Facilitating neonatal MARSI evidence into practice: Investigating multimedia resources with Australian Neonatal Nurses – A participatory action research project

BackgroundMedical adhesive-related skin injuries (MARSI) are common in hospitalised neonates.AimsTo (i) identify adhesives and removal techniques, (ii) develop and distribute neonatal MARSI resources, and (iii) evaluate the resources.MethodsA participatory action research cycle was conducted from 2017 to 2019 to identify practices and recommendations, establish MARSI elements, develop and evaluate resources with Australian Neonatal Nurses.ResultsTwenty-three different adhesives, six peer-reviewed publications and 18 product information sources were reviewed. A poster with adhesive base and top layers, application and removal recommendations outlined, and 10 video tutorials were produced. Survey responses from 223 nurses revealed the definition of MARSI and risks were poorly known. Resource awareness was limited despite widespread promotion but were reported as useful.ConclusionsTo address neonatal MARSI, nursing clinicians need to understand adhesive base layers. Quick reference resources are now available but further evaluation is needed on MARSI and evidence utilisation in neonatal practice.     

Electrophysical agents and research: from instinct to evidence

Abstract

Objectives: Anecdotally the focus on evidence-based practice in many health sciences is not reflected in the availability and usage patterns of electrophysical agents. This proposition is examined in relation to therapeutic ultrasound (US) and microwave (MW).

Methods: Research published in English between 1998 and 2008 and using MW or US to treat musculoskeletal conditions was identified and reviewed. Usage and availability of each modality was also examined and compared with evidence of clinical effectiveness identified in the literature review.

Results: While MW is rarely available or used, recent research suggests positive outcomes in treating different musculoskeletal conditions, particularly with a frequency of 434 MHz. By contrast, US is often available and used but the research on this remains equivocal.

Discussion: The known effectiveness of MW and US in treating musculoskeletal problems is not reflected in usage patterns. Usage appears to be based on other than evidence of the clinical utility of these two modalities. How much it derives from patients' expectations and issues clinicians may have in using research not targeted at practitioners is unknown. There are implications for educators, clinicians, researchers and journal editors. These may include the need for more syntheses of research findings and books that focus on clinical conditions rather than research per se. These ideas need further exploration.

Conclusion: The choice of MW or US is apparently based on other than evidence of effectiveness.     

Dyspnea in Patients with Advanced Stage Cancer: A Nurses Guide to Assessment and Treatment

ObjectiveTo provide oncology nurses with education on the specific distressing symptom of dyspnea in patients with advanced cancer, including proper assessment and a hierarchical approach to both nonpharmacologic and pharmacologic dyspnea interventions.Data SourcesSources include published research findings, literature reviews, and guidelines, as well as professional opinion from practicing nurses and clinicians.ConclusionIndividuals with advanced cancer often experience the distressing respiratory symptom, dyspnea. Assessment tools and treatment recommendations and guidelines are available for clinicians to appropriately evaluate and treat dyspnea. Improved awareness of symptom presence and treatment options will assist nurses in advocating for their patients with advanced cancer and obtaining and delivering the necessary treatments for dyspnea relief.Implications for NursingPublished evidence supports the many treatment options available for dyspnea relief at varying levels. Assessment, individualized treatment, education, and reassessment are key and ongoing to assist patients with advanced cancer to achieve respiratory comfort.     

Supporting People and Their Caregivers Living with Advanced Cancer: From Individual Experience to a National Interdisciplinary Program

ObjectivesTo discuss the unmet needs of patients living with advanced cancer and their caregivers and to review strategies, including collaborating with community and non-profit organizations, to help improve the experience of living with, and beyond, advanced cancer.Data SourcesPublished articles, first person experience (SB), community organization input, and survey data (Canadian Cancer Society).ConclusionPeople living with advanced cancer face significant challenges, including persistent physical symptoms and psychosocial concerns, difficulties with coordination of care, and possible lack of available resources and supports if the person is no longer being followed by cancer health care professionals. More research is required to better understand the needs of patients and their caregivers living with advanced cancer. Existing resources and supports may be inadequate for this population, and delineation of the unique needs of this population may lead to tailored care plans and, ultimately, an improved experience for patients and caregivers alike.Implications for Nursing PracticeOncology nurses are ideally suited to care for this population to help elucidate their unique unmet needs and collaborate with patients and other clinicians to develop interventions to address such unmet needs. Oncology nurses can liaise with community organizations to identify sources of support and resources for patients and their loved ones and advocate for improved care for patients affected by advanced cancer.     

