Clint Moloney

Implementation of oral health recommendations into two residential aged care facilities in a regional Australian city

Background  Residents of aged care facilities usually have a large number of oral health problems. Residents who suffer from dementia are at particular risk. A systematic review of the best available evidence with regard to maintaining the oral health of older people with dementia in residential aged care facilities provided a number of recommendations. Objectives  The aim of the implementation project was to introduce evidence-based oral hygiene practices for patients with dementia in two publicly funded residential aged care facilities and monitor for changes in nursing awareness, knowledge, documentation and practice to improve patient outcomes and ensure appropriate accreditation standards were met. An additional aim was to identify barriers and strategies to overcome barriers to implementation of evidence-based recommendations. Methods  Two facilities, a 40-bed facility and a 71-bed facility in the health service district of the regional Australian city of Toowoomba, provided the setting. A quality improvement approach was taken, using a number of strategies from the National Health and Medical Research Council guidelines for implementation studies. The implementation involved a number of stages, including project development, interactive oral health education, oral audits of residents, changes to oral hygiene practice via care plans and critical reflection. Results  The multidisciplinary approach to improving oral healthcare appeared to improve knowledge and awareness and move oral health practices in facilities closer to best practice. Specialised training in oral health was provided to a Clinical Nurse Consultant. Regular oral audits were introduced and facility staff were trained in the use of the oral audit tool. Care plans at one facility were of better quality and more comprehensive than before the intervention. Comments made during critical reflection suggested improvements in the oral health of residents, increased use of oral swabs and saliva substitutes, improved care of dentures and mention of the use of mouth props in resident care plans. There was also some evidence that changes brought about by the implementation are sustainable. Conclusion  The majority of recommendations provided in the systematic review of oral healthcare for dementia patients were applicable to the applied context. The importance of day-to-day leaders was highlighted by the apparently varied outcomes across target facilities. The quality improvement approach would appear to have considerable advantages when applied to improving practice in residential aged care.

Challenges for implementing wireless hand-held technology in health care: views from selected Queensland nurses.

Many health-care providers in Australia are exploring the use of wireless technology to improve service delivery. It appears that the solutions so far have been dictated by the hardware vendors and that the business case is yet to drive the implementations. A focus group discussion was facilitated with eight senior management staff involved in health care in Western Australia. This resulted in a set of challenges, which were used to invite opinions from nursing staff in Queensland. A total of 31 interviews were conducted. The analysis returned a set of 63 themes, which were grouped. These groupings reflected the challenges as lack of user-friendly applications, unreliable technology, substandard testing, shortage of staff, concerns for security, reliance on technology, existing problems, work schedule, training, outdated health policy, coverage of wireless links, confidentiality and lack of awareness. The interviews clearly indicated the need for training and awareness procedures. The present study provides some of the information necessary to realize an enterprise-wide implementation of wireless technology.

A systematic review of psychometric evidence and expert opinion regarding the assessment of faecal incontinence in older community-dwelling adults.

