Nurses' resilience and the emotional labour of nursing work: An integrative review of empirical literature

BACKGROUND

The emotional labour of nursing work involves managing the emotional demands of relating with patients, families and colleagues. Building nurses' resilience is an important strategy in mitigating the stress and burnout that may be caused by ongoing exposure to these demands. Understandings of resilience in the context of emotional labour in nursing, however, are limited.

OBJECTIVES

To investigate the state of knowledge on resilience in the context of emotional labour in nursing.

DESIGN

Integrative literature review.

DATA SOURCES

CINAHL, Medline, Scopus, and PsycINFO electronic databases were searched for abstracts published between 2005 and 2015 and written in English. Reference lists were hand searched.

REVIEW METHODS

Whittemore and Knafl's integrative review method was used to guide this review. The constant comparative method was used to analyze and synthesize data from 27 peer-reviewed quantitative and qualitative articles. Methodological quality of included studies was assessed using the Mixed Methods Assessment Tool.

RESULTS

Emotional labour is a facet of all aspects of nursing work and nurse-patient/family/collegial interactions. Emotional dissonance arising from surface acting in emotional labour can lead to stress and burnout. Resilience can be a protective process for the negative effects of emotional labour. Several resilience interventions have been designed to strengthen nurses' individual resources and reduce the negative effects of workplace stress; however they do not specifically address emotional labour. Inclusion of emotional labour-mitigating strategies is recommended for future resilience interventions.

CONCLUSION

Resilience is a significant intervention that can build nurses' resources and address the effects of emotional dissonance in nursing work. There is a need for further investigation of the relationship between resilience and emotional labour in nursing, and robust evaluation of the impact of resilience interventions that address emotional labour.

Association of methamphetamine use and restrictive interventions in an acute adult inpatient mental health unit: A retrospective cohort study

The aim of the present study was to describe incidences of restrictive interventions and the association of methamphetamine use at an acute adult inpatient mental health unit in metropolitan Melbourne, Victoria, Australia. A total of 232 consecutive consumer admissions to the inpatient unit across a 3-month period were described for illicit substance use and the use of restrictive interventions (seclusion, mechanical restraint, and physical restraint) prior to and during admission. Of all admissions, 25 (10.8%) involved consumers subjected to a restrictive intervention. Methamphetamine use was either self-reported or detected by saliva test for 71 (30.6%) consumers. Following multivariate analyses, methamphetamine use (odds ratio (OR): 7.83, 95% confidence interval (CI): 2.33-26.31) and restrictive intervention in the emergency department prior to admission (OR: 8.85, 95% CI: 2.83-27.70) were significant independent predictors of the use of restrictive interventions after inpatient admission. Anecdotal observations provided by clinical mental health staff that consumers intoxicated with methamphetamine appear to require restrictive intervention more frequently than other consumers was confirmed with the results of the current study. As the state of Victoria in Australia is on a pathway to the elimination of the use of restrictive interventions in mental health services, clinicians need to develop management strategies that provide specialist mental health care using the least-restrictive interventions. Although 26.8% of methamphetamine users were secluded after admission, restrictive interventions should not be the default management strategy for consumers who present with self-report or positive screen for methamphetamine use.

Educating Mental Health Clinicians About Sensory Modulation to Enhance Clinical Practice in a Youth Acute Inpatient Mental Health Unit: A Feasibility Study

