An environmental scan of an aged care workplace using the PARiHS model: assessing preparedness for change.

AIM: The environmental scan aimed to deepen our understanding of the aged care work culture and to ascertain the readiness of the workers to advance towards team-based quality care provision. BACKGROUND: The workplace context was a high-care unit within a large residential aged care facility. METHODS: We used the Promoting Action on Research Implementation in Health Services (PARiHS) framework to assess workplace readiness via interviews, individual surveys and observation of practice. RESULTS: A profile of current culture emerged as mutually supportive and task focused, but at the same time lacking corporate team features of shared decision-making and feedback for practice improvement. However, latent within the frontline leaders and personal care staff, there was evidence of some embedded knowledge and capacity for corporate team performance. CONCLUSIONS: This study has validated an evidence-based method for conducting environmental scanning in aged care, recommended before any major change is introduced. IMPLICATIONS FOR NURSING MANAGEMENT: Environmental scanning helps gauge workforce capacity and limitations; this information can enable managers to capitalize on identified cultural strengths to fortify change and avoid pitfalls of personal and collective vulnerabilities.

Exploring the role of music therapy in cardiac rehabilitation after cardiothoracic surgery: a qualitative study using the Bonny method of guided imagery and music.

BACKGROUND: Cardiac rehabilitation integrates physical, psychological, and vocational strategies to restore and sustain optimal health. OBJECTIVE: An innovative study using music therapy (Bonny Method of Guided Imagery and Music [BMGIM]) explored the experiences of cardiac rehabilitation participants in an outpatient setting at 2 major metropolitan teaching hospitals. METHODS: Commencing 6 to 15 weeks after cardiothoracic surgery, 6 study participants were recruited for 6 weekly music therapy (BMGIM) sessions. Qualitative analysis of the patient narrative within a semiotic framework demonstrated that patients used music therapy to spontaneously explore their recovery process. RESULTS: Five grand themes emerged: (1) looking through the frame, (2) feeling the impact, (3) spiralling into the unexpected, (4) sublime plateau, and (5) rehearsing new steps. The themes related to physical changes, adjustment after surgery, and anticipated lifestyle. CONCLUSIONS: This study demonstrates that music therapy (BMGIM) may be used to access and understand the internal recovery process of postcardiothoracic surgical patients, providing an additional clinical tool to augment the external rehabilitation process.

Working together to improve the care of older people: a new framework for collaboration.

AIM: This paper is a report of a study identifying the care issues experienced by older people in the acute setting that could be improved through a collaborative approach to action. BACKGROUND: Actively involving consumers in the governance of healthcare organizations is viewed positively, although there is less agreement on how to do this. Co-operative inquiry is a useful approach to involve consumers and clinicians in structured dialogue about understanding and changing care, whereas traditional quality improvement methodologies are often singular in their dimensions of change. METHOD: Using a co-operative inquiry approach, five workshops were facilitated over a 4-month period in 2008 with four volunteer older people, four clinicians and three facilitators (n=11). All participants were actively involved in generating ideas and actions using a range of facilitation techniques and data collection methods. FINDINGS: There was increased awareness, understanding and acceptance of clinicians' and consumers' experiences and expectations of care. The complexity behind changing so-called simple care (providing warm drinks, appetizing food), which were the key concerns for consumers, relied on the active management and broader transformation of the system, including teamwork, communication processes and organizational and individual values and beliefs. CONCLUSION: Consumers and clinicians put different emphasis on perspectives related to improving care of older people in the acute hospital setting. The disconnect between what consumers viewed as 'simple' organizational behaviours to change and what the clinicians viewed as complex, led to a recognition that the approach to organizational change needs to be reconceptualized.

The use of memory recall strategies in the management of behaviours associated with dementia.

