From pilot to a multi-site trial: refining the Early Detection of Deterioration in Elderly Residents (EDDIE +) intervention

BACKGROUND

Early Detection of Deterioration in Elderly Residents (EDDIE +) is a multi-modal intervention focused on empowering nursing and personal care workers to identify and proactively manage deterioration of residents living in residential aged care (RAC) homes. Building on successful pilot trials conducted between 2014 and 2017, the intervention was refined for implementation in a stepped-wedge cluster randomised trial in 12 RAC homes from March 2021 to May 2022. We report the process used to transition from a small-scale pilot intervention to a multi-site intervention, detailing the intervention to enable future replication.

METHODS

The EDDIE + intervention used the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to guide the intervention development and refinement process. We conducted an environmental scan; multi-level context assessments; convened an intervention working group (IWG) to develop the program logic, conducted a sustainability assessment and deconstructed the intervention components into fixed and adaptable elements; and subsequently refined the intervention for trial.

RESULTS

The original EDDIE pilot intervention included four components: nurse and personal care worker education; decision support tools; diagnostic equipment; and facilitation and clinical support. Deconstructing the intervention into core components and what could be flexibly tailored to context was essential for refining the intervention and informing future implementation across multiple sites. Intervention elements considered unsustainable were updated and refined to enable their scalability. Refinements included: an enhanced educational component with a greater focus on personal care workers and interactive learning; decision support tools that were based on updated evidence; equipment that aligned with recipient needs and available organisational support; and updated facilitation model with local and external facilitation.

CONCLUSION

By using the i-PARIHS framework in the scale-up process, the EDDIE + intervention was tailored to fit the needs of intended recipients and contexts, enabling flexibility for local adaptation. The process of transitioning from a pilot to larger scale implementation in practice is vastly underreported yet vital for better development and implementation of multi-component interventions across multiple sites. We provide an example using an implementation framework and show it can be advantageous to researchers and health practitioners from pilot stage to refinement, through to larger scale implementation.

TRIAL REGISTRATION

The trial was prospectively registered with the Australia New Zealand Clinical Trial Registry (ACTRN12620000507987, registered 23/04/2020).

Impact of a prospective feedback loop on care review activities in older patients at the end of life. A stepped-wedge randomised trial

Background

Hospitalisation rates for older people are increasing, with end-of-life care becoming a more medicalised experience. Innovative approaches are warranted to support early identification of the end-of-life phase, communicate prognosis, provide care consistent with people’s preferences, and improve the use of healthcare resources. The Intervention for Appropriate Care and Treatment (InterACT) trial aimed to increase appropriate care and treatment decisions for older people at the end of life, through implementation of a prospective feedback loop. This paper reports on the care review outcomes.

Methods

A stepped-wedge randomised controlled trial was conducted in three large acute hospitals in Queensland, Australia between May 2020 and June 2021. The trial identified older people nearing the end of life using two validated tools for detecting deterioration and short-term death. Admitting clinical teams were provided with details of patients identified as at-risk with the goal of increasing awareness that end of life was approaching to facilitate appropriate patient centred care and avoid non-beneficial treatment. We examined the time between when the patient was identified as ‘at-risk’ and three outcomes: clinician-led care review discussions, review of care directive measures and palliative care referrals. These were considered useful indicators of appropriate care at the end of life.

Results

In two hospitals there was a reduction in the review of care directive measures during the intervention compared with usual care at 21 days (reduced probability of − 0.08; 95% CI: − 0.12 to − 0.04 and − 0.14; 95% CI: − 0.21 to − 0.06). In one hospital there was a large reduction in clinician-led care review discussions at 21 days during the intervention (reduced probability of − 0.20; 95% CI: − 0.28 to − 0.13). There was little change in palliative care referrals in any hospital, with average probability differences at 21 days of − 0.01, 0.02 and 0.04.

Discussion

The results are disappointing as an intervention designed to improve care of hospitalised older people appeared to have the opposite effect on care review outcomes. The reasons for this may be a combination of the intervention design and health system challenges due to the pandemic that highlight the complexity of providing more appropriate care at the end of life.

