Go with the Flow: Choosing a Feeding System for Infants in the Neonatal Intensive Care Unit and Beyond Based on Flow Performance

ObjectiveThe objectives of this study are to determine the flow rate of disposable and commercially available nipples and to develop a continuum of flow rates from slowest to fastest for commonly available nipple/bottle systems.MethodTwenty-five nipples were chosen for investigation. Nipples were tested using a Medela classic breast pump set at a suction rate of 150 mm Hg using water at room temperature. The amount of liquid transferred from nipple to pump collection bottle in 1 minute was recorded. Each bottle was tested three times, and an average was calculated.ResultsCommercially available nipples marketed as “slow flow” have a wide variety of flow rates. Disposable nipples have some variability in flow rate from one trial to the next as well as from one disposable nipple to the next.ConclusionThere are a wide variety of nipples that are marketed as slow flow that have different flow rates. Using the results of this study, clinicians may be able to determine the bottle and nipple that are most appropriate for an individual infant, based on flow rate, and provide guidance to parents for purchasing commercial bottle systems.     

Development of the Australian hospital patient experience question set for parents

BackgroundThe Australian Commission on Safety and Quality in Health Care developed the Australian Hospital Patient Experience Question Set to ask adult patients about their experience of inpatient care. This question set was not validated for paediatric care.AimTo adapt and validate the Australian Hospital Patient Experience Question Set for parents and carers of children who received inpatient care.MethodsInterviews with fourteen parents and carers were conducted. Content analysis was used to revise the question set and to identify experience specific to children and parents. The Question Set was revised, including three new questions to reflect parent experience. Content validity of each new question was assessed. Data was split and construct validity assessed using exploratory and confirmatory factor analysis (n = 1500).FindingsTwo main qualitative categories of care included ‘parent experience’ and ‘children being heard’. Emotional support was an integral aspect of parent experience. The revised question set (13-question, one-factor model of good fit) demonstrated construct validity (n = 500: Root Mean Square Error of Approximation = 0.042, Confirmatory Fit Index = 0.997, Tucker Lewis Index = 0.996, Composite reliability = 0.962).DiscussionThis study adds empirical support for a common measurement framework for experience of care in children's health services. Parents spoke of the value of having a parent and a child reported survey. The next step is for children to report on their own experience.ConclusionThe revised (parent-reported) question set provides a validated tool which reflects the unique experience of parents and facilitates consistent monitoring and improvement of patient experience in a paediatric inpatient setting.     

A framework analysis of free-text data from the neonatal survey 2014

ObjectiveTo systematically analyse parents' free-text comments provided in a survey about their experiences of neonatal care.MethodsUsing framework analysis of free-text data from the survey, a thematic framework was developed for coding 3738 comments. Most themes had positive and negative subcategories. Comments within the most frequently coded themes were re-coded into sub-themes to provide a more detailed insight into parents' experiences.ResultsThree quarters of comments referred to the ‘care from staff’ (n = 2447) with the majority (81%) being positive. Of these comments, a large proportion were ‘general’ or about positive ‘staff behaviour/attitude’. The most frequently coded comments on parents' negative experiences focused on relationships formed with staff, specifically, information and communication (n = 734).ConclusionsNeonatal units wishing to understand how best to improve parents' experiences would benefit from including an open-ended question in surveys of parents and reviewing these alongside the quantitative data.     

What neurological patients regard as quality of life

• ? The aim of this study was to investigate how patients with progressive neurological disorders describe what they perceive as quality of life.
• ? The patients (n = 169) were interviewed while staying at a neurological rehabilitation centre by way of an open question, what ‘quality of life’ represented to them.
• ? Patients' statements were classified and a comparison was made with Kajandi's three levels of factors constituting quality of life. The categories that came forth were ‘living in a sense of affinity’, ‘being independent’, ‘living on one's own terms’ and ‘feeling that life is meaningful’. The statements constituting the basis of the categories were impressive and illustrated wisdom.
• ? The results underline the uniqueness of each patient's situation, and how important it is that nursing and treatment are adjusted to the needs of the individual.