There is an emergence of literature describing effective sensory modulation (SM) interventions to de-escalate violence and aggression among mental health inpatients. However, the evidence is limited to adult settings, with the effect of SM in youth acute settings unknown. Yet, before SM may be used as a de-escalation intervention in youth acute settings, multidisciplinary staff need to be educated about and supported in the clinical application of SM. In the current study, an online SM education package was developed to assist mental health staff understand SM. This was blended with action learning sets (ALS), small group experiential opportunities consisting staff and consumers to learn about SM resources, and the support of SM trained nurses. The aims of the study were to evaluate the effectiveness of this SM education intervention in (a) transferring knowledge of SM to staff, and (b) translating this knowledge into practice in a youth acute inpatient mental health unit. A mixed methods research design with an 11-item pre- and post-education questionnaire was used along with three-month follow-up focus groups. The SM education improved understanding about SM (all 11-items p ≤ 0.004, r ≥ 0.47). Three-months after SM education, four themes evident in the focus group data emerged about the practice and process of SM; (1) translating of learning into practice, (2) SM in practice, (3) perceptions of SM benefits, and (4) limitations of SM. A blended SM education process enhanced clinical practice in the unit, yet participants were mindful of limitations of SM in situations of distress or escalating agitation.

Educating emergency department nurses about trauma informed care for people presenting with mental health crisis: a pilot study

BACKGROUND

Practicing with trauma informed care (TIC) can strengthen nurses' knowledge about the association of past trauma and the impact of trauma on the patient's current mental illness. An aim of TIC is to avoid potentially re-traumatising a patient during their episode of care. A TIC education package can provide nurses with content that describes the interplay of neurological, biological, psychological, and social effects of trauma that may reduce the likelihood of re-traumatisation. Although mental health nurses can be TIC leads in multidisciplinary environments, the translation of TIC into clinical practice by nurses working in emergency departments (EDs) is unknown. However, before ED nurses can begin to practice TIC, they must first be provided with meaningful and specific education about TIC. Therefore, the aims of this study were to; (1) evaluate the effectiveness of TIC education for ED nursing staff and (2) describe subsequent clinical practice that was trauma informed.

METHODS

This project was conducted as exploratory research with a mixed methods design. Quantitative data were collected with an 18-item pre-education and post-education questionnaire. Qualitative data were collected with two one-off focus groups conducted at least three-months after the TIC education. Two EDs were involved in the study.

RESULTS

A total of 34 ED nurses participated in the TIC education and 14 ED nurses participated in the focus groups. There was meaningful change (p < 0.01, r ≥ 0.35) in 9 of the 18-items after TIC education. Two themes, each with two sub-themes, were evident in the data. The themes were based on the perceived effectiveness of TIC education and the subsequent changes in clinical practice in the period after TIC education.

CONCLUSION

Emergency department nurses became more informed of the interplay of trauma on an individual's mental health. However, providing care with a TIC framework in an ED setting was a considerable challenge primarily due to time constraints relative to the day-to-day ED environment and rapid turnover of patients with potentially multiple and complex presentations. Despite this, nurses understood the effect of TIC to reduce the likelihood of re-traumatisation and expressed a desire to use a TIC framework.

Recovery-Oriented Mental Health Practice in a Community Care Unit: An Exploratory Study

A recovery-oriented model of care has become the major focus of mental health service delivery in the state of Victoria, Australia. However, there is a total absence of knowledge of recovery-oriented mental health practice in community care units (CCUs). Therefore, the aims of this exploratory study were to: (a) describe what aspects of the current model of care fit within the domains of recovery; and (b) describe the pragmatic processes that staff use to mold their care within the domains of recovery. Twenty-one key stakeholders provided informed voluntary consent to participate in one-to-one interviews. Six content domains evolved to include: (a) a common vision: "a continuous journey"; (b) promoting hope; (c) promoting autonomy and self-determination; (d) meaningful engagement; (e) holistic and personalized care; and (f) community participation and citizenship. The CCU appeared to be on a journey of transformation toward personal recovery. However, clinicians were grappling with an identified tension among personal recovery and clinical recovery. The tension among personal recovery and clinical recovery may be attributed to the psychosocial rehabilitation model of care, which was previously systemic in Victorian CCUs.