Trial registration

Australia New Zealand Clinical Trial Registry, ACTRN12619000675123 (registered 6 May 2019).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03554-x.

A stepped-wedge randomised controlled trial assessing the implementation, effectiveness and cost-consequences of the EDDIE+ hospital avoidance program in 12 residential aged care homes: study protocol

Background

Older people living in residential aged care homes experience frequent emergency transfers to hospital. These events are associated with risks of hospital acquired complications and invasive treatments or interventions. Evidence suggests that some hospital transfers may be unnecessary or avoidable. The Early Detection of Deterioration in Elderly residents (EDDIE) program is a multi-component intervention aimed at reducing unnecessary hospital admissions from residential aged care homes by empowering nursing and care staff to detect and manage early signs of resident deterioration. This study aims to implement and evaluate the program in a multi-site randomised study in Queensland, Australia.

Methods

A stepped-wedge randomised controlled trial will be conducted at 12 residential aged care homes over 58 weeks. The program has four components: education and training, decision support tools, diagnostic equipment, and implementation facilitation with clinical systems support. The integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework will be used to guide the program implementation and process evaluation. The primary outcome measure will be the number of hospital bed days used by residents, with secondary outcomes assessing emergency department transfer rates, admission rates, length of stay, family awareness and experience, staff self-efficacy and costs of both implementation and health service use. A process evaluation will assess the extent and fidelity of program implementation, mechanisms of impact and the contextual barriers and enablers.

Discussion

The intervention is expected to improve outcomes by reducing unnecessary hospital transfers. Fewer hospital transfers and admissions will release resources for other patients with potentially greater needs. Residential aged care home staff might benefit from feelings of empowerment in their ability to proactively manage early signs of resident deterioration. The process evaluation will be useful for supporting wider implementation of this intervention and other similar initiatives.

Trial registration

The trial is prospectively registered with the Australia New Zealand Clinical Trial Registry (ACTRN12620000507987, registered 23/04/2020).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02294-8.

A stepped-wedge randomised-controlled trial assessing the implementation, impact and costs of a prospective feedback loop to promote appropriate care and treatment for older patients in acute hospitals at the end of life: study protocol

BACKGROUND

Hospitalisation rates for the older population have been increasing with end-of-life care becoming a more medicalised and costly experience. There is evidence that some of these patients received non-beneficial treatment during their final hospitalisation with a third of the non-beneficial treatment duration spent in intensive care units. This study aims to increase appropriate care and treatment decisions and pathways for older patients at the end of life in Australia. This study will implement and evaluate a prospective feedback loop and tailored clinical response intervention at three hospitals in Queensland, Australia.

METHODS

A stepped-wedge cluster randomised trial will be conducted with up to 21 clinical teams in three acute hospitals over 70 weeks. The study involves clinical teams providing care to patients aged 75 years or older, who are prospectively identified to be at risk of non-beneficial treatment using two validated tools for detecting death and deterioration risks. The intervention's feedback loop will provide the teams with a summary of these patients' risk profiles as a stimulus for a tailored clinical response in the intervention phase. The Consolidated Framework for Implementation Research will be used to inform the intervention's implementation and process evaluation. The study will determine the impact of the intervention on patient outcomes related to appropriate care and treatment at the end of life in hospitals, as well as the associated healthcare resource use and costs. The primary outcome is the proportion of patients who are admitted to intensive care units. A process evaluation will be carried out to assess the implementation, mechanisms of impact, and contextual barriers and enablers of the intervention.

DISCUSSION

This intervention is expected to have a positive impact on the care of older patients near the end of life, specifically to improve clinical decision-making about treatment pathways and what constitutes appropriate care for these patients. These will reduce the incidence of non-beneficial treatment, and improve the efficiency of hospital resources and quality of care. The process evaluation results will be useful to inform subsequent intervention implementation at other hospitals.

TRIAL REGISTRATION

Australia New Zealand Clinical Trial Registry (ANZCTR), ACTRN12619000675123p (approved 6 May 2019).

