The use of goal attainment scaling during clinical medication review in older persons with polypharmacy

BackgroundStudies have shown that a clinical medication review (CMR) reduces drug-related problems (DRPs), but the effects on clinical outcomes are less clear. Perhaps, CMRs in older persons could me more effective when they focus on patients’ personal goals and health-related complaints.ObjectiveThe aim of this study was to investigate whether goal attainment scaling (GAS) is a useful tool for determining goals and monitoring their attainment during CMR.MethodsThis study was an analysis based on data of the intervention group of the DREAMeR-study; a randomised controlled trial investigating the effects of CMR in primary care. 315 persons aged ≥70 years using ≥7 drugs were randomised to the intervention: a CMR focused on personal goals using GAS. Outcome measures were: percentage of persons with health-related goals, attainment of goals measured with GAS-scores after three and six months, type of health-related goals and implementation rates of recommendations for GAS-related DRPs and other DRPs.ResultsA total of 406 health-related goals were set for 283 of 315 included persons (90%). Of the 350 evaluated goals (86%), 37% was attained after three months and 43% after six months. The goals ‘reduce pain’ (n = 66, 16%), ‘improve mobility’ (n = 57, 14%) and ‘reduce number of pills’ (n = 37, 9.1%) were most prevalent. The implementation rate of recommendations for GAS-related DRPs was 81% compared to 62% for not GAS-related DRPs (p < 0.05).ConclusionGoal setting is important for prioritizing the most important problems during clinical medication review and Goal Attainment Scaling seems to be a useful tool for monitoring the attainment of these goals.     

Behavior change in diabetes practitioners: An intervention using motivation,action planning and prompts

ObjectivesIt is important for health professionals to have behavior change skills to empower people to manage long-term-conditions. Theoretically derived, competency-based training can be particularly effective where it considers reflective and automatic routes to behavior change.The aim of this study was to develop, deliver and evaluate a motivational, action and prompting behavior change skills intervention for diabetes health practitioners in Scotland, UK.MethodsThis was a longitudinal intervention study. A 2-day intervention was delivered to 99 health professionals. Participants set behavioral goals to change practice, completing action and coping plans post-training. Motivation and plan quality were evaluated in relation to goal achievement at 6-week follow-up.ResultsPost-training, practitioners could develop high quality work-related action and coping plans, which they were motivated to enact. Although under half responded at follow-up, most reported successful goal achievement. There was no difference in plan quality for goal achievers, non-achievers and non-responders. Barriers and facilitators of behavior change included institutional, service-user and individual factors.ConclusionsThe intervention successfully used planning to implement participants’ behaviour change goals.Practice ImplicationsPlanning interventions are helpful to support clinicians to change their practice to help people self-manage diabetes care but may not fit demands of day-to-day clinical practice.     

Life activity choices by people with aphasia: repeated interviews and proxy agreement

Background: Person-centered rehabilitation requires that meaningful life activities are identified on a case-by-case basis, but the discovery process can be inaccessible for clients with aphasia. Card-sorting methodology addresses core barriers and help clients communicate their preferences.

Aims: To characterize life activities that people with aphasia want to do, to estimate consistency in selections over time, and to replicate previous findings about the ability of family members and friends to identify their loved ones’ activity preferences.

Methods & Procedures: We administered the Life Interests and Values (LIV) Cards to 26 people with aphasia, asking them which of 95 depicted life activities they wanted to do more in their lives. Half the activity cards were presented again one to ten weeks later. Twenty family members or friends responded as proxies by selecting from a questionnaire with the same items.

Outcomes & Results: Participants with aphasia selected diverse activities, though as a group they identified significantly more activities from the “social” activity category than from the “home and community”, “creative and relaxing”, or “physical” categories. Across the repeated interviews, they selected identical activities on average 78% of the time. Item-to-item agreement between people with aphasia and their proxy responders was significantly lower at 69%.

Conclusions: People with aphasia have diverse activity interests and are reliable informants about their preferences. Because significant others have limited ability to predict these choices, their impressions are inadequate substitutes for direct interviews.     