Police and mental health clinician partnership in response to mental health crisis: A qualitative study

Police officers as first responders to acute mental health crisis in the community, commonly transport people in mental health crisis to a hospital emergency department. However, emergency departments are not the optimal environments to provide assessment and care to those experiencing mental health crises. In 2012, the Northern Police and Clinician Emergency Response (NPACER) team combining police and mental health clinicians was created to reduce behavioural escalation and provide better outcomes for people with mental health needs through diversion to appropriate mental health and community services. The aim of this study was to describe the perceptions of major stakeholders on the ability of the team to reduce behavioural escalation and improve the service utilization of people in mental health crisis. Responses of a purposive sample of 17 people (carer or consumer advisors, mental health or emergency department staff, and police or ambulance officers) who had knowledge of, or had interfaced with, the NPACER were thematically analyzed after one-to-one semistructured interviews. Themes emerged about the challenge created by a stand-alone police response, with the collaborative strengths of the NPACER (communication, information sharing, and knowledge/skill development) seen as the solution. Themes on improvements in service utilization were revealed at the point of community contact, in police stations, transition through the emergency department, and admission to acute inpatient units. The NPACER enabled emergency department diversion, direct access to inpatient mental health services, reduced police officer 'down-time', improved interagency collaboration and knowledge transfer, and improvements in service utilization and transition.

Scoping review of research in Australia on the co-occurrence of physical and serious mental illness and integrated care

The physical health of people with serious mental illness (SMI) has become a focal area of research. The aim of the present study was to ascertain the attention and distribution of research from within Australia on physical illness and SMI co-occurrence, and to identify gaps. A scoping review of peer-reviewed research literature from Australia, published between January 2000 and March 2014, was undertaken through an electronic literature search and coding of papers to chart trends. Four trends are highlighted: (i) an almost threefold increase in publications per year from 2000-2006 to 2007-2013; (ii) a steady release of literature reviews, especially from 2010; (iii) health-related behaviours, smoking, integrated-care programmes, and antipsychotic side-effects as the most common topics presented; and (iv) paucity of randomized, controlled trials on integrated-care models. Despite a marked increase in research attention to poorer physical health, there remains a large gap between research and the scale of the problem previously identified. More papers were descriptive or reviews, rather than evaluations of interventions. To foster more research, 12 research gaps are outlined. Addressing these gaps will facilitate the reduction of inequalities in physical health for people with SMI. Mental health nurses are well placed to lead multidisciplinary, consumer-informed research in this area.

"Cultural brokerage" and beyond: piloting the role of an urban Aboriginal Mental Health Liaison Officer

Background

Suboptimal use of mental health services persists for Aboriginal and Torres Strait Islander peoples¹. Coupled with poorer life expectancy than other Australians, barriers to care have included poorly established partnership and communication among mental health services and Aboriginal peoples, and cultural insensitivity. As such, a goal of the Aboriginal mental health workforce is to engage their people and improve the social and emotional well-being of Aboriginal peoples. In 2013, the Northern Area Mental Health Service piloted a 0.8 full time equivalent position of an Aboriginal Mental Health Liaison Officer in an urban setting. Therefore, aims of this study were to describe the development of the role and stakeholder perceptions on how the role impacts on the typical journey of Aboriginal consumers engaging with mental health services. Meeting the aims may provide an exemplar for other mental health services.

Methods

An illustrative case study using quantitative and qualitative data collection was undertaken. Descriptive statistics were computed to profile consumers and referral pathways. Thematic analysis was used to profile key stakeholder perceptions of the role.

Results

The Aboriginal Mental Health Liaison Officer received 37 referrals over a 9 month period. The major source of referral was from an emergency department (49 %). Seventy-three percent of referrals by the Aboriginal mental health liaison officer at discharge were to community mental health teams. Thematic analysis of data on the development of the role resulted in two themes themes; (1) realisation of the need to improve accessibility and (2) advocating for change. The description of the role resulted in four themes; (1) the initiator: initiating access to the service, (2) the translator: brokering understanding among consumers and clinicians, (3) the networker: discharging to the community, and (4) the facilitator: providing cyclic continuity of care.

Conclusions

The liaison component of the role was only a part of the multiple tasks the urban Aboriginal Mental Health Liaison Officer fulfils. As such, the role was positively described as influencing the lives of Aboriginal consumers and their families and improving engagement with health professionals in the mental health service in question.

