Clinical supervision for allied health staff: necessary but not sufficient.

Objectives The aim of the present study was to explore the perspectives of allied health professionals on appropriate content for effective clinical supervision of staff. Methods A set of statements regarding clinical supervision was identified from the literature and confirmed through a Q-sort process. The final set was administered as an online survey to 437 allied health professionals working in two Australian health services. Results Of the 120 respondents, 82 had experienced six or more clinical supervision sessions and were included in the analysis. Respondents suggested that clinical supervision was beneficial to both staff and patients, and was distinct from line management performance monitoring and development. Curiously, some of the respondents did not agree that observation of the supervisee's clinical practice was an aspect of clinical supervision. Conclusions Although clinical supervision is included as a pillar of clinical governance, current practice may not be effective in addressing clinical risk. Australian health services need clear organisational policies that outline the relationship between supervisor and supervisee, the role and responsibilities of managers, the involvement of patients and the types of situations to be communicated to the line managers. What is known about the topic? Clinical supervision for allied health professionals is an essential component of clinical governance and is aimed at ensuring safe and high-quality care. However, there is varied understanding of the relationship between clinical supervision and performance management. What does this paper add? This paper provides the perspectives of allied health professionals who are experienced as supervisors or who have experienced supervision. The findings suggest a clear role for clinical supervision that needs to be better recognised within organisational policy and procedure. What are the implications for practitioners? Supervisors and supervisees must remember their duty of care and ensure compliance with organisational policies in their clinical supervisory practices.

Feasibility and acceptability of a volunteer-mediated diversional therapy program for older patients with cognitive impairment.

Understanding the perceptions of stakeholders is critical for determining acceptability and feasibility of volunteer-mediated programs. This study evaluated the feasibility and acceptability for staff, volunteers, patients and their carers, of a volunteer diversional therapy program for patients with cognitive impairment undergoing inpatient rehabilitation. Post-program structured interviews were conducted with the volunteers (n = 10), patients (n = 30) and their carers (n = 3); and nursing staff (n = 6) participated in a focus group. Thematic analysis identified five themes (values, attitudes, knowledge, purpose, support) in two dimensions (personal, team culture). Overall, patients, carers, staff and volunteers were satisfied with the volunteer program and perceived benefits for quality of care. Recommendations for improvements to the program related to staff engagement with the program and the volunteers' education and training. The volunteer diversional therapy pilot program for patients with cognitive impairment on a sub-acute ward was acceptable and feasible for patients, carers, staff and volunteers.

Feasibility, acceptability, and effectiveness of an electronic sensor bed/chair alarm in reducing falls in patients with cognitive impairment in a subacute ward.

Falls from bed are common in subacute hospital settings, particularly for patients with cognitive impairment. This repeated measures, single cohort study in 1 subacute ward evaluated effectiveness of an electronic sensor alarm in reducing falls in patients (n = 34) with cognitive impairment. Nursing staff feedback (focus group, survey) was used to determine electronic sensor alarm feasibility. The electronic alarm system was found to be a feasible, effective, and acceptable fall prevention strategy for patients with cognitive impairment.

Clinical supervision for allied health professionals: a systematic review.

BACKGROUND: It is recommended that allied health professionals (AHPs) participate in regular clinical supervision (CS). However, AHP understanding of CS processes and outcomes is unclear. This systematic review reports the evidence for CS for AHPs and other health professionals. METHODS: Five databases and reference lists of included articles were searched. Papers included described CS definitions, processes and outcomes of CS. Due to the paucity of CS research for AHPs, nursing and medical disciplines were included. Two reviewers critically appraised the 33 included papers. RESULTS: The majority of papers were exploratory. Definitions and processes for CS were not clearly identified. Outcomes of CS included the relationships between CS and job satisfaction and workplace stress. Proctor's model and the Manchester Clinical Supervision Scale were the most common framework and evaluation approach. Contradictory positions of which components of Proctor's model should be included in CS were reported. Methodological flaws and a lack of comparative studies were common. DISCUSSION: Although not extensively supported by evidence, CS was generally held to be a positive experience and tends to be provided without a clear definition or model, using new or untested tools. Further research to evaluate CS for AHPs, is needed.