Cost-effectiveness of an Environmental Cleaning Bundle for Reducing Healthcare-associated Infections

BACKGROUND

Healthcare-associated infections (HAIs) remain a significant patient safety issue, with point prevalence estimates being ~5% in high-income countries. In 2016-2017, the Researching Effective Approaches to Cleaning in Hospitals (REACH) study implemented an environmental cleaning bundle targeting communication, staff training, improved cleaning technique, product use, and audit of frequent touch-point cleaning. This study evaluates the cost-effectiveness of the environmental cleaning bundle for reducing the incidence of HAIs.

METHODS

A stepped-wedge, cluster-randomized trial was conducted in 11 hospitals recruited from 6 Australian states and territories. Bundle effectiveness was measured by the numbers of Staphylococcus aureus bacteremia, Clostridium difficile infection, and vancomycin-resistant enterococci infections prevented in the intervention phase based on estimated reductions in the relative risk of infection. Changes to costs were defined as the cost of implementing the bundle minus cost savings from fewer infections. Health benefits gained from fewer infections were measured in quality-adjusted life-years (QALYs). Cost-effectiveness was evaluated using the incremental cost-effectiveness ratio and net monetary benefit of adopting the cleaning bundle over existing hospital cleaning practices.

RESULTS

Implementing the cleaning bundle cost $349 000 Australian dollars (AUD) and generated AUD$147 500 in cost savings. Infections prevented under the cleaning bundle returned a net monetary benefit of AUD$1.02 million and an incremental cost-effectiveness ratio of $4684 per QALY gained. There was an 86% chance that the bundle was cost-effective compared with existing hospital cleaning practices.

CONCLUSIONS

A bundled, evidence-based approach to improving hospital cleaning is a cost-effective intervention for reducing the incidence of HAIs.

Protocol for a randomised trial testing a community fibrosis assessment service for patients with suspected non-alcoholic fatty liver disease: LOCal assessment and triage evaluation of non-alcoholic fatty liver disease (LOCATE-NAFLD)

Background

Non-alcoholic fatty liver disease (NAFLD) is the most common type of chronic liver disease in Australia and its recent increase mirrors the obesity and type 2 diabetes epidemics. Currently, many patients who present to primary care with abnormal liver function tests or steatosis on liver ultrasound are referred for assessment in secondary care. Due to the large number of patients with NAFLD, this results in long waits for clinical and fibrosis assessment, placing unnecessary burden on the public hospital system.

Methods

We will conduct a 1:1 parallel randomised trial to compare two alternative models of care for NAFLD. Participants will be randomised to usual care or the LOCal Assessment and Triage Evaluation (LOCATE) model of care and followed for 1 year. We will recruit patients from the non-neighbouring Sunshine Coast and Metro South Hospital and Health Services (HHSs) in Queensland, Australia. Our primary outcome of interest is time to diagnosis of high-risk NAFLD, based on the number of participants in each arm of the study who receive a diagnosis of clinically significant fibrosis. Two hundred and 34 participants will give us a 95% power to detect a 50% reduction in the primary outcome of time to diagnosis of high-risk disease. We will also conduct an economic evaluation, evaluating the cost-effectiveness of the new model of care. We will also evaluate the implementation of the new model of care.

Discussion

It is anticipated that the results of this study will provide valuable new information regarding the management of NAFLD in the Australian setting. A relatively simple change to care could result in earlier identification of patients with significant liver disease and lower overall costs for the health system. Results will be directly disseminated to key staff for further distribution to consumers, policy- and decision-makers in the form of evidence briefs, plain language summaries and policy recommendations.

Trial registration

The trial was registered on 30 January, 2020 and can be found via ANZCTR - number ACTRN12620000158965.