     

Phenomenology of Australian civilian hospital nurses’ lived experiences of the out-of-hospital environment following a disaster

BackgroundDisasters disrupt the fabric of communities. This includes disruption to the healthcare system that supports a disaster-affected community. Nurses are important members of disaster response teams. However, there is limited literature that describes nurses’ roles or experience in responding to disasters.AimThis paper employs a phenomenological approach to uncover moments of being an Australian civilian hospital nurse in the out-of-hospital environment following a disaster.MethodThis study uncovers moments of what it is like being an Australian civilian hospital nurse deployed to the out-of-hospital environment following a disaster. Individual interviews were undertaken at two points in time with each participant. Audio-recorded interviews were transcribed to textual narratives, which was then analysed. Several activities were undertaken to uncover moments and provide exemplars of moments, from the narrative.FindingsEight hospital nurses participated in this study. Five moments were uncovered: ‘on the way to a disaster’, ‘prior to starting work’, ‘working a shift in a disaster’, ‘end of a shift’, and ‘returning home’. Each moment has its uniqueness and singularity exemplifying an experience of nurses in the out-of-hospital disaster environment.DiscussionWhen compared to a hospital context, assisting during and/or following a disaster in the out-of-hospital environment is challenging. For example, nurses may need to do more with less resources, provide more frequent psychosocial support for more extenuating circumstances, and experience an unsettling return home at the end of the deployment.ConclusionsThis paper has provided new insights into what it may be like being an Australian civilian hospital nurse in the out-of-hospital disaster environment as part of a disaster medical assistance teams. Strategies to support nurses who assist during and/or following a disaster are important, so nurses can in turn provide care to people in disaster-affected communities.     

Levels of ability and functioning: using the WHODAS II in an Irish context

Purpose:?During pilot implementation of the National Physical and Sensory Disability Database in the Republic of Ireland, data were collected that allowed activity limitations and participation restrictions experienced by adults with physical or sensory disability to be assessed. This research will explore the relationships between socio-demographic variables, causes of disability and the domains of ability and functioning of the WHO Disability Assessment Schedule II (i.e., understanding and communication, getting around, self-care, getting along with people, life activities and participation in society).

Method:?1304 people with a physical/sensory disability, less than 66 years of age and receiving or needing a specialised health and personal social service completed the WHODAS II.

Results:?’Life Activities', ‘Getting around’ and ‘Participation in Society’ were the domains where there was greatest difficulty, as experienced by the complete sample. Females experienced greater difficulty in ‘getting around’ and ‘life activities’ than males. Furthermore, an increase in age was associated with an increase in the difficulty of getting around and undertaking life activities and less difficulty in getting along with people. There was also a significant difference in each domain on diagnostic category. Interestingly, a high level of difficulty in ‘Participation in Society’ was recorded for each of the diagnostic categories.

Conclusions:?Further research is required to explore the variability in levels of ability and functioning. This type of research could also be used as a baseline to measure changes over time. Finally, it is important not to become complacent about the ongoing efforts towards inclusiveness and greater participation.     

The South African Triage Scale (adult version) provides reliable acuity ratings

ObjectiveTo estimate the inter- and intra-rater reliability of triage ratings on Emergency Centre patients by South African nurses and doctors using the South African Triage Scale (SATS).MethodsA cross-sectional reliability study was performed. Five emergency physicians and ten enrolled nursing assistants independently assigned triage categories to 100 written vignettes unaware of the ratings given by others. Four different quantitative reliability measures were calculated and compared. Graphical displays portrayed rating distributions for vignettes with mean ratings at different acuity categories.ResultsThe estimated quadratically weighted kappa for the group of emergency physicians was 0.76 (95% CI: 0.67–0.84) and for the group of nurses 0.66 (95% CI: 0.58–0.74). These values were close to the estimated intra-class correlation coefficients. For intra-rater reliability, the average exact agreement was 84%. The graphical displays showed that the least variability was evident in the vignettes that had a mean rating of ‘emergency’, ‘very urgent’ or ‘routine’.ConclusionThis study indicates good inter- and intra-rater reliability among nurses and doctors using the SATS. It suggests that the SATS is reliably applied, and supports the feasibility of further implementation of the SATS in similar settings.     

