Engagement and retention in specialist services for people with personality disorder

OBJECTIVE

To quantify levels of engagement and retention in specialist services for people with personality disorder (PD).

METHOD

Demographic and clinical data were collected on referrals to 10 specialist services for people with PD. Follow-up data on retention and drop-out from services were collected over the following 30 months.

RESULTS

Seven hundred and thirteen (60.1%) of 1186 people referred to services were taken by them, of whom 164 (23.0%) subsequently dropped out prior to the completion of an episode of care. Men, younger people and those with higher levels of personality disturbance were less likely to complete a package of care.

CONCLUSION

Specialist community-based services for adults with PD are able to engage most of those that are referred to them, but further efforts need to be made to find ways to engage younger people and men with PD.

Pilot study of a novel educational programme for 11-16 year olds with type 1 diabetes mellitus: the KICk-OFF course

AIMS

To pilot an educational programme (KICk-OFF) for children and adolescents with type 1 diabetes mellitus (DM). Evaluation included (i) independent assessment of curriculum quality, (ii) acceptability to families and (iii) possible impact on standardised outcome measures (HbA1c, body mass index (BMI), diary reports of hypoglycaemia, quality of life (QoL)).

METHODS

48 children aged 11-16 years (mean age 13.60 (SD 1.36) years) were recruited from three UK centres. Six 5-day outpatient courses on carbohydrate counting and insulin dose adjustment were held. Semi-structured interviews were conducted with children and parents before and after the course. Glycaemic control (HbA1c), BMI and frequency of hypoglycaemia were assessed before the course and at 3 and 6 months after intervention. QoL was assessed before the course and at 2 weeks, 3 and 6 months.

RESULTS

Educational evaluation indicated the course format was appropriate and consistent. Parent and child interviews suggested that pre-course expectations were largely met. There were no changes in HbA1c, BMI or episodes of hypoglycaemia, but children and parents reported improved QoL (p<0.05).

CONCLUSIONS

KICk-OFF was well-received by children and parents and was associated with improved QoL. In this small pilot study, glycaemic control did not change but findings justify conducting a future randomised controlled trial involving a revised curriculum, a larger study population including a control group and longer follow-up.

Elation or frustration? Outcomes following the provision of equipment during the Communication Aids Project: data from one CAP partner centre

BACKGROUND

The Communication Aids Project (CAP) was a 4-year initiative by the UK Department for Education and Skills to provide communication equipment for students who were unable to speak in order to facilitate their access to education. Each child was given three goals or targets which were then evaluated after 6 months of provision of the communication aid.

METHODS

We evaluated the targets of 60 children, between the ages of 3 and 18 years. Six months after receipt of equipment, the targets were mailed to the initial referrer who was requested to record whether the child had achieved, partially achieved or not achieved each target. Evidence and explanations of these outcomes were also requested. Data were analysed using descriptive statistics, and the explanations were grouped into common themes using a keyword analysis.

RESULTS

Sixty-three per cent of targets were not achieved and 36% were achieved. We investigated any possible associations to attempt to explain some of the possible reasons for the children's non-achievement of targets. Targets were grouped into operational, linguistic, social and academic, but there were no differences between the successes because of target type. Age may be an influence on success, but neither school placement or type of communication aid influenced success. The explanations for non-achievement highlighted the misunderstanding or interpreting of the underlying skills of the communication aid user as a potential cause.

CONCLUSION

The CAP raised the profile of children with Augmentative and Alternative Communication needs within education. However, only one-third of the targets of children using the equipment were achieved. The reasons for this include inappropriate provision of equipment, demands of the equipment, lack of appropriate support and targets. The major consequence, however, is the need for detailed assessment and provision appropriate to the individual needs of each child. There is a need for research into the best methods of providing communication aids and the support needed for successful communication.

Nurses in general practice settings: roles and responsibilities

Nurses are an important human resource, vital for the delivery of health services in countries across the globe. To improve the quality, access and affordability of primary care services to support rural and remote communities, in 2001, the Australian Government implemented the Nursing in General Practice Initiative [NIGPI] to increase the numbers of nurses to work in general practice settings. The NIGPI positions nurses as both a human resource and a human commodity. This paper examines how developments emerging from this initiative enable and constrain the role and responsibilities of nurses working in general practices in Australia.

