The challenges confronting clinicians in rural acute care settings: a participatory research project

INTRODUCTION

In Australia, as in many other developed countries, the current healthcare environment is characterised by increasing differentiation and patient acuity, aging of patients and workforce, staff shortages and a varied professional skills mix, and this is particularly so in rural areas. Rural healthcare clinicians are confronted with a broad range of challenges in their daily practice. Within this context, the challenges faced by rural acute care clinicians were explored and innovative strategies suggested. This article reports the findings of a study that explored these challenges across disciplines in acute healthcare facilities in rural New South Wales (NSW), Australia.

METHODS

A mixed method approach, involving a consultative, participatory 3 stage data collection process was employed to engage with a range of healthcare clinicians from rural acute care facilities in NSW. Participants were invited to complete a survey, followed by focus group discussions and finally facilitated workshops using nominal group technique.

RESULTS

The survey findings identified the respondents' top ranked challenges. These were organised into four categories: (1) workforce issues; (2) access, equity and opportunity; (3) resources; and (4) contextual issues. Participants in the focus groups were provided with a summary of the survey findings to prompt discussion about the challenges identified and impact of these on their professional and personal lives. The results of the final workshop stage of the study used nominal group process to focus the discussion on identifying strategies to address identified challenges.

CONCLUSIONS

This study builds on research conducted in a large metropolitan tertiary referral hospital. While it was found that rural clinicians share some of the challenges identified by their metropolitan counterparts, some identified challenges and solutions were unique to the rural context and require the innovative solutions suggested by the participants. This article provides insight into the working world of rural healthcare clinicians and offers practical solutions to some of the identified issues. The findings of this study may assist rurally based healthcare services to attract and retain clinical staff.

A team approach: implementing a model of care for preventing osteoporosis related fractures

The implementation of a multidisciplinary team-based model of care has led to significant increases in identification of patients with osteoporosis who are at risk of refracture, together with improved treatment uptake and ongoing management.

INTRODUCTION

Osteoporosis-related fractures and consequent hospital admissions are largely preventable; however, little attention has been paid to how to achieve this, in particular, through improved models of care. Presentation to emergency departments (ED) with minimal trauma fracture (MTF) provides opportunity for patients at risk to be identified, referred and managed through a systematic process ensuring prompt intervention and continuing follow-up. This study is aimed to design and implement a care model for people over 50 years of age, presenting to ED with an MTF.

METHOD

Established a multidisciplinary fracture prevention team to identify and capture at-risk patients for referral and management. Clinical data revealed the extent of lost opportunities. An electronic flagging system and data acquisition tool were developed and piloted. Established a referral pathway to detect, manage and follow-up patients, coordinated by a fracture prevention nurse.

RESULTS

Increased awareness of osteoporosis as a cause of MTF, better identification of at-risk patients across departments and services and development of a flagging and referral protocol has resulted in 100% capture of at-risk patients presented to ED. As a result there has been a significant increase in patients attending the fracture prevention clinic (FPC) (p < 0.001) from 11% in 2007 to 29% in 2008 and a significantly reduced time between fracture and when patients are seen in the FPC (p < 0.001).

CONCLUSION

A multipronged systematic team approach to identifying and capturing patients with a high risk of refracture and a dedicated nurse coordinator role has created efficiencies in the detection and management of osteoporosis.

Doing clinical research: the challenges and benefits

The need for research in practice is well documented within nursing and other health care disciplines. This acceptance is predicated on the belief that clinically applied research will inform and improve practice and health service delivery resulting in better outcomes for consumers and their families. Nurses, however, find doing clinical research challenging. This paper describes nurses' experiences of doing clinical research. The main challenges of doing clinical research arise from a culture that prioritises practice where nursing work is core business and there is the need to address immediate and short term goals. There are also problems associated with the use of research language amongst clinical nurses and ambiguity in relation to research role expectations. Lack of support and resources for doing research along with keeping up the momentum for a research project also pose significant challenges. The benefits of doing clinical nursing research include experiential learning that has the potential to lead to practice change and improved patient outcomes that are evidence based.

