Economic factors and longevity in spinal cord injury: a reappraisal

Strauss D, DeVivo M, Shavelle R, Brooks J, Paculdo D. Economic factors and longevity in spinal cord injury: a reappraisal.

Objective

To review and reassess the findings of Krause and colleagues on the effect of economic and other risk factors on life expectancy after spinal cord injury, using an expanded and updated database.

Design

Pooled person-year analysis.

Setting

Model Spinal Cord Injury Systems hospitals.

Participants

A total of 7331 persons injured since 1973 who were enrolled in the National Spinal Cord Injury Database and received an evaluation between November 1995 and December 2005.

Interventions

Not applicable.

Main Outcome Measures

Mortality, determined by routine follow-up supplemented by information from the Social Security Death Index. Logistic regression models based on the predictor variables were developed to estimate the chance of dying in a given year.

Results

As in the Krause study, life expectancies of persons with the greatest handicap in economic self-sufficiency were substantially shorter than average. However, the positive effect of favorable economics was much less than previously reported, largely because having health insurance coverage through workers’ compensation was no longer a powerful (or statistically significant) predictor of survival.

Conclusions

The beneficial effect of favorable economics appears to be much less than previously reported. Further, the interpretation of the effects of modifiable factors (such as economics and social integration) is complicated by questions of cause and effect.     

The SAFE or SORRY? programme. part II: effect on preventive care

Background

Patient care guidelines are usually implemented one at a time, yet patients are at risk for multiple, often preventable, adverse events simultaneously.

Objective

The SAFE or SORRY? programme targeted three adverse events (pressure ulcers, urinary tract infections and falls) and was successful in reducing the incidence of these events. This article explores the process of change and describes the effect on the preventive care given.

Design

Separate data on preventive care were collected along the cluster randomised trial, which was conducted between September 2006 and November 2008.

Settings

Ten hospital wards and ten nursing home wards.

Participants

We monitored nursing care given to adult patients with an expected length of stay of at least five days.

Methods

The SAFE or SORRY? programme consisted of the essential recommendations of guidelines for pressure ulcers, urinary tract infections and falls. A multifaceted implementation strategy was used to implement this multiple guidelines programme. Data on preventive care given to patients were collected in line with these guidelines and the difference between the intervention and the usual care group at follow-up was analysed.

Results

The study showed no overall difference in preventive pressure ulcer measures between the intervention and the usual care group in hospitals (estimate = 6%, CI: −7-19) and nursing homes (estimate = 4%, CI: −5-13). For urinary tract infections, even statistically significantly fewer hospital patients at risk received preventive care (estimate = 19%, CI: 17-21). For falls in hospitals and nursing homes, no more patients at risk received preventive care.

Conclusion

Though the SAFE OR SORRY? programme effectively reduced the number of adverse events, an increase in preventive care given to patients at risk was not demonstrated. These results seem to emphasise the difficulties in measuring the compliance to guidelines. More research is needed to explore the possibilities for measuring the implementation of multiple guidelines using process indicators.     

Change of Strength and Rate of Rise of Tension Relate to Functional Arm Recovery After Stroke

Renner CIE, Bungert-Kahl P, Hummelsheim H. Change of strength and rate of rise of tension relate to functional arm recovery after stroke.

Objective

To examine the relationship between individual strength parameters and functional motor ability over time during rehabilitation in stroke patients.

Design

A multiple-baseline experiment with assessment at inclusion and after 3 and 6 weeks.

Setting

Secondary-care rehabilitation center.

Participants

A convenience sample of 16 subacute stroke patients.

Interventions

Not applicable.

Main Outcome Measures

Maximal voluntary force and rate of rise of tension of hand grip, wrist extension, and elbow flexion and extension were recorded at all 3 times. At the same time, functional motor assessments were evaluated by the Action Research Arm Test (ARAT), Box and Block test, and Rivermead Test.