Anaesthetic considerations for interventional neuroradiology

In the past decade, the neuroradiological diagnosis and treatment of cerebrovascular diseases has undergone significant advances. With the introduction of varying diagnostic and interventional neuroradiological techniques and advances in the materials used for endovascular treatment, increasingly complex diagnostic and therapeutic neuroradiological procedures are being performed on extremely sick patients. As the interventional neuroradiology field expands, the neuroanaesthetist will become more involved in management of patients undergoing neuroradiological procedures. This produces challenges for the neuroanaesthetist, and understanding the anaesthetic implications of the current developments in neuroradiology is important in the management of these patients. This review provides an overview of diagnostic and therapeutic neuroradiological procedures, with special reference interventional neuroradiology, and the anaesthetic management of patients undergoing these procedures.

Successful use of feedback to improve antibiotic prescribing and reduce Clostridium difficile infection: a controlled interrupted time series

OBJECTIVES

To investigate the effect of reinforcing a narrow-spectrum antibiotic policy on antibiotic prescription and Clostridium difficile infection (CDI) rates by feedback of antibiotic use to doctors, as part of a departmental audit and feedback programme.

DESIGN

A prospective controlled interrupted time-series (ITS) study, with pre-defined pre- and post-intervention periods, each of 21 months.

SETTING

Three acute medical wards for elderly people in a teaching hospital.

PARTICIPANTS

Six thousand one hundred and twenty-nine consecutive unselected acute medical admissions aged >or=80 years.

INTERVENTIONS

A 'narrow-spectrum' antibiotic policy (reinforced by an established programme of audit and feedback of antibiotic usage and CDI rates) was introduced, following an unplanned rise in amoxicillin/clavulanate (Augmentin) use. It targeted broad-spectrum antibiotics for reduction (cephalosporins and amoxicillin/clavulanate) and narrow-spectrum antibiotics for increase (benzyl penicillin, amoxicillin and trimethoprim). Changes in the use of targeted antibiotics (intervention group) were compared with those of untargeted antibiotics (control group) using segmented regression analysis. Changes in CDI rates were examined by the Poisson regression model. Methicillin-resistant Staphylococcus aureus (MRSA) acquisition rates acted as an additional control.

RESULTS

There was a reduction in the use of all targeted broad-spectrum antibiotics and an increase in all targeted narrow-spectrum antibiotics, statistically significant for sudden change and/or linear trend. All other antibiotic use remained unchanged. CDI rates fell with incidence rate ratios of 0.35 (0.17, 0.73) (P=0.009). MRSA incidence did not change [0.79 (0.49, 1.28); P=0.32].

CONCLUSIONS

This is the first controlled prospective ITS study to use feedback to reinforce antibiotic policy and reduce CDI. Multicentre ITS or cluster randomized trials of this and other methods need to be undertaken to establish the most effective means of optimizing antibiotic use and reducing CDI.

Being strategic: utilising consumer views to better promote an expanded role for nurses in Australian general practice

Australian consumers have articulated their perceptions of the role of the nurse in general practice. Practice Nurses (PNs) and General Practitioners (GPs) have also highlighted the issues they believe currently and potentially impact on this role in Australia. This paper identifies and discusses the nexus between the consumers' perceptions and expectations and health professionals' issues. Data collected from focus groups and interviews in 2 Australian studies of consumer perception of nursing in general practice, are re-considered alongside findings reported in the Royal Australian College of General Practitioners and the Royal College of Nursing, Australia report; General Practice Nursing in Australia. Consumers, doctors and nurses working in general practices in Australia, raised similar issues. However, consumers considered these issues in relation to their health care needs, whereas the GPs and PNs tended to focus more on professional and structural tensions related to the current and potentially expanded role of the PN. Understanding consumer views vis-a-vis issues raised by PNs and GPs about the role of nursing in general practice provides direction for both professions to better work with consumers to enhance their understanding of what general practice services could be and how changes, like expanding the role of nurses, may bring about improvements in the health outcomes of consumers. Health professionals can benefit from reflecting on the experiences and expectations of consumers if they desire to make general practice services more responsive to individual consumer's needs and at the same time adopt a primary health care focus.