Evaluating bio-burden of frequently touched surfaces using Adenosine Triphosphate bioluminescence (ATP): Results from the Researching Effective Approaches to Cleaning in Hospitals (REACH) trial

BACKGROUND

Environmental cleaning is an important approach to reducing healthcare-associated infection. The aim of this short research paper is to describe changes in the efficacy of post-discharge cleaning by examining the amount of bio-burden on frequent touch points (FTPs) in patient areas, using a validated Adenosine Triphosphate (ATP) bioluminescence sampling method. In so doing, we present findings from a secondary outcome of a recent trial, the Researching Effective Approaches to Cleaning in Hospitals (REACH) study.

METHODS

The REACH study used a prospective, stepped-wedge randomised cluster design. Cross sectional ATP sampling was conducted at three of the 11 participating hospitals. At each hospital, during the control and intervention phase of the study, six Frequent Touch Points (FTPs) were sampled: toilet flush, bathroom tap, inside bathroom door handle, patient call button, over bed tray table, and bed rails.

RESULTS

Across the three hospitals, 519 surfaces in 49 rooms (control phase) and 2856 surfaces in 251 rooms (intervention phase) were sampled. Bedroom FTP cleaning improved across all three hospitals. The cleaning of bathroom FTPs was generally high from the outset and remained consistent throughout the whole study period. Average cleaning outcomes for bathroom FTPs were consistently high during the control period however outcomes varied between individual FTP. Changes in cleaning performance over time reflected variation in intervention effectiveness at the hospital level.

CONCLUSION

Findings confirm improvement in cleaning in the FTPs in bedrooms, demonstrating improvements in discharge cleaning aligned with the improvements seen when using fluorescent marking technology as a marker of performance.

Effectiveness of a structured, framework-based approach to implementation: the Researching Effective Approaches to Cleaning in Hospitals (REACH) Trial

Background

Implementing sustainable practice change in hospital cleaning has proven to be an ongoing challenge in reducing healthcare associated infections. The purpose of this study was to develop a reliable framework-based approach to implement and quantitatively evaluate the implementation of evidence-based practice change in hospital cleaning.

Design/methods

The Researching Effective Approaches to Cleaning in Hospitals (REACH) trial was a pragmatic, stepped-wedge randomised trial of an environmental cleaning bundle implemented in 11 Australian hospitals from 2016 to 2017. Using a structured multi-step approach, we adapted the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to support rigorous and tailored implementation of the cleaning bundle intervention in eleven diverse and complex settings. To evaluate the effectiveness of this strategy we examined post-intervention cleaning bundle alignment calculated as a score (an implementation measure) and cleaning performance audit data collected using ultraviolet (UV) gel markers (an outcome measure).

Results

We successfully implemented the bundle and observed improvements in cleaning practice and performance, regardless of hospital size, intervention duration and contextual issues such as staff and organisational readiness at baseline. There was a positive association between bundle alignment scores and cleaning performance at baseline. This diminished over the duration of the intervention, as hospitals with lower baseline scores were able to implement practice change successfully.

Conclusion

Using a structured framework-based approach allows for pragmatic and successful implementation of clinical trials across diverse settings, and assists with quantitative evaluation of practice change.

Trial registration

Australia New Zealand Clinical Trial Registry ACTRN12615000325505, registered on 4 September 2015.

An environmental cleaning bundle and health-care-associated infections in hospitals (REACH): a multicentre, randomised trial

BACKGROUND

The hospital environment is a reservoir for the transmission of microorganisms. The effect of improved cleaning on patient-centred outcomes remains unclear. We aimed to evaluate the effectiveness of an environmental cleaning bundle to reduce health care-associated infections in hospitals.

METHODS

The REACH study was a pragmatic, multicentre, randomised trial done in 11 acute care hospitals in Australia. Eligible hospitals had an intensive care unit, were classified by the National Health Performance Authority as a major hospital (public hospitals) or having more than 200 inpatient beds (private hospitals), and had a health-care-associated infection surveillance programme. The stepped-wedge design meant intervention periods varied from 20 weeks to 50 weeks. We introduced the REACH cleaning bundle, a multimodal intervention, focusing on optimising product use, technique, staff training, auditing with feedback, and communication, for routine cleaning. The primary outcomes were incidences of health-care-associated Staphylococcus aureus bacteraemia, Clostridium difficile infection, and vancomycin-resistant enterococci infection. The secondary outcome was the thoroughness of cleaning of frequent touch points, assessed by a fluorescent marking gel. This study is registered with the Australian and New Zealand Clinical Trial Registry, number ACTRN12615000325505.

