Physiotherapists Both Reproduce and Resist Biomedical Dominance when Working With People With Low Back Pain: A Qualitative Study Towards New Praxis.

Despite recommendations to incorporate physical and psychosocial factors when providing care for people with back pain, research suggests that physiotherapists continue to focus on biological aspects. This study investigated how interpersonal and institutional norms influence this continued enactment of the biological aspects of management. We used theoretically-driven analysis, drawing from Foucauldian notions of power, to analyse 28 ethnographic observations of consultations and seven group discussions with physiotherapists. Analysis suggested that physiotherapy training established expectations of what a physiotherapist 'should' focus on, and institutional circumstances strongly drew the attention of physiotherapists towards biological aspects. Resistance to these forces was possible when, for example, physiotherapists reflected upon their practice, used silences and pauses during consultations, and actively collaborated with patients. These circumstances facilitated use of non-biomedical management approaches. Findings may assist physiotherapists to rework the enduring normative focus on biomedical aspects of care when providing care for patients with back pain.

Incidence, duration and cost of futile treatment in end-of-life hospital admissions to three Australian public-sector tertiary hospitals: a retrospective multicentre cohort study.

OBJECTIVES: To estimate the incidence, duration and cost of futile treatment for end-of-life hospital admissions. DESIGN: Retrospective multicentre cohort study involving a clinical audit of hospital admissions. SETTING: Three Australian public-sector tertiary hospitals. PARTICIPANTS: Adult patients who died while admitted to one of the study hospitals over a 6-month period in 2012. MAIN OUTCOME MEASURES: Incidences of futile treatment among end-of-life admissions; length of stay in both ward and intensive care settings for the duration that patients received futile treatments; health system costs associated with futile treatments; monetary valuation of bed days associated with futile treatment. RESULTS: The incidence rate of futile treatment in end-of-life admissions was 12.1% across the three study hospitals (range 6.0%-19.6%). For admissions involving futile treatment, the mean length of stay following the onset of futile treatment was 15 days, with 5.25 of these days in the intensive care unit. The cost associated with futile bed days was estimated to be $AA12.4 million for the three study hospitals using health system costs, and $A988 000 when using a decision maker's willingness to pay for bed days. This was extrapolated to an annual national health system cost of $A153.1 million and a decision maker's willingness to pay of $A12.3 million. CONCLUSIONS: The incidence rate and cost of futile treatment in end-of-life admissions varied between hospitals. The overall impact was substantial in terms of both the bed days and cost incurred. An increased awareness of these economic costs may generate support for interventions designed to reduce futile treatments. We did not include emotional hardship or pain and suffering, which represent additional costs.

Experience of clinical supervisors of international medical graduates in an Australian district hospital.

Objective Herein we record the experience of clinical supervisors of international medical graduates (IMGs) working as junior staff in a district hospital by examining supervisor perspectives on IMG performance, the factors affecting their performance and the requirements of supervision under these circumstances. Methods The present study had an open-ended exploratory qualitative design. Thirteen 13 open-ended, in-depth interviews were undertaken with supervisors of IMGs employed in a public district hospital in Queensland, Australia. Results The supervisors reported that, although performance was an individual and variable characteristic, IMGs tended to perform less well than Australian graduates and required more intensive supervision. Factors that affected performance were motivation and experience, and specifically lack of familiarity with the Australian healthcare system, lack of recent of practice, education, language, communication and cultural factors. English language proficiency was regarded as crucial to performance. Conclusions The additional work required to supervise IMGs in order to enable them to perform at a satisfactory level and successfully integrate into the Australian healthcare system needs to be recognised and resourced. Assistance with attaining proficiency in English and with communication skills over and above the standard required to pass the International English Language Testing System examination should be seriously considered as a means of improving performance. What is known about the topic? To date, there is little research available about the experience of supervisors of IMGs in Australia. What does this paper add? The findings of the present study make an important contribution to the literature by examining the critical role clinical supervisors of IMGs have in helping IMGs adapt to the Australian healthcare system and ensuring that they are able to provide quality health care. It identifies current challenges and highlights areas in need of attention to ensure a strong healthcare system for Australia. What are the implications for practitioners? Supervisors of IMGs need recognition of the extra time and expertise required in their role if they are to be effectively supported in their endeavours to integrate IMGs into the Australian health workforce. More attention needs to be given to the development of English language proficiency of IMGs, including colloquial usage, and communication in medical practice.