Results

We found no correlation between maximal voluntary force increases of various muscle contractions measurements. Neither the increase of grip strength nor that of wrist extension force correlated with improvement in ARAT score. Yet the improvement in the rate of rise of tension of hand grip (Spearman rho=.91) and of wrist extension (Spearman rho=.73) correlated with the improvement of the ARAT score and explained 77% of the variance of the ARAT.

Conclusions

The change in the rate of rise of tension of the hand grip has a better predictive value for the functional recovery compared to the change in maximal voluntary force in patients with moderate arm and hand weakness after stroke. The rate of rise of tension of hand grip seems an adequate quantifiable parameter to detect small improvements during functional recovery.     

Longitudinal Changes in Physical Capacity Over 20 Years in Athletes With Spinal Cord Injury

Shiba S, Okawa H, Uenishi H, Koike Y, Yamauchi K, Asayama K, Nakamura T, Tajima F. Longitudinal changes in physical capacity over 20 years in athletes with spinal cord injury.

Objective

To investigate the longitudinal changes in physical capacity over 20 years in athletes with spinal cord injury (SCI).

Design

Longitudinal study (20-y follow-up).

Setting

Laboratory setting.

Participants

Persons with SCI (N=7).

Interventions

Not applicable.

Main Outcome Measures

Maximum oxygen consumption V?o₂max) measured in 1986-1988 and in 2006.

Results

Subjects with SCI maintained stable V?o₂max in 2006. Six of the 7 continued various wheelchair sports activities, while 1 person quit sports activities 1 year after the baseline study. The latter person showed reduced V?o₂max by 53%, while 2 persons who continued strenuous wheelchair sports activities showed increased V?o₂max by 43% and 45% after 20 years.

Conclusion

The results indicated that physical capacity reflected the level of sports activity in subjects with SCI who maintained sports activities.     

Long-term clinical benefits and costs of an integrated rehabilitation programme compared with outpatient physiotherapy for chronic knee pain

Background

Chronic knee pain is a major cause of disability in the elderly. Management guidelines recommend exercise and self-management interventions as effective treatments. The authors previously described a rehabilitation programme integrating exercise and self-management [Enabling Self-management and Coping with Arthritic knee Pain through Exercise (ESCAPE-knee pain)] that produced short-term improvements in pain and physical function, but sustaining these improvements is difficult. Moreover, the programme is untried in clinical environments, where it would ultimately be delivered.

Objectives

To establish the feasibility of ESCAPE-knee pain and compare its clinical effectiveness and costs with outpatient physiotherapy.

Design

Pragmatic, randomised controlled trial.

Setting

Outpatient physiotherapy department and community centre.

Participants

Sixty-four people with chronic knee pain.

Interventions

Outpatient physiotherapy compared with ESCAPE-knee pain.

Outcomes

The primary outcome was physical function assessed using the Western Ontario and McMaster Universities Osteoarthritis Index. Secondary outcomes included pain, objective functional performance, anxiety, depression, exercise-related health beliefs and healthcare utilisation. All outcomes were assessed at baseline and 12 months after completing the interventions (primary endpoint). ANCOVA investigated between-group differences.

Results

Both groups demonstrated similar improvements in clinical outcomes. Outpatient physiotherapy cost £130 per person and the healthcare utilisation costs of participants over 1 year were £583. The ESCAPE-knee pain programme cost £64 per person and the healthcare utilisation costs of participants over 1 year were £320.

Conclusions

ESCAPE-knee pain can be delivered as a community-based integrated rehabilitation programme for people with chronic knee pain. Both ESCAPE-knee pain and outpatient physiotherapy produced sustained physical and psychosocial benefits, but ESCAPE-knee pain cost less and was more cost-effective.Clinical Trial Registration No.: ISRCTN63848242.     

Quality of faculty, students, curriculum and resources for nursing doctoral education in Korea: A focus group study

Background

The rapidly increasing number of nursing doctoral programs has caused concern about the quality of nursing doctoral education, including in Korea.

Objectives

To describe the perceived quality of Korean nursing doctoral education in faculty, student, curriculum and resources.

Design

Focus group.

Settings

Fourteen Korean nursing doctoral programs that are research focused and include coursework.

