Promoting mental health care in a rural paediatric unit through participatory action research

Objective:  To explore, advance and evaluate mental health practices in a rural general paediatric unit through participatory action research.
Design:  A participatory action research approach guided this study, providing an opportunity for nursing staff to become actively involved in the design, direction and outcomes of the research.
Setting:  A 16-bed paediatric unit of a rural general hospital.
Participants:  A purposive convenience sample of all paediatric nursing staff ( n =  20; of 24 nurses).
Outcome measures:  In the first phase of this study, focus groups were conducted to explore the experiences of nurses.
Results:  Participants considered mental health to be a specialist discipline area and the role of the mental health nurse to be complex. They felt that their lack of training and experience with mental health issues was detrimental to the delivery of optimal patient care. There was concern about differing approaches to treatment, relationships with other mental health services and the suitability of the ward environment for young people with a mental health problem. Participants called for training by qualified mental health staff and the development of policies and clinical guidelines to facilitate their delivery of care to patients with a mental health problem in an acute medical environment.
Conclusions:  There is a clear need for nursing specialities to work together to ensure that optimal care is given to patients admitted to general hospital with a mental health issue. Given the absence of accessible specialist child mental health inpatient units in regional and remote areas, upskilling paediatric nurses must be a priority.     

Regional differences among employed nurses: A Queensland study

Objective:  To ascertain differences in the working lives of geographically dispersed nurses.
Design:  Cross-sectional.
Setting:  Registered, enrolled and assistants-in-nursing members of the Queensland Nurses' Union employed in nursing in Queensland, Australia.
Participants:  A total of 3000 members of the Union, equally stratified by sector (public, private, aged care). Among them, 1192 responded and 1039 supplied postcodes matching the Australian Standard Geographical Classification.
Main outcome measures:  Statistically significant differences in working lives of nurses employed in different geographical locations.
Results:  Nurses in outer regional/remote/very remote localities are more likely to be employed as permanent full-time staff and self-report higher levels of work stress. These levels could be explained by: lack of replacement staff for leave, longer working and on call hours and lack of support for new staff. Distance remains a major barrier to accessing continuing professional education. However, outer regional/remote/very remote nurses were more likely to be provided employer support for professional education. Inner regional nurses were more likely to work part time, would work more hours if offered and were more likely to have taken a break from nursing as a result of family commitments.
Conclusion:  The data confirm that current policies are not addressing the differences in the working lives of geographically dispersed nurses. Policies addressing orientation, mentoring and workloads should be implemented to address these issues.     

Health risks for older US adolescents in foster care: the significance of important others' health behaviours on youths' health and health behaviours

Background   Little research to date has examined older foster care youths' physical health and the associated health behaviours of the youth and important people in their lives (parents, peers and important non-parental adults).
Methods   Older US foster care youth ( n = 188) completed surveys on multiple indicators of self-report physical health, including number of chronic health problems, overall health and sick symptoms, as well as their own health-compromising behaviours and the health-compromising behaviours of important others.
Results   The findings suggested that boys, particularly those placed in non-kin foster homes and group homes, appeared to have poorer health than did boys in these placement settings. Girls, however, engaged in similar levels of health-compromising behaviours as boys. Furthermore, the health-compromising behaviours of peers and important non-parental adults (VIPs), but not parents, were associated with youths' health behaviours, which, in turn, were associated with the physical health status of the foster care youth.
Conclusion   Youth report high levels of health-related problems and involvement in health-compromising behaviours. Healthcare practitioners can help to improve the health and well-being of children in foster care by becoming informed about adolescent health behaviours, as well as the health behaviours of their peers and other important non-parental adults.     