EXECUTIVE SUMMARY: Background Many people who develop dementia are placed in long-term care facilities, as they often require high-level care that can no longer be provided by family and friends. As yet no cure for dementia exists and management of dementia-associated behaviours can be complex. Mental recall is one type of behaviour therapy whereby a representation of past experience is elicited. To date there has not been a systematic review conducted that focuses specifically on recall techniques for managing behaviours associated with dementia.Aim To determine the effects of using recall strategies in managing behaviours associated with dementia. INCLUSION CRITERIA: Types of studies Any quantitative and qualitative study designs were considered.Types of participants People aged over 60 years who had a clinical diagnosis of dementia and displayed behaviours associated with dementia.Types of intervention Any behaviour therapy modality that used recall was considered for this review. For the purpose of this review memory or mental recall related to the ability to recall previously encountered items from memory.Types of outcome measures The outcome of interest was a positive change in the behaviour associated with dementia.Search strategy Using a collection of keywords and MeSH terms, a selection of electronic bibliographic databases were searched for both published and unpublished studies between the years 1990 and 2009. A three-step search strategy was utilised: firstly an initial limited search of MEDLINE and CINAHL was undertaken, followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms was then performed across all included databases. Thirdly, the reference list of all identified reports and articles were searched for additional studies.Critical appraisal Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review.Data extraction and synthesis Data was extracted from papers included in the review using the appropriate standardised data extraction tool. Due to the heterogeneity of papers statistical pooling was not appropriate and the findings are summarised in narrative form.Results Only three papers met inclusion criteria; one quasi-experimental and two case series.Methodological quality was weak and caution is required when interpreting results. The quasi-experimental study focussed on teaching and supporting spousal caregivers of people with dementia to use a cueing system to modify the frequency of repetitive verbalisations. Results suggested that for those caregivers who followed the intervention as advised by the therapist, reductions in verbalisations were demonstrated compared to pre-intervention. There was however, a wide variation in the severity of the problem, with results showing a variable amount of change in vocalisations following the intervention. The results of the case series suggest that incorporating a behavioural approach that includes a cueing system with or without fading cues may be successful for some residents with dementia but not all.Implications for practice Due to the strength of the results no conclusive recommendations can be made regarding the utilisation of cueing systems to change problem behaviours associated with dementia. There is weak evidence to suggest that recall approaches can be of benefit to some people with dementia who exhibit behaviours such as demanding and repetitive verbalisations and aggression. Issues regarding expertise in developing and delivering such interventions, as well as training and support of caregivers, both formal and informal, will need to be considered.Implications for research Primary research utilising rigorous research methods that evaluate the effects of cueing systems to modify behaviours associated with dementia is imperative in order to recommend or refute such a behavioural approach. Other issues such as factors likely to affect a person's response to recall strategies and the optimal training methods for staff and informal caregivers of people with dementia, including strategies for encouragement and support should be considered.

The use of behavioural reinforcement in the management of behaviours of concern associated with dementia.

EXECUTIVE SUMMARY: Introduction People with dementia often require high-level care due to behaviours that are associated with dementia such as verbal and physical aggression. Behavioural therapies that utilise approaches such as behavioural reinforcement are one possible strategy to manage such behaviours.Aims The objective of this review was to synthesise the best available evidence in relation to the use of behavioural reinforcement in the management of behaviours associated with dementia. INCLUSION CRITERIA: Types of participants Participants were adults aged over 60 years who had a clinical diagnosis of dementia and who exhibited any of the following behaviours associated with dementia e.g. verbal and physical aggression, vocalisations and wandering.Types of intervention Any behaviour therapy modality that used reinforcement techniques was considered.Types of outcomes The outcome of interest was a change in the behaviour associated with dementia.Types of studies Any quantitative or qualitative study designs were considered. In the absence of high quality studies, designs such as case series were considered.Search strategy The search strategy aimed to find both published and unpublished studies using a three-step approach. Papers were limited to the English language and a date restriction of 1990 to 2009 was set. METHODS OF REVIEW: Critical appraisal Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review. Disagreements that arose between the reviewers were resolved through discussion.Data extraction Quantitative data was extracted from papers included in the review using a standardised data extraction tool.Data synthesis Only quantitative papers met the review's inclusion criteria and were subsequently included. Due to the heterogeneity in the study design, populations, interventions and outcomes of papers, meta-analyses could not be undertaken. A narrative summary of each paper is thus provided.Results Only five papers were included; one repeated measures quasi-experimental study, three case series and one case report. Priority was given to the quasi-experimental study due to its design and quality score. The methodological quality of the other papers was weak. In total only eleven subjects were included that focussed on different schedules of reinforcement and different behaviours. The quasi-experimental study did not demonstrate significant results between presenting a visual stimulus continuously or intermittently and wandering. The preliminary evidence from the case series/report all reported a reduction in the undesirable behaviour following implementation of a reinforcement method.Conclusions Due to the evidence currently available, the utilisation of reinforcement approaches to assist in reducing or eliminating behaviours associated with dementia can be neither recommended nor refuted.Implications for practice There is weak evidence to suggest that implementing a reinforcement schedule may reduce behaviours such as physical or verbal aggression and vocalisations. The evidence for wandering is equivocal. Making a decision to utilise this type of behavioural approach should be based on clinical judgement, the preference of the patient or family and the context in which the care is delivered.Implications for research Due to the limited available evidence on this topic that can only provide weak empirical evidence, further experimental investigations such as controlled trials should be conducted to test the hypothesis that reinforcement strategies may assist in reducing or eliminating behaviour/s associated with dementia.