Participants

Four groups of deans, faculty, students and graduates; students completed three semesters of doctoral program; and graduates completed doctoral programs within the most recent 3 years.

Methods

Focus groups examined the strengths and weaknesses of faculty, students, curriculum, and resources.

Results

Faculty strengths were universities’ recognition of faculty research/scholarship and the ability of faculty to attract extramural funding. Faculty weaknesses were aging faculty; high faculty workload; insufficient number of faculty; and teaching without expertise in nursing theories. Student strengths were diverse student backgrounds; multidisciplinary dissertation committee members, and opportunities to socialize with peers and graduates/faculty. Students’ weaknesses were overproduction of PhDs with low academic quality; a lower number and quality of doctoral applicants; and lack of full-time students. Curriculum strengths were focusing on specific research areas; emphasis on research ethics; and multidisciplinary courses. Curriculum weaknesses were insufficient time for curriculum development; inadequate courses for core research competencies; and a lack of linkage between theory and practice. Resources strengths were inter-institutional courses with credit transfer. Weaknesses were diminished university financial support for graduate students and limited access to school facilities. Variations in participant groups (providers [deans and faculty] vs. receivers [students and graduates]) and geographical location (capital city vs. regional) were noted on all the four components.

Conclusions

The quality characteristics of faculty, students, curriculum, and resources identified in this first systematic evaluation of the quality of nursing doctoral education can inform nursing schools, universities, and policy-makers about areas for improvement in Korea and possibly in the world. Geographical variations found in these four components of doctoral education warrant attention by policy-makers in Korea.     

Validity of a Functional Dynamic Walking Test for the Elderly

Lark SD, Pasupuleti S. Validity of a functional dynamic walking test for the elderly.

Objective

To determine the validity of a safe, quick, and simple method of measuring dynamic balance in the elderly during gait called the parallel walk test.

Design

Control study.

Setting

Outpatient clinic, community.

Participants

Twenty-seven elderly fallers (age 82±6y) registered at a falls clinic and 34 elderly nonfallers (age 76±7y) were recruited to this study based on Mini Mental State Examination and Barthel Index scores.

Interventions

Subjects were timed as they walked 6m between 2 parallel lines on the floor at 3 different widths (20, 30.5, 38cm) in their own footwear. They were scored for foot placement on the line (1 point) or outside the lines (2 points). Participants also performed a timed 6-m tandem walk test, a 30-second tandem stance, and a 30-second parallel stance.

Main Outcome Measures

Scores and time to complete the parallel walk test and tandem walk test along with the time of standing for tandem and parallel stance. Validity coefficients were calculated for the sensitivity and specificity of the parallel walk test.

Results

All subjects completed the parallel walk test, but few attempted and completed the tandem walk test. The fallers had significantly greater scores at 20 and 30.5cm and took significantly longer to complete the 6m at all widths. The 20-cm width was most discriminatory. The parallel walk test showed a significant correlation with the tandem stance.

Conclusions

All subjects attempted and completed the parallel walk test but not the tandem walk test. The time to completion and scoring accurately measures dynamic balance during gait in elderly fallers. The parallel walk test could be a useful tool in the clinical setting for assessing balance in gait pre- and postintervention.     

The evolving professional nursing self-image of students in baccalaureate programs: A cross-sectional survey

Background

We have previously examined the professional self-image of practicing nurses in Belgium and its association with various professional decisions, however there is limited knowledge about the professional self-image of nurses-to-be. Despite prior research on nursing students’ perceptions of nursing or their self-esteem, students’ professional image, defined as “the way students perceive themselves in their clinical practice environment and their anticipated work environment”, has not been described nor compared to that of practicing nurses.

Objective

To describe the professional nursing self-image among students in their final year of baccalaureate education.

Design

Cross-sectional survey.

Settings

Nine geographically spread baccalaureate programs in the Flemish region of Belgium.

Participants

427 evaluable students from 455 recruited from 663 potential.