Police and clinician diversion of people in mental health crisis from the Emergency Department: a trend analysis and cross comparison study

Background

The Northern Police and Clinician Emergency Response (NPACER), a combined police and clinician second response team, was created to divert people in mental health crisis away from the hospital emergency department (ED) to care in the community or direct admission to acute inpatient services. The aim of this study was to evaluate the NPACER by comparing trends in service utilisation prior to and following its inception.

Methods

A retrospective comparison of electronic records was undertaken with interrupted time series analysis to assess the impact of NPACER on ED presentations over 27-months (N = 1776). Chi-squared tests were used to analyze service utilization; (1) in the six-months before and after the implementation of NPACER and (2) within the post NPACER period between times of the day it was operational.

Results

NPACER reduced the number of mental health crisis presentations to the ED. When the NPACER team was operational, 16 % of people in crisis went to ED compared with 100 % for all other times of the day, over a six-month period. The NPACER team enabled direct access to the inpatient unit for 51 people assessed at a police station and in the community compared with no direct access when NPACER was not operational.

Conclusions

NPACER enabled reductions in presentations to the ED by diverting people to more appropriate and less restrictive environments. The model also facilitated direct admission to acute inpatient mental health services when people in crisis were assessed in the community or transported to a police station for assessment.

Applying the World Health Organization Mental Health Action Plan to evaluate policy on addressing co-occurrence of physical and mental illnesses in Australia

Objectives The aim of the present study was to document Australian policies on the physical health of people with mental illness and evaluate the capacity of policy to support health needs. Methods A search of state and federal policies on mental and physical illness was conducted, as well as detailed analysis of policy content and the relationships between policies, by applying the World Health Organization Mental Health Action Plan 2013–2020 as an evaluative framework. Results National policy attention to the physical health of people with mental illness has grown, but there is little interconnection at the national and state levels. State policies across the country are inconsistent, and there is little evidence of consistent policy implementation. Conclusions A coherent national health policy framework on addressing co-occurring physical and mental illnesses that includes healthcare system reforms and ensuring the interconnectedness of other relevant services should be prioritised. What is known about the topic? People with mental illness have a lower life expectancy and poorer physical health than people who do not have a mental illness. Government policy is critical to reducing inequalities in physical health and increasing longevity. What does this paper add? Evaluating policy developments against the World Health Organization’s Mental Health Action Plan 2013–2020, this review identified a lack of cohesive national-level policy on how to improve the physical health of people with mental illness. Although there are some state-based policies regarding strategies for better prevention and management of the physical health of people with mental illness, evidence of policy implementation is either scarce or inconsistent. The capacity of current policy to translate into reforms that increase the physical and overall health of people suffering mental health difficulties seems very limited. What are the implications for practitioners? This paper outlines major policy gaps and an overall need for a national-level policy. National-level leadership on integrated health care is required, with monitoring to ensure health care reforms are genuinely informed by consumer and clinician views and are effective.

When reduction strategies are put in place and mental health consumers are still secluded: an analysis of clinical and sociodemographic characteristics

Internationally, seclusion practices continue to be the subject of intense clinical health service and academic scrutiny. Despite extensive efforts to reduce and eliminate this controversial practice, seclusion remains a clinical intervention widely used in contemporary mental health service settings. Early identification of people who are at risk for seclusion and the timely application of alternative evidence-based interventions are critical for reducing incidents of seclusion in real-world practice settings. This retrospective study aimed to determine the relationship between sociodemographic and clinical characteristics, and the use of seclusion for those mental health consumers for whom evidence-based seclusion-reduction initiatives had little impact. A 12-month centred moving average was fitted to seclusion data from a psychiatric inpatient unit over 2 years to determine stabilization in seclusion reduction. The number of consumers admitted was calculated from the point of stabilization for 1 year (n = 469). In this cohort, univariate analysis sought to compare the characteristics of those who were secluded and those who were not. A multivariate logistic regression model was undertaken to associate future seclusion based on significant independent variables. Of those people admitted, 88 (19%) were secluded. The majority of seclusions occurred in the first 5 days (70/88, 79%). Multivariate logistic regression indicated that three variables maintained their independent associative risk of seclusion: (i) age less than 35 years; (ii) assessment of risk of violence to others; and (iii) a history of seclusion. The implications of these findings for nursing practice are discussed.