Objectives  This review had two objectives: (i) to determine what is required in an assessment of faecal incontinence issues for older community-dwelling adults; and (ii) to determine the psychometric tools most effective for assessment of faecal incontinence in older community-dwelling adults. Inclusion criteria  For the review of psychometric tools, studies were included if they were concerned with people living in the community, included a significant proportion of the sample aged 65 years or over, and either examined psychometric properties of assessment tools or assessed sensitivity of assessment tools to non-surgical interventions available in the community setting. For the review of expert opinion, the search was limited to expert opinion provided by an expert in faecal incontinence that related to community-based assessment. Only articles published in English were eligible for inclusion and no limits were placed on publication dates. Search strategy  An initial search of Medline and CINAHL databases identified terminology frequently used in the literature with regard to assessment of faecal incontinence. An extensive search was then undertaken using all identified key words and index terms. The third step involved a search of reference lists and bibliographies of all relevant articles. Methodological quality  All identified studies that met the inclusion criteria were assessed for methodological validity in the case of studies considered for inclusion in the psychometric review. Validity of expert text was also assessed prior to it being included in the review. Results  The final search strategy identified approximately 7000 references. Full-text versions of 144 references were critically appraised for inclusion in the review. Of these, 25 sources were included in the review of expert opinion and 16 in the review of psychometric properties. In the review of expert opinion, 254 conclusions were extracted for synthesis. The 31 thematic categories were organised under five major themes: History-taking, bowel assessment, psychosocial aspects, physical examination and specialist referral. From the sources that survived critical appraisal, 52 conclusions relating to psychometric properties of assessment tools were derived. There was limited, if any, analysis of psychometric properties for the majority of assessment tools. The Wexner and Vaizey symptom severity scales demonstrated acceptable test-retest reliability and convergent validity. The Fecal Incontinence Quality of Life Scale (FIQLS) demonstrated reasonable reliability and good convergent and criterion-related validity. There was, however, some evidence questioning its discriminant validity. Conclusions  This systematic review represents an important first stage in developing guidelines for assessment of faecal incontinence in community-dwelling older people. Assessment should be comprehensive in nature. Gaps in expert opinion are evident regarding issues such as assessment of cognitive decline and specialist referral. Continence advisors need to be appropriately trained in using and interpreting results from assessment tools and conducting physical examinations. Although studies in the review of psychometric properties suffer from limitations such as inadequate sample sizes, the Vaizey and Wexner scales would appear to be the tools of choice. The FIQLS is clearly the tool of choice at this stage for measuring faecal incontinence quality of life. Further validation of tests used in faecal incontinence assessments is required.

Online intravenous pump emulator: as effective as face-to-face simulation for training nursing students

BACKGROUND The expansion of online education for nursing students has created the challenge of finding innovative ways to teach clinical skills. An online intravenous pump emulator (IVPE) modelled on actual IV pumps used in clinical healthcare settings was developed to facilitate online education delivery. OBJECTIVES The objectives of the study were to implement the online IVPE and evaluate student learning outcomes and perceptions of device use. DESIGN A mixed method, quasi-experimental design was used. SETTING The study was conducted in the School of Nursing and Midwifery at a regional university in Queensland, Australia. PARTICIPANTS Participants were 179 first year nursing students enrolled in a medications course, ranging in age from 18 to 44years, of whom 150 were female. METHODS Participants were assigned to one of three groups and trained in the use of IV infusion pumps. Group 1 (n=57) were trained online using the IVPE (ONL); Group 2 (n=73) were trained on-campus using an actual IV pump (ONC); Group 3 (n=49) were trained both on-campus using the actual IV pump and online using the IVPE (ONL+ONC). Competence in using the actual IV pump was assessed for all participants at the conclusion of the training period. RESULTS No significant differences in learning outcomes, measured by assessment scores out of 80 points, were found between the ONL (M=65.5±9.2) and ONC (M=62.0±14.8; p>.05) groups. Significantly better learning outcomes were evident for the ONL+ONC group (M=68.7±4.9) compared to the ONC group (p<.01). CONCLUSIONS This study highlights that the nursing students became more competent in the skill of preparing and administrating IV infusions when face-to-face and online learning were combined.

A qualitative evaluation of the effectiveness of videoconferencing to support the training of orthopaedic registrars

Videoconferencing has been used for the professional supervision of trainee orthopaedic registrars at the Toowoomba Hospital. We have conducted a qualitative evaluation of the perceptions of those involved. Six focus groups were held with doctors, nurses, patients and other healthcare administration staff. In total there were 12 staff involved and six patients. A qualitative analysis of the transcripts resulted in a set of determinants of the perceived effectiveness of the videoconferencing system. Some were positive and some were negative factors. For example, the participants expressed a view that a videoconferencing system was better than the previous system of communication, which was via a telephone or email. However, the participants felt that the system was limited by the technology employed. It appears that there was widespread approval for the use of videoconferencing for remote supervision of orthopaedic trainees. While the participants felt that this could yield benefits, the size of these benefits has yet to be determined.