Moving forward: nurses are key to achieving the United Nations Development Program's Millennium Development Goals

AMIEVA S. & FERGUSON S. (2011) Moving forward: nurses are key to achieving the United Nations Development Program's Millennium Development Goals. International Nursing Review 59 , 55–58 Aim: This article highlights the role of nurses in achieving the Millennium Development Goals (MDGs) 4 and 5 (reducing child and maternal mortality) and proposes actions for nurses that stream into the strategic frameworks of the World Health Organization and the United Nations. Background: The least amount of progress has been made with MDG 5 and failing to achieve MDG 5 jeopardizes the progress of MDG 4. Conclusion: This article makes the following recommendations to nurses: partner with local healthcare leaders, ensure equitable access to health services, collect health data to close research gaps and take on policy making responsibilities.     

How active are patients in setting goals during rehabilitation after stroke? A qualitative study of clinician perceptions

Purpose: We investigated stroke rehabilitation clinician’s perceptions of the patient as an active partner in setting goals within stroke rehabilitation and factors that influence patient engagement.

Methods: Semi-structured interviews, subject to general inductive analysis with 20 Clinicians’ working in three UK based stroke rehabilitation teams (one in-patient ward and two community based rehabilitation teams).

Results: There were three key themes that impacted on the patients active involvement in setting goals for rehabilitation after stroke: Patient barriers to goal setting (knowledge of the patient and family, who is the patient and the stroke’s impact); How we work as a team (the role of the patient in setting goals, the effect of clinician attributes on goal setting); and How systems impact goal setting (goal-setting practice, home versus hospital, and professional/funder expectations of clinicians’).

Conclusions: Goal setting served a range of different, sometimes conflicting, functions within rehabilitation. Clinicians’ identified the integral nature of goals to engage and motivate patients and to provide direction and purpose for rehabilitation. Further, there was an identified need to consider the impact of prioritizing clinician-derived goals at the expense of patient-identified goals. Lastly the reliance on the SMART goal format requires further consideration, both in terms of the proposed benefits and whether they disempower the patient during rehabilitation.

• Implications for rehabilitation

• Goal setting is often promoted as a relatively simple, straightforward way to structure interactions with patients

• Patient-related factors together with resourcing constraints are significant barriers to patient-centered goal setting, particularly during inpatient rehabilitation

• Clinicians need to have pragmatic tools that can be integrated into practice to ensure that goal-setting practice can be maximized for patients with different intrinsic characteristics

     

The development of a patient-specific method for physiotherapy goal setting: a user-centered design

Purpose: To deliver client-centered care, physiotherapists need to identify the patients’ individual treatment goals. However, practical tools for involving patients in goal setting are lacking. The purpose of this study was to improve the frequently used Patient-Specific Complaints instrument in Dutch physiotherapy, and to develop it into a feasible method to improve physiotherapy goal setting.

Methods: An iterative user-centered design was conducted in co-creation with the physiotherapists and patients, in three phases. Their needs and preferences were identified by means of group meetings and questionnaires. The new method was tested in several field tests in physiotherapy practices.

Results: Four main objectives for improvement were formulated: clear instructions for the administration procedure, targeted use across the physiotherapy process, client-activating communication skills, and a client-centered attitude of the physiotherapist. A theoretical goal-setting framework and elements of shared decision making were integrated into the new-called, Patient-Specific Goal-setting method, together with a practical training course.

Conclusions: The user-centered approach resulted in a goal-setting method that is fully integrated in the physiotherapy process. The new goal-setting method contributes to a more structured approach to goal setting and enables patient participation and goal-oriented physiotherapy. Before large-scale implementation, its feasibility in physiotherapy practice needs to be investigated.

• Implications for rehabilitation

• Involving patients and physiotherapists in the development and testing of a goal-setting method, increases the likelihood of its feasibility in practice.

