Emily Haesler

Management of Patients With Venous Leg Ulcers: Challenges and Current Best Practice

Introduction It is well documented that the prevalence of venous leg ulcers (VLUs) is increasing, coinciding with an ageing population. Accurate global prevalence of VLUs is difficult to estimate due to the range of methodologies used in studies and accuracy of reporting. (1) Venous ulceration is the most common type of leg ulceration and a significant clinical problem, affecting approximately 1% of the population and 3% of people over 80 years of age (2) in westernised countries. Moreover, the global prevalence of VLUs is predicted to escalate dramatically, as people are living longer, often with multiple comorbidities. Recent figures on the prevalence of VLUs are based on a small number of studies, conducted in Western countries, and the evidence is weak. However, it is estimated that 93% of VLUs will heal in 12 months, and 7% remain unhealed after five years. (3) Furthermore, the recurrence rate within 3 months after wound closure is as high as 70%. (4) (-6) Thus, cost-effective adjunct evidence-based treatment strategies and services are needed to help prevent these ulcers, facilitate healing when they occur and prevent recurrence. The impact of a VLU represents social, personal, financial and psychological costs on the individual and further economic drain on the health-care system. This brings the challenge of providing a standardised leg ulcer service which delivers evidence-based treatment for the patient and their ulcer. It is recognised there are variations in practice and barriers preventing the implementation of best practice. There are patients not receiving appropriate and timely treatment in the initial development of VLUs, effective management of their VLU and preventing recurrence once the VLU has healed. Health-care professionals (HCPs) and organisations must have confidence in the development process of clinical practice guidelines and have ownership of these guidelines to ensure those of the highest quality guide their practice. These systematic judgments can assist in policy development, and decision making, improve communication, reduce errors and improve patient outcomes. There is an abundance of studies and guidelines that are available and regularly updated, however, there is still variation in the quality of the services offered to patients with a VLU. There are also variations in the evidence and some recommendations contradict each other, which can cause confusion and be a barrier to implementation. (7) The difference in health-care organisational structures, management support and the responsibility of VLU management can vary in different countries, often causing confusion and a barrier to seeking treatment. These factors further complicate the guideline implementation process, which is generally known to be a challenge with many diseases. (8).

A systematic review of reliable and valid tools for the measurement of patient participation in healthcare

Introduction Patient participation in healthcare is recognised internationally as essential for consumer-centric, high-quality healthcare delivery. Its measurement as part of continuous quality improvement requires development of agreed standards and measurable indicators. Aim This systematic review sought to identify strategies to measure patient participation in healthcare and to report their reliability and validity. In the context of this review, patient participation was constructed as shared decision-making, acknowledging the patient as having critical knowledge regarding their own health and care needs and promoting self-care/autonomy. Methods Following a comprehensive search, studies reporting reliability or validity of an instrument used in a healthcare setting to measure patient participation, published in English between January 2004 and March 2014 were eligible for inclusion. Results From an initial search, which identified 1582 studies, 156 studies were retrieved and screened against inclusion criteria. Thirty-three studies reporting 24 patient participation measurement tools met inclusion criteria, and were critically appraised. The majority of studies were descriptive psychometric studies using prospective, cross-sectional designs. Almost all the tools completed by patients, family caregivers, observers or more than one stakeholder focused on aspects of patient–professional communication. Few tools designed for completion by patients or family caregivers provided valid and reliable measures of patient participation. There was low correlation between many of the tools and other measures of patient satisfaction. Conclusion Few reliable and valid tools for measurement of patient participation in healthcare have been recently developed. Of those reported in this review, the dyadic Observing Patient Involvement in Decision Making (dyadic-OPTION) tool presents the most promise for measuring core components of patient participation. There remains a need for further study into valid, reliable and feasible strategies for measuring patient participation as part of continuous quality improvement.

Recent evidence on the development and maintenance of constructive staff–family relationships in the care of older people – a report on a systematic review update

AIM This paper is an update to a systematic review that presents the best available evidence on the factors that are most effective in promoting constructive staff-family relationships in the care of older people in the institutional healthcare setting. METHODS Systematic review. RESULTS The updated review supports findings from the earlier review. Additional evidence points to the importance of monitoring care, family involvement in decision-making, staff upholding the uniqueness of the older person, trust, the involvement of the multidisciplinary care team and family dynamics as factors underpinning effective staff-family relationships. CONCLUSION A number of factors critical to the development and maintenance of positive staff-family relationships in the institutional setting have been identified. The delivery of quality care is predicated on staff having an understanding of these factors.Aim  This paper is an update to a systematic review that presents the best available evidence on the factors that are most effective in promoting constructive staff–family relationships in the care of older people in the institutional healthcare setting. Methods  Systematic review. Results  The updated review supports findings from the earlier review. Additional evidence points to the importance of monitoring care, family involvement in decision-making, staff upholding the uniqueness of the older person, trust, the involvement of the multidisciplinary care team and family dynamics as factors underpinning effective staff–family relationships. Conclusion  A number of factors critical to the development and maintenance of positive staff–family relationships in the institutional setting have been identified. The delivery of quality care is predicated on staff having an understanding of these factors.