The Effect of Capitation on Switching Primary Care Physicians

Objective.  To examine the relationship between patient case-mix, utilization, primary care physician (PCP) payment method, and the probability that patients switch their PCPs.
Data Sources/Study Setting.  Administrative enrollment and claims/encounter data for 1994–1995 from four physician organizations.
Study Design.  We developed a conceptual model of patient switching behavior, which we used to guide the specification of multivariate logistic analyses focusing on interactions between patient case-mix, utilization, and PCP reimbursement methods.
Data Collection/Extraction Methods.  Claims data were aggregated to the encounter level; a switch was defined as a change in PCP since the previous encounter. The PCPs were reimbursed on either a capitated or fee-for-service (FFS) basis.
Principal Findings.  Patients with stable chronic conditions (Ambulatory Diagnostic Groups [ADG] 10) and capitated PCPs were 36 percent more likely to switch PCPs than similar patients with FFS PCPs, controlling for patient age and sex and physician fixed effects. When the number of previous encounters was included in the model, this relationship was no longer significant. Instead high utilizers with capitated PCPs were significantly more likely to switch PCPs than were similar patients with FFS PCPs.
Conclusions.  A patient's demographics and utilization are associated with the probability that the patient will switch PCPs. Capitated PCP payment was associated with higher rates of switching among high utilizers of health care resources. These findings raise concerns about the continuity and quality of care experienced by vulnerable patients in an era of changing financial incentives.     

Is there adequate feeding assistance for the hospitalised elderly who are unable to feed themselves?

Objective:  To observe patients at meal times in order to determine the type and amount of feeding assistance required by hospitalised elderly patients and the adequacy of assistance nursing staff provide to patients.
Methods:  The study was an observational study. Patients admitted to the ward were observed over a one-week period encompassing all meals (breakfast, lunch, dinner and snacks) served on a 14-day menu cycle.
Subjects:  A total of 46 hospitalised elderly patients with mean age 86.5 ± 4.8 years admitted to the ward.
Setting:  The study was undertaken in a general teaching hospital geriatric ward in Sydney.
Results:  A high percentage of patients required some assistance with feeding at meals (70%, n = 32). The partially dependent patients had their needs basically fulfilled by ward staff. However, of the nine totally dependent patients, three were observed lacking any assistance (33%). The amount of assistance time from nursing staff was found shorter than that from non-nursing staff, 123 and 137 minutes, respectively. Nursing assistants were the main providers of assisted eating in the ward. However, little attention and time were given to that task by registered nurses.
Discussion:  Provision of assisted eating by nursing staff presents many problems. More than 40% of hospital food was wasted and patients' recommended intakes for preserving health were not met. Hospital feeding policies and staff arrangements therefore need reviewing.
Conclusions:  Although assisting patients who are unable to feed themselves is a time-consuming process, it is a vital and necessary part of nursing care.     

Patients' perceptions and experiences of transitions in diabetes care: a longitudinal qualitative study

Objective  To examine patients' perceptions and experiences over time of the devolvement of diabetes care/reviews from secondary to primary health-care settings.
Design  Repeat in-depth interviews with 20 patients over 4 years.
Participants and setting  Twenty type 2 diabetes patients recruited from primary- and secondary-care settings across Lothian, Scotland.
Results  Patients' views about their current diabetes care were informed by their previous service contact. The devolvement of diabetes care/reviews to general practice was presented as a 'mixed blessing'. Patients gained reassurance from their perception that receiving practice-based care/reviews signified that their diabetes was well-controlled. However, they also expressed resentment that, by achieving good control, they received what they saw as inferior care and/or less-frequent reviews to others with poorer control. While patients tended to regard GPs as having adequate expertise to conduct their practice-based reviews, they were more ambivalent about nurses taking on this role. Opportunities to receive holistic care in general practice were not always realized due to patients seeing health-care professionals for diabetes management to whom they would not normally present for other health issues.
Conclusions  It is important to educate patients about their care pathways, and to reassure them that frequency of reviews depends more on clinical need than location of care and that similar care guidelines are followed in hospital clinics and general practice. A patients' history of service contact may need to be taken into account in future studies of service satisfaction.     

