Multidimensional severity assessment in bronchiectasis: an analysis of seven European cohorts

INTRODUCTION

Bronchiectasis is a multidimensional disease associated with substantial morbidity and mortality. Two disease-specific clinical prediction tools have been developed, the Bronchiectasis Severity Index (BSI) and the FACED score, both of which stratify patients into severity risk categories to predict the probability of mortality.

METHODS

We aimed to compare the predictive utility of BSI and FACED in assessing clinically relevant disease outcomes across seven European cohorts independent of their original validation studies.

RESULTS

The combined cohorts totalled 1612. Pooled analysis showed that both scores had a good discriminatory predictive value for mortality (pooled area under the curve (AUC) 0.76, 95% CI 0.74 to 0.78 for both scores) with the BSI demonstrating a higher sensitivity (65% vs 28%) but lower specificity (70% vs 93%) compared with the FACED score. Calibration analysis suggested that the BSI performed consistently well across all cohorts, while FACED consistently overestimated mortality in 'severe' patients (pooled OR 0.33 (0.23 to 0.48), p<0.0001). The BSI accurately predicted hospitalisations (pooled AUC 0.82, 95% CI 0.78 to 0.84), exacerbations, quality of life (QoL) and respiratory symptoms across all risk categories. FACED had poor discrimination for hospital admissions (pooled AUC 0.65, 95% CI 0.63 to 0.67) with low sensitivity at 16% and did not consistently predict future risk of exacerbations, QoL or respiratory symptoms. No association was observed with FACED and 6 min walk distance (6MWD) or lung function decline.

CONCLUSION

The BSI accurately predicts mortality, hospital admissions, exacerbations, QoL, respiratory symptoms, 6MWD and lung function decline in bronchiectasis, providing a clinically relevant evaluation of disease severity.

Elective surgery: a comparison of in-patient versus day surgery practices in Ireland

BACKGROUND

Currently, there is a paucity of research which has assessed practices at the point of care for day surgery patient.

AIM

To outline the patient journey from first referral for surgery and identify structures and processes which facilitate or constrain the provision of day surgery.

METHOD

A retrospective medical charts review of 200 consecutively presenting patients undergoing elective surgery in two Irish teaching hospitals. Data collection was completed from January 2009 to March 2009. This analysis spanned from first referral to the hospital until discharge and follow up.

RESULTS

Great variability was noted in practices between the two hospitals. While some of the differences in practice become barriers to increased rates of day surgery, others did not have an impact.

CONCLUSION

This study echoes findings of other similar studies in that management of patients undergoing elective surgery which varies significantly across Irish hospitals.

Preventing infection in general surgery: improvements through education of surgeons by surgeons

Surgical patients are at particular risk of healthcare-associated infection (HCAI) due to the presence of a surgical site leading to surgical site infection (SSI), and because of the need for intravascular access resulting in catheter-related bloodstream infection (CRBSI). A two-year initiative commenced with an initial audit of surgical practice; this was used to inform the development of a targeted educational initiative by surgeons specifically for surgical trainees. Parameters assessed during the initial audit and a further audit after the educational initiative were related to intra- and postoperative aspects of the prevention of SSIs, as well as care of peripheral venous catheters (PVCs) in surgical patients. The proportion of prophylactic antibiotics administered prior to incision across 360 operations increased from 30.0% to 59.1% (P<0.001). Surgical site dressings were observed in 234 patients, and a significant decrease was found in the percentage of dressings that were tampered with during the initial 48h after surgery (16.5% vs 6.2%, P=0.030). In total, 574 PVCs were assessed over the two-year period. Improvements were found in the proportion of unnecessary PVCs in situ (37.9% vs 24.4%, P<0.001), PVCs in situ for >72h (10.6% vs 3.1%, P<0.001) and PVCs covered with clean and intact dressings (87.3% vs 97.6%, P<0.001). Significant improvements in surgical practice were established for the prevention of SSI and CRBSI through a focused educational programme developed by and for surgeons. Potentially, other specific measures may also be warranted to achieve further improvements in infection prevention in surgical practice.