Sexuality, sexual health and older people: A systematic review of research on the knowledge and attitudes of health professionals

OBJECTIVES Sexuality remains important to older people and should be recognised as an important part of their overall care. However, this appears to be poorly understood and addressed by many healthcare professionals. This systematic review reports on knowledge and attitudes of health professionals towards sexuality and sexual health of older people, including factors that impact knowledge and perceptions. REVIEW METHODS AND DATA SOURCES The review, conducted using Joanna Briggs Institute methods, included 23 studies of varied methodology published between January 2004 and January 2015. RESULTS Findings indicated that healthcare professionals often consider older peoples sexuality as outside their scope of practice and there is lack of knowledge and confidence in this area. Cultural norms and taboos, length of time spent working with older people, familiarity with the older person, previous training and degree of exposure to people who are not heterosexual were all identified as factors that impact knowledge and attitude. CONCLUSIONS Better role modelling and education are needed to improve knowledge and attitudes toward later life sexuality.

Let's talk about sex: older people's views on the recognition of sexuality and sexual health in the health‐care setting

To report on the findings of a systematic review which examined the experiences and views of older people aged 65 years and over on health professionals’ recognition of sexuality and sexual health and whether these aspects of the person are incorporated into care.

Evidence-based guidelines for pressure ulcer management at the end of life.

It is important to develop an individualised plan of care for people at the end of life to prevent pressure ulcers, and to treat them if they do occur. This article discusses patient and risk assessment, prevention and care for pressure ulcers for the palliative care patient and the recommendations given in the palliative care section of the Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline (National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance, 2014).

Feasibility and acceptability of a physician-delivered weight management programme

Background. Primary health care requires new approaches to assist patients with overweight and obesity. This is a particular concern for patients with limited access to specialist or allied health services due to financial cost or location. The Change Program is a toolkit that provides a structured approach for GPs working with patients on weight management. Objective. To assess the acceptability and feasibility of a GP-delivered weight management programme. Methods. A feasibility trial in five Australian general practices with 12 GPs and 23 patients. Mixed methods were used to assess the objective through participant interviews, online surveys and the NOrmalization MeAsure Development (NoMAD) tool based on Normalization Process Theory. Content analysis of interviews is presented alongside Likert scales, free text and the NoMAD tool. Results. The Change Program was acceptable to most GPs and patients. It was best suited to patient–GP dyads where the patient felt a strong preference for GP involvement. Patients’ main concerns were the time and possible cost associated with the programme if run outside a research setting. For sustainable implementation, it would have been preferable to recruit a whole practice rather than single GPs to enable activation of systems to support the programme. Conclusion. A GP-delivered weight management programme is feasible and acceptable for patients with obesity in Australian primary health care. The addition of this structured toolkit to support GPs is particularly important for patients with a strong preference for GP involvement or who are unable to access other resources due to cost or location.

Exploring Self-Efficacy in Australian General Practitioners Managing Patient Obesity: A Qualitative Survey Study

Background. Obesity is a leading cause of morbidity and mortality in the Australian community, and general practitioners (GPs) are commonly approached by patients for assistance in losing weight. Previous studies have shown that GPs have low self-efficacy and low outcome expectation when it comes to managing overweight and obese patients, which affects their willingness to initiate and continue with weight counselling. This qualitative survey study aimed to explore the factors influencing confidence and behaviour in obesity management in GPs. Method. Twelve GPs recruited to deliver a pilot of an obesity management program participated in semistructured interviews, and interpretive analysis underpinned by social cognitive theory was performed on the transcripts. Results. Analysis identified five main themes: (1) perceived knowledge and skills, (2) structure to management approach, (3) the GP-patient relationship, (4) acknowledged barriers to weight loss and lifestyle change, and (5) prior experience and outcome expectation. Conclusions. GPs are likely to welcome tools which provide a more structured approach to obesity management. Shifting away from weight and BMI as sole yardsticks for success or failure and emphasising positive lifestyle changes for their own sake may improve GP self-efficacy and allow for a more authentic GP-patient interaction.