Health promotion and some implications of consumer choice

AIM

To stimulate debate around how health promotion practices add to the choices confronting consumers in a health market place and some implications as a consequence.

BACKGROUND

We live in a world characterized by consumerism, in which health professionals must compete with a wide array of other producers for the consumer's attention.

EVALUATION

A critical review of consumer choice related to health applying theoretical insights from the works by Zygmunt Bauman.

KEY ISSUES

Nurses working at influencing the health status of consumers at an individual level (whatever the setting) need to understand how to address the acknowledgement that people are confronted with a multiplicity of choices (good and bad) in their daily lives and from which they need to make a choice. How health promotion practices are 'sold' to consumers is an important consideration for nurses.

CONCLUSIONS

The possibility for nurses to talk past consumers and vice versa exists. Choices made by consumers are premised on what is 'sold', how, by whom and why and has a lot to do with how to get the attention of the consumer.

The North West Adelaide Health Study: detailed methods and baseline segmentation of a cohort for selected chronic diseases

The North West Adelaide Health Study is a population-based biomedical cohort study investigating the prevalence of a number of chronic conditions and health-related risk factors along a continuum. This methodology may assist with evidence-based decisions for health policy makers and planners, and inform health professionals who are involved in chronic disease prevention and management, by providing a better description of people at risk of developing or already diagnosed with selected chronic conditions for more accurate targeting groups for health gain and improved health outcomes. Longitudinal data will provide information on progression of chronic conditions and allow description of those who move forward and back along the continuum over time.

Detailed methods are provided regarding the random recruitment and examination of a representative sample of participants (n = 4060), including the rationale for various processes and valuable lessons learnt. Self-reported and biomedical data were obtained on risk factors (smoking, alcohol consumption, physical activity, family history, body mass index, blood pressure, cholesterol) and chronic conditions (asthma, chronic obstructive pulmonary disease, diabetes) to classify participants according to their status along a continuum. Segmenting this population sample along a continuum showed that 71.5% had at least one risk factor for developing asthma, chronic obstructive pulmonary disease or diabetes. Almost one-fifth (18.8%) had been previously diagnosed with at least one of these chronic conditions, and an additional 3.9% had at least one of these conditions but had not been diagnosed.

This paper provides a novel opportunity to examine how a cohort study was born. It presents detailed methodology behind the selection, recruitment and examination of a cohort and how participants with selected chronic conditions can be segmented along a continuum that may assist with health promotion and health services planning.

Understanding Life Transitions

I wanted to share with readers the outcomes of a research project I have been involved with. It was funded by a three-year nationally competitive discovery grant (2003-2005) from the Australian Research Council (ARC [DP 0346092]). This was a collaborative project between the Research Unit, Royal District Nursing Services, South Australia and University of South Australia, School of Nursing and Midwifery.

Issues in data generation using email group conversations for nursing research

AIM

The purpose of this paper is to provide an overview of the issues we have confronted when generating and analysing dialogue data by using electronic mail.

BACKGROUND

The decision to use email for our research arose from our developing understanding of some of the consequences of illness that people living with chronic illness confront in their lives. As researchers, we recognized the potential of the Internet for computer-mediated communication using email for communication between researchers and research participants.

DISCUSSION

We consider the functional aspects of generating data by email, such as the software needed, and then explore the issues encountered during the research process including ethical considerations, fluctuating participation, participants' familiarity with using email, facilitating lurkers towards participation, establishing group norms, and the role of the facilitator.

CONCLUSION

As a collaborative inquiry, email conversation allowed us to spend time with participants over 2 years to explore chronic illness experience. However the scope and viability of computer-mediated communication as a qualitative method of research remains relatively unexplored, hence this paper.