Role and Evaluation of Palliative Home Care Services

Abstract

Evidence-based practice (EBP) first evolved within medicine in the early 1990s, and has since influenced nearly every clinical discipline. Despite differing definitions, its central tenet remains the appropriate integration of relevant best practice (usually based on published research findings when available) into clinical practice. EBP has also attracted criticisms; but, notwithstanding these, there are many reasons why healthcare professionals need to have an understanding of EBP as it now stands, ranging from its potential to contribute to improved clinical outcomes, through to participation in the further development and refinement of EBP. Minimally, clinicians should be aware of, understand, and be able to find EBP resources that provide access to research already appraised for both its quality and relevance. More extensive EBP skills remain highly desirable, and might be viewed as essential skills for life-long learning regardless of EBP.     

Perspectives of school-work transitions among youth with spina bifida,their parents and health care providers

Purpose Youth with disabilities encounter many challenges in finding employment and transitioning to post-secondary education. In this article, we explore the nature of school-work transitions for youth with spina bifida, which few studies have previously addressed. Method We conducted in-depth interviews with 44 participants (nine youth and 12 young adults with spina bifida, 11 parents and 12 clinicians). We analyzed our data using a qualitative content analysis approach. Results We identified several enablers to school-work transitions, including professional support, social support and school accommodations. Lacking such support created several challenges for youth with spina bifida. We also identified several barriers to school-work transitions, including lack of education and information on finances, housing and transportation; discrimination and stigma; and challenges coping with spina bifida at school and work. Conclusions Although some supports are available, youth with spina bifida encounter many challenges in transitioning to post-secondary education and employment. With clinicians at the helm, efforts should be put in place within the health and social services system to better prepare youth, as they transition to adulthood, to become connected to appropriate information and resources to help them to succeed in their school and employment goals.

• Implications for Rehabilitation

• Youth with spina bifida encounter many challenges in transitioning to post-secondary education or work. Clinicians, educators and parents should continue to support youth with spina bifida in choosing their vocations, setting career goals and developing career plans.

• Starting from a young age, parents, clinicians and educators should help youth with spina bifida prepare for school work transitions by fostering their independence, life skills and self-management of spina bifida-related symptoms.

• Clinicians and educators should help connect youth with spina bifida to appropriate information and resources to support their school-work transitions, including information on finances, housing, transportation, school accommodations and employment supports.

     

Inclusion of rehabilitation medicine concepts in school of medicine resources

Abstract

Purpose: To perform a gap analysis of rehabilitation medicine learning objectives (RMLOs) coverage within school of medicine (SOM) curriculum and educational resources as a basis for development of educational resources to fill any identified gaps. Method: Following ethics approval, interviews were carried out with SOM academics and clinicians to assess the relevance of a set of RMLOs and the extent to which RMLOs were addressed in SOM resources. Interviewee opinion was quantified via Likert scales and additional free comments were subjected to thematic analysis. Results: Most RMLOs were perceived as relevant by more than half of the 18 participants. There was evidence of relevant material relating to each RMLO in SOM resources. Thematic analysis suggested that rehabilitation medicine was addressed at the SOM in less detail than outlined in the RMLOs, and that additional rehabilitation content could be included in SOM resources across a number of courses and year levels. Conclusions: Rehabilitation medicine is considered relevant by clinicians and academics at the SOM. The most effective way of filling identified gaps in coverage of rehabilitation medicine at the SOM will be via engagement across a number of medical and surgical disciplines.