Using Remote Access Laboratories in nursing education

Remote Access Laboratory (RAL) based learning activities are commonplace in engineering faculties; in other disciplines such activities are not widely used. Practicing safe-installations of intravenous pump driver setups and related clinical reasoning skills are important components for the training of nurses. The aim of this research project is to develop and trial remote access technologies that enable nursing students to test their knowledge, skills, and clinical reasoning with intravenous infusion pump drivers. This has been possible by extending the concept of RAL from a physical and tangible experiment, to more conceptual experimentation in any form conducted remotely. In such a context clinical reasoning becomes possible. This paper discusses a prototype that has been build through collaboration betweens the Faculty of Engineering and Surveying and the Department of Nursing and Midwifery. An initial evaluation with a group of nursing students has been completed to assess if such activities can assist with the training of student nurses. Previous work has identified the need to scaffold learning activities that rely on RAL technology; the key conclusion in this paper is that in the context of nursing this have to be taken a step further. RAL activities here require contextualisation to become an effective learning tool.

Face-to-face instruction combined with online resources improves retention of clinical skills among undergraduate nursing students

BACKGROUND There is growing evidence that online resources used to develop clinical skills among students in the healthcare professions can produce equivalent learning outcomes to traditional face-to-face training methods. Whether clinical competence is retained equally well for online and face-to-face training methods is not yet established. OBJECTIVES The objective of the study was to compare retention of competence in using an IV infusion pump among nursing students trained in its use using three different protocols. DESIGN A quasi-experimental design was used. SETTING The study was conducted in the School of Nursing and Midwifery at a regional university in Queensland, Australia. PARTICIPANTS Participants were 102 first year nursing students (female=89, male=13) enrolled in a medications course, ranging in age from 18 to 44years. METHODS Three groups of participants were trained in the use of an IV infusion pump and competence was assessed following a 26-week period of no access to the pump. Group 1 participants (ONL; n=34) were trained online using an Intravenous Pump Emulator (IVPE); Group 2 participants (ONC; n=38) were trained on campus using an actual IV pump in a traditional face-to-face setting; Group 3 participants (ONL+ONC; n=30) were trained both on campus using the actual IV pump and online using the IVPE. RESULTS As hypothesised, no significant differences in learning outcomes, measured by assessment scores out of 80 points, were found between the ONL (M=68.7±5.9) and ONC (M=65.5±11.5; p>0.05) groups. The ONL+ONC group recorded the highest mean assessment score (M=70.0±5.0) and completed the assessment task significantly faster (p<0.001) than the other two groups. CONCLUSIONS This study suggests that nursing students retained clinical competence in preparing and administrating IV infusions better when face-to-face and online learning were combined.

Does metabolic syndrome predict surgical complications? A protocol for a systematic review and meta-analysis

BackgroundMetabolic syndrome (MetS) is defined by an accumulation of risk factors that include cardiovascular disease, diabetes, chronic high blood pressure, obesity, and hypercholesterolaemia which results in an increased risk of developing serious chronic diseases. MetS is widespread as it is estimated to affect up to 30% of the global population. For people with MetS who undergo surgery, an emerging body of literature points to significantly poorer postoperative outcomes compared with non-affected populations. Surgical patients with MetS are at significantly higher risk of a range of adverse outcomes including death, morbid cardiovascular events, coma, stroke, renal failure, myocardial infarction, and surgical site infections. Increased complication rates result in prolonged hospital stays, a greater need for post-hospitalisation care, and reduced effectiveness of surgical interventions.Methods/designWe will search the following electronic bibliographic databases: MEDLINE, EMBASE, ScienceDirect, and CINAHL, and the reference lists of included articles. We will also search for unpublished literature. Two authors will screen titles and abstract information independently and select studies according to established inclusion and exclusion criteria. Data will be extracted by the study investigators using Review Manager 5 and will include information on demographics, incidence, prevalence, and outcome variables. Subgroup analysis and sensitivity analysis will be performed to assess the heterogeneity of included studies. Meta-analysis will also be carried out if appropriate study groups are identified. A descriptive narrative for statistical data will also be provided to highlight findings of the systematic review and meta-analysis.DiscussionThis study will report and summarise adverse outcomes among adult patients with MetS undergoing surgery across a range of surgical specialties. Developing insights into outcomes of this population of interest is necessary to develop guidelines towards better management of surgical patients with metabolic syndrome.Systematic review registrationPROSPERO CRD42016051071