The transformation from custodial to recovery-oriented care: a paradigm shift that needed to happen

As custodial mental health services are beginning to adopt a recovery-oriented model of care, it is imperative that successes in the transformation to recovery are captured. The aim of this illustrative case study was to describe the organizational procedure that enabled the systematic transformation of a custodial mental health service to a service with a self-professed recovery orientation as its model of service delivery. One-to-one interviews with key stakeholders and a document analysis were completed to thoroughly describe the transformation of the service. Four major themes arose from the data: (a) "We had this whole paradigm shift that needed to happen;" (b) "Think recovery," the development of a manualized guide; (c) "Stepping out my recovery;" adaptation of the service guide to the secure care context; and (d) developing the culture. The "developing the culture" major theme was subcategorized to consist of (a) the right people, (b) education, (c) reflective learning, and (d) leadership. The themes provided insights to assist mental health nurses to understand the processes involved in systems transformation. However, the major successes of the service, although only recently evaluated, commenced over a decade ago and yet continue to evolve.

The effectiveness of specialist roles in mental health metabolic monitoring: a retrospective cross-sectional comparison study

BACKGROUND

People with serious mental illness (SMI) exhibit a high prevalence of cardiovascular diseases. Mental health services have a responsibility to address poor physical health in their consumers. One way of doing this is to conduct metabolic monitoring (MM) of risk factors for cardiovascular diseases. This study compares two models of MM among consumers with SMI and describes referral pathways for those at high risk of cardiovascular diseases.

METHODS

A retrospective cross-sectional comparison design was used. The two models were: (1) MM integrated with case managers, and (2) MM integrated with case managers and specialist roles. Retrospective data were collected for all new episodes at two community mental health services (CMHS) over a 12-month period (September 2012 - August 2013).

RESULTS

A total of 432 consumers with SMI across the two community mental health services were included in the analysis. At the service with the specialist roles, MM was undertaken for 78% of all new episode consumers, compared with 3% at the mental health service with case managers undertaking the role. Incomplete MM was systemic to both CMHS, although all consumers identified with high risk of cardiovascular diseases were referred to a general practitioner or other community based health services. The specialist roles enabled more varied referral options.

CONCLUSIONS

The results of this study support incorporating specialist roles over case manager only roles for more effective MM among new episode consumers with SMI.

Recovery-oriented care in acute inpatient mental health settings: an exploratory study

Australian mental health nurses will need to care with consumers of mental health services, within the domains of recovery. However, in acute inpatient mental health settings, nurses are without a clear description of how to be recovery-oriented. The intent of this qualitative study was to ask nurses to reflect on and describe current practice within acute inpatient services that are not overtly recovery-oriented. Results show that nurses can identify recovery and articulate with pragmatic clarity how to care within a recovery-oriented paradigm. Pragmatic modes of care described by nurses support using "champions" to assist with eventual system transformation in the delivery of mental health services.

Recovery-oriented care in a secure mental health setting: "striving for a good life"

Recovery-oriented care acknowledges the unique journey of the consumer to regain control of his or her life in order to live a good life. Recovery has become a dominant policy-directed model of mental health service delivery. Even services that have traditionally been institutional and custodial have been challenged to embrace a recovery-oriented model. The aim of this qualitative study was to provide a description of service delivery in a secure in-patient mental health service, which has developed a self-professed recovery-oriented model of service delivery. An in-depth case study of the secure in-patient service using an exploratory research design was undertaken to meet the aim of this study. Qualitative data was gathered from interviews with consumers and staff (n = 15) and a focus group with carers (n = 5). Data were analyzed using a content analysis approach. Ethical approval for the study was obtained. The stakeholders readily described the secure service within recovery domains. They described a common vision; ways to promote hope and autonomy; examples of collaborative partnership which enhanced the goal of community integration; a focus on strength-based, holistic care; and the management of risk by taking calculated risks. Discrepancies in the perceptions of stakeholders were determined. This case study research provides a demonstrable example of recovery-in-action in one secure mental health service in Australia. It is intended to assist mental health services and clinicians seeking guidance in developing strategies for building and maintaining partnerships with consumers and carers in order for secure services to become truly recovery-oriented.