Effective clinical supervision for regional allied health professionals: the supervisor's perspective.

OBJECTIVE: To explore the effectiveness of the current clinical supervision (CS) processes for allied health professionals (AHPs) at a regional health service from the perspective of the supervisor. METHOD: A mixed method study with two phases, involving AHPs across nine disciplines, employed at a regional health service and providing CS. In the first phase 14 supervisors participated in focus groups which were followed by the completion of a questionnaire by 26 supervisors. RESULTS: Focus group results indicated confusion between CS, line and performance management and mentoring. Clinical supervision was perceived to contribute to the quality of patient care and reflective practice. The challenges of time for busy clinical staff were reported. The questionnaire response rate was 52.1% and the mean total score for the questionnaire was 162.96 (s.d. 13.47), being 76% of the maximum possible total score. Clinical supervision was considered to improve care quality despite the avoidance of addressing personal issues. Identified CS improvements included empowerment through education, resources development, streamlined documentation and use of best practice protocols. CONCLUSIONS: The results identified AHP supervisors' perceptions of CS and possible improvements to CS processes, including differentiating CS from line management, protecting CS time and the provision of critical feedback. WHAT IS KNOWN ABOUT THE TOPIC? There are limited published reports about CS for AHPs, with AHP supervisor experience and knowledge not previously reported. WHAT DOES THE PAPER ADD? This is the first study to identify current supervisor understanding and practice of CS for AHPs. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS? CS is a valued activity, the effectiveness of which may be supported by education and resources.

Comparison of two fall risk assessment tools (FRATs) targeting falls prevention in sub-acute care.

FRATs are designed to identify both persons at high risk of falls and to allow for cost-effective targeting of fall prevention strategies. This study compares two FRATs (BHS FRAT and TNH-STRATIFY) for accuracy of predicting falls and targeting of fall prevention strategies in a sub-acute hospital. Comparisons of retrospective audit data over two periods (use of the BHS-FRAT; post TNH-STRATIFY implementation) were used in the evaluation (n=362). Inter-rater reliability of the TNH-STRATIFY was evaluated from independent assessment by two nurses for 30 sub-acute patients and using intraclass correlation coefficient (ICC(2,1)). Event rate (ER) and standard measures of predictive accuracy were calculated for both FRATs. The proportions of patients with documented fall prevention strategies addressing identified fall risk factors were compared between audit phases. The TNH-STRATIFY had high inter-rater reliability (ICC(2,1)=0.96). The BHS-FRAT and TNH-STRATIFY demonstrated poor predictive accuracy using recommended high risk cut-off scores, with low specificity(ER) (0.07 and 0.13 respectively) and very low Youden Index(ER) (0.04 and 0.07 respectively), although these measures improved using modified cut-off scores. Positive and negative predictive values were moderate for the BHS-FRAT (0.51, 0.64) and TNH-STRATIFY (0.52, 0.61). The falls rate and proportion of recurrent fallers did not change between audit phases. Implementation rates for prevention strategies for key risk factors were higher following implementation of the TNH-STRATIFY. The results indicated that the TNH-STRATIFY, combined with associated nursing care plan falls documentation, improved the targeting of prevention strategies for key risk factors such as cognitive impairment, incontinence and mobility impairment.

Effective clinical supervision for regional allied health professionals - the supervisee's perspective.

AIM: Clinical supervision (CS) for health professionals supports quality clinical practice. This study explored current CS effectiveness for allied health professionals (AHPs) at a regional health service from a supervisee perspective and identified improvements. METHOD: The Manchester Clinical Supervision Scale (MCSS) was completed by 30 supervisees to determine their perceptions of CS effectiveness. RESULTS: Supervision sessions typically occurred monthly (56.7%) and were one-to-one (86.2%). The mean total MCSS score was 142.83 (s.d. 15.73), greater than the reported threshold score of 136 for effective CS. The mean subscale scores of 'trust/rapport' and 'improved care/skills' were high, in contrast to the mean subscale scores for 'finding time' and 'personal issues', which were significantly lower than the other subscales (P<0.001). Low scores for 'finding time' and 'personal issues' subscales may be associated with emotional exhaustion and depersonalisation. CONCLUSIONS: In this first study evaluating CS for AHPs using the MCSS, CS was reported as being valued and important. However, there is a need for improvement in addressing personal issues that affect work performance and for finding time for CS. As effective CS is an important component of clinical governance by supporting safe and effective healthcare provision, it is vital that CS processes are improved.