The ethics of research using electronic mail discussion groups

AIM

The aim of this paper is to identify and discuss the ethical considerations that have confronted and challenged the research team when researchers facilitate conversations using private electronic mail discussion lists.

BACKGROUND

The use of electronic mail group conversations, as a collaborative data generation method, remains underdeveloped in nursing. Ethical challenges associated with this approach to data generation have only begun to be considered. As receipt of ethics approval for a study titled; 'Describing transition with people who live with chronic illness' we have been challenged by many ethical dilemmas, hence we believe it is timely to share the issues that have confronted the research team. These discussions are essential so we can understand the possibilities for research interaction, communication, and collaboration made possible by advanced information technologies.

DISCUSSION

Our experiences in this study have increased our awareness for ongoing ethical discussions about privacy, confidentiality, consent, accountability and openness underpinning research with human participants when generating data using an electronic mail discussion group. We describe how we work at upholding these ethical principles focusing on informed consent, participant confidentiality and privacy, the participants as threats to themselves and one another, public-private confusion, employees with access, hackers and threats from the researchers.

CONCLUSION

A variety of complex issues arise during cyberspace research that can make the application of traditional ethical standards troublesome. Communication in cyberspace alters the temporal, spatial and sensory components of human interaction, thereby challenging traditional ethical definitions and calling to question some basic assumptions about identity and ones right to keep aspects of it confidential. Nurse researchers are bound by human research ethics protocols; however, the nature of research by electronic mail generates moral issues as well as ethical concerns. Vigilance by researchers is required to ensure that data are viewed within the scope of the enabling ethics approval.

Women's experiences of fatigue in chronic illness

AIM

The aim of this paper is to add a qualitative dimension to the body of knowledge about fatigue by revealing the meaning given by women living with chronic illness to the experience of fatigue.

BACKGROUND

Fatigue is a common symptom experienced by people who live with chronic illness. It pervades every aspect of life and may be experienced in physical, psychological, emotional or social dimensions. Management of fatigue relies heavily on the individual's ability to employ self-care actions. The invisibility of fatigue is recognized as one of the most frustrating aspects, which can lead to lack of understanding and misunderstanding by others.

METHOD

We report the findings of data from research in progress (2003-2005). Data were generated via email group conversations between us and 30 women who live with long-term illness.

FINDINGS

A recurring conversational thread has been women's experiences of fatigue when living with long-term illness. Although fatigue has been reported to be a major obstacle to maintaining usual daily activities and quality of life, few studies have explored this common symptom from the perspective of people themselves. Common themes found in the experience of fatigue as described by women are the meaning of fatigue, awareness as self-care, fatigue as invisible to others, seeking medical validation and accountability for self-care.

CONCLUSION

It is vital for healthcare workers to give opportunities for women to talk about fatigue, validate their experiences and provide support with self-care. Healthcare workers are encouraged to challenge their own meanings and expectations surrounding a person's report of fatigue so that opportunities for therapeutic intervention can be facilitated.

'Moving on': the transition to living well with chronic illness

This paper describes the process of 'moving on' when living with a chronic illness or condition. The findings of this study emerged from daily email conversations between six women who live with long term illness and the three researchers during a three month period in 2003. In collaboration with the women, researchers have drawn out seven interrelated themes which are seen to constitute the process of 'moving on'. The concept of readiness to change is discussed as fundamental to the relationship between potential learning as a result of living with illness and 'moving on'. We conclude that health workers are in a strong position to facilitate the learning that will assist people to 'move on' and incorporate illness as an ordinary part of life.

Bispectral index monitoring may not reliably indicate cerebral ischaemia during awake carotid endarterectomy † †This study was conducted in the Department of Neurosurgery, Newcastle General Hospital, Newcastle Upon Tyne NE4 6BE, UK. Preliminary results were presented at the British Neurosurgery Research Group Meeting, Sheffield, March 29–30, 2001

BACKGROUND

Intraoperative ischaemia during carotid cross-clamping in patients undergoing carotid endarterectomy (CEA) is a major complication and prompt recognition of insufficient collateral blood supply is crucial. Electroencephalogram (EEG) is believed to be one of the useful forms of monitoring cerebrovascular insufficiency during CEA. The aim of this study was to evaluate the utility of bispectral index (BIS) monitoring, a processed EEG parameter, for the reliable detection of intraoperative cerebral ischaemia during awake CEA.