"I was never like that": Australian findings on the psychological and psychiatric sequelae of corticosteroids in haematology treatments.

GOALS OF WORK: Corticosteroid treatments have been well documented to cause severe emotional and even psychiatric disturbances. Despite that corticosteroid use is at the core of most treatment protocols for haematological malignancies, there is a dearth of published research (and controversy in the existing research) on the emotional and psychiatric sequelae of corticosteroid use for haematology patients and its connection with pre-existing mental history. This paper aims to address this hiatus and confusion by examining the emotional and psychiatric side effects of corticosteroids on haematology patients in Australia. MATERIALS AND METHODS: The findings are from a pilot study that explored the prior mental health history and effects of corticosteroid use of ten haematology patients in Australia. Data was collected through an iterative, phenomenological, qualitative research methodology using open-ended interviews conducted at the time and location of the participant's choice. The interviews were audio-recorded and transcribed verbatim. The language texts were then entered into the QSR NUD*IST computer program and analysed thematically. MAIN RESULTS: The significant finding from the study was that corticosteroids used in haematology treatments have the potential to affect anyone and are not related to an individual's prior mental health history. No participant presented evidence of psychiatric history or counseling and many reported emotional stability during previous times of difficulty. All participants reported emotional distress directly related to corticosteroid use. Participants reported difficulties during the period of withdrawal from corticosteroids and relief during periods free from the administration of corticosteroids. CONCLUSIONS: The findings provide evidence that emotional disturbances associated with corticosteroid use in haematology are a direct result of the drugs used and not a symptom of the individual's prior emotional health. Recommendations are given which have important implications for the management, support and education of patients and their families in relation to the potential emotional side effects from steroid administration and withdrawal.

And Tell Yourself, "This is not Me, it's the Drug": Coping with the Psychological Impact of Corticosteroid Treatments in Hematology - Further Results from a Pilot Study.

BACKGROUND: Corticosteroids are documented as associated with psychological adverse effects, including insomnia, irritability, aggression, neuropsychological deficits, mood disorders (including severe depression), delirium, and psychosis. Given the severity of these potential adverse effects and that corticosteroid use is central to the treatment of most hematological malignancies, it would be expected that a thorough research literature would exist on the effects of corticosteroid use in hematology. However, scant research is available. This leaves many questions unanswered and a vacuum for clinical practice. Thus, there is a strong need for empirical data, not only on the psychological adverse effects experienced by patients, but also on the coping strategies patients use to manage them. OBJECTIVE: To present findings on the coping strategies used by ten hematology patients in Australia undergoing treatment involving corticosteroids as a first step in understanding the emotional and psychological effects experienced by this group of patients. METHODS: The pilot study was conducted from January 2007 until March 2008.The study participants were ten hematology outpatients (eight with multiple myeloma, two with acute immune thrombocytopenia purpura) from two major Australian public hospitals (Princess Alexandra Hospital, Brisbane, Queensland, and Fremantle Hospital, Fremantle, Western Australia) who were taking dexamethasone and/or prednisolone and referred to the study by their treating hematologists on the basis that they were experiencing difficulties with their corticosteroid therapy.Data were collected through an iterative, phenomenological, qualitative research methodology using open-ended interviews. Interview transcriptions were entered into the QSR NUD*IST (Non-numeric, Unstructured Data * Index and Searching Technology) computer program and analyzed thematically. RESULTS: Coping strategies found to be helpful by patients included believing that corticosteroids are necessary for disease control, knowing that the negative emotional states being experienced are due to the corticosteroids, stoicism and self-reliance based on a cognitive-rational approach, keeping busy, remaining fit and active, and, for some, using antidepressants to help with mood swings. For sleep disturbances, patients found it helpful to try to accept the sleeplessness, engage in distraction, and have light sleeps. Support from family and friends who understand the range of corticosteroid adverse effects, including patients' need to withdraw during treatment, was seen as important. Counseling was not considered helpful. Tapering corticosteroid doses and cessation of corticosteroids were also discussed as aids to coping. CONCLUSION: These findings provide a start to understanding how individuals cope with corticosteroid therapy for hematological conditions. There is a need for further extensive research in this area.

The case for Aboriginal Health Workers in palliative care.