A family-centred model of care in paediatric speech-language pathology.

Developments in paediatric models of care support family-centred practice (FCP); however, there is limited evidence for its use in speech-language pathology. This randomized controlled study examined whether parent satisfaction with FCP (n = 10) was greater than with usual practice (UP; n = 10) over 14 weeks for children with mild-moderate speech and/or language disorders. The FCP included parental goal decision-making; greater parent responsibility for clinic therapy tasks; and two home visits. There was a non-significant trend for the FCP group to have a higher mean score for the "Providing specific information" scale of the Measures of Process of Care. Goals for the FCP and UP groups were respectively targeted towards the Activities and Participation or the Body Function components of the International Classification of Functioning, Disability and Health-Children and Youth. While there were no significant differences between groups for speech/language outcomes post-intervention; it is clinically interesting that more children in the FCP group improved on the Renfrew Action Picture Test than the UP group. This study did not demonstrate a significant benefit for FCP over a relatively short timeframe in a small sample of children. Further research is warranted to determine if there is evidence for the use of FCP in speech-language pathology.

Does otolith organ dysfunction influence outcomes after a customized program of vestibular rehabilitation?

BACKGROUND AND PURPOSE: Vestibular rehabilitation (VR) is a successful approach to the treatment of vestibular dysfunction. The purpose of this study was to investigate the influence of otolith dysfunction on the response to VR in individuals with a peripheral vestibular disorder. PARTICIPANTS AND METHODS: Eighteen participants with loss of semicircular canal function only, and 29 participants with combined loss of semicircular canal and otolith organ function were recruited. All participants received a comprehensive clinical assessment before and after an 8-week customized program of VR. RESULTS: Both groups achieved significant improvements on most measures at the end of the 8-week VR program. However, no significant differences were identified between participants with versus without otolith dysfunction with respect to change in symptom severity (P = .81), self-perceived handicap (P = .92), functional limitations (P = .93), or balance performance after VR. DISCUSSION AND CONCLUSIONS: Otolith dysfunction does not significantly influence the response to rehabilitation of individuals with a peripheral vestibular disorder. Vestibular rehabilitation is associated improvements in symptom severity, self-perceived handicap, and balance function in individuals with otolith dysfunction.

Physiotherapy as an adjunct to prolapse surgery: an assessor-blinded randomized controlled trial.

INTRODUCTION: This assessor-blinded randomized controlled trial investigated the effect of a pre- and post-operative physiotherapy-supervised pelvic floor muscle (PFM) training program in women undergoing surgery for prolapse or hysterectomy. METHODS: Participants were assessed pre-operatively, and at 3, 6, and 12 months post-operatively by a blinded physiotherapy assessor. Following randomization, participants were allocated to a control group (CG) which included "usual care" (as provided by the surgeon and the hospital staff), or a treatment group (TG) which included one pre-operative and seven post-operative treatment sessions over 12 months. Primary outcomes were bladder and prolapse symptoms, measured by the Urogenital Distress Inventory (UDI) and the Incontinence Impact Questionnaire (IIQ). RESULTS: Fifty-one participants were randomized. The 12-month post-operative findings showed there was no difference in the prevalence of the primary outcomes (ORs 1.2, 1.3). There were no significant differences between groups on the change scores of the UDI (mean: 44.1 [5.1]; 54.0 [5.4], P = 0.20) nor the IIQ (median: 0.0 [9,14]; 10.0 [5,19], P = 0.09). The repeated measures analyses also demonstrated no significant changes. CONCLUSION: The program tested did not improve bladder or prolapse symptoms in this trial. Reasons may include the effectiveness of surgery alone, wide variance in data, small sample size, insufficient training by the TG, and PFM training by the usual care group.

Thoracic kyphosis affects spinal loads and trunk muscle force.