FINDINGS

Between May 9, 2016, and July 30, 2017, we implemented the cleaning bundle in 11 hospitals. In the pre-intervention phase, there were 230 cases of vancomycin-resistant enterococci infection, 362 of S aureus bacteraemia, and 968 C difficile infections, for 3 534 439 occupied bed-days. During intervention, there were 50 cases of vancomycin-resistant enterococci infection, 109 of S aureus bacteraemia, and 278 C difficile infections, for 1 267 134 occupied bed-days. After the intervention, vancomycin-resistant enterococci infections reduced from 0·35 to 0·22 per 10 000 occupied bed-days (relative risk 0·63, 95% CI 0·41-0·97, p=0·0340). The incidences of S aureus bacteraemia (0·97 to 0·80 per 10 000 occupied bed-days; 0·82, 0·60-1·12, p=0·2180) and C difficile infections (2·34 to 2·52 per 10 000 occupied bed-days; 1·07, 0·88-1·30, p=0·4655) did not change significantly. The intervention increased the percentage of frequent touch points cleaned in bathrooms from 55% to 76% (odds ratio 2·07, 1·83-2·34, p<0·0001) and bedrooms from 64% to 86% (1·87, 1·68-2·09, p<0·0001).

INTERPRETATION

The REACH cleaning bundle was successful at improving cleaning thoroughness and showed great promise in reducing vancomycin-resistant enterococci infections. Our work will inform hospital cleaning policy and practice, highlighting the value of investment in both routine and discharge cleaning practice.

FUNDING

National Health and Medical Research Council (Australia).

Changes in knowledge and attitudes of hospital environmental services staff: The Researching Effective Approaches to Cleaning in Hospitals (REACH) study

BACKGROUND

The Researching Effective Approaches to Cleaning in Hospitals (REACH) study tested a multimodal cleaning intervention in Australian hospitals. This article reports findings from a pre/post questionnaire, embedded into the REACH study, that was administered prior to the implementation of the intervention and at the conclusion of the study.

METHODS

A cross-sectional questionnaire, nested within a stepped-wedge trial, was administered. The REACH intervention was a cleaning bundle comprising 5 interdependent components. The questionnaire explored the knowledge, reported practice, attitudes, roles, and perceived organizational support of environmental services staff members in the hospitals participating in the REACH study.

RESULTS

Environmental services staff members in 11 participating hospitals completed 616 pre- and 307 post-test questionnaires (n = 923). Increases in knowledge and practice were seen between the pre-and post-test questionnaires. Minimal changes were observed in attitudes regarding the role of cleaning and in perceived organizational support.

CONCLUSION

To our knowledge, this is the first study to report changes in knowledge, attitudes, and perceived organizational support in environmental services staff members, in the context of a large multicenter clinical trial. In this underexplored group of hospital workers, findings suggest that environmental services staff members have a high level of knowledge related to cleaning practices and understand the importance of their role.

The high costs of getting ethical and site-specific approvals for multi-centre research

Background

Multi-centre studies generally cost more than single-centre studies because of larger sample sizes and the need for multiple ethical approvals. Multi-centre studies include clinical trials, clinical quality registries, observational studies and implementation studies. We examined the costs of two large Australian multi-centre studies in obtaining ethical and site-specific approvals.

Methods

We collected data on staff time spent on approvals and expressed the overall cost as a percent of the total budget.

Results

The total costs of gaining approval were 38 % of the budget for a study of 50 centres (mean cost AUD $6960 per site) and 2 % for a study of 11 centres (mean cost AUD $2300 per site). Seventy-five and 90 % of time was spent on repeated tasks, respectively, and many time-consuming tasks, such as reformatting documents, did nothing to improve the study design or participant safety.