Measuring patient participation in health care: a comprehensive systematic review protocol

Review question/objective The primary objective of this review is to generate a list of evidence‐based determinants used for assessing patient participation. The review will synthesize the best available evidence for assessing patient participation in health care. Patient participation is the active involvement of the patient in planning, delivery, monitoring and evaluation of their own care. A patient is an individual receiving care services from an organization providing health care. In the context of this review, patient participation will include the active involvement of non‐professional carers/caregivers (e.g. family members and significant others) who support the patient, particularly adults who are unable to advocate on their own behalf (e.g. those with cognitive impairment). The review questions are: What are the available instruments that can be used to measure patient participation in healthcare? What criteria do available instruments incorporate? Are the identified instruments used to measure patient participation in healthcare reliable and valid? What is the feasibility of the identified instruments to measure patient participation in healthcare? What other available strategies can be used to assess patient participation in healthcare? What are the components of other available strategies? Are other identified strategies feasible to assess patient participation in healthcare? Background Promoting patient participation is recognized as a component of high quality health care, and there is evidence that a patient‐centered focus can result in significant benefits in terms of care quality and experience of care. Outcomes relating to quality of care include a reduction in mortality,1 readmission rates,2 length of stay and infection,3 as well as improved adherence to treatment regimens,4 and improved functional status.5 Involvement of the patient in quality improvement initiatives can lead to improved quality of care,6‐8 as well as better patient outcomes.9‐11 Hospitals that provide patient‐centered care have financial benefits including reduced length of stay, lower inpatient costs, decreased adverse events, higher employee retention rates, reduced operating costs and decreased malpractice claims.12 Measurement of patient participation in health care is a relatively new concept, introduced in western Europe, North America and Australia over the previous 25 years.13 The World Health Organization World Alliance for Patient Safety is actively focused on the role that patients and their families could play in the improvement of health care.14 Evidence is emerging that patient participation can enhance decision making processes, reduce medical errors, optimize self‐management for patients with chronic illness and improve patient adherence to health care practices.15 As such, health services internationally now include consumer‐centered care and partnering with consumers as an aspect of service delivery and design. In 1998, Cahill observed that a standardized definition of patient participation and reliable, valid measures for assessing the extent to which this concept is executed in practice are needed.16 Over a decade later, the concept of patient participation remains poorly defined. Various terms, including patient involvement, partnership, empowerment, collaboration and patient‐centered care are used interchangeably.15 Despite the now common practice of gathering feedback from patients, its use to stimulate quality improvement remains poorly characterized. In an overview of measurement of patient participation in health care, Coulter, Fitzpatrick et al., highlighted the first stage of the measurement process as being the development of agreed standards, each with a set of measureable indicators focused on patient‐centered care and patient priorities.17 Development of measurable indicators has been a focus of health service quality improvement internationally. In 2006, the Organization for Economic Co‐operation and Development (OECD) prepared an overview of health care quality indicators in 23 countries represented in the OECD; laying the foundation for international benchmark indicators that embrace and build upon health service quality frameworks already implemented in six major OECD countries (Australia, Canada, Denmark, the Netherlands, the United Kingdom and the United States).18 Within Australia, 10 National Safety and Quality Health Service (NSQHS) standards have been designed to protect the public from harm and to improve the quality of health service provision.19 These standards are integral to the Australian health care accreditation process, as they determine the criteria on which an organizations performance will be assessed, and indicators against which performance will be measured. Similarly, other OECD countries document standards and quality indicators that are comparable to those used in the Australian setting.18 The second Australian NSQHS standard, ‘Partnering with Consumers’, describes the systems and strategies to create a consumer‐centered health system through inclusion of consumers in the development and design of quality health care.19 This requires active involvement of consumers in the review, design and implementation of health services with a goal of improved safety, quality and efficiency. Thus, the first stage of the process defined by Coulter, Fitzpatrick et al., in which agreed standards are defined, is prescribed within the NSQHS Standards.17 Equally, health care quality indicators in other OECD countries prescribe to the principle of consumer involvement, variously referred to as patient centeredness, patient focus or responsiveness.18 The development of measureable indicators of patient participation is ongoing both in Australia and internationally. The Australian Institute of Health and Welfare (AIHW) includes ‘patient experience’ as a national quality indicator to be reported by health care facilities that encompasses patient satisfaction, involvement in and support for health care, but specific ways in which this should be measured and reported remain undefined.20 The OECD is also yet to finalize its work on measurable quality indicators of patient participation.18 Reliable strategies to measure and evaluate the achievement of quality indicators of patient participation have therefore received minimal attention within the NSQHS Standards structure; although work identifying the most appropriate measurement strategies is ongoing. As part of the OECD project on quality indicators in health care, the Norwegian Knowledge Center for Health Services reviewed surveys that have been used to measure patient experience in international health care settings. The reviewers identified numerous large scale patient surveys that have been undertaken in OECD and non‐OECD countries to measure patient experiences, and identified both qualitative and quantitative strategies that could be adopted by health care facilities, including some surveys that were under development at the time of the review.18 Elwyn, Edwards et al., reviewed instruments for measuring patient involvement in shared decision making and found existing instruments had not been specifically developed to measure patient involvement, were developed for different purposes and were not validated.21 In their comprehensive report on measuring patient experience with health care services, Coulter, Fitzpatrick et al., outlined a range of measurement strategies including surveys, interviews, focus groups, patient diaries, ‘mystery shopping’ and journey mapping.17 However, the authors did not report the implementation, validation or effectiveness of these tools. Health care services currently use a range of strategies to evaluate patient‐centered care and partnerships with patients and their significant others. The two primary approaches to measuring patient participation are external observation methods and self‐report instruments. Examples of tools using external observation for measuring patient involvement in shared decision making are the Option Scale,22 and Rochester Participatory Decision‐Making Scale (RPAD).23 More often, health care services rely on self‐report instruments for measuring patient satisfaction and experience. Surveys are often given to a patient when they leave hospital after a period of inpatient care, or the patient is asked to complete a questionnaire prior to discharge. Post discharge feedback may provide more reliable information about the quality of care because respondents have had time to reflect on their experiences.17 More recently, rapid feedback involving online surveys have also been used.24 Although some of the items in these surveys relate to patient participation in their health care, the focus is often patient satisfaction and experience, rather than involvement. A review of patient experience and satisfaction surveys conducted within public and private hospitals in Australia identified that 80% of surveys included items which related to patient participation in care decisions.25 The Australian Commission on Safety and Quality in Health Care has hosted a series of roundtable meetings where experts have provided advice towards the development of core common questions for hospital patient experience measurement. However, it is important to note that the evidence‐base for criteria to measure patient participation in health care and improvements as a result of patient participation was not established. This systematic review endeavors to provide an updated synthesis of evidence on effective strategies through which patient involvement in health care can be measured and assessed, with a goal of assisting health care services to demonstrate patient‐centered care in practice and benchmark their performance on the international stage. The primary outcome for this review will be a preliminary list of evidence‐based criteria used for assessing patient participation. Specifically, this will assist

