Aspasia Karageorge

Improving quality of life by increasing outings after stroke: Study protocol for the Out-and-About trial

Rationale Almost one-third of Australians need help to travel outdoors after a stroke. Ambulation training and escorted outings are recommended as best practice in Australian clinical guidelines for stroke. Yet fewer than 20% of people with stroke receive enough of these sessions in their local community to change outcomes. Aims The Out-and-About trial aims to determine the efficacy and cost effectiveness of an implementation program to change team behavior and increase outings by people with stroke. Design A two-group cluster-randomized trial will be conducted using concealed allocation, blinded assessors, and intention-to-treat analysis. Twenty community teams and their stroke clients (n = 300) will be recruited. Teams will be randomized to receive either the Out-and-About program or written guidelines only. Study Outcomes The primary outcome is the proportion of people with stroke receiving multiple escorted outings during therapy sessions, measured at baseline and 13 months postintervention. Secondary outcomes include number of outings and distance traveled, measured using a self-report diary at baseline and six months postbaseline, and a global positioning system after six months. Cost effectiveness will measure quality-adjusted life years and health service use, measured at baseline and six months postbaseline. Discussion A potential outcome of this study will be evidence for a costed, transferable implementation program. If successful, the program will have international relevance and transferability. Another potential outcome will be validation of a novel and objective method of measuring outdoor travel (global positioning system) to supplement self-report methods.

A behavior change program to increase outings delivered during therapy to stroke survivors by community rehabilitation teams: The Out-and-About trial

Background Australian guidelines recommend that outdoor mobility be addressed to increase participation after stroke. Aim To investigate the efficacy of the Out-and-About program at increasing outings delivered during therapy by community teams, and outings taken by stroke survivors in real life. Method Cluster-randomized trial involving 22 community teams providing stroke rehabilitation. Experimental teams received the Out-and-About program (a behavior change program comprising a training workshop with barrier identification and booster session, printed educational materials, audit, and feedback). Control teams received printed clinical guidelines only. The primary outcome was the percentage of stroke survivors receiving four or more outings during therapy. Secondary outcomes included the number of outings received by stroke survivors during therapy and undertaken in real life. Results At 12 months after implementation of the behavior change program, 9% of audited experimental group stroke survivors received four or more outings during therapy compared with 5% in the control group (adjusted risk difference 4%, 95% CI − 9 to 17, p = 0.54). They received 1.1 (SD 0.9) outings during therapy compared with 0.6 (SD 1.0) in the control group (adjusted mean difference 0.5, 95% CI − 0.4 to 1.4; p = 0.26). After six months of rehabilitation, observed experimental group stroke survivors took 9.0 (SD 3.0) outings per week in real life compared with 7.4 (SD 4.0) in the control group (adjusted mean difference 0.5, 95% CI − 1.8 to 2.8; p = 0.63). Conclusion The Out-and-About program did not change team or stroke survivor behavior.

Bullying and sexual harassment of junior doctors in New South Wales, Australia: rate and reporting outcomes

Objective The aim of this study was to describe rates of exposure to bullying and sexual harassment in junior doctors in first- or second-year prevocational medical training (PGY1 or PGY2 respectively) positions in New South Wales (NSW) and the Australian Capital Territory (ACT), and to explore the types of actions taken in response.Methods A cross-sectional survey of junior doctors in PGY1 or PGY2 positions was undertaken in 2015 and 2016 (n=374 and 440 respectively). Thematic analysis was undertaken on free-text responses to describe the reporting process and outcomes in more depth.Results The estimated response rate was 17-20%. Results from both surveys followed almost identical trends. Most respondents in 2015 and 2016 reported being bullied (n=203 (54.3%) and 253 (57.5%) respectively), 16-19% reported sexual harassment (n=58 and 82 respectively) and 29% of females reported sexual harassment. Qualitative analysis elucidated reasons for not taking action in response to bullying and harassment, including workplace normalisation of these behaviours, fear of reprisal and lack of knowledge or confidence in the reporting process. For respondents who did take action, most reported ineffective or personally harmful outcomes when reporting to senior colleagues, including being dismissed or blamed, and an intention not to trust the process in the future.Conclusions The findings suggest that interventions targeted at the level of junior doctors to improve the culture of bullying and harassment in medicine are unlikely to be helpful. Different approaches that address the problem in a more systemic way are needed, as is further research about the effectiveness of such interventions.What is known about the topic? Bullying and sexual harassment are common workplace experiences in the medical profession.What does this paper add? Over half the junior doctors in the present study experienced bullying and nearly one-fifth experienced sexual harassment. Junior doctors are reluctant to speak out, not only for fear of reprisal, but also because they do not believe it is worth doing so.What are the implications for practitioners? The data confirm a systemic problem of bullying in NSW. Primarily focusing on interventions with junior doctors (e.g. resilience training) is unlikely to solve the problem. Different and multipronged approaches (e.g. raising awareness in senior colleagues and training bystanders to intervene) should be tried and studied.