• Implications for Rehabilitation

• Rehabilitation-related knowledge and skills are relevant to medical education.

• Many of these issues are already partially addressed in existing educational resources.

• The design and delivery of medical school curricula should include a trans-disciplinary and inter-year approach to the inclusion of rehabilitation concepts and aptitudes.

• This could be done by introducing relevant concepts early, making resources available online, and embedding rehabilitation items across different disciplines, courses and assessments.

     

Culturally sensitive communication at the end-of-life in the intensive care unit: A systematic review

ObjectivesThe objectives of this systematic review were the following: (i) to describe whether culturally sensitive communication is used by clinicians (nurses and physicians) when communicating with patients and families at the end-of-life in the intensive care unit and (ii) to evaluate the impact of culturally sensitive communication at the end-of-life. The systematic review question was how is culturally sensitive communication used by clinicians when communicating with patients and families at the end-of-life in the intensive care unit?Data sourcesA search of CINAHL, MEDLINE, Embase, and PsycINFO databases identified all peer-reviewed research evidence published in English between January 1994 and November 2017. Two authors independently assessed articles for inclusion. From the 124 articles resulting from the search, nine were included in this systematic review.Review methodsArticles were independently assessed for quality by two authors using Caldwell et al.'s framework to critique health research. The data available in this systematic review were heterogeneous, with varied study designs and outcome measures, making the data unsuitable for meta-analysis. The most appropriate method for data synthesis for this systematic review was narrative synthesis.ResultsFrom the narrative synthesis, two major themes emerged: communication barriers and cultural and personal influences on culturally sensitive communication. Communication barriers were identified in eight studies, influencing the timing and quality of culturally sensitive communication at the end-of-life. Cultural and personal influences on communication at the end-of-life was present in eight studies.ConclusionsThe findings of this systematic review show that clinicians lack the knowledge to enable effective interaction with culturally diverse patients and families at the end-of-life.     

Difficulties and opportunities for research as perceived by nurses in Asturias (Spain)

ObjectivesTo identify, through communicative consensus, the difficulties and opportunities for research perceived by nurses in Asturias (Spain).MethodsThe Regional Ministry of Health and the Health Service of Asturias made an open call and 80 nurses from all fields (clinical, teaching, and management) were assigned to 10 groups. Using a nominal group technique, these nurses identified and prioritized the difficulties and opportunities they perceived for research. Through independent pairs, the research group analyzed the content of the contributions made.ResultsIn order of priority, the difficulties perceived were related to training deficit, lack of resources, lack of available time, little acknowledgement and support, and professional idiosyncrasy and sociology. The opportunities perceived were grouped into training opportunities, material resources –when known to exist–, support from experts, access to information resources, the existence of financial support, and time available when working in primary care.ConclusionsThe nurses identified the difficulties and opportunities that should be taken into account if strategies to stimulate nursing research are to be established. The situation should continue to be analyzed in order to provide possible solutions to the difficulties encountered, especially those related to professional idiosyncrasy and sociology.     

Technology for trauma: testing the validity of a smartphone app for pre-hospital clinicians

Introduction:With the introduction of regional trauma networks in England, ambulance clinicians have been required to make triage decisions relating to severity of injury, and appropriate destination for the patient, which may require ‘bypassing’ the nearest Emergency Department. A ‘Trauma Unit Bypass Tool’ is utilised in this process. The Major Trauma Triage tool smartphone application (App) is a digital representation of a tool, available for clinicians to use on their smartphone. Prior to disseminating the application, validity and performance against the existing paper-based tool was explored.Methods:A case-based study using clinical scenarios was conducted. Scenarios, with appropriate triage decisions, were agreed by an expert panel. Ambulance clinicians were assigned to either the paper-based tool or smartphone app group and asked to make a triage decision using the available information. The positive predictive value (PPV) of each tool was calculated.Results:The PPV of the paper tool was 0.76 and 0.86 for the smartphone app. User comments were mainly positive for both tools with no negative comments relating to the smartphone app.Conclusion:The smartphone app version of the Trauma Unit Bypass Tool performs at least as well as the paper version and can be utilised safely by pre-hospital clinicians in supporting triage decisions relating to potential major trauma.     