Conclusions

Improvements have been made to the ethical approval application system, but more gains could be made without increasing risks of harm to research participants. We propose that ethical review bodies and individual sites publish statistics on how long they take to process approvals which could then be nationally benchmarked.

Researching effective approaches to cleaning in hospitals: protocol of the REACH study, a multi-site stepped-wedge randomised trial

Background

The Researching Effective Approaches to Cleaning in Hospitals (REACH) study will generate evidence about the effectiveness and cost-effectiveness of a novel cleaning initiative that aims to improve the environmental cleanliness of hospitals. The initiative is an environmental cleaning bundle, with five interdependent, evidence-based components (training, technique, product, audit and communication) implemented with environmental services staff to enhance hospital cleaning practices.

Methods/design

The REACH study will use a stepped-wedge randomised controlled design to test the study intervention, an environmental cleaning bundle, in 11 Australian hospitals. All trial hospitals will receive the intervention and act as their own control, with analysis undertaken of the change within each hospital based on data collected in the control and intervention periods. Each site will be randomised to one of the 11 intervention timings with staggered commencement dates in 2016 and an intervention period between 20 and 50 weeks. All sites complete the trial at the same time in 2017. The inclusion criteria allow for a purposive sample of both public and private hospitals that have higher-risk patient populations for healthcare-associated infections (HAIs). The primary outcome (objective one) is the monthly number of Staphylococcus aureus bacteraemias (SABs), Clostridium difficile infections (CDIs) and vancomycin resistant enterococci (VRE) infections, per 10,000 bed days. Secondary outcomes for objective one include the thoroughness of hospital cleaning assessed using fluorescent marker technology, the bio-burden of frequent touch surfaces post cleaning and changes in staff knowledge and attitudes about environmental cleaning. A cost-effectiveness analysis will determine the second key outcome (objective two): the incremental cost-effectiveness ratio from implementation of the cleaning bundle.

The study uses the integrated Promoting Action on Research Implementation in Health Services (iPARIHS) framework to support the tailored implementation of the environmental cleaning bundle in each hospital.

Discussion

Evidence from the REACH trial will contribute to future policy and practice guidelines about hospital environmental cleaning. It will be used by healthcare leaders and clinicians to inform decision-making and implementation of best-practice infection prevention strategies to reduce HAIs in hospitals.

Trial registration

Australia New Zealand Clinical Trial Registry ACTRN12615000325505

The adolescent dissociative experiences scale: psychometric properties and difference in scores across age groups

Adolescence is thought to be a key developmental period for dissociative processes. However, there has been little empirical investigation of dissociation in adolescence. This paper reports the results of a study (N = 768) that investigated the psychometric properties of the Adolescent Dissociative Experiences Scale (A-DES) and compares dissociation scores across the adolescent age range (11 to 16 years). The A-DES had good internal reliability and a one-factor solution. No significant age or gender differences in A-DES scores were found. The implications of these findings for future research and theory are outlined.

User views of a regional secure unit--findings from a patient satisfaction survey

This paper includes key findings of a patient satisfaction survey, conducted within an English Medium Secure Unit, offering care and treatment for 45 male and female mentally disordered offenders. It aims to identify patients' perceptions of the quality of their care and other aspects of their lives within the secure unit. Following permission from the local Ethics Committee, two interviewers collected data within a two week period, using a semi-structured interview schedule. All but three of the respondents agreed to be interviewed. Talking to nurses was perceived as highly satisfying. However, provision for specific cultural and women's needs, facilities for visitors, opportunities to practise religious beliefs and access to care plans were highlighted as unsatisfactory. The study concludes with recommendations for improvement, some of which have already been considered and implemented.

Mental health services--maintaining strategic direction

AIM AND KEY ISSUES: This article reviews the theoretical basis of strategic management in an attempt to provide managers with a better understanding of the underpinning concepts and consequent actions they need to take to avoid loss of control and ultimate failure.