Occupational performance modification and personal change among clients receiving rehabilitation services for rheumatoid arthritis

Background:  A client's personal process of change is recognised as an important element in the rehabilitation process that may affect the acceptance and outcome of recommended occupational therapy self-management interventions. Recent research has examined the transformative process of changing underlying values, beliefs, feelings and knowledge, collectively known as meaning perspectives, in clients receiving rehabilitation for various chronic conditions.
Aim/methods:  This article presents the findings of a Grounded Theory Qualitative retrospective study of 10 adults diagnosed with rheumatoid arthritis receiving occupational therapy to modify their daily living environment and activities to maximise the quality of life and occupational performance. They were interviewed twice in a semidirected manner.
Results:  Two personal change processes were identified for two different courses of the illness: progressive adaptation during a course of gradual steady development of symptoms without remission, and complex adaptation that led to transformation during a course of acute development of symptoms with periods of remission.
Conclusion:  Implications for more effective and efficient occupational therapy interventions are suggested.     

Exploring kidney patients' experiences of receiving individual peer support

Background  Peer support schemes of various types are commonly offered to patients as an adjunct to health and social care services provided by professionals. For patients with chronic illness, peer support interventions have recently become associated with more directive attempts to increase self management and improve healthcare outcomes. There is little qualitative research on patients' experiences of one-to-one peer support.
Purpose  To explore kidney patients' experiences of receiving individual peer support.
Setting  Two large teaching hospital renal units in South London, with peer support services for patients on the pre-dialysis care pathway.
Methods  Qualitative telephone interviews with a purposive, maximum variation sample of 20 people who had received peer support.
Results  The majority of respondents were overwhelmingly positive about their experience of peer support and its benefits. They valued peer support because it had given them access to practical information about kidney disease, based on lived experience, which helped them reach decisions about treatment. Peer supporters offered patients empathy and understanding; confirmation that they were not alone in suffering; positive role models of coping with treatment for kidney disease; and hope for the future. Peer support helped patients adapt to chronic illness by normalizing adherence to demanding treatment regimes and increasing patients' sense of empowerment and agency.
Conclusions  A brief meeting with a peer supporter delivered similar perceived benefits to those described by participants in support groups. Possible explanations for this include selection and training of peer supporters; careful matching of patients with peer supporters; and responsiveness to individual user-defined needs for information and psychosocial support.     

ADHD and transition to adult services--the experience of community paediatricians

Background   Attention Deficit Hyperactivity Disorder (ADHD) is now recognized as a disorder that can persist into adulthood, and therefore, there is a need for transitional care.
Aim   To find out about the experiences of community pediatricians across the UK when transferring patients with ADHD to adult care.
Method   A questionnaire was sent out to 100 consultant community pediatricians asking about their experiences.
Results   The majority of respondents thought a proportion of their patients would require referral to adult services and only 22% were aware of a dedicated clinic for adults in their area. Many had tried to address the issue locally often with little success.
Conclusion   There is a gap in provision of services for young people with ADHD when they leave pediatric care, with many pediatricians struggling to find appropriate ongoing care for their patients. Commissioners need to address the problem.     

Translating Research into Practice Intervention Improves Management of Acute Pain in Older Hip Fracture Patients

Objective. To test an interdisciplinary, multifaceted, translating research into practice (TRIP) intervention to (a) promote adoption, by physicians and nurses, of evidence-based (EB) acute pain management practices in hospitalized older adults, (b) decrease barriers to use of EB acute pain management practices, and (c) decrease pain intensity of older hospitalized adults.
Study Design. Experimental design with the hospital as the unit of randomization.
Study Setting. Twelve acute care hospitals in the Midwest.
Data Sources. (a) Medical records (MRs) of patients ≥65 years or older with a hip fracture admitted before and following implementation of the TRIP intervention and (b) physicians and nurses who care for those patients.
Data Collection. Data were abstracted from MRs and questions distributed to nurses and physicians.
Principal Findings. The Summative Index for Quality of Acute Pain Care (0–18 scale) was significantly higher for the experimental (10.1) than comparison group (8.4) at the end of the TRIP implementation phase. At the end of the TRIP implementation phase, patients in the experimental group had a lower mean pain intensity rating than those in the comparison group (  p <.0001).
Conclusion. The TRIP intervention improved quality of acute pain management of older adults hospitalized with a hip fracture.