Clinical trial variability: quality control in a randomized clinical trial

IntroductionA major issue in clinical trials in manual medicine is treatment variability. The challenge is to insure that the bounded treatment options are both representative of field practitioner behavior and consistent among research clinicians. This investigation assesses the treatment comparability of field practitioners and research clinicians, for a flexion-distraction treatment procedure, as quality control for a randomized clinical trial.MethodsUsing a series of vignettes, we studied the level of agreement of treatment protocols between field clinicians, research clinicians and a reference clinician regarding treatment location, range of motion during treatment, and number of repetitions used within the flexion-distraction protocol.ResultsResults indicated that reliability around decision making for anticipated location of spinal treatment was highest regardless of clinician group. For the research clinicians this level of agreement was ICC = 0.88. Decision-making for treatment direction was second highest, at kappa = 0.64 for the research clinicians. Reliability around the number of repetitions is poor ranging from ICC = 0.18 to 0.34 depending on clinician type.DiscussionUnderstanding the disparity in treatment protocols is of value in the construction and maintenance of quality control in an actual randomized clinical trial setting. More work was recommended in the preparation of clinical trials and the understanding of clinical decision-making because these disparate factors may dramatically impact the generalizability of clinical trial results.     

The working shoulder: assessing demands,identifying risks,and promoting healthy occupational performance

Abstract

Background: Occupational shoulder injuries are a concern for society and clinicians. To best treat and assess the influence of physical work tasks on shoulder health, it is necessary to first understand shoulder function and dysfunction, common occupational pathologies, and existing methods to assess and prevent work-related shoulder injuries.

Objectives: The objectives of this paper are to present fundamental shoulder biomechanics, discuss known occupational risk factors for shoulder injury, review assessment and prevention techniques for shoulder injuries, and describe the range of tools available to evaluate work tasks for potential physical shoulder stressors.

Major findings: The complex shoulder mechanism has a unique role for performing work. Recognition of the delicate balance between creating arm mobility and maintaining joint stability is crucial to understanding how the region can be injured during work. Tools exist to aid clinicians in thinking critically about occupational shoulder injury, and can provide information about both specific and general physical exposures.

Conclusions: The shoulder is a complicated assembly of many neuromusculoskeletal elements, and these tissues can be injured in a variety of ways. This paper provides background on the nature of these injuries and discusses preventative strategies available to pragmatically assist clinicians.     

Animal-assisted activities in the intensive care unit: A scoping review

BackgroundAnimal-assisted activities have demonstrated benefits for patients and clinicians in acute care settings. However, concern exists regarding the use of animal-assisted activities in intensive care settings.AimTo synthesise research evidence on animal-assisted activities in intensive care units.MethodsA scoping review of research literature published in English was undertaken. In May 2021, five databases (CINAHL, MEDLINE, Embase, Scopus and PSYCInfo) were systematically searched. Title, abstract and then full text screening was undertaken independently by the research team.ResultsSix primary research studies were identified from the 1190 records screened. All six studies were of a feasibility or observational study design, with five of the studies published in the last three years, highlighting the emerging evidence base for this practice. This scoping review synthesises the key characteristics of animal-assisted activities in intensive care units, including risk mitigation strategies. Strong satisfaction with and support for animal-assisted activities was reported by patients, family members and clinicians. However, studies reporting biophysical outcomes were inconclusive due to small sample sizes.ConclusionsEvidence supporting animal-assisted activities in intensive care units remains largely anecdotal. Further research is required to ascertain the feasibility, appropriateness, meaningfulness and effectiveness of animal-assisted activities for improving patient outcomes, and family members and intensive care clinicians’ wellness.     