An evidence-based approach to the prevention and initial management of skin tears within the aged community setting: a best practice implementation project

Background Maintaining skin integrity in a community setting is an ongoing issue, as research suggests that the prevalence of skin tears within the community is greater than that in an institutional setting. While skin tear prevention and management principles in these settings are similar to those in an acute care setting, consideration of the environmental and psychological factors of the client is pivotal to prevention in a community setting. Evidence suggests that home environment assessment, education for clients and care givers, and being proactive in improving activities of daily living in a community setting can significantly reduce the risk of sustaining skin tears. Objectives The aim of this implementation project was to assess and review current skin tear prevention and management practices within the community setting, and from this, to implement an evidence‐based approach in the education of clients and staff on the prevention of skin tears. As well. the project aims to implement evidence‐based principles to guide clinical practice in relation to the initial management of skin tears, and to determine strategies to overcome barriers and non‐compliance. Methods The project utilized the Joanna Briggs Institute Practical Application of Clinical Evidence System (PACES) audit tool for promoting changes in the community health setting. The implementation of this particular project is based in a region within Anglicare Southern Queensland. A small team was established and a baseline audit carried out. From this, multiple strategies were implemented to address non‐compliance which included education resources for clients and caregivers, staff education sessions, and creating skin integrity kits to enable staff members to tend to skin tears, and from this a follow‐up audit undertaken. Results Baseline audit results were slightly varied, from good to low compliance. From this, the need for staff and client education was highlighted. There were many improvements in the audit criteria following client and staff education sessions and staff self‐directed learning packages (Appendix I, II and III). Future strategies required to sustain improvements in practice and make further progress are to introduce a readily available Anglicare Skin Integrity Assessment Tool to the nursing staff for undertaking new client admissions over 65 years, and to provide ongoing education to staff members, clients and care givers in order to reduce the prevalence of skin tears in the community setting. Conclusions This implementation project demonstrated the importance of education of personal care workers, clients and their caregivers for prevention of skin tears in the community setting. This in turn created autonomy and empowered clients to take control of their health.

Assessment and non-pharmacological management among adults with a dementia diagnosis in a residential care setting: a best practice implementation project

Background This evidence implementation project reports on a project conducted in the 17 bed special care unit of Symes Thorpe Residential Facility in Queensland, that focused on improving assessment and management of elderly residents diagnosed with dementia. The motivation for the project, and its value, should be understood in the context of a lack of a validated tool or standardized documentation being used to assess behaviors of residents diagnosed with dementia, as well as little targeted education being provided to staff on behaviour management strategies. Objectives To promote evidence based assessment and non‐pharmacological management of challenging behavior in elderly adults living with dementia in a residential setting in Queensland. Methods The project design was based on the Joanna Briggs Institutes Practical Application of Clinical Evidence System and Getting Research into Practice audit and feedback tool. A baseline audit of care documentation in the 17 residents in the special care unit was conducted. Meetings were held with the project team to reflect on the findings of the baseline audit and plan strategies to improve practice. A validated tool, the Cohen‐Mansfield Agitation Inventory, was introduced to improve assessment of patients together with a program of staff education to inform the use of the Inventory. A staff education program was introduced to improve staff awareness and use of strategies for behavior management of residents in the special care unit. Two follow up audits were conducted. The second audit was undertaken 3 months post introduction of the Cohen Mansfield Agitation Inventory and staff education program. Results The follow up audits demonstrated 100% compliance in use of the Cohen Mansfield Agitation Inventory, and 100% staff attendance at education sessions. The audit also showed significant increase and improvement in quality of related resident care documentation, for example documenting outcomes of use of non‐pharmacological therapy such as music, exercise, pets etc. Conclusions The findings show that a comprehensive education program can make an effective contribution to the understanding of challenging behaviors in dementia residents, and the associated documentation required to monitor them effectively.