The learner’s perspective in GP teaching practices with multi-level learners: a qualitative study

BackgroundMedical students, junior hospital doctors on rotation and general practice (GP) registrars are undertaking their training in clinical general practices in increasing numbers in Australia. Some practices have four levels of learner. This study aimed to explore how multi-level teaching (also called vertical integration of GP education and training) is occurring in clinical general practice and the impact of such teaching on the learner.MethodsA qualitative research methodology was used with face-to-face, semi-structured interviews of medical students, junior hospital doctors, GP registrars and GP teachers in eight training practices in the region that taught all levels of learners. Interviews were audio-recorded and transcribed. Qualitative analysis was conducted using thematic analysis techniques aided by the use of the software package N-Vivo 9. Primary themes were identified and categorised by the co-investigators.Results52 interviews were completed and analysed. Themes were identified relating to both the practice learning environment and teaching methods used.A practice environment where there is a strong teaching culture, enjoyment of learning, and flexible learning methods, as well as learning spaces and organised teaching arrangements, all contribute to positive learning from a learners’ perspective.Learners identified a number of innovative teaching methods and viewed them as positive. These included multi-level learner group tutorials in the practice, being taught by a team of teachers, including GP registrars and other health professionals, and access to a supernumerary GP supervisor (also termed “GP consultant teacher”). Other teaching methods that were viewed positively were parallel consulting, informal learning and rural hospital context integrated learning.ConclusionsVertical integration of GP education and training generally impacted positively on all levels of learner. This research has provided further evidence about the learning culture, structures and teaching processes that have a positive impact on learners in the clinical general practice setting where there are multiple levels of learners. It has also identified some innovative teaching methods that will need further examination. The findings reinforce the importance of the environment for learning and learner centred approaches and will be important for training organisations developing vertically integrated practices and in their training of GP teachers.