OBJECTIVES: The findings are drawn from a 2-year research project, funded by the National Health and Medical Research Council (NHMRC), which aimed to develop an innovative model for Indigenous palliative care. The findings presented in this article explore one important strategy for putting Aboriginal families and their communities at the centre of the model: that is, the employment of Aboriginal Health Workers (AHWs) in relation to the provision of palliative care in the Northern Territory. METHODS: The data were collected from 72 qualitative interviews conducted throughout the regional, rural and remote areas of the Northern Territory with Indigenous patients and carers in the Northern Territory and the health professionals who care for them. RESULTS: While highlighting the valuable role of AHWs, the findings emphasise that the current lack of availability of such workers for palliative care provision for Indigenous peoples needs serious consideration.

Insights on Aboriginal peoples' views of cancer in Australia.

Although the incidence of cancer in Indigenous peoples is similar to its incidence in the overall Australian population, Indigenous peoples are less likely to access early detection and medical interventions resulting in higher mortality and morbidity rates. To explore and address this discrepancy, the National Health and Medical Research Council funded a research study to examine Indigenous peoples' views of cancer and cancer treatments with an end goal of developing an innovative model of Indigenous Palliative Care. Seventy-two participants were interviewed from four geographical areas within the Northern Territory (Australia) including patients, caregivers, Indigenous and non-Indigenous health care workers, and interpreters. Indigenous peoples' views of cancer have to be examined within a historical, socio-political, and cultural context. There is no Indigenous word for cancer and the Western biomedical language that semantically constructs the notion of cancer is not widely understood. Additionally, for many Indigenous people, the aetiology of cancer is embedded in beliefs about the spiritual world of curses and payback from perceived misdeeds. The paper advocates for cross-cultural education initiatives, stressing the importance of a two way education strategy incorporating a process whereby medical and nursing personnel would improve their understanding of Indigenous peoples' view of cancer and Indigenous peoples would learn more about prevention and treatment of cancer from a biomedical perspective.

'It's very difficult to get respite out here at the moment': Australian findings on end-of-life care for Indigenous people.

Whilst access to respite care has been found to represent an important source of support for terminally ill patients and their families, the availability of these services to Indigenous Australians has to date remained undocumented. This potential need for respite in Indigenous communities was explored as part of a National Health and Medical Research Council (NH&MRC) funded study designed to develop an innovative model for Indigenous palliative care. The data needed for model development were collected through a series of open-ended, qualitative interviews conducted with a cross-section of consumers and health professionals within the Northern Territory, Australia. The findings reflected a serious need for Indigenous respite services, coupled with a severe deficiency in the present availability of these services, especially within rural and regional areas. This lack of local respite services was documented to be negatively impacting upon the ability of carers to fulfil their caring duties and was found placing undue physical, emotional and economic stress upon carers, patients and their families. Furthermore, the lack of access to local respite services documented was found to be forcing rural and regional patients to relocate to metropolitan areas away from the family, community and land to which strong ties are held. The lack of Indigenous respite services was also found to obstruct patients' and carers' wishes for death to occur in the local community, rather than in far away cities. Significant obstacles were found to be hindering the provision of respite care to Indigenous Australians, namely beliefs about families looking after their own, resource restrictions, limited staff availability in local areas, as well as problems associated with hostel use in metropolitan areas. The conclusions drawn from this study suggest the importance of tackling the obstacles preventing local respite services being established in areas close to where patients and carers live.

The "right story" to the "right person": communication issues in end-of-life care for Indigenous people.

OBJECTIVES: To explore communication issues faced by health care workers and Indigenous patients and their families in a palliative care setting. Effective communication with Aborigines is especially important because Aboriginal beliefs of health and sickness are so different from Western views. METHOD: Data were collected from 72 qualitative interviews conducted throughout the regional, rural and remote areas of the Northern Territory with Indigenous patients and carers and the health professionals who care for them. RESULTS: Participants highlighted the struggle associated with effective communication when working in a cross-cultural setting at the interface of Indigenous and Western health care. The findings record the wisdom and insight from practitioners who have extensive experience dealing with communication difficulties.

Re-entering life: paediatric acute myeloid leukaemia at one year post treatment.

To date, there is scant psychosocial research on the experience of childhood AML. This article presents findings from the perspective of the child patients, their parents and siblings at one year post-treatment. The findings highlight challenges associated with re-entering life post-treatment with an emphasis on the ongoing sense of uncertainty, the changed sense of normalcy, and the difficulty of returning to the hospital for check-ups. A number of recommendations are made including the desirability of providing hospital space for check-ups away from the treatment area and the need for ongoing reassurance and support.