Loss of NPC1 function in a patient with a co-inherited novel insulin receptor mutation does not grossly modify the severity of the associated insulin resistance

In Npc1 null mice, a model for Niemann Pick Disease Type C1, it has been reported that hepatocyte insulin receptor function is significantly impaired, consistent with growing evidence that membrane fluidity and microdomain structure have an important role in insulin signal transduction. However, whether insulin receptor function is also compromised in human Niemann Pick disease Type C1 is unclear. We now report a girl who developed progressive dementia, ataxia and opthalmoplegia from 9 years old, followed by severe acanthosis nigricans, hirsutism and acne at 11 years old. She was diagnosed with Niemann Pick Disease type C1 (OMIM#257220) based on positive filipin staining and reduced cholesterol-esterifying activity in dermal fibroblasts, and homozygosity for the p.Ile1061Thr NPC1 mutation. Further analysis revealed her also to be heterozygous for a novel trinucleotide deletion (c.3659 + 1_3659 + 3delGTG) at the end of exon 20 of INSR, encoding the insulin receptor, leading to deletion of Trp1193 in the intracellular tyrosine kinase domain. INSR mRNA and protein levels were normal in dermal fibroblasts, consistent with a primary signal transduction defect in the mutant receptor. Although the proband was significantly more insulin resistant than her father, who carried the INSR mutation but was only heterozygous for the NPC1 variant, their respective degrees of IR were very similar to those previously reported in a father-daughter pair with the closely related p.Trp1193Leu INSR mutation. This suggests that loss of NPC1 function, with attendant changes in membrane cholesterol composition, does not significantly modify the IR phenotype, even in the context of severely impaired INSR function.

Tracheostomy management in acute care facilities--a matter of teamwork

AIM

Implement and evaluate an inter-disciplinary team approach to tracheostomy management in non-critical care.

BACKGROUND

Trends towards early tracheostomy in intensive care units (ICU) have led to increased numbers of tracheostomy patients. Together with the push for earlier discharge from ICU, this poses challenges across disciplines and wards. Even though tracheostomy is performed across a range of patient groups, tracheostomy care is seen as the domain of specialist clinicians in critical care. It is crucial to ensure quality care regardless of the patient's destination after ICU.

DESIGN

A mixed method evaluation incorporating quantitative and qualitative approaches.

METHOD

Data collection included pre-implementation and postimplementation clinical audits and staff surveys and a postimplementation tracheostomy team focus group. Descriptive and inferential analysis was used to identify changes in clinical indicators and staff experiences. Focus group data were analysed using iterative processes of thematic analysis.

RESULTS

Findings revealed significant reductions in mean hospital length of stay (LOS) for survivors from 50-27 days (p < 0.0001) and an increase in the number of tracheostomy patients transferred to non-critical care wards in the postgroup (p = 0.006). The number of wards accepting patients from ICU increased from 3-7 and there was increased staff knowledge, confidence and awareness of the team's role.

CONCLUSION

The team approach has led to work practice and patient outcome improvements. Organisational acceptance of the team has led to more wards indicating willingness to accept tracheostomy patients. Improved communication has resulted in more timely referral and better patient outcomes.

RELEVANCE TO CLINICAL PRACTICE

This study highlights the importance of inter-disciplinary teamwork in achieving effective patient outcomes and efficiencies. It offers a model of inter-disciplinary practice, supported by communication and data management that can be replicated across other patient groups.

(W)riting across and within: Providing a vehicle for sharing local nursing and midwifery projects and innovation

INTRODUCTION

This paper describes the development and outcomes of a locally-based journal that is contributed to and managed by nurses, midwives and academics within an area health service (AHS) in NSW, Australia.

BACKGROUND

Nurses and midwives are often engaged in scholarly and rigorous activities aimed at improving practice and patient outcomes. However, often these endeavours remain unreported, unpublished and hence not shared for the benefit of others. Reasons given for nurses' and midwives' persistent reluctance to publish are well documented in the literature. Lack of expertise and understanding of the publication process, together with lack of confidence and opportunity are the reasons most often cited. To overcome these barriers we developed a local journal called Handover that provides a non-threatening, supportive opportunity for nurses and midwives to develop skills in writing and reviewing articles for publication. Handover was established and is managed by editorial committee members from the area health service and the two local universities. Each institution agreed to co-fund the journal which is published twice yearly. Two editions of the journal have been published with wide ranging content and contributions from across the AHS. Writing mentorship and support systems have been established. Reviewers workshop have been conducted and novice reviewers mentored by experienced reviewers.

CONCLUSION

Our experience indicates that a locally based and owned journal can motivate and support novice writers and offers one solution to many of the barriers to publication identified in the literature.

Migration of nurses in Australia: where and why?