Methods

Data collected in each school during regular hours using an adapted version of the BELIMAGE (Belgian professional self-image instrument for hospital nurses) including questions on personal demographics, education and competence, nursing care, team and practice environment. Voluntary participation with returned questionnaire deemed informed consent.

Results

Respondents identified several curricular components as contributing to their perceived competence. They also identified several skills deemed important to professional nursing, however did not feel competent in all of these. Important nursing care aspects included individualizing patient care, detecting care problems and potential complications, and promoting patient well-being; within a care environment with open interdisciplinary communication, where care problems could be discussed with nursing colleagues, where one cares for the same patient regularly, and led by a team leader with vision. Society's view of nursing was generally more negative than students’. Most students planned on working in nursing after their studies and many had thought about additional education at some point. Most were proud of becoming a nurse, would recommend nursing to others, and would choose nursing again as field of study.

Conclusions

Students’ evolving professional self-image was positive, rich, and enthusiastic; and higher than that observed in working nurses in a prior study. There is a significant gap between nursing care aspects deemed important and perceived competence in these areas, which has implications for both educators and future employers. Once employed, students are likely to experience differences in their perceptions of professional self-image with those of senior colleagues; another area of attention for employers.     

The size, extent and nature of the learning disability nursing research base: a systematic scoping review

Background

A research base should be of sufficient quality and quantity to inform nursing practice. It must allow nurses to access information about clients’ needs and to identify effective strategies for meeting those needs. This paper presents the findings of a scoping review of ‘learning disability nursing research’. The review aimed to determine whether there is a research base sufficient to support learning disability nursing practice.

Method

We undertook searches of the Cochrane Library and electronic databases (Medline, Psychinfo, Embase, CINAHL and British Nursing Index) for the years 1996-2006. Full references and abstracts were downloaded for papers returned. Papers considered relevant to the topic of the review were organised into three categories according to whether the main focus of the research was people with learning disabilities, carers or family members, or nurses. For each paper, information about the locality of the research, the topic of the research, design/method and sample size was extracted.

Findings

We identified 180 relevant research studies, most of which made use of convenience samples of less than one hundred people. Very few studies evaluated the clinical impact of nursing interventions or the delivery of care by learning disability nurses. A small number of studies examined the impact or patient experiences of nurse-led interventions. These tend to small-scale evaluations of new service initiatives, such as the management of behavioural problems. Overall there was an absence of strong evidence about the effectiveness of specific nursing interventions.

Conclusions

The extent of learning disability nursing research is limited in quantity and it is difficult to draw comparisons across research studies. Much of the available evidence is drawn from small-scale evaluations; which may provide useful guidance and inspiration for service development but do not, in themselves, constitute a sufficient body of research evidence to support learning disability nursing practice.     

The association between nursing diagnoses, resource utilisation and patient and caregiver outcomes in a nurse-led home care service: longitudinal study

Background

The information generated by nurses through standardised nursing languages is insufficiently evaluated and exploited, mainly in home care services, as is its potential impact on outcomes.

Objectives

To find out how often nursing diagnoses are made during nursing home care visits, and to explore their relation with use of resources, mortality, institutionalisation and satisfaction.

Design

Observational, longitudinal follow-up study.

Settings

Home care services delivered by Primary Healthcare Districts in Málaga, Costa del Sol, Almería and Granada, in Spain.

Participants

Patients and caregivers who initiated the Home Care Programme.

Methods

The accumulated incidence of nursing diagnosis was analysed over 34 months of follow-up. Diagnoses were made by nurse case managers in their daily practice. Several regression models were devised to analyse their linkage with the use of resources, mortality, institutionalisation and satisfaction.

Results

Two hundred and forty-seven subjects were included (129 patients and 118 caregivers). 93.8 had been diagnosed (2.8 diagnoses per subject). Risk of caregiver strain and mobility impairment accounted for 40% of total home visits (p = 0.033). Significant differences were observed in the use of physiotherapy and rehabilitation services. The home visits for caregivers were, in 78% of cases, due to the recipient’s baseline functional status. No relation was detected for institutionalisation or for patient satisfaction. There was a higher rate of anxiety diagnosed in the caregiver when the recipient was at greater risk for mortality (RR: 2.08 CI 95%: 1.26-3.42) (p = 0.012).