Factors influencing clinical consistency and variability in voice prosthesis management

Abstract

Purpose: Anecdotally it is recognised that management of tracheoesophageal speech (TES) post-laryngectomy varies between speech language pathology (SLP) services and clinicians. This study reviewed patterns of practice for TES management to examine patterns of practice and explore factors influencing variability.

Method: A national survey was completed by SLP’s from clinical services which manage TES. This online survey examined demographic and caseload information, initial voice prosthesis (VP) placement and procedures, VP cleaning and care recommendations, humidification management, equipment and service provision, and service delivery options at each site.

Result: Lead clinicians from 34 sites (85% response rate) responded. Most clinical practice regarding initial VP insertion and management, as well as the timing and delivery of voice rehabilitation was highly consistent. Patient use of antifungal medications, TES and associated equipment provision, humidification management immediately post-surgery and some aspects of initial VP insertion were variable between services. The nature of the clinical setting, equipment funding and level of research evidence influenced variability in practice.

Conclusion: Variability exists in a number of aspects of practice across Australian services offering TES management. Sources of variability need to be addressed nationally to ensure there is consistent, quality care available for all patients.     

A guide for clinicians – physical activity and energy expenditure explained

Abstract

Background: Regular physical activity (PA) is a key component in the maintenance of a healthy lifestyle and is known to decrease the risk of numerous chronic health conditions. Accurate measurement of PA is essential to determine the effect of exercise interventions on long-term PA levels and to identify population health behaviours. However, measurement of PA is complex and multimodal with numerous measurement tools available.

Objectives: The aim of this review is to improve conceptual clarity regarding PA and to examine the difficulties relating to PA measurement in order to enable clinicians to choose the optimal PA measurement tool.

Major findings: PA is a multidimensional concept. Movement and energy expenditure (EE) are the most common dimensions used in the quantification of PA. There are numerous PA measurement options including doubly labelled water, calorimetry, heart rate monitors and motion sensors (pedometers and accelerometers). Choosing the optimal measurement tool is influenced by the parameter of PA that is of most relevance. Motion sensors appear to provide the most promising and accurate cost-effective method of measuring free-living PA, particularly when accelerometer and physiological data are integrated. However, consideration must be given to the intrinsic difficulties associated with motion monitors, particularly the use of generic values and algorithms in calculating EE, which limit the external validity and applicability of motion sensors in different populations.

Conclusions: Although the optimal method of measuring PA remains unknown, forming appropriate research and clinical questions and providing conceptual clarity should guide clinicians in selecting the most appropriate measurement option.     

A new statistical trend in clinical research – Bayesian statistics

Abstract

Background: The emphasis on evidence-based practice in physical therapy has increased the number of clinicians who perform and interpret clinical research. Unfortunately, the traditional statistical analysis (frequentist approach) used most often in clinical research (except meta-analysis) has been criticized by biostatisticians for potential bias and misleading results if used with data from single studies. Alternatively, Bayesian inference can be used instead of the traditional frequentist approach although this trend has yet to be seen in rehabilitation research. Used for at least three decades, the Bayesian approach provides a formal framework for researchers to incorporate prior knowledge and current evidence to derive new probabilities for various hypotheses. Since the results are presented in terms of probability, clinicians can interpret and apply research findings to clinical practice directly.

Objectives: The objectives of this review are to discuss the common misconceptions among users of the frequentist approach, the inherent limitations of the frequentist approach, as well as to introduce the characteristics and limitations of the Bayesian approach using illustrated examples.

Conclusions: The Bayesian approach can be used as an alternative or adjunct to the frequentist method in future studies. This approach is also robust in situations that are unfavourable to traditional statistics such as sequential clinical trials. However, biostatisticians may have to be consulted for some sophisticated Bayesian analysis. As the Bayesian approach may gain popularity, a good understanding of this method will benefit clinicians in interpreting research papers and planning their future clinical studies.     