METHODS

We monitored 52 patients continuously with the BIS monitor together with assessment of neurological function (contralateral upper and lower limb strength and the verbal component of the Glasgow Coma Scale for speech) in patients undergoing awake CEA.

RESULTS

Overall mean BIS value in all patients was 96 (SD 2.9). In five patients who showed clinical evidence of cortical ischaemia during carotid cross-clamping, there was no change in the original range of BIS values throughout the procedure (96.7 [3.2]). In one patient BIS values decreased to 38 about 5 min after the incision and recovered within the next 10 min. The mean BIS value in the remaining 46 patients who did not develop clinical signs of ischaemia was 95.4 (2.6). Three cases are presented which demonstrate the inability of the BIS monitor to detect cerebral ischaemia.

CONCLUSIONS

Lack of correlation of BIS with the signs of cerebral ischaemia during CEA makes it unreliable for detection of cerebrovascular insufficiency. We conclude that awake neurological testing is the preferred method of monitoring in these patients.

Adolescents' and their parents' views on the acceptability and design of a new diabetes education programme: a focus group analysis

BACKGROUND

The present study was conducted as part of an ongoing project to develop an innovative educational intervention for young people with type 1 diabetes. We aimed to seek the views of children and adolescents with type 1 diabetes and their parents regarding (i) the acceptability of the new programme and (ii) practical aspects regarding course design and delivery.

METHODS

Twenty-four children and 29 parents attended one of eight separate focus groups. Semi-structured interview schedules were developed around two main areas of discussion: views on the education programme; and views on the design and delivery of current and future education. Discussions were tape-recorded and transcribed, before undergoing systematic qualitative analysis.

RESULTS

Participants agreed that the proposed intervention was feasible, and were enthusiastic that it could improve quality of life and 'normality'. Potential problems included self-management during school-time and parental anxiety. In terms of course design/delivery, participants emphasized the need to maximize enjoyment on the course (e.g. integrating fun and practical sessions, holding parts of the course outside of the clinic setting), and encourage effective learning and adherence to the regimen (e.g. including separate parent education, and using IT-based reference material).

CONCLUSIONS

The qualitative methodology proved an effective way of eliciting child and parent views and informing the development of the proposed intervention. These findings can now be incorporated into the development of the education programme.

Risk reduction in general practice and the role of the receptionist

Medical receptionists play a crucial role in any practice as they are usually the first points of contact for patients and the intermediaries through whom contacts with medical practitioners are made. This article reports the findings of a qualitative study of medical receptionists undertaken to explore their role in general practice, particularly in relation to activities involving direct patient assessment, monitoring, counselling and therapy. The findings highlight a number of significant issues in relation to the potential liability of receptionists, medical practitioners, medical centre owners and insurers.

Primary health care and general practice nurses: What is the nexus?

This paper presents the findings from three separate qualitative studies that sought to explore the current and potential role of nurses employed in general medical practices in Australia. General practitioners', practice nurses' and consumers' views and perceptions were gathered from individual and group interviews. The data indicate that practice nurses (PNs) are involved in first level or primary care of individuals and engage in some form of preventive health care. Some PNs have a family/community focus in addition to their focus of care on individuals. Engagement in health promotion was found to be opportunistic rather than planned, and focussed on interventions to free individuals from medically defined diseases - the aim being compliance with therapeutic procedures and advice. The broader concept of health promotion, as documented in the Ottawa Charter for Health Promotion, was not pronounced in the PNs' reported practice. Consumers do not articulate confidence in PNs acting autonomously as primary health care practitioners but rather as complementary to general practitioners (GPs), undertaking initial assessment for triage purposes and providing ongoing management, education and support under the GPs' delegation. They would also like them to be family-oriented and holistic in their practice; supporting emotional and social needs in the context of their family lives.