Peripheral intravenous cannulas for blood drawing: Nurses' views through content analysis

BackgroundPeripheral intravenous cannulas are commonly used for blood sampling. Conflicting evidence on the safety and reliability of blood sampling from peripheral intravenous cannulas provides little support to guide practice of clinicians.AimTo elicit views of nurses working in acute care of their opinions on the safety and efficacy of obtaining blood samples from peripheral intravenous cannulas.MethodsA cross-sectional electronic survey was utilised. Participants included nurses working in Australian acute care services nationally. The STROBE checklist was followed. The survey was distributed by two professional nursing bodies to their members between September and December 2017. Content analysis was used to analyse open-ended responses.FindingsOf the 338 participants who completed the survey, 269 provided comments. Themes supporting the use of peripheral intravenous cannulas for blood sampling included ‘efficiency’, ‘patient care’, ‘last resort’, and ‘other’. Reasons for not using a peripheral intravenous cannula for sampling provided themes of ‘PIVC use’, ‘dwell time’, ‘test type required’, ‘patency/insertion site care’, ‘preference’, and ‘other’.DiscussionThe choice regarding method of blood sampling is left to the discretion of individual practitioners. Diverse rationales were provided by respondents to support their practice in sampling blood. This may be influenced by variations in hospital policies and conflicting research evidence to support or refute the practice.ConclusionBlood sampling from peripheral intravenous cannulas or venepuncture is practiced differently between nurses based on multiple rationales. Research is needed to provide evidence for safe practice and support hospital policies.     

The clinical utility of the pain assessment tool in ventilated,sedated, and muscle-relaxed neonates

BackgroundThe neonatal Pain Assessment Tool (PAT) is considered a reliable and valid tool for assessing neonatal pain. No research has been conducted on the clinical utility of the PAT when assessing pain in ventilated, sedated, and muscle-relaxed neonates.ObjectiveThe objective of the study was to determine the clinical utility of the PAT when assessing pain in ventilated, sedated, and muscle-relaxed neonates.MethodsNeonatal nurses from the Royal Children's Hospital completed online surveys to assess the clinical utility of the PAT. Three focus groups were then conducted to further explore the variation of pain scores from the survey and clarify the challenges in interpreting the pain score.ResultsNurses perceived the PAT clinically useful in neonates who were ventilated and minimally sedated. However, the PAT was not clinically useful in neonates who were ventilated and heavily sedated or muscle-relaxed. Further exploration via focus groups highlighted two themes related to the ‘variation in the timing of the pain score’ and the ‘integration of critical thinking and judgement’ used when assessing pain in neonates.ConclusionsThe clinical utility of the PAT is acceptable for minimally sedated neonates; however, it decreases the more sedated a neonate becomes, and the PAT's usefulness is extremely poor in the muscle-relaxed neonate. A better understanding of the timing and interpretation of the pain score in relation to the neonate's clinical status may enable improved decision-making and pain management. The PAT requires further validity, reliability, and clinical utility research, particularly in critically ill and muscle-relaxed neonates.     

Anatomical landmark position – Can we trust what we see? Results from an online reliability and validity study of osteopaths

BackgroundPractitioners traditionally use observation to classify the position of patients' anatomical landmarks. This information may contribute to diagnosis and patient management.ObjectivesTo calculate a) Inter-rater reliability of categorising the sagittal plane position of four anatomical landmarks (lateral femoral epicondyle, greater trochanter, mastoid process and acromion) on side-view photographs (with landmarks highlighted and not-highlighted) of anonymised subjects; b) Intra-rater reliability; c) Individual landmark inter-rater reliability; d) Validity against a ‘gold standard’ photograph. Design: Online inter- and intra-rater reliability study.SubjectsPhotographed subjects: convenience sample of asymptomatic students; raters: randomly selected UK registered osteopaths.Methods40 photographs of 30 subjects were used, a priori clinically acceptable reliability was ≥0.4. Inter-rater arm: 20 photographs without landmark highlights plus 10 with highlights; Intra-rater arm: 10 duplicate photographs (non-highlighted landmarks). Validity arm: highlighted landmark scores versus ‘gold standard’ photographs with vertical line. Research ethics approval obtained.RatersOsteopaths (n = 48) categorised landmark position relative to imagined vertical-line; Gwet's Agreement Coefficient 1 (AC1) calculated and chance-corrected coefficient benchmarked against Landis and Koch's scale; Validity calculation used Kendall's tau-B.ResultsInter-rater reliability was 'fair' (AC1 = 0.342; 95% confidence interval (CI) = 0.279–0.404) for non-highlighted landmarks and 'moderate' (AC1 = 0.700; 95% CI = 0.596–0.805) for highlighted landmarks. Intra-rater reliability was 'fair' (AC1 = 0.522); range was ‘poor’ (AC1 = 0.160) to ‘substantial’ (AC1 = 0.896). No differences were found between individual landmarks. Validity was ‘low’ (T_B = 0.327; p = 0.104).ConclusionBoth inter- and intra-rater reliability was ‘fair’ but below clinically acceptable levels, validity was ‘low’. Together these results challenge the clinical practice of using observation to categorise anterio-posterior landmark position.     