Prevalence and Predictors of Burnout Among Hospice and Palliative Care Clinicians in the U.S.

ContextMany clinical disciplines report high rates of burnout, which leads to low quality of care. Palliative care clinicians routinely manage patients with significant suffering, aiming to improve quality of life. As a major role of palliative care clinicians involves educating patients and caregivers regarding identifying priorities and balancing stress, we wondered how clinician self-management of burnout matches against the emotionally exhaustive nature of the work.ObjectivesWe sought to understand the prevalence and predictors of burnout using a discipline-wide survey.MethodsWe asked American Academy of Hospice and Palliative Medicine clinician members to complete an electronic survey querying demographic factors, job responsibilities, and the Maslach Burnout Inventory. We performed univariate and multivariable regression analyses to identify predictors of high rates of burnout.ResultsWe received 1357 responses (response rate 30%). Overall, we observed a burnout rate of 38.7%, with higher rates reported by nonphysician clinicians. Most burnout stemmed from emotional exhaustion, with depersonalization comprising a minor portion. Factors associated with higher odds of burnout include nonphysician clinical roles, working in smaller organizations, working longer hours, being younger than 50 years of age, and working weekends. We did not observe different rates between palliative care clinicians and hospice clinicians. Higher rated self-management activities to mitigate burnout include participating in interpersonal relationships and taking vacations.ConclusionBurnout is a major issue facing the palliative care clinician workforce. Strategies at the discipline-wide and individual levels are needed to sustain the delivery of responsive, available, high-quality palliative care for all patients with serious illness.     

Intertester reliability of shoulder complaints diagnoses in primary health care

Objective: Shoulder complaints are frequently encountered in general practice, but precise diagnosing is challenging. This study investigated agreement of shoulder complaints diagnoses between clinicians in a primary health care setting.

Design: Cross-sectional study.

Setting: Four primary health care clinicians used patients’ history and functional examination of the shoulder by selective tissue tension techniques (STTs), to diagnose shoulder complaints.

Subjects: 62 patients, aged 18–75 years.

Main outcome measure: Reliability of diagnoses was assessed by observed intertester agreement and Cohen’s kappa. A total of 372 diagnostic pairs were available for intertester comparisons.

Results: Six diagnoses were assigned by all clinicians; supraspinatus-, infraspinatus-, subscapularis-tendinopathies; chronic subacromial bursitis; glenohumeral capsulitis, and acromioclavicular joint lesion. The observed agreement on these diagnoses ranged from 0.84 for glenohumeral capsulitis to 0.97 for acromioclavicular joint lesion. Kappa scores were 0.46 (95% CI 0.33, 0.58) for chronic subacromial bursitis; 0.53 (95% CI 0.34, 0.68), 0.59 (95% CI 0.47, 0.70), and 0.68 (95% CI 0.53, 0.82) for infraspinatus -, supraspinatus -, and subscapularis-tendinopathy, respectively. For glenohumeral capsulitis and acromioclavicular lesion kappa scores were 0.66 (95% CI 0.57, 0.73) and 0.78 (95% CI 0.61, 0.90). Kappa scores were higher for individual diagnoses than for individual tests, except for limitation in passive abduction (0.70, 95% CI 0.62, 0.78) and passive lateral rotation (0.66, 95% CI 0.57, 0.73).

Conclusions: Although experienced clinicians showed substantial intertester agreement, precise diagnoses of shoulder complaints in primary health care remain a challenge. The present results call for further research on refined diagnoses of shoulder complaints.

• Key points

• Based on medical history and a systematic functional examination by selective tissue tension techniques (STTs), we investigated the agreement of shoulder complaints diagnoses across four primary health care clinicians and 62 patients.

• ??Agreements on diagnoses were generally better than the agreement on individual tests.

• ??Good kappa scores were obtained for the diagnoses glenohumeral capsulitis, rotator cuff tendinopathy, and acromioclavicular lesion.

• ??Further research is necessary to investigate the diagnostic validity of functional shoulder examination by the STTs method.