The Australian health care workforce has benefited from an increasing migration of nurses over the past decades. The nursing profession is the largest single health profession, making up over half of the Australian health care workforce. Migration of nurses into the Australian nursing workforce impacts significantly on the size of the workforce and the capacity to provide health care to the Australian multicultural community. Migration of nurses plays an important role in providing a solution to the ongoing challenges of workforce attraction and retention, hence an understanding of the factors contributing to nurse migration is important. This paper will critically analyse factors reported to impact on migration of nurses to Australia, in particular in relation to: (1) globalisation; (2) Australian society and nursing workforce; and (3) personal reasons. The current and potential implications of nurse migration are not limited to the Australian health care workforce, but also extend to political, socioeconomic and other aspects in Australia.

Pictures and perspectives: a unique reflection on interdialytic weight gain

The purpose of this study was to explore the perspectives of managing interdialytic weight gain for individuals on hemodialysis. A qualitative design was used to elicit patients' stories with some participants using images to support their story telling. Data were analyzed using an iterative theming process. Themes that arose from preliminary data analysis include magnitude of loss, constant struggle, and transition to acceptance. Transition to acceptance is not a linear progression to understanding and compliance but a multifaceted, tortuous struggle unique to individuals and largely dependent upon support, belief in a life worth living, and willingness to engage in surveillance and maintenance of behavior. Appreciating the impact and meaning of fluid restriction for individuals on hemodialysis will assist health professionals to identify support strategies that facilitate healthy fluid gain behaviors.

Review: Toward Realizing the Potential of Diversity in Composition of Interprofessional Health Care Teams

Interprofessional approaches to health and social care have been linked to improved planning and policy development, more clinically effective services, and enhanced problem solving; however, there is evidence that professionals tend to operate in uniprofessional silos and that attempts to share knowledge across professional borders are often unsuccessful.

Beyond barriers. The challenge of cultural diversity for nurse academics in the Australian context

In spite of the increasing significance of cultural diversity for nursing, some Australian nurse teachers are not well prepared for the challenges they face, nor have nursing curricula been re-conceptualized to meet the changing needs of society and more specifically nursing students. Although numerous teaching and Learning programmes for inclusion of diversity are reported in the literature, both within Australia and overseas, there appears to be little commitment to the adoption of a more fundamental change in curricula and teaching and learning practices. In particular there appears to be little attention to how teachers negotiate meaningful social dynamics within multicultural learning contexts. This article reports on the findings of a study carried out across two Schools of Nursing in Australia. The purpose of the study was to explore why schools have been reluctant to move to more culturally diverse models of teaching and learning. This paper reports on the findings of focus groups with teachers about their experiences of teaching in the context of cultural diversity. Study findings explore teachers' perceptions of cultural diversity and its impact on teaching and learning nursing. Teachers reported a range of tensions arising from lack of a shared philosophical view about curricula generally, lack of consideration of diversity as a significant issue for both teachers and students, limited perceptions of community as a key driver of curricula and a reluctance to address the difficult and contentious issues arising from diversity in the classroom.

A 7 year prospective comparative study of three topical beta blockers in the management of primary open angle glaucoma

AIM

To determine the long term efficacy of monotherapy with topically applied beta blocking agents and to determine whether selective beta blockers were able to preserve the visual field more effectively than non-selective agents.

METHOD

A prospective randomised, open, comparative study of three topically applied beta blockers-timolol, betaxolol, and carteolol-was carried out on 153 patients (280 eyes) with newly diagnosed open angle glaucoma. Those patients who were not withdrawn were followed by the same observers for a minimum of 2 years and a maximum of 7 years, with clinical observations, Goldmann tonometry and 24.2 Humphrey visual field analysis.

RESULTS

All three drugs lowered the IOP significantly from untreated levels but betaxolol took up to 12 months in some instances to reach the maximum pressure reduction. After 7 years only 43% of the eyes begun on timolol, 34% of those started on carteolol, and 29% of those on betaxolol were still being treated with these medications alone. Visual fields were analysed throughout the trial by CPSD and MD and at the end by linear regression analysis (PROGRESSOR). The visual fields remained the same without apparent improvement or deterioration throughout the period of follow up. Eight patients (11 eyes) were withdrawn because of continuing field loss in spite of reduction in IOP (six using carteolol and five using betaxolol).

CONCLUSIONS

Analysis shows that less than half the eyes initially treated with topical beta blockers might be expected to still be being treated with their original medication after 5 years. The rest required either additional medication or trabeculectomy. There was no statistically significant improvement or deterioration in the visual fields over a 7 year period. On the evidence of this trial there are no particular advantages in using selective beta blockers.