‘Having to learn this so late in our lives…’ Swedish elderly patients’ beliefs,experiences, attitudes and expectations of e-health in primary health care

Objective: The elderly are an increasing group and large consumers of care in Sweden. Development of mobile information technology shows promising results of interventions for prevention and treatment of chronic diseases. Exploring the elderly patients’ beliefs, attitudes, experiences and expectations of e-health services helps us understand the factors that influence adherence to such tools in primary care.

Material and methods: We conducted focus group interviews with 15 patients from three primary health care centers (PHCCs) in Southern Sweden. Data were analysed with thematic content analysis with codes and categories emerged from data during analysis.

Results: We found one comprehensive theme: ‘The elderly’s ambivalence towards e-health: reluctant curiosity, a wish to join and need for information and learning support’. Eight categories emerged from the text during analysis: ‘E-health – a solution for a non-existing problem?’, ‘The elderly’s experiences of e-health’, ‘Lack of will, skills, self-trust or mistrust in the new technology’, ‘Organizational barriers’, ‘Wanting and needing to move forward’, ‘Concerns to be addressed for making e-health a good solution’, ‘Potential advantages with e-health versus ordinary health care’ and ‘Need for speed, access and correct comprehensive information’.

Conclusions: Elderly patients in Sweden described feelings of ambivalence towards e-health, raising concerns as accessibility to health care, mistrust in poor IT systems or impaired abilities to cope with technology. They also expressed a wish and need to move forward albeit with reluctant curiosity. Successful implementation of e-health interventions should be tailored to target different attitudes and needs with a strong focus on information and support for the elderly.

• Key points

• Exploring the elderly patients’ beliefs, experiences, attitudes and expectations of the fast developing e-health services helps us understand the factors that influence adherence to such tools in primary care.

• Elderly patients in Sweden reported ambivalence and different experiences and attitudes towards e-health, raising concerns as accessibility to health care, costs and mistrust in poor IT systems or impaired abilities to cope with technology.

• They also expressed a wish and need to move forward albeit with reluctant curiosity. Successful implementation of e-health interventions should be tailored to target different attitudes and needs with a strong focus on information and support for the elderly.

     

Perception of multimodal cognitive treatment for people with chronic widespread pain – Changing one's life plan

Purpose.?The aim of this study was to gain a deeper understanding of chronic widespread pain patients' perception of a multimodal treatment with a cognitive approach.

Methods.?A reformulated grounded theory study based on interviews with 16 participants in the programme was conducted at the end of a 6-month treatment period.

Results.?The result describes a conceptual model of the informants' perception of the treatment. The core category ‘changing one's life plan’ comprised of three categories: ‘changing one's perception of life’, ‘depending on support’ and ‘managing one's life’. Changing one's perception of life could be deep and overwhelming ‘overall life changes’ or more superficial ‘life adjustments’. Support by health professionals and the patient group were of importance. At the end of the rehabilitation program managing one's life was perceived as either ‘reorientation’ or ‘stagnation’. The informants who experienced overall life changes achieved reorientation with support by others, while those who experienced life adjustments did not change their way of managing one's life to any great extent.

Conclusion.?The core category changing one's life plan included the categories; changing one's perception of life, depending on support and managing one's life. Informants experiencing overall life changes were more likely to achieve reorientation than those who experienced life adjustments.     