Culture of rural nursing practice: a critical theoretical analysis of determinants of power in nursing.

OBJECTIVE: This paper investigates the culture of workplace learning within a study of eight small hospitals in rural New South Wales (NSW), Australia. DESIGN: The study used a focus group method of data collection, undertaken before then after a series of interventions designed to nurture a culture that supports learning within the rural health care setting. PARTICIPANTS: Student AINs, AINs, ENs and RNs from any of the eight hospitals. CONCLUSION: Framed within a critical social perspective it applies a theory of culture to understand the determinants of social divisiveness that was occurring between different levels of the nursing workforce. These results are further analysed within a theoretical discussion of culture and power in nursing.

Developing support for remote nursing education through workplace culture that values learning.

OBJECTIVE: The present study presents the cultural challenges of introducing workplace learning associated with a nursing educational pathway into small rural hospitals. DESIGN AND INTERVENTION: Focus groups were conducted before and after an action research intervention to determine whether changes in understanding and values on learning had occurred. SETTING: Eight multipurpose services or small rural hospitals across rural New South Wales were involved in the intervention. SUBJECT: Nursing staff from eight rural health facilities participated voluntarily in the present study. OUTCOMES: Two outcomes were achieved: The development of mentoring, locally tailored to the needs and expectations of nursing participants; Values and understanding of learning were enhanced, with advanced levels of learning being identified and demonstrated by staff in the practice setting. CONCLUSION: Small rural hospitals can provide opportunities for advanced clinical learning. Forms of major mentoring are, however, critical to this process.

Abnormal Pap test results and the rurality factor.

OBJECTIVE: To review the published socio-cultural determinants that put women in rural areas at greater risk of having an abnormal Pap test result. DESIGN: Literature review. CONCLUSION: An Australian woman is at increased risk of developing cervical dysplasia if she lives in a rural area, identifies as an Indigenous Australian or is from a non-English speaking country. Being aged over 50 years, increases the risk of cervical cancer but not cervical intra-epithelial neoplasia (CIN) 1, which peaks in the 20-24 year age group. Other connections with cervical dysplasia relate to a woman or her partner's sexual history, her nutritional status and possibly even her personality type. Smoking, social isolation, high negative life change events and having lived a 'troubled' life are all identified in the literature as increasing a woman's risk of having an abnormal Pap test result. Receiving an abnormal Pap test result often leads to feelings of fear, anxiety, guilt, shock, vulnerability, powerlessness, depression, shame and feeling dirty for the woman concerned. Compounding these negative feelings are social, practical and financial difficulties that have to be addressed. It is argued that social and medical models of health must complement each other to improve the well being of rural women experiencing an abnormal Pap result.

The power of place.

OBJECTIVE: to describe the power that 'place' holds over the postnatal-care experiences of women. DESIGN: a study informed by phenomenology within a feminist framework was undertaken to examine the experiences of women electing early postnatal discharge. Three extended conversations with each woman participating in the study were audiotaped and transcribed. Journal notes made by the researcher added to the audiotaped data. Thematic analysis revealed major structures of experience. SETTING: data were obtained from conversations with women in their respective homes. PARTICIPANTS: five women, parity 1-3, living in the Sydney metropolitan area and birthing in their local hospitals participated in the study. FINDINGS: four major constructs of experience were revealed through analysis and include spatiality, corporeality, temporality and relationality. In this paper, components of spatiality expressed through the power place exerts in matters of physical environment,control, confidence, safety, time, talk and the heart of the matter are presented. KEY CONCLUSIONS: the experiences of women entering the foreign place of hospital to birth their children were those of alienation and disempowerment while the familiar territory of home offered stronger feelings of security and support. IMPLICATIONS FOR PRACTICE: failing to recognise the impact of place on the experiences of postnatal women reduces the likelihood that midwives will be able to offer sensitive and appropriate care.

Rural community mental health nursing: a grounded theory account of sole practice.

This paper examines community mental health in rural and remote settings, characterized as sole practice. Using a grounded theory approach, the research reported here explored how meanings of health and health care are advanced within the context of rural mental health care, dominated and in the main led by nurses. Five different practice sites in rural New South Wales were involved. The study articulated a model of therapeutics that foregrounds a relationship of intense professional intimacy and trust against a context of geographical disadvantage and professional isolation. The meanings of the relationship are elaborated in terms of unusually high levels of responsibility, professional ingenuity, powerlessness and the independent and risky character of life in the bush.