Clinical decision-making and therapeutic approaches in osteopathy – A qualitative grounded theory study

There is limited understanding of how osteopaths make decisions in relation to clinical practice. The aim of this research was to construct an explanatory theory of the clinical decision-making and therapeutic approaches of experienced osteopaths in the UK.Twelve UK registered osteopaths participated in this constructivist grounded theory qualitative study. Purposive and theoretical sampling was used to select participants. Data was collected using semi-structured interviews which were audio-recorded and transcribed. As the study approached theoretical sufficiency, participants were observed and video-recorded during a patient appointment, which was followed by a video-prompted interview. Constant comparative analysis was used to analyse and code data.Data analysis resulted in the construction of three qualitatively different therapeutic approaches which characterised participants and their clinical practice, termed; Treater, Communicator and Educator. Participants' therapeutic approach influenced their approach to clinical decision-making, the level of patient involvement, their interaction with patients, and therapeutic goals. Participants' overall conception of practice lay on a continuum ranging from technical rationality to professional artistry, and contributed to their therapeutic approach. A range of factors were identified which influenced participants' conception of practice.The findings indicate that there is variation in osteopaths' therapeutic approaches to practice and clinical decision-making, which are influenced by their overall conception of practice. This study provides the first explanatory theory of the clinical decision-making and therapeutic approaches of osteopaths.     

Clinical review: RIFLE and AKIN – time for reappraisal

In recent years, the use of the consensus definitions of acute kidney injury (RIFLE and AKIN) in the literature has increased substantially. This indicates a highly encouraging acceptance by the medical community of a unifying definition for acute kidney injury. This is a very important and positive step in the right direction. There remains some variation in how the criteria are interpreted and used in the literature, including use/nonuse of urine output criteria, use of change in estimated glomerular filtration rate rather than change in creatinine, and choice of baseline creatinine. The present review is intended to aid the reader in critically appraising studies using these consensus definitions. Since no single definition will be perfect, a logical next step would be to reconcile existing definitions, moving the medical community towards using a single consensus definition as has been done with sepsis and acute lung injury/acute respiratory distress syndrome. As new data emerge, integration of novel biomarkers into the consensus definition will be a welcome refinement.     

The effectiveness of primary care streaming in emergency departments on decision-making and patient flow and safety – A realist evaluation

Primary care streaming was implemented in UK Emergency Departments (EDs) to manage an increasing demand for urgent care. We aimed to explore its effectiveness in EDs with different primary care models and identify contexts and mechanisms that influenced outcomes: streaming patients to the most appropriate clinician or service, ED flow and patient safety.MethodWe observed streaming and interviewed ED and primary care staff during case study visits to 10 EDs in England. We used realist methodology, synthesising a middle-range theory with our qualitative data to refine and create a set of theories that explain relationships between contexts, mechanisms and outcomes.ResultsMechanisms contributing to the effectiveness of primary care streaming were: quality of decision-making, patient flow, redeploying staff, managing patients across streams, the implementation of governance protocols, guidance, training, service evaluation and quality improvement efforts. Experienced nurses and good teamworking and strategic and operational management were key contextual factors.ConclusionWe recommend service improvement strategies, operational management, monitoring, evaluation and training to ensure that ED nurses stream patients presenting at an ED seeking urgent care to the most appropriate clinicians for their needs in a safe and efficient manner.     

FIRST-YEAR nursing students’ experiences of simulation involving care of older patients. A descriptive and exploratory study

Mastering geriatric nursing skills takes time and its acquisition should start early in undergraduate nursing training. The purpose of this study is to synthesise and evaluate the learning experiences that first-year nursing students had following geriatric patient simulation and practice of clinical patient handover. Qualitative content analysis of survey comments from first-year students (n = 216) at a large university in Norway were performed. Simulation training included systematic patient observation of scenarios based on genuine geriatric cases in nursing homes and practice of clinical patient handover. Content analyses identified four generic categories: (1) ‘embodying theoretical knowledge’; (2) ‘increased awareness about one's self’; (3) ‘understanding that collaboration is needed’; (4) ‘preparing for future work life’. These themes provide evidence for students integrating geriatric theoretical knowledge with clinical skills as a result of simulation. Analysis of learning experiences shows that geriatric scenario simulation and practice of clinical patient handover are valuable instruments before entering clinical training with geriatric patients, even for novice students. The use of genuine simulation cases and instruction on the use of clinical handover instruments are effective in producing conceptual changes that prepare students for their first encounter with complex, real-world geriatric scenarios.     

Partial do-not-resuscitate orders: A hazard to patient safety and clinical outcomes?