Conclusions

These data confirm results from other studies which find nursing diagnoses to be sound predictors of resources use. Their synergy with other case-mix systems in home care should be investigated.     

Preventing the use of physical restraints on residents newly admitted to psycho-geriatric nursing home wards: a cluster-randomized trial

Background

Although there is an urgent need for restraint-free care, the number of randomized clinical trials on preventing or reducing physical restraints has been limited.

Objectives

To investigate the effectiveness of an educational intervention to prevent the use of physical restraints on residents newly admitted to psycho-geriatric nursing home wards.

Design

Cluster-randomized trial.

Setting

Fourteen Dutch psycho-geriatric nursing home wards.

Participants

138 residents admitted to 14 psycho-geriatric nursing home wards after baseline measurement of the trial were selected, out of which 33 residents died or informed consent had not been obtained. A total of 105 residents were included in the analyses.

Methods

The nursing home wards were randomly assigned to either educational intervention or control status. The educational intervention consisted of an educational programme for nurses combined with a nurse specialist's consultation. The data were collected at 1, 4 and 8 months post-intervention. The use of physical restraints was measured by blinded, trained observers on four separate occasions over a 24-h period. The Minimum Data Set was used to determine residents’ characteristics, such as their cognitive status.

Results

During the study period, no statistically significant differences between the experimental group and the control group regarding restraint status, restraint intensity, multiple restraints and types of restraints were found. One month post-intervention, 38% of the residents newly admitted to the experimental wards were restrained. Bilateral bedrails were the most frequently used restraints at Post-test 1 (24%), Post-test 2 (23%) and Post-test 3 (28%), followed by the use of infrared systems at Post-tests 2 and 3.

Conclusion

An educational programme combined with the consultation of a nurse specialist does not prevent the use of physical restraints on residents newly admitted to psycho-geriatric nursing home wards. Although other studies have shown promising results with the effectiveness of these types of intervention on restraint reduction, the development of additional interventions to prevent restraint usage is recommended.     

Reliability of physical examination tests used in the assessment of patients with shoulder problems: a systematic review

Background

Shoulder pain is a common clinical problem, and numerous tests are used to diagnose structural pathology.

Objectives

To systematically review the reliability of physical examination procedures used in the clinical examination of patients with shoulder pain.

Data sources

MEDLINE, PEDro, AMED, PsychInfo, Cochrane Library (2009) and CINAHL were searched from the earliest record on the database to June 2009.

Study eligibility criteria

Reliability studies that included any patients with shoulder pain were analysed for their quality and reliability results.

Study appraisal and synthesis methods

Pre-established criteria were used to judge the quality of the studies (high quality >60% methods score) and satisfactory levels of reliability (kappa or intraclass correlation coefficient ≥0.85, sensitivity analysis 0.70). A qualitative synthesis was performed based on levels of evidence.

Results

Thirty-six studies were included with a mean methods score of 57%. Seventeen studies were deemed to be of high quality; high-quality studies were less likely to meet the pre-agreed level of reliability. The majority of studies indicated poor reliability for all procedures investigated.

Limitations

Overall, the evidence regarding reliability was contradictory.

Conclusions and implications

There is no consistent evidence that any examination procedure used in shoulder assessments has acceptable levels of reliability. Alternate methods of classification which are reliable should be used to classify patients with shoulder problems.     

Characterizing wandering behaviors in persons with traumatic brain injury residing in veterans health administration nursing homes

Belanger HG, King-Kallimanis B, Nelson AL, Schonfeld L, Scott SG, Vanderploeg RD. Characterizing wandering behaviors in persons with traumatic brain injury residing in Veterans Health Administration nursing homes.

Objective

To examine the prevalence and correlates of wandering in persons with traumatic brain injury (TBI) in nursing homes (NHs).

Design

Using a cross-sectional design, logistic regression modeling was used to analyze a national database.