Benefits of whole-body vibration to people with COPD: a community-based efficacy trial

Background

Benefits of community-based whole-body vibration (WBV) as a mode of exercise training for people with chronic obstructive pulmonary disease (COPD) have not been investigated. The low skill demand of WBV may enhance habitual sustainability to physical activity by people with COPD, provided efficacy of WBV can be established. The purpose of this trial was to compare a community-based WBV intervention with a sham WBV (SWBV) intervention and monitor exacerbations, exercise tolerance, and functional performance of the lower limbs of people with COPD.

Methods

Community-dwelling adults with a GOLD clinical diagnosis of COPD were recruited to the trial. This was a Phase II efficacy trial with crossover to sham intervention interspersed with two-week washout. Each six-week intervention consisted of two sessions per week of either WBV or SWBV. The interventions were completed in the home of each participant under supervision. The outcome measures were selected psychological (perceived dyspnoea) and physiological (heart rate and oxygen saturation) responses to exercise, simulated activities of daily living (timed-up-and got test and 5-chair stands test), and selected kinematic variables of gait across the 14-week trial.

Results

Sixteen adults with stable COPD were recruited to the trial. No exacerbations were reported during the WBV or SWBV interventions. After WBV, performance of activities of daily living (ADLs) and gait improved (p ≤ 0.05), while there was no change after SWBV (p > 0.05). Despite five withdrawals during the washout period, a 100% compliance to each six-week intervention was noted.

Conclusions

Results showed that WBV did not exacerbate symptoms of COPD that can be associated with physical inactivity. The WBV intervention improved tests to simulate ADLs such as rising from a chair, turning, and walking gait with greater effect than a SWBV intervention. If a placebo effect was systemic to the WBV intervention, the effect was negligible. As a standalone community-based intervention, WBV was an efficacious mode of exercise training for people with stable COPD that did not negatively effect exercise tolerance or exacerbate the disease, while concurrently improving functional performance of the lower limbs.

Trial registration

Australian and New Zealand Clinical Trials Registry ACTRN12612000508875.

Whole-body vibration as a mode of dyspnoea free physical activity: a community-based proof-of-concept trial

Background

The potential of whole-body vibration (WBV) as a mode of dyspnoea free physical activity for people with chronic obstructive pulmonary disease (COPD) is unknown among community-based settings. Furthermore, the acute effects of WBV on people with COPD have not been profiled in community-based settings. The aim of this community-based proof-of-concept trial was to describe acute effects of WBV by profiling subjective and objective responses to physical activity.

Findings

Seventeen community-dwelling older adults with COPD were recruited to participate in two sessions; WBV and sham WBV (SWBV). Each session consisted of five one-minute bouts interspersed with five one-minute passive rest periods. The gravitational force was ~2.5 g for WBV and ~0.0 g for SWBV. Reliability of baseline dyspnoea, heart rate, and oxygen saturation was first established and then profiled for both sessions. Acute responses to both WBV and SWBV were compared with repeated measures analysis of variance and repeated contrasts. Small changes in dyspnoea and oxygen saturation lacked subjective and clinical meaningfulness. One session of WBV and SWBV significantly increased heart rate (p ≤ 0.02), although there was no difference among WBV and SWBV (p = 0.67).