National survey of the provision of day surgery across public and private hospitals in Ireland

BACKGROUND

Day surgery (DS) is viewed as the optimal environment for many surgical procedures. Yet, Irish DS rates are low compared to international figures.

AIMS

To describe the current provision of DS in Ireland and to identify barriers to its expansion.

METHODS

Thirty-seven public hospitals and 17 private hospitals providing DS were surveyed during July/August 2009.

RESULTS

Thirty-seven hospitals replied (67%) (30 public, 7 private). DS beds ranged from 3 to 39. Fourteen (38%) had dedicated DS units, and no unit had a consultant in charge. Twenty-one (57%) provided pre-assessment with 36 (96%) providing patient information leaflets both pre- and post-operatively. Stay-in rate was less than 5%. Eight units had reviewed the adverse event rates following DS. Seven barriers to optimizing DS were identified, the main one being lack of dedicated DS theatres.

An examination of the services provided by Psychiatric Consultation Liaison Nurses in a general hospital

The political, professional and economic context in which mental health care is delivered has witnessed significant changes in recent times. The movement of psychiatric patients from institutions to community settings has seen the emphasis of the loci of care delivery shifting with increasing numbers presenting to general hospitals. The speciality of the Psychiatric Consultation Liaison Nurse (PCLN) has emerged as a bridge between mental health and general hospital services. A descriptive, non-experimental research approach was employed to establish patient profiles and to provide an overview of the depth of service provision. This design was selected as the most appropriate because of the limited information on the PCLN in an Irish setting and secondly, as the study was limited to one rural geographical location. A questionnaire was utilized to collate the details of patients who had received a mental health assessment. The findings presented here are the profiles of patients assessed by the PCLN during the 3-month study period. The results add further credence to the existing evaluative studies in presenting the characteristics of patients within the Irish context and further contribute to the unique body of evidence that defines the mental health nurse in an advancing role.

Psychiatric nurses' knowledge, experience and attitudes towards clients with borderline personality disorder

There is evidence in the literature to suggest that mental health care staffs' attitudes towards clients with borderline personality disorder (BPD) are less than favourable. This study reports on a survey of psychiatric nurses' knowledge, experience and attitudes towards care received by clients with a diagnosis of BPD. The questionnaire was sent to all clinical nurses (n = 157) working in a psychiatric service in Dublin, Ireland and received a response rate of 41.4% (n = 65). The results indicate that the majority of nurses have regular contact with clients with BPD and nurses on inpatient units reported more frequent contact than nurses in the community. Eighty per cent of nurses view clients with BPD as more difficult to care for than other clients and 81% believe that the care they receive is inadequate. Lack of services was cited as the most important factor contributing to the inadequate care and the development of a specialist service is reported as the most important resource to improve care.

Job satisfaction in psychiatric nursing

In recent years, mental health services across Europe have undergone major organizational change with a move from institutional to community care. In such a context, the impact of change on the job satisfaction of psychiatric nurses has received little attention in the literature. This paper reports on the job satisfaction of psychiatric nurses and data were collected in 2003. The population of qualified psychiatric nurses (n = 800) working in a defined geographical health board area was surveyed. Methodological triangulation with a between-methods approach was used in the study. Data were collected on job satisfaction using a questionnaire adopted from the Occupational Stress Indicator. A response rate of 346 (43%) was obtained. Focus groups were used to collect qualitative data. Factors influencing levels of job satisfaction predominantly related to the nurses work location. Other factors influencing job satisfaction included choice of work location, work routine, off duty/staff allocation arrangements, teamwork and working environment. The results of the study highlight to employers of psychiatric nurses the importance of work location, including the value of facilitating staff with choices in their working environment, which may influence the recruitment and retention of nurses in mental health services.

Wound cleansing for pressure ulcers

BACKGROUND

Pressure ulcers (also called pressure sores, bed sores and decubitus ulcers) are areas of tissue damage that occur in the very old, malnourished or acutely ill, who cannot reposition themselves. Pressure ulcers impose a significant financial burden on health care systems and negatively affect quality of life. Wound cleansing is considered an important component of pressure ulcer care.

OBJECTIVES

This systematic review seeks to answer the following question:What is the effect of wound cleansing solutions and wound cleansing techniques on the rate of healing of pressure ulcers?