• The integration of a goal-setting method into the physiotherapy process offers the opportunity to focus more fully on the patient’s goals.

• Patients should be informed about the aim of every step of the goal-setting process in order to increase their awareness and involvement.

• Training physiotherapists to use a patient-specific method for goal setting is crucial for a correct application.

     

Rapid achievement of the child survival millennium development goal: evidence from the Navrongo experiment in Northern Ghana

OBJECTIVE: To determine the impact of deploying nurses and volunteers to village locations on demographic and health outcomes. METHOD: We implemented an experimental design that emphasizes the value of aligning community health services with traditional social institutions that organize village life. Data for this analysis come from the Navrongo demographic surveillance system, a longitudinal database that tracks fertility, mortality, and migration events over time. The experiment uses conventional demographic methods for estimating mortality rates from longitudinal demographic surveillance registers. RESULTS: Posting nurses to community locations reduced childhood mortality rates by over half in 3 years and accelerated attainment of the childhood-survival millennium development goal (MDG) in the study areas relative to trends observed in comparison areas. CONCLUSION: Results from the Navrongo experiment demonstrate that community health and family planning programmes can have an impact on childhood mortality. Posting nurses to communities can dramatically accelerate the pace of progress in achieving the childhood-survival MDGs. Community-volunteer approaches, however, have no additional impact, a finding that challenges the child survival value of international investment in volunteer-based health programmes. The total cost of the intensive arm of the project is less than $10 per capita per year. Navrongo research thus demonstrates affordable means of attaining the child survival MDG agenda with existing technologies.     

Action word understanding and overt motor behavior

Cutaneous reflexes induced in lower leg muscles by non-noxious electrical stimulation to the foot sole are strongly modified depending on the stimulated location. Little is known, however, about the functional importance of this location-specificity. We examined modulation of cutaneous reflexes in the peroneus longus muscle during co-activation of the peroneus longus (PL), soleus, and tibialis anterior muscles in ten healthy volunteers. We successfully recorded 121 intramuscular single motor units (MU) of cutaneous reflexes in PL elicited by stimulating either fore-medial, fore-lateral, or heel regions of the plantar foot while performing plantarflexion and eversion (PF + EV), dorsiflexion and eversion (DF + EV), or isolated eversion (EV). Firing probability increased following fore-lateral stimulation during the PF + EV and EV tasks, but not during the DF + EV. Fore-medial stimulation, irrespective of the task, suppressed the reflex. Heel stimulation facilitated the reflex only during the PF + EV and DF + EV tasks. In general, cutaneous reflex magnitudes were larger during the PF + EV task than during the others, irrespective of whether the effects were facilitatory or suppressive. These results suggest that the magnitude of the reflex effects on the PL motoneurons strongly depends on activation of plantarflexors and dorsiflexors.     

Measuring Spasticity and Fine Motor Control (Pinch) Change in the Hand After Botulinum Toxin-A Injection Using Dynamic Computerized Hand Dynamometry

ObjectivesTo evaluate change in fine motor hand performance and to investigate the relationship between existing clinical measures and dynamic computerized dynamometry (DCD) after botulinum toxin-A (BTX-A) injections for adults with upper limb spasticity.DesignPretest/posttest clinical intervention study.SettingHospital outpatient spasticity clinics.ParticipantsA convenience sample of adults (N=28; mean age, 51y) with upper limb spasticity after acquired brain injury.InterventionsBTX-A injections for upper limb spasticity management.Main Outcome MeasuresDCD protocol using a piezoelectric pinch meter (termed DCD[pinch]); current clinical upper limb measures: Modified Ashworth Scale, Tardieu Scale, Action Research Arm Test, Michigan Hand Outcomes Questionnaire, and Goal Attainment Scale.ResultsBTX-A produced a significant change on DCD(pinch) and some current clinical measures, with correlations observed between DCD(pinch) and current clinical measures.ConclusionsDCD(pinch) sensitively and objectively assessed the effects of BTX-A on upper limb spasticity during a simulated functionally based pinch and release task.