BACKGROUND

The authors argue that community care for the severely mentally ill is failing and that in part the reason for this perceived failure is a closer allegiance to primary care that has shifted the focus away from mental illness. Such a shift, coupled with poor management and a desire by Community Mental Health Nurses (CMHNs) to retain a broad focus and maintain the 'autonomy' they gain when not held in the gravitational grasp of Consultant Psychiatrists, has resulted in strategic drift. The authors suggest 10 possible reasons to explain why CMHNs currently fail to meet the needs of the severely mentally ill. Among these are a lack of explicit strategic implementation plans, professional ambivalence and self-interest, poor management of resources and conflicting demands from key interest groups.

CONCLUSION

It seems that mental health services in this country have reached the point where resistance to change should be crumbling in the face of perceived failure to deliver the required services. Whilst it could be argued that a major and potent source of internal change is performance gaps, few things force change more than sudden and unexpected information about poor organizational performance.

Primary healthcare workers: training needs in mental health

Particular attention is currently being given to the role of primary healthcare workers in supporting people with mental health problems in primary care (McFadyen et al, 1996). The aim of this study was to survey the views of primary healthcare workers regarding their previous mental health training and to identify their current perceived mental health training needs. A sample of 200 primary healthcare workers within Trent Health Region were interviewed using a short semi-structured interview schedule. Forty-six completed questionnaires were also received. An additional 22 respondents participated in exploratory in-depth interviews. Respondents included GPs, health visitors, practice nurses, district nurses, midwives and community psychiatric nurses. The need for further training in communication skills, particularly basic counselling skills, was highlighted. Respondents also perceived a need for additional training in coping with their own personal stress, the assessment and treatment of depression and stress/anxiety management in clients. Several themes which developed from the research were explored, including communication skills training, problems with collaborative working, coping with personal stress, the prevention of burnout and depression training. The reason why some respondents had no mental health training needs whatsoever was also addressed.

Creating a new brand of mental health nurse

Mental health nurse training provision has been criticized for failing to develop practitioners with the appropriate skills to care for clients with severe mental illness (Owen and Sweeney, 1995), However, a tide of change is about to wash over the initial and ongoing education of mental health nurses.

Strategies for reducing stress and burnout in nursing

Three models of stress-the stimulus model, the response model and the cognitive-phenomenological-transactional (CPT) model-have been described in detail elsewhere (Farrington, 1995), and the notion of accepting occupational stress as an industrial disease has been suggested (Nursing Times, 1995). This article focuses on the nursing experience of stress and describes strategies for reducing stress and burnout on a personal and organizational level. It concludes by presenting a small-scale research study which examined the nature and impact of events perceived by postregistration nurses to cause personal psychological distress. The findings of the research show that certain stimuli are consistently perceived as being psychologically traumatizing in the daily working life of the student nurse. Nursing clearly remains an emotionally demanding occupation and more work is needed to examine the way in which events and microstressors are cognitively processed by nurses.

The failure of community care for the severely mentally ill

For the past 10 years or more there has been an ongoing debate about community mental health (CMH) nursing. It is clearly important in any discourse about CMH nursing to begin by examining where this branch of nursing is at present, i.e. what route it has taken, as well as considering where it is destined to travel. The views expressed in this article are supported by a literature review undertaken as part of a research study into CMH nursing. The first and quantitative stage, which was completed in late 1995, and the second qualitative part of the study has now reached the data analysis stage. The preliminary findings from this study are discussed in this article.

Developing a research culture for nursing in higher education

For colleges of nursing that have moved into higher education over the last 12-18 months, the forthcoming Research Assessment Exercise 1996, conducted by the Higher Education Funding Council, is unlikely to be very meaningful or impact on research activities. While the mission of colleges of nursing, before integration, was to provide good quality teaching, underpinned by innovative curriculum design, the future of nursing in higher education, after integration, is likely to be quite different.

Models of clinical supervision

This article describes several schools of practice in relation to clinical supervision and discusses models of supervision, particularly an integrative approach to clinical supervision in mental health practice. While it is recognised that clinical supervision is more likely to occur in mental health nursing, the article concludes by suggesting a broader application of the underlying principles described.

