Caroline Fryer

Exercise class participation among residents in low-level residential aged care could be enhanced: a qualitative study

QUESTION What do residents in low-level residential care perceive as motivators and barriers to participating in exercise classes at the facility? DESIGN Qualitative study using focus groups. PARTICIPANTS Residents, nursing staff and allied health staff of a low-level residential care facility. RESULTS Key motivators for residents to attend the exercise classes included personal benefits, such as improved health and opportunities to socialise, and the support and encouragement that they received from family members and health professionals. The barriers to participating in the exercise classes included: health issues like pain, incontinence, and hearing impairments; external constraints such as the location of the classes and the early morning time; and internal constraints associated with a lack of knowledge about the classes and the benefits of exercising. While the key themes that arose from this study are consistent with findings from studies of community-dwelling adults, several of the barrier subthemes were unique. CONCLUSION Recommendations from our findings to enhance exercise class participation include careful consideration of: class scheduling; class location; social aspects associated with exercise classes; support of social networks and health providers; health issues perceived to limit exercise; and marketing of classes.

'I understand all the major things': how older people with limited English proficiency decide their need for a professional interpreter during health care after stroke.

Objective To explore the process of decision-making of older people with limited English proficiency (LEP) about using a professional interpreter during their health care after stroke. Design A constructivist grounded theory approach was used. Up to two in-depth interviews were conducted with 13 older people with LEP from seven different language groups, and one older person who preferred to speak English, who had recently received health care after an acute stroke. Professional interpreters assisted with 19 of the 24 study interviews. Data were analysed and theoretical processes developed using a constant comparative method. Results Professional interpreters were not a strong presence in the health care experience after stroke for participants. The use of professional interpreters was a complex decision for participants, influenced by their perception of the language and health care expertise of themselves and others, their perceived position to make the decision and whom they trusted. Getting by in English allowed participants to follow rules-based talk of health professionals, but did not enable them to understand detailed information or explanation, or to engage in the management of their condition in a meaningful way. Conclusion Health professionals have an opportunity and a mandate to demonstrate leadership in the interpreter decision by providing knowledge, opportunity and encouragement for people with LEP, to use an interpreter to engage in, and understand, their health care after stroke. Health professionals may need to advise when interpretation is needed for health care situations, when communication difficulties may not be anticipated by the person with LEP.

A qualitative study using the Theoretical Domains Framework to investigate why patients were or were not assessed for rehabilitation after stroke

Objective: To explore the factors perceived to affect rehabilitation assessment and referral practices for patients with stroke. Design: Qualitative study using data from focus groups analysed thematically and then mapped to the Theoretical Domains Framework. Setting: Eight acute stroke units in two states of Australia. Subjects: Health professionals working in acute stroke units. Interventions: Health professionals at all sites had participated in interventions to improve rehabilitation assessment and referral practices, which included provision of copies of an evidence-based decision-making rehabilitation Assessment Tool and pathway. Results: Eight focus groups were conducted (32 total participants). Reported rehabilitation assessment and referral practices varied markedly between units. Continence and mood were not routinely assessed (4 units), and people with stroke symptoms were not consistently referred to rehabilitation (4 units). Key factors influencing practice were identified and included whether health professionals perceived that use of the Assessment Tool would improve rehabilitation assessment practices (theoretical domain ‘social and professional role’); beliefs about outcomes from changing practice such as increased equity for patients or conversely that changing rehabilitation referral patterns would not affect access to rehabilitation (‘belief about consequences’); the influence of the unit’s relationships with other groups including rehabilitation teams (‘social influences’ domain) and understanding within the acute stroke unit team of the purpose of changing assessment practices (‘knowledge’ domain). Conclusion: This study has identified that health professionals’ perceived roles, beliefs about consequences from changing practice and relationships with rehabilitation service providers were perceived to influence rehabilitation assessment and referral practices on Australian acute stroke units.

An ethical approach to health promotion in physiotherapy practice

ISSUE ADDRESSED With increased emphasis on reducing the global burden of non-communicable disease, health professionals who traditionally focused on the individual are being encouraged to address population-level health problems. While physiotherapists are broadening their clinical role to include health promotion strategies in their clinical practice, the ethical foundations of this practice focus have received less attention. METHODS We use a physiotherapy clinical scenario to highlight different physiotherapeutic approaches and to analyse underpinning ethical values and implications for practice. RESULTS We suggest there are potential harms of incorporating health promotion into physiotherapy management of individuals if the population-based research does not resonate with an individuals particular circumstances, capacity to change or view of what counts as important and meaningful. We propose that critical reasoning and ethical judgment by the physiotherapist is required to determine how health promotion messages applied in primary care settings might work to benefit and enhance a clients well being rather than impose burdens or cause harm. CONCLUSION We suggest four ethical reasoning strategies designed to assist physiotherapists to frame and understand fundamental ethical principles of beneficence, harm, autonomy and justice when implementing health promotion and self-management approaches in clinical practice.