Setting

One hundred thirty-four NH facilities operated by the Veterans Health Administration.

Participants

NH residents (N=625) with TBI as well as a sample (n=164) drawn from a larger dataset of NH residents without TBI using 1:K matching on age.

Interventions

Not applicable.

Main Outcome Measure

Wandering.

Results

Wanderers with and without TBI did not differ significantly overall. The prevalence of wandering among patients with TBI was 14%, compared with 6.5% of the general nursing home population. The results of the multivariate logistic regression suggested that wandering was associated with poor memory, poor decision making, behavior problems, independence in locomotion and ambulation, and dependence in activities of daily living related to basic hygiene.

Conclusions

Wandering is relatively common in NH residents with TBI. As expected, it is associated with cognitive, social, and physical impairments. Further research with a larger sample should examine those with comorbid dementia and/or psychiatric diagnoses.     

Interpreting patients as a means of clinical practice: Introducing nursing hermeneutics

Background

The increased reference to hermeneutics from nursing scientists, researchers and academics has emphasized that interpretation has traditionally been a fundamental part of nursing practice. In nursing research a propensity for acquiring knowledge and understanding by using, multiple modalities has been demonstrated. In recent years, the use of hermeneutic phenomenology, has featured amongst these modalities. Hermeneutic phenomenology is an inquiry arm of, philosophical hermeneutics.

Objectives

To explore the hypotheses that the patient can be considered as “text” and as such to be, interpreted in order to gain information for decision-making in clinical practice.

Design

A qualitative approach (hermeneutic phenomenological) to nursing clinical practice.

Settings

The clinical case of a patient suffering from cancer is described in the paper who was treated, in an Oncology Centre in Cyprus.

Methods

A hermeneutical model of clinical decision-making in nursing is implemented in practice. The, model was initially used in medical practice; however it finds applications to nursing as well. According, to the model, a patient is perceived as a literary text which may be interpreted on four levels: (1) the, literal facts of the patient's body and the literal story told by the patient, (2) the nursing diagnostic, meaning of the literal data, (3) the praxis (the nursing interventions) emanating from the nursing, diagnosis, and (4) the change effected by the clinical encounter in both the patient's and nurse's lifeworlds.

Results

Nursing interventions were successfully informed by the interpretation process.     

Assistive Walking Devices in Nonambulant Patients Undergoing Rehabilitation After Stroke: The Effects on Functional Mobility, Walking Impairments, and Patients' Opinion

Tyson SF, Rogerson L. Assistive walking devices in nonambulant patients undergoing rehabilitation after stroke: the effects on functional mobility, walking impairments, and patients' opinion.

Objective

To assess the immediate effects of assistive walking devices on functional mobility, walking impairments, and patients' opinions in nonambulant patients after stroke.

Design

Randomized crossover trial.

Setting

Inpatient rehabilitation units of 3 United Kingdom hospitals.

Participants

Twenty nonambulant patients with stroke undergoing rehabilitation to restore walking.

Interventions

Five walking conditions: (1) Walking with no device (the control condition), (2) walking with a walking cane, (3) ankle foot orthosis, (4) slider shoe, and (5) a combination of all 3 devices.

Main Outcome Measures

Functional mobility (functional ambulation categories), walking impairments (speed, step length of the weak leg), and patients' opinions.

Results

Functional mobility improved with all assistive devices (P<.0001-.005; effect sizes 1.68-0.52; number needed to treat=2-5). Walking impairments were unchanged (P<.800-.988). Participants were generally positive about the devices. They felt their walking, confidence, and safety improved and found the appearance and comfort of the devices acceptable. They would rather walk with the devices than delay walking until a normative gait pattern was achieved without them.

Conclusions

Assistive walking devices improved functional mobility in nonambulant rehabilitation patients with stroke. No changes in walking impairments were found. Participants were generally positive about using the devices. The results support the use of assistive walking devices to enable early mobilization after stroke; 2 patients would need to be treated with a cane or combined devices for 1 to improve functional mobility.