BACKGROUND AND PURPOSE: Patients with increased thoracic curvature often come to physical therapists for management of spinal pain and disorders. Although treatment approaches are aimed at normalizing or minimizing progression of kyphosis, the biomechanical rationales remain unsubstantiated. SUBJECTS: Forty-four subjects (mean age [+/-SD]=62.3+/-7.1 years) were dichotomized into high kyphosis and low kyphosis groups. METHODS: Lateral standing radiographs and photographs were captured and then digitized. These data were input into biomechanical models to estimate net segmental loading from T2-L5 as well as trunk muscle forces. RESULTS: The high kyphosis group demonstrated significantly greater normalized flexion moments and net compression and shear forces. Trunk muscle forces also were significantly greater in the high kyphosis group. A strong relationship existed between thoracic curvature and net segmental loads (r =.85-.93) and between thoracic curvature and muscle forces (r =.70-.82). DISCUSSION AND CONCLUSION: This study provides biomechanical evidence that increases in thoracic kyphosis are associated with significantly higher multisegmental spinal loads and trunk muscle forces in upright stance. These factors are likely to accelerate degenerative processes in spinal motion segments and contribute to the development of dysfunction and pain.

The influence of otolith dysfunction on the clinical presentation of people with a peripheral vestibular disorder.

BACKGROUND AND PURPOSE: Traditional vestibular function testing has measured horizontal semicircular canal function only. Otolith function tests have recently been developed, but their clinical significance has not been determined. The purpose of this study was to investigate the influence of otolith dysfunction on the clinical presentation of individuals with a peripheral vestibular disorder. SUBJECTS AND METHODS: Twenty-one subjects with loss of horizontal semicircular canal function only and 37 subjects with combined loss of horizontal semicircular canal and otolith organ function were recruited. All subjects received a comprehensive clinical assessment, including self-report questionnaires and measures of balance performance. RESULTS: No significant differences were identified between subjects with or without otolith dysfunction with respect to symptom severity, self-perceived handicap, functional limitations, or balance performance. DISCUSSION AND CONCLUSION: Otolith dysfunction does not significantly influence the clinical presentation of individuals with a peripheral vestibular disorder. Other factors, including symptom severity, may be more influential.

Hand-held dynamometry for muscle strength measurement in children with cerebral palsy.

The aim of this study was to investigate the reliability of hand-held dynamometry for measuring isometric lower-limb muscle strength in children with cerebral palsy (CP). Twenty-three children (14 males, nine females) with CP (spastic diplegia; Gross Motor Function Classification System Levels I-III) aged 5 years 7 months to 14 years 5 months (mean 9 y 6 mo [SD 2 y 8 mo]) attended two test sessions 1 week apart. A 'make' test, using a gradual build-up of force to a maximum isometric contraction, was employed and peak values were normalized to body weight for analyses. Within-session reliability was high with an intraclass correlation coefficient (ICC) of 1,1>0.79 for all muscle groups, and there was acceptable between-session reliability ICC>0.70 and measurement errors for hip flexors and extensors (measured in supine), knee flexors and extensors, and ankle dorsiflexors (with stabilization). Within- and between-session reliability was poor (ICC<0.70) for hip extensors (in prone), knee extensors (20 degrees flexion), ankle dorsiflexors (without stabilization), and ankle plantarflexors. Measurement error differed in each test and across limbs, with stabilization producing inconsistent reliability outcomes. Changes in strength measurements in children with CP should take into account measurement error for particular muscle groups. Changes should be determined for separate muscle groups and limbs, and reported relative to body weight. Different testing positions may be required for greater reliability.

The effect of osteoporotic vertebral fracture on predicted spinal loads in vivo.