Telephone and face-to-face interviews generate similar falls circumstances information from community-dwelling adults with stroke

Face-to-face and telephone interviews are used frequently in research and clinical practice for the retrieval of falls information from people with stroke, yet agreement between the two methods has rarely been reported. In a previous publication, as part of a larger investigation of falls incidence, consequences and risk factors in a community dwelling stroke population, we briefly noted agreement between face-to-face and telephone interviews. The following was reported: “A structured interview, with standardised questions, was performed to collect data on the circumstances and consequences of each fall. Thirty-seven interviews were conducted on the telephone and 66 during a faceto-face interview. A pilot study indicated high levels of agreement between telephone and face-to-face interviews (per cent agreement 75-100%, kappa statistics 0.50-1.00 for individual interview items).” This report provides more detail of our investigation of the agreement between telephone and face-to-face interviews to gather data related to falls circumstances and consequences in community dwelling adults with stroke. Nine participants (from the 68 participants in the main study) had both face-to-face and telephone interviews after any reported falls during the six month falls data collection period. The nine participants had a mean age of 63 years, five were female, six had a left side hemi-paresis, and three a right side hemi-paresis. The order of testing (telephone or face-to-face) was alternated between participants to avoid order bias and different interviewers were used for the face-to-face and telephone interviews to prevent responses being led in the second interview. One participant had 32 falls with similar circumstances and consequences and so only data from the first fall was included for this participant to prevent the high level of agreement skewing the data. A fall was defined as ‘an event which results in a person coming to rest inadvertently on the ground or other lower level and other than a consequence of sustaining a violent blow, loss of consciousness, sudden onset of paralysis such as stroke or an epileptic seizure’. The interviewers decided whether a participant’s reported ‘fall’ met the above definition during fall interviews. Standardised questions about the circumstances and consequences of a fall with specific categories for answers were used for each interview (Table 1). The median time between the first fall interview and reported date of fall was 4.5 days with an interquartile range of eight days. The majority of second interviews were completed within one week of the first interview; one interview was completed at 28 days. Agreement between interview modes was considered excellent if the Kappa statistic was greater than 0.800, substantial if the kappa statistic lay between 0.600 and 0.799, moderate if the kappa statistic was between 0.500 and 0.599, and fair to poor if the kappa statistic was below 0.5. Eight of the 14 interview questions demonstrated excellent agreement between telephone and faceto-face interview formats, a further four questions had substantial agreement and two questions yielded moderate agreement between the interview modes (Table 1). All kappa statistics indicated statistically significant agreement (p<0.05). Percentage agreement between interviews was >75% for all questions (Table 1). While our results indicated that either face-to-face or telephone interviews may be used to collect data about fall events, it is recognised that there will be times when a face-to-face interview or the use of a proxy interview respondent, such as a carer, is more appropriate for the accurate collection of detailed falls information e.g. if poor hearing and no assistive device on phone, if English is

A qualitative evaluation of scalpel skill teaching of podiatry students

BackgroundDegrees in health disciplines need a balance of theoretical knowledge and sufficient clinical practice to meet registration requirements, in particular those requiring specialist skills such as the use of scalpels and other small instruments, such as podiatry. However, despite this requirement there is a scarcity of literature and research to inform teaching of these particular manual clinical skills. Therefore, the aims of this study were to determine the current approaches being used to teach manual skills, in particular scalpel skills, in university podiatry programs in Australia and New Zealand, and to explore what issues, challenges and innovations exist.MethodsA qualitative study, consisting of semi-structured interviews with staff at eight university podiatry programs in Australia and New Zealand was undertaken to determine how these skills are taught and evaluated, and how poor performers are managed. A conventional content analysis technique was used to analyse and code interview data, with the resultant categories reported.ResultsApproaches to teaching manual clinical skills, in particular scalpel skills, appear to be consistent between university programs in Australia and New Zealand in utilising didactic-style content, demonstration, physical practice on inanimate objects and real skin, and often the use of supplementary audio-visual material. The main reported differences between programs were in methods and processes of practice, with controversy regarding the use of inanimate objects versus real skin for practice.ConclusionsDespite a lack of research and literature surrounding this topic, the approach to teaching is relatively consistent between programs with greatest disparity being the structure and duration of practice. Key issues for teaching staff in teaching manual skills were students’ clinical exposure, motivation, levels of anxiety and dexterity.