Progressive exhaustion: A qualitative study on the experiences of Iranian family caregivers regarding patients undergoing hemodialysis

ObjectiveThe aim of this study was to explore the burden of care for patients undergoing hemodialysis from the experiences of family caregivers.MethodsIn this qualitative study, a content analysis approach was used for data collection and analysis. Participants were 16 family caregivers selected through purposive sampling from four medical education centers affiliated with Ahvaz Jundishapur University of Medical Sciences, Iran. Semi-structured interviews were held to collect data.ResultsFour categories were developed as follows: ‘care challenges’, ‘psychological vulnerabilities’, ‘the chronic nature of care ’and “care in the shade”. The categories led to the development of the main theme of ‘progressive exhaustion’ experienced by the family caregivers during the provision of care to patients undergoing hemodialysis.ConclusionFamily caregivers have a significant role in the process of patient care, and this role leads them to progressive exhaustion; therefore, the overall health of the caregivers should be taken into account and more attention should be paid to their quality of life, social welfare, and satisfaction level.     

Learning from history: Frances Gillam Holden,a leadership perspective then and now

BackgroundCritical evaluation of leadership styles through a historical lens is uncommon. There could be missed opportunity for current and emerging nurse leaders to critically evaluate the leadership styles of the past in order to discerningly reflect on their own current leadership.AimTo critically examine the work of Australian nurse Frances Gillam Holden as she developed her vision for servant leadership for nursing in Australia in the late 19th century.MethodsExploration of, and critical reflection on, literature outlining Frances Gillam Holden's work.FindingsHolden's work and experience demonstrate the challenges faced by the profession's leaders at the turn of the century as they attempted to negotiate new ‘scientific’ knowledge and integrate this into nursing leadership. An examination of Holden's experience also demonstrates the difficulties faced by Australian nurse leaders during this time and consideration is given to what leadership in nursing looks like in the present day.DiscussionWithin the wealth of historical narratives, along with their complexities, the impact of this knowledge can have a demonstrated effect that can be far reaching and long lasting. This is particularly evident in regard to the role of nurses, nursing, and the development of modern approaches to nursing leadership, particularly with regard to the rise of nurse leaders in the form of ‘e-nurses’ and the use of social media to inform and lead the profession.ConclusionUnderstanding the influence and impact of nursing history, and historical nursing leaders such as Holden, on current leadership practices is being recognised more as contributing to contemporary nursing identity.     

Can language enhance physical therapists’ willingness to follow Choosing Wisely recommendations? A best-worst scaling study

BackgroundChoosing Wisely recommendations could reduce physical therapists’ use of low-value care.ObjectiveTo investigate whether language influences physical therapists’ willingness to follow the Australian Physiotherapy Association's (APA) Choosing Wisely recommendations.DesignBest-worst Scaling surveyMethodsThe six original APA Choosing Wisely recommendations were modified based on four language characteristics (level of detail, strength- qualified/unqualified, framing, and alternatives to low-value care) to create 60 recommendations. Physical therapists were randomised to a block of seven choice tasks, which included four recommendations. Participants indicated which recommendation they were most and least willing to follow. A multinomial logistic regression model was used to create normalised (0=least preferred; 10=most preferred) and marginal preference scores.Results215 physical therapists (48.5% of 443 who started the survey) completed the survey. Participants' mean age (SD) was 38.7 (10.6) and 47.9% were female. Physical therapists were more willing to follow recommendations with more detail (marginal preference score of 1.1) or that provided alternatives to low-value care (1.3) and less willing to follow recommendations with negative framing (−1.3). The use of qualified (‘don't routinely’) language (vs. unqualified - ‘don't’) did not affect willingness. Physical therapists were more willing to follow recommendations to avoid imaging for non-specific low back pain (3.9) and electrotherapy for low back pain (3.8) vs. recommendation to avoid incentive spirometry after upper abdominal and cardiac surgery.ConclusionPhysical therapists were more willing to follow recommendations that provided more detail, alternatives to low-value care, and were positively framed. These findings can inform the development of future Choosing Wisely recommendations and could help reduce low-value physical therapy.