed by neuropathic pain (158.0 mg/day) and GAD (150.0 mg/day). Only 1.0% (136/13,480) of patients were prescribed an ADD of pregabalin over the maximum approved dose of 600 mg/day. Of these, 18.4% (25/136) of patients had a history of substance abuse compared with 14.0% (1884/13,480) in the full population.

CONCLUSION

Data from this DUS indicated that the majority of pregabalin prescribing in the UK was consistent with product labelling. The proportion of patients with prescribed ADD > 600 mg/day was small and with a similar proportion with a history of substance abuse as in the full population.

Online video in clinical skills education of oral medication administration for undergraduate student nurses: a mixed methods, prospective cohort study

BACKGROUND

Improvements in the safety of the prescribing, dispensing and administration of medicines are identified as a priority across international healthcare systems. It is therefore essential that higher education institutions play their part in helping to meet this patient safety objective. New developments in clinical skills education which are aligned to emerging educational theory are available, but evaluations and supportive evidence are limited.

OBJECTIVES

To evaluate the use of an online best practice exemplar as an adjunct to the clinical skills teaching of oral medication administration to undergraduate student nurses.

DESIGN

Mixed-methods prospective cohort design.

SETTINGS AND PARTICIPANTS

Two intakes of undergraduate nursing students (n=168, n=154) undertaking a first year clinical skills based module at a British university.

METHODS

The Control group received standard teaching using lectures and skills classes facilitated by experienced clinical skills lecturers. The Intervention group received the standard teaching and unlimited access to an online video clip of medication administration. Performance and satisfaction were measured using module assessment results and a satisfaction questionnaire. Qualitative data were gathered using focus groups (n=16, n=20).

RESULTS

The Intervention group was significantly (p=0.021) more likely to pass the assessment and rate their satisfaction with the teaching significantly higher (p<0.05) on more than half of the items from the Student Satisfaction Survey. Two Categories were identified from focus group data; Classroom Learning and Transfer to Practice. Classroom Learning included four themes of Peers, Self, Teaching and Time and when Classroom Learning was positive, the Transfer to Practice of the clinical skill was enhanced.

CONCLUSIONS

An online video of a best practice exemplar as an adjunct to taught clinical skills sessions improves student assessment results and satisfaction ratings. The video was also reported to positively influence all themes identified in Classroom Learning and was perceived to promote the Transfer to Practice of teaching input.

Support needs and preferences of young adolescents with asthma and allergies: "just no one really seems to understand"

The objectives of this study were to identify support needs, support resources, and support barriers for young adolescents with asthma and allergies and to describe preferences for an accessible support intervention. Adolescents (N = 57) completed a survey questionnaire. Eight young adolescents, 10 parents, and 5 older adolescents participated in separate group interviews. Young adolescents' challenges included transition to self-care, balancing restrictions with safety, social isolation, and loneliness. Young teens recommended supportive networks facilitated by older adolescent peers and wanted to meet with other young adolescents living with asthma and allergies online and share information, advice, and encouragement with them.

The effect of delivery method on breastfeeding initiation from the The Ontario Mother and Infant Study (TOMIS) III

OBJECTIVE

To report on the relationship between delivery method (cesarean vs. vaginal) and type (planned vs. unplanned) and breastfeeding initiation in hospital and continuation to 6 weeks postpartum as self-reported by study participants.

DESIGN

Quantitative sequential mixed methods design.

SETTING

Women were recruited from 11 hospital sites in Ontario, Canada.

PARTICIPANTS

Participants included 2,560 women age 16 years or older who delivered live, full-term, singleton infants.

METHODS

Data were collected from an in-hospital questionnaire, hospital records, and a 6-week postpartum interview.

RESULTS

Ninety-two percent of women reported initiating breastfeeding, and 74% continued to 6 weeks. The method of delivery, when defined as cesarean versus vaginal, was not a determining factor in breastfeeding initiation in hospital or in the early postdischarge period. An unexpected delivery method (i.e., unplanned cesarean or instrument-assisted vaginal deliveries) was associated, at a statistically significant level, with an increased likelihood of initiating breastfeeding and continuation to 6 weeks postdischarge.

CONCLUSION

Breastfeeding can be considered a coping strategy that serves to normalize an abnormal experience and allows the individual to once again assume control. These unexpected results warrant further investigation to understand why women make the decision to initiate breastfeeding, why they choose to continue breastfeeding, and how they can be supported to achieve exclusive breastfeeding as recommended for infants in the first 6 months.

An ecological quantification of the relationships between water, sanitation and infant, child, and maternal mortality

BACKGROUND

Water and sanitation access are known to be related to newborn, child, and maternal health. Our study attempts to quantify these relationships globally using country-level data: How much does improving access to water and sanitation influence infant, child, and maternal mortality?

METHODS

Data for 193 countries were abstracted from global databases (World Bank, WHO, and UNICEF). Linear regression was used for the outcomes of under-five mortality rate and infant mortality rate (IMR). These results are presented as events per 1000 live births. Ordinal logistic regression was used to compute odds ratios for the outcome of maternal mortality ratio (MMR).