Shared governance: developing a British model

This article will examine the concept of shared governance and describe the development of a model for a British NHS trust. The philosophy of shared governance will be related to a decentralised style of management and the consequences that this will have for managers and staff nurses. The introduction of shared governance in the USA has realised many benefits. However, limitations have also been illustrated and these will be discussed in relation to the proposed model for Leicester General Hospital.

Stress and nursing

This article looks at definitions and models of stress and examines sources of stress in nursing and the assessment and measurement of stress factors.

Suicide and psychological debriefing

The death of a patient by suicide is one of many upsetting experiences that nurses face. However, psychological debriefing after such an event is not commonly available.

Cancer, emotional responses and cognitive behavioural psychotherapy

Cancer and its treatment is known to have a substantial psychological morbidity and, while adjuvant psychological therapy (APT) is well established, relatively little work has been done to investigate the effectiveness of psychotherapy, particularly cognitive behaviour therapy (CBT), for patients with cancer. This article focuses initially on emotional responses to the diagnosis of cancer, individual vulnerability and the prevalence of psychological problems in patients with cancer. The use of cognitive behaviour therapy is then described, together with key issues in its application and specific problems. The work concludes by considering differences in applying CBT to patients with cancer compared to patients with other physical illnesses and the notion of 'relapse inoculation'.

The fourth paradigm: a new model of leadership for managing nurse education

Over 20 years ago Toffler suggested that 'tomorrow's individual will have to cope with even more hectic change than we do today' and that for education the lesson is clear, 'its prime objective must be to increase the individuals 'copeability'--the speed and economy with which he/she can adapt to continual change and the faster the rate of change, the more attention must be devoted to discerning the pattern of future events' (Toffler 1970). Knowledge and understanding about what produces change in education is often unclear, however, many theories exist to account for change, which has been described as 'the most recalcitrant subject in the social sciences' (Clark 1983). This work considers change and process and includes types of change, the process and management of change, and models of organization. The integration of colleges of nursing into higher education and university departments is then discussed before the article concludes, by putting forward a new model of leadership for nurse education--the fourth paradigm.

Change, revolt and the student nurse

Nurse education is facing great changes which challenge traditional methods of training and educating student nurses. Project 2000, college amalgamation and links with universities have coincided with a drive towards increasing opportunities for nurses to achieve graduate status and generally raise the academic status of nursing as a profession. The student nurses caught up in these changes must be more than passive recipients of information, or dissatisfaction will occur. The author considers the unsettling effect of change on students and, through examination of factors such as teachers' attitudes and adult education, concludes that student participation in programme planning and policy-making must become more widespread of educators are to avoid dissatisfaction turning to revolt.

Transcultural psychiatry, ethnic minorities and marginalization

Cultural and racial bias has been woven into the fabric of Western psychiatry in its historic development. Western psychiatry emphasizes the medical model as being fundamental to the discipline. Many communities in large cities and industrial areas have become multicultural and multiracial. Culture-bound syndromes are not specific to non-Western ethnic minorities. Black people are overrepresented among psychiatric patients in institutions. Mental health services for ethnic minorities have been haphazard and inconsistent. Cultural experiences and the practical realities of racism are overdue their recognition.

Intuition and expert clinical practice in nursing

The quest for the essence of nursing in the UK continues unabated. Similarly, the concept of what constitutes expert clinical practice and the problem of how it can be achieved are topical issues. This article considers the notion of a developmental process in nursing and the concept of reflective practice, and examines the idea of intuition as a key component in the functioning of the expert nurse.

Mental health nursing: now you see it, now you don't

As we enter the closing decade of this century, mental health nursing has reached a crisis point and is on the road to invisibility. If the marginalization of mental health nursing continues it will reach the end of that road before the year 2000.

Caring for people with learning difficulties in Czechoslovakia

In June 1992 a massive step forward was made in Czechoslovakia when the first school for people with learning difficulties was opened. This article examines the problems facing this school and the background to its creation.