Psychiatry training experiences: a narrative synthesis.

Objective: In Australia and internationally, psychiatry has struggled to fill training places to keep up with demand for service. The objective of this study was to review the components of psychiatry terms and placements that determine a positive experience and potentially influence interest in vocational training in psychiatry. Method: A literature review and narrative synthesis was undertaken on 20 papers identified as meeting inclusion criteria. Results: The top themes contributing to positive experiences during the psychiatry term were: receiving high quality supervision; supported autonomy; and witnessing patient recovery. There was a paucity of Australian literature preventing investigation of the Australian context alone. Conclusions: There is a need to better understand how the junior doctor and medical student psychiatry experience influences perceptions of psychiatry and intention to specialise, especially in the Australian context.

The experience of psychiatry training in rural NSW

Objective: To examine the experience of psychiatry training in rural New South Wales. Method: All rural trainees in New South Wales and key psychiatrists involved in their training were invited to complete a survey in May–July 2013. Results: Responses were received from 26 out of 44 rurally placed psychiatry trainees (57% response rate) and 37 out of 55 psychiatrists involved in training in a rural area (67% response rate). Positive and negative aspects of rural training were reported. In general, trainees reported positive experiences regarding supervision, consultant input and their Site Coordinator of training. Their experience of other aspects of training and education in rural areas was often negative with 52% of trainees feeling at a disadvantage due to fewer registrar peers and 60% feeling educationally isolated. Difficulty progressing through training, workforce shortages, difficulty accessing formal aspects of training and limited options for advanced training were reported. Metropolitan trainees on rotation to rural terms receive accommodation, travel and an increase in wage from the rural Local Health District. Rural trainees on rotation to the city for their mandatory subspecialty training receive no such support. Conclusions: There are many challenges for rural trainees. Support from the Royal Australian and New Zealand College of Psychiatrists and state and federal governments to enhance the rural training experience is vital.

Previous experience and walking capacity predict community outings after stroke: An observational study.

ABSTRACT Background: Following hospital discharge, stroke survivors may experience a decline in mobility, outings, and community participation. The aim of this study was to examine the relationship between demographic and clinical measures, and the level of participation by community-dwelling stroke survivors. Methods: A prospective, multicenter, observational study was conducted. Participants were 83 community-dwelling stroke survivors with participation goals who were undergoing post-inpatient rehabilitation in Australia. Predictors collected at baseline, early after hospital discharge were demographic (age, gender, living situation, home access) and clinical measures (walking capacity, driving status, baseline outings). The outcome of interest was community participation 6 months later, measured over 7 days as number of outings (collected in a self-report diary). An outing was any excursion beyond the perimeter of the participants’ dwelling into a public street. Results: Number of outings 6 months after admission to the study (mean 8.5/week, SD 5.3) was predicted by number of outings at baseline, walking capacity, and age. Driving status did not predict number of outings. Conclusion: The strongest predictors of community participation were the number of outings early post-inpatient rehabilitation, walking capacity, and age. The only significant modifiable predictor was walking capacity.