SEARCH STRATEGY

We searched the Specialised Trials Register of the Cochrane Wounds Group (up to August 2005), and the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2005). We searched bibliographies of relevant publications retrieved. We contacted drug companies and experts in the field to identify studies missed by the primary search.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing wound cleansing with no wound cleansing, or different wound cleansing solutions, or different cleansing techniques, were eligible for inclusion if they reported an objective measure of pressure ulcer healing.

DATA COLLECTION AND ANALYSIS

Two authors extracted data independently and resolved disagreements through discussion and reference to the Cochrane Wounds Group editorial base. A structured narrative summary of the included studies was conducted. For dichotomous outcomes, relative risk (RR), plus 95% confidence intervals (CI) were calculated; for continuous outcomes, weighted mean difference (WMD), plus 95% CI were calculated. Meta analysis was not conducted, because of the small number of diverse RCTs identified.

MAIN RESULTS

No studies compared cleansing with no cleansing. Two studies compared different wound cleansing solutions: a statistically significant improvement in Pressure Sore Status Tool scores occurred for wounds cleansed with saline spray containing Aloe vera, silver chloride and decyl glucoside (Vulnopur) compared to isotonic saline (P value = 0.025), but no statistically significant change in healing was seen when water was compared to saline (RR 3.00, 95% CI 0.21, 41.89). One study compared cleansing techniques, but no statistically significant change in healing was seen for ulcers cleansed with, or without, a whirlpool (RR 2.10, 95% CI 0.93 to 4.76).

AUTHORS' CONCLUSIONS

We identified only three studies addressing cleansing of pressure ulcers. One noted a statistically significant improvement in pressure ulcer healing for wounds cleansed with saline spray containing Aloe vera, silver chloride and decyl glucoside (Vulnopur) when compared with isotonic saline solution. Overall, there is no good trial evidence to support use of any particular wound cleansing solution or technique for pressure ulcers.

An examination of the role and function of psychiatric nurses in clinical practice in Ireland

AIM OF THE STUDY

The aim of the study was to describe the role and function of all grades of psychiatric nurse in clinical practice so as to clarify the nature and scope of psychiatric nursing services.

BACKGROUND AND RATIONALE

The psychiatric nursing role in Ireland and the United Kingdom (UK) in recent years has undergone a period of great change. There is a new emphasis on health promotion, early intervention, community development, with nursing being provided closer to where people live and work as well as making access to services easier for vulnerable groups of the population. Role ambiguity and the difficulty with defining psychiatric nursing work is a constant theme in the psychiatric nursing literature and this leaves the profession of psychiatric nursing rather vulnerable during this period of intense change.

DESIGN AND METHODS

A descriptive qualitative research design with a multimethods approach to data collection was utilized involving three disparate but complimentary methods.

RESULTS AND FINDINGS

Following data analysis, nine categories of nursing role were identified; these included both independent and interdependent roles. Clearly psychiatric nursing occupied a pivotal role in all mental health care settings. A major proportion of psychiatric nursing related to caring interactions and this appears to be a central nursing element. The assessment and maintenance of patient's safety was also important as mental health problems may place the patient or others in a position where their physical safety is threatened.

CONCLUSION

It is concluded that Irish psychiatric nurses have been innovative and initiated many new services in response to emerging needs. Our understanding of psychiatric nursing is far from complete and the immediate challenge is to determine the knowledge and skills base required for independent therapeutic roles in response to changing mental health care needs.

The approaches to learning of student nurses in the Republic of Ireland and Northern Ireland

In recent years during a period of change in nurse education, there has been an increased interest in educational theory and nurse educators have examined and questioned the fundamental principles upon which the system of education is constructed. In nurse education it is likely that no single theory of learning can account for all aspects of learning and there are reflections of many learning theories in the nursing curriculum. The literature in the area of student learning is complex and wide ranging and is poorly represented in the nurse education literature. In recognition of a lack of understanding and clarity on learning approaches in nurse education during a period of unprecedented change in Irish and United Kingdom (UK) nurse education, this paper aims to highlight the importance of understanding student nurse learning. A study is described which investigated the approaches to learning of student nurses from the Republic of Ireland, who were receiving a traditional apprenticeship training, and student nurses from Northern Ireland in a Project 2000 programme. On comparative statistical analysis significant differences were identified between the two groups in their approaches to learning. It is concluded that students' constructs of learning in nurse education are primarily dependent on their interpretation of the demands of the task, on assessment, teaching and the learning environment. The study provides nurse educationalists with important evaluative information from the students' perspective. It suggests that the way forward is to identify the significant contextual factors influencing student learning and to incorporate them into the nursing curriculum. Such an approach will serve to focus the system on variability in the quality of learning rather than on stability in human attributes.