The aetiology of osteoporotic vertebral fractures is multi-factorial, and cannot be explained solely by low bone mass. After sustaining an initial vertebral fracture, the risk of subsequent fracture increases greatly. Examination of physiologic loads imposed on vertebral bodies may help to explain a mechanism underlying this fracture cascade. This study tested the hypothesis that model-derived segmental vertebral loading is greater in individuals who have sustained an osteoporotic vertebral fracture compared to those with osteoporosis and no history of fracture. Flexion moments, and compression and shear loads were calculated from T2 to L5 in 12 participants with fractures (66.4 +/- 6.4 years, 162.2 +/- 5.1 cm, 69.1 +/- 11.2 kg) and 19 without fractures (62.9 +/- 7.9 years, 158.3 +/- 4.4 cm, 59.3 +/- 8.9 kg) while standing. Static analysis was used to solve gravitational loads while muscle-derived forces were calculated using a detailed trunk muscle model driven by optimization with a cost function set to minimise muscle fatigue. Least squares regression was used to derive polynomial functions to describe normalised load profiles. Regression co-efficients were compared between groups to examine differences in loading profiles. Loading at the fractured level, and at one level above and below, were also compared between groups. The fracture group had significantly greater normalised compression (p = 0.0008) and shear force (p < 0.0001) profiles and a trend for a greater flexion moment profile. At the level of fracture, a significantly greater flexion moment (p = 0.001) and shear force (p < 0.001) was observed in the fracture group. A greater flexion moment (p = 0.003) and compression force (p = 0.007) one level below the fracture, and a greater flexion moment (p = 0.002) and shear force (p = 0.002) one level above the fracture was observed in the fracture group. The differences observed in multi-level spinal loading between the groups may explain a mechanism for increased risk of subsequent vertebral fractures. Interventions aimed at restoring vertebral morphology or reduce thoracic curvature may assist in normalising spine load profiles.

Effect of test position on pelvic floor muscle assessment.

The aims of this study were to analyse the effect of different body positions on pelvic floor muscle (PFM) assessment using digital muscle testing, manometry and transabdominal ultrasound. In addition, subject acceptance of each testing position was recorded. Subjects were 20 women's health physiotherapists. The testing protocol included the best of three maximum voluntary contractions tested in each of four positions (crook lying, supine, sitting and standing). Significant differences in muscle strength and subject acceptance between positions were found with each tool, most often between lying and upright positions. Digital muscle testing and vaginal squeeze-pressure scores were highest in the lying position, and vaginal resting pressure and transabdominal ultrasound scores were highest in the standing position. Subjects preferred the lying positions for internal examinations. The clinical significance of these differences and the reasons for these variations require further investigation.

Reliability of pelvic floor muscle strength assessment using different test positions and tools.

AIMS: The aims of this study were to determine the intra-therapist reliability for digital muscle testing and vaginal manometry on maximum voluntary contraction strength and endurance. In addition, we assessed how reliability varied with different tools and different testing positions. METHODS: Subjects included 20 female physiotherapists. The modified Oxford scale was used for the digital muscle testing, and the Peritron perineometer was used for the vaginal resting pressure and vaginal squeeze pressure assessments. Strength and endurance testing were performed. The highest of the maximum voluntary contraction scores was used in strength analysis, and a fatigue index value was calculated from the endurance repetitions. Bent-knee lying, supine, sitting, and standing positions were used. The time interval for between-session reliability was 2-6 weeks. RESULTS: Kappa values for the between-session reliability of digital muscle testing were 0.69, 0.69, 0.86, and 0.79 for the four test positions, respectively. Intra-class correlation coefficient (ICC) values for squeeze pressure readings for the four positions were 0.95, 0.91, 0.96, and 0.92 for maximum voluntary contraction, and 0.05, 0.42, 0.13, and 0.35 for endurance testing. ICC values for resting pressure were 0.74, 0.77, 0.47, and 0.29. CONCLUSIONS: Reliability of digital muscle testing was very good in sitting and good in the other three positions. vaginal resting pressure demonstrated very good reliability in all four positions for maximum voluntary contraction, but was unreliable for endurance testing. Vaginal resting pressure was not reliable in upright positions. Both measurement tools are reliable in certain positions, with manometry demonstrating higher reliability coefficients.

Investigation of the timed 'up & go' test in children.