Conclusions

This community-based proof-of-concept trial showed that a session of WBV can be completed with the absence of dyspnoea for people with COPD. Furthermore, there were no meaningful differences among WBV and SWBV for heart rate and oxygen saturation. There is scope for long-term community-based intervention research using WBV given the known effects of WBV on peripheral muscle function and functional independence.

The PICHFORK (Pain InCHildren Fentanyl OR Ketamine) trial comparing the efficacy of intranasal ketamine and fentanyl in the relief of moderate to severe pain in children with limb injuries: study protocol for a randomized controlled trial

Background

The effectiveness of intranasal (IN) fentanyl as an analgesic for painful pediatric limb injuries in the Emergency Department (ED) has been reported previously. However, efficacy of IN ketamine in sub-dissociative doses is not well studied in the ED setting. A non-blinded pilot study undertaken by this study group suggested that IN ketamine showed similar analgesic effectiveness to that reported with IN fentanyl in similar non-blinded studies. The aim of this randomized, controlled, equivalence trial is to compare the analgesic effect of sub-dissociative dose IN ketamine with IN fentanyl for children with isolated musculoskeletal limb injuries.

Methods/Design

This is a prospective, randomized, controlled, double-blind equivalence trial of children agedthree to thirteen years and less than 50 kg body weight, with isolated musculoskeletal limb injury, presenting to the ED with moderate to severe pain, defined as a verbal response of at least six to a standard 11-point scale (0 = none, 10 = worst pain imaginable). Pain score, sedation, satisfaction with analgesic intervention, and adverse effects will be assessed over a 60 minute interval for each participant. Intranasal ketamine (1 mg/kg) or fentanyl (1.5 microgram/kg) will be administered via blinded syringe and mucosal atomization device in a standardized volume at 0.03 ml/kg, with a maximum volume of 1.5 ml divided equally to both nares. Participants will also receive 10 mg/kg ibuprofen orally. The primary outcome measure will be median change in pain score from pre-administration to 30 minutes post-administration. Non-parametric Mann–Whitney U tests will be computed to compare median change in the primary outcome measure for IN ketamine and fentanyl. A sample size of 36 participants per group is needed to detect the expected 40 mm reduction in pain rating with a 95% confidence interval (CI) no greater than ± 10 mm at 30 minutes. Rescue analgesia will be given as IN fentanyl or intravenous morphine.

Discussion

This is the first randomized-controlled trial comparing the efficacy of these two analgesic agents via the intranasal route. If IN ketamine is found to be equally effective to IN fentanyl for this indication, it will provide another analgesic agent that may be considered for the relief of acute pain in children in the ED.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12612000795897.

Efficacy of a whole-body vibration intervention to effect exercise tolerance and functional performance of the lower limbs of people with chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a respiratory condition characterised by dyspnoea, excessive sputum production, chronic cough, bronchitis and emphysema. Functionally, exercise tolerance is poor for people with COPD and is linked to difficulty in performing daily tasks. More specifically, exercise difficulties are due partly to dyspnoea and lower limb skeletal muscle dysfunction. The benefit of exercise that does not exacerbate the disease while improving exercise tolerance is salient. Whole-body vibration (WBV) is a mode of physical activity known to improve muscular function of the lower limbs, yet efficacy has not been investigated for a WBV intervention conducted in a home-based setting for people with COPD.

METHODS/DESIGN

This clinically registered trial is a non-randomised placebo cross-over intervention based in the home of each participant (ACTRN12612000508875). Participants diagnosed with COPD will complete a six-week WBV intervention and then after a two-week washout period, will complete a six-week placebo training intervention. Participants will complete sessions twice a week. The duration of the trial is 14 weeks. Community-dwelling older adults with COPD will provide informed voluntary consent to participate. Outcome measures will include immediate, acute, and long-term responses to exercise.

DISCUSSION

Quantifying responses to WBV among people with COPD will allow discussion of efficacy of WBV as a mode of physical activity. The skill required by the participant to perform physical activity with WBV is not demanding and may enhance habitual sustainability. The results of this trial could be used to support further research in both clinical and community settings.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR12612000508875).