Student evaluation: a performance indicator of quality in nurse education

This study, which forms part of a doctoral thesis, is derived from the increasing demand for economic models of nurse education as a process within a wider economic agenda which converts inputs (e.g. training costs) into outputs (e.g. registered nurses). In such a climate the pursuance and determination of quality in nurse education should be of fundamental concern to the nursing profession. The development of models for evaluation and measurement of quality must take due cognisance of the stakeholders' interests and concerns, and student nurses, as the consumers of nurse education, must be regarded as major stakeholders. This paper describes the use of the course experience questionnaire, an instrument designed to investigate the students' perspective on teaching and learning. The study incorporates a comparative analysis between Project 2000 students in Northern Ireland and students in the apprenticeship programme in the Republic of Ireland, from general, psychiatric, sick children's and mental handicap nursing. This comparative analysis does provide the nursing profession with a level of feedback on which to make decisions in the interest of quality. Nurse teachers should examine potential reasons why their programmes are poorly or highly rated and the actions that may be required to remedy imperfections on the one hand and the actions that may be taken to promote excellence on the other. As nurse education continues to forge links with universities, nurse teachers, by adopting student evaluation as a performance indicator, can maximize an essential element in the web of public accountability.

The teaching/learning preferences of student nurses in the Republic of Ireland; background issues and a study

Teaching and learning in all forms of education is being increasingly reviewed in a climate of educational accountability. The literature generally displays a certain irrationality about nurse education; on the one hand teachers are espousing student-centred ideologies while on the other hand, students are expressing preferences for teacher-structured approaches. The research on nurse education generally concludes that the roles of teacher and student operate around a mechanistic view of man with the teacher being viewed as the front of all knowledge and the students the passive recipients of that which was given. This paper reports on related background issues, and a study of the teaching/learning preferences of student nurses from general, psychiatric, sick children's and mental handicap nursing. Whilst students reflected preferences for more teacher-structured strategies, significant differences were identified between the preferences of the four groups of student nurses. It is concluded that any insistence on a doctrinaire approach to teaching and learning would be unnecessarily restrictive to the whole process of nurse education. Nurse tutors therefore need to reflect on what they do, particularly that which influences the relationship between the students and what they learn. It is then the responsibility of nurse tutors to act on what they have learned about that relationship and their part in it.

Triangulation: a means of reconciliation in nursing research

The nursing profession has adopted many of its theoretical foundations, including research approaches, from other academic disciplines. This has resulted in the acceptance of one epistemological perspective to the exclusion of others. In this context, the evolution of nursing research reflects a rather conservative approach. The quantitative approach was the dominant paradigm of the 1950s, 1960s and during the 1970s and 1980s the research approach has been increasingly located in the qualitative paradigm. It is noted that each research perspective has several inherent differences which give rise to a specific type of research endeavour. Within the literature there is general support for the separateness of the quantitative qualitative paradigm. However in accepting the inherent differences between the two methods, nurse researchers have been concerned that neither method in isolation from the other will truly provide an understanding of human beings and of their health-related needs, problems or nursing care. Triangulation as a research strategy represents a means of integrating the two research approaches. Triangulation, first used in 1959, is defined as a combination of multi methods in a study of the same object or event to depict more accurately the phenomenon being investigated. The literature exploring the merits of triangulation is incomplete. However, it is reported that triangulation, by reconciling the paradigmatic assumptions inherent to quantitative and qualitative methods, provides rich and productive data. Triangulation does offer an alternative to the bi-polar quantitative and qualitative approaches and a means of reconciling the two methodological encampments.