RESULTS

Under-five mortality rate decreased by 1.17 (95%CI 1.08-1.26) deaths per 1000, p < 0.001, for every quartile increase in population water access after adjustments for confounders. There was a similar relationship between quartile increase of sanitation access and under-five mortality rate, with a decrease of 1.66 (95%CI 1.11-1.32) deaths per 1000, p < 0.001. Improved water access was also related to IMR, with the IMR decreasing by 1.14 (95%CI 1.05-1.23) deaths per 1000, p < 0.001, with increasing quartile of access to improved water source. The significance of this relationship was retained with quartile improvement in sanitation access, where the decrease in IMR was 1.66 (95%CI 1.11-1.32) deaths per 1000, p < 0.001. The estimated odds ratio that increased quartile of water access was significantly associated with increased quartile of MMR was 0.58 (95%CI 0.39-0.86), p = 0.008. The corresponding odds ratio for sanitation was 0.52 (95%CI 0.32-0.85), p = 0.009, both suggesting that better water and sanitation were associated with decreased MMR.

CONCLUSIONS

Our analyses suggest that access to water and sanitation independently contribute to child and maternal mortality outcomes. If the world is to seriously address the Millennium Development Goals of reducing child and maternal mortality, then improved water and sanitation accesses are key strategies.

Training multidisciplinary leaders for health promotion in developing countries: lessons learned

The global picture of maternal mortality and morbidity has changed very little over the past 20 years despite isolated (and often medically based) efforts to improve the situation. A multidisciplinary approach to this very complicated social and cultural problem has been recommended. This article describes the approach taken by the Save the Mothers program in Uganda (Master of Public Health Leadership) and its focus on training national, primarily nonmedical, advocates to bring about the political and cultural change needed to improve maternal health. Emphasis is placed on attracting the right students (through targeted advertising and interviews of candidates), delivering the appropriate package of information to these multidisciplinary students (through problem-based learning and experiential opportunities in the community), and fostering networks among students and graduates to keep the issue of maternal mortality high on their personal and political agendas. Students benefit from a flexible program that allows them to continue to work and study simultaneously while ensuring a high-quality program with faculty who are experts in their area of teaching. Students require practical assistance in their research endeavors and are encouraged to focus their topic on a field related to their place of employment.

Online Support Intervention for Adolescents With Asthma and Allergies

Objectives. To determine appropriate components and contents of an online peer support intervention for young adolescents and to evaluate intervention processes, perceived benefits, and satisfaction with the intervention.

Methods. Three months of support were provided through synchronous chat, e-mail exchange, instant messaging, and bulletin boards. Online support group sessions were facilitated by trained peer mentors (older youth/young adults with asthma and allergies) and health professionals. Participant use of online options was tracked (eg, log-ons, e-mails, chat minutes). Qualitative data were elicited from peer mentor reports, online support group chat transcripts, project coordinators’ field notes, peer mentor exit interviews, and adolescent telephone interviews.

Results. Almost all adolescents were satisfied with this online support intervention. Topics discussed in the support groups were pertinent to their educational and support needs. Peer mentors provided emotional, affirmation, and information support. Participants appreciated opportunities for social comparison and reciprocal exchange of support with peers.

Conclusion and implications. A major contribution was documentation of the complex intervention ingredients and processes through qualitative and quantitative methods that elicited diverse stakeholders’ perspectives. This strategy enables adaptation and integration into practice. Adolescents who benefited most felt isolated, suggesting the importance of targeting vulnerable youth for support programs.

Health Professionals’ Preparation for Supporting Children and Parents Affected by Asthma and Allergies

Although social support originates from sources both informal (eg, family, peers) and formal (eg, health professionals), most reported research focuses on informal support providers. The perspectives and learning needs of health professionals as potential support providers for children and families affected by asthma and allergies form a gap in the reported research. The objective of this study was to assess health professionals’ learning needs and preferences pertinent to the support and education of children with asthma and allergies. A 26-item online survey and qualitative interviews (n, 10) elicited information from health professionals about the perceived support and educational needs of children with asthma and allergies, experience and challenges working with children, health professionals’ educational needs regarding support of children, and continuing education needs and barriers. Health professionals believed that children needed professional education, support, and strategies to reduce the effects of asthma and allergies on their lifestyle. Time (66.0%) and cost (80.9%) were significant barriers to non-Web-based education, but only 14.6% rated time and cost a barrier to Web-based education. Family or work commitments were slightly greater obstacles for non-Web-based education (63.8%) than for Web-based education (51.2%). Although these health professionals were interested in learning from and connecting with their peers, promoting peer support for children with asthma and allergies received a lower rating on their list of educational needs. This needs assessment study confirms that health professionals have limited time, funds, and options for asthma- and allergy-related professional development activities. It validates the need and value of Web-based education with access to an instructor, experts, and group discussions, and it supports the inclusion of asthma-specific information and practical skills for teaching children and for addressing challenges when teaching. Exposure to and understanding of the value of incorporating peer support and social support into existing health programs may be limited.