The timed 'Up & Go' test (TUG) is a test of basic or functional mobility in adults which has rarely been used in children. Functional mobility was defined for this study as an individual's ability to manoeuvre his or her body capably and independently to accomplish everyday tasks. Reliability and validity of TUG scores were examined in 176 children without physical disabilities (94 males, 82 females; mean age 5y 9mo [SD 1y 8mo]; range 3 to 9y) and in 41 young people with physical disabilities due to cerebral palsy or spina bifida (20 males, 21 females; mean age 8y 11mo [SD 4y 3mo], range 3 to 19y). Mean TUG score for children without physical disability was 5.9s (SD 1.3). Reliability of the TUG test was high, with intraclass correlation coefficients (ICC) of 0.89 within session, and 0.83 for test-retest reliability. Mean score of the group aged 3 to 5 years was significantly higher (6.7s SD 1.2) than that of the older group (5.1s, SD 0.8; p=0.001). Scores in the younger group reduced significantly over a 5-month follow-up period (p=0.001), indicating that the TUG was responsive to change. Within-session reliability of the TUG in young people with disabilities was very high (ICC=0.99). There were significant differences in TUG scores between children classified at levels I, II, and III of the Gross Motor Function Classification System (p=0.001). TUG scores showed a moderate negative correlation with scores on the Standing and Walking dimensions of the Gross Motor Function Measure (n=22, rho=-0.52, p=0.012). There was no significant difference in TUG scores between typically developing male and female children. The TUG can be used reliably in children as young as 3 years using the protocol described in this paper. It is a meaningful, quick, and practical objective measure of functional mobility. With further investigation, the TUG is potentially useful as a screening test, an outcome measure in intervention studies for young people with disabilities, a measure of disability, and as a measure of change in functional mobility over time.

A pilot study of falls risk and vestibular dysfunction in older fallers presenting to hospital emergency departments.

PURPOSE: To compare falls risk in older fallers and non-fallers, with an emphasis on dizziness and signs of vestibular dysfunction. METHOD: The fallers had presented to the Emergency Department of the Royal Melbourne Hospital, Australia following a fall and were discharged directly home (n = 20) (75% female, mean age 78 years). The non-fallers were an age and gender matched group, who had not fallen in the past 12 months (n = 20). All clients received a home-based assessment, which involved a comprehensive assessment of falls risk. RESULTS: Over three-quarters of the fallers took four or more medications, had balance impairments, and used a gait aid in the community. The fallers had a significantly higher falls risk score (P < 0.001), demonstrated significantly poorer balance (P < 0.001) and walked significantly more slowly (P < 0.001) than the non-fallers. There was no significant difference between the groups in their reports of dizziness (P = 0.68), although static balance testing (CTSIB condition 5) suggested a greater degree of underlying vestibular dysfunction in the group of fallers (P < 0.001). CONCLUSION: Older people discharged home from the ED following a fall are at high risk of falling in the future and have a greater level of vestibular dysfunction based on simple clinical testing. Additional clinically applicable tests of vestibular function are required to further investigate the relationship between vestibular dysfunction and falling in older people.

Survey of clinical practice: pre- and postoperative physiotherapy for pelvic surgery.

BACKGROUND: The objective of this survey was to obtain information about current physiotherapy practice for patients undergoing pelvic surgery. The aims were to evaluate whether differences exist in service provision between women's health physiotherapists (WHPTs) and hospital physiotherapists (HPTs) and in the guidelines used by physiotherapists to direct their service delivery. METHODS. A questionnaire was posted to the members of the Victorian Continence and Women's Health Physiotherapy Group (n = 130) and physiotherapists working in metropolitan and rural hospitals (n = 90). The questionnaire comprised questions relating to the aspects of treatment, including how referrals are made, funding, interventions provided and how they are delivered, and use of outcome measures. Data were summarized using descriptive statistics and Chi-square analysis of differences between WHPTs and HPTs. RESULTS: The response rate was 75.9%. In 67% of cases, service delivery was initiated by surgeon request, and most commonly for gynecologic patients (85%). Individual consultations were used on 96% of occasions and 8% were group sessions. Content of physiotherapy treatment for in-patients varied, with WHPTs significantly more likely to prescribe pelvic floor muscle exercises (P = 0.003), bowel advice (P = 0.001), avoidance of risk activities (P = 0.002), and awareness of postoperative symptoms (P = 0.001). Conversely, HPTs were significantly more likely to perform respiratory checks (P = 0.002) and mobilization (P = 0.001). Eighty-seven percent of respondents regarded their service as suboptimal, citing the need for evidence to support the content and best timing of intervention. CONCLUSION: Differences exist in physiotherapy treatment for pelvic surgery patients. Further research is required to establish whether, and which, elements of physiotherapy intervention are effective.