BACKGROUND: Patients and families commonly discuss end-of-life decisions with clinicians to create a treatment plan based on patient wishes. In some instances, respect for patient autonomy in making choices may create the potential for patient harm. Medical treatments are often performed in groupings in order to work effectively. When such combinations are separated as a result of patient or surrogate choices, critical elements of life- saving care may be omitted, and the patient may receive nonbeneficial or harmful treatment. A partial do-not-resuscitate order may serve as an example. LITERATURE REVIEW AND DISCUSSION: The limited literature available regarding partial do-not-resuscitate order(s) suggests the practice is clinically and ethically problematic. Not much is known about the prevalence of these orders, but some clinicians believe they are a growing phenomenon. Medical and bioethics organizations have produced guidelines and recommendations on the use of full do-not-resuscitate order(s) with little mention of partial do-not-resuscitate order(s). Partial do-not-resuscitate order(s) are designed based on the patient's anticipated need for resuscitation and are intended to manage dying in a tolerable manner based on what the decision maker believes is "best." Through an analysis of the medical literature, we propose that a partial do-not-resuscitate order contradicts this "best" management intention because it is impossible for the decision maker, or care providers, to anticipate all possible prearrest and arrest situations. We propose that a partial do-not-resuscitate order highlights larger problems: 1) a misunderstanding of the meaning and scope of a do-not-resuscitate order and 2) a need for discussions around goals of care. CONCLUSION: Discouraging partial do-not-resuscitate(s) order may help promote more accurate and comprehensive advance care planning.     

A time to weep and a time to laugh: humour in the nurse–patient relationship in an adult cancer setting

Purpose

The literature highlights the value of humour in health-care settings. Humour impacts on the physiological, psychosocial and cognitive well-being of a person. The diagnosis of cancer is extremely stressful, and treatments are difficult. Patients and nurses may use humour as a coping mechanism to contend with the stresses caused directly or indirectly by cancer. This study investigated the use of humour during interactions between patients and nurses in an adult cancer ward.

Methods

This study used a modified ethnographic methodology that included fieldwork participant observation and informal interviews (n?=?30 h) and formal interviews (n?=?10). In total, 9 nurses and 12 patients participated in participant observation. From these, five nurses and five patients were interviewed. Data were analysed using thematic analysis.

Results

Findings highlighted the importance of humour in the nurse–patient relationship. Patients consciously use humour during nurse–patient interactions in an attempt to help nurses cope with the stress they encounter in clinical practice. Patients perceive having a sense of humour as a positive nurse attribute. Nurses expressed concerns regarding compromising professionalism when using humour and felt the need for guidance from senior staff. Constant assessment and reflection help ensure humour is used appropriately in the adult health-care setting.

Conclusion

The benefits of humour are recognised by both adult cancer patients and nurses. A deeper understanding of patient and nurse perceptions of the use of humour can inform strategies for its therapeutic use in the clinical setting.     

Disability and access to health care – a community based descriptive study

Abstract

Purpose: The World Disability Report highlighted the need for adequate access to health and medical rehabilitation services for those with disability. Participants in a large community based survey in a low-income area were asked questions relating to their use of health related services. Method: Using random, cluster sampling a representative sample of 1083 households in a deprived area of Cape Town were approached and 152 people with disability were interviewed. Results: Those with disability were more likely to be male (χ²?=?4.24, p?=?0.03) and unemployed (χ²?=?66.89, p?>?0.001) compared to those without disability. The percentages reporting unmet needs were respectively: 54% for home-based care; 34.5% for assistive devices, 28.9% for medical rehabilitation services; and 2.5% for health services. Those over 65 years of age were less likely to have had the medical rehabilitation that they required (χ²?=?8.00, p?=?0.018). There were fewer respondents with sensory and language disorders but these groups reported proportionately more unmet needs. The main problems with accessing services included inadequate finances (71%) and transport problems (72%). Conclusion: It is recommended that all efforts be expended to extend appropriate rehabilitation services, including home based-care and appliances to those identified as having disability, particularly to those older than 65 years. In addition, the services need to be affordable and accessible in terms of suitable transport, particularly in the light of the high unemployment rate and the large number of respondents with mobility problems.

• Implications for Rehabilitation

• People with disability may be the most in need of additional health related care and the least able to access it.

• Transport and financial considerations were found to limit the ability to access appropriate care.

• Rehabilitation and health services need to reach out through home-based care and appropriate forms of rehabilitation delivery to ensure that those who are most in need of care, such as the elderly and those with more neglected forms of disability, are provided with the services that they require.