Frances Kam Yuet Wong

Development of a Questionnaire to Measure the Level of Reflective Thinking

Many courses aim to promote reflective thinking or reflection upon practice, but there is a scarcity of readily usable instruments to determine whether students engage in reflective thinking and, if so, to what extent. This paper reports the development and testing of such an instrument. To ensure validity, the constructs measured were derived from the extensive literature on reflective thinking, particularly the writing of Mezirow. A combination of the literature review and initial testing led to the development of a four-scale instrument measuring four constructs; habitual action, understanding, reflection and critical reflection. The final version of the instrument was tested with a sample of 303 students from eight classes of a health science faculty. The reliability of the scales was established by acceptable Cronbach alpha values. Confirmatory factor analysis showed a good fit to the proposed four-factor structure. Comparison of mean scores between the eight classes showed predicted significant differences on each of the four scales between undergraduate and postgraduate students.

A four‐category scheme for coding and assessing the level of reflection in written work

Where courses have as an aim the promotion of reflective practice, it will enhance the achievement of the goal if the level of reflective thinking is assessed. To do this in a satisfactory way requires a reliable protocol for assessing the level of reflection in written work. This article presents a protocol that can be used to guide the allocation of work to four categories, namely: habitual action/non‐reflection, understanding, reflection, and critical reflection. Intermediate categories can also be used. Detailed descriptors of each category to guide the process are provided. The protocol was tested by four assessors independently using it to grade a set of written work, and very good agreement was obtained.

Evaluation of a nurse-led disease management programme for chronic kidney disease: A randomized controlled trial

BACKGROUND Patients with end stage renal failure require dialysis and strict adherence to treatment plans to sustain life. However, non-adherence is a common and serious problem among patients with chronic kidney disease. There is a scarcity of studies in examining the effects of disease management programmes on patients with chronic kidney disease. OBJECTIVES This paper examines whether the study group receiving the disease management programme have better improvement than the control group, comparing outcomes at baseline (O1), at 7 weeks at the completion of the programme (O2) and at 13 weeks (O3). METHODS This is a randomized controlled trial. The outcome measures were non-adherence in diet, fluid, dialysis and medication, quality of life, satisfaction, symptom control, complication control and health service utilisation. RESULTS There was no significant difference between the control and study group for the baseline measures, except for sleep. Significant differences (p<0.05) were found between the control and study group at O2 in the outcome measures of diet degree non-adherence, sleep, symptom, staff encouragement, overall health and satisfaction. Sustained effects at O3 were noted in the outcome measures of continuous ambulatory peritoneal dialysis (CAPD) non-adherence degree, sleep, symptom, and effect of kidney disease. CONCLUSIONS Many studies exploring chronic disease management have neglected the group with end stage renal failure and this study fills this gap. This study has employed an innovative model of skill mix using specialist and general nurses and demonstrated patient improvement in diet non-adherence, CAPD non-adherence, aspects of quality of life and satisfaction with care. Redesigning chronic disease management programmes helps to optimize the use of different levels of skills and resources to bring about positive outcomes.

Can home visits help reduce hospital readmissions? Randomized controlled trial

AIM This paper is a report of a study to determine whether home visits can reduce hospital readmissions. Background. The phenomenon of hospital readmission raises concerns about the quality of care and appropriate use of resources. Home visits after hospital discharge have been introduced to help reduce hospital readmission rates, but the results have not been conclusive. METHOD A randomized controlled trial was carried out from 2003 to 2005 . The control group (n = 166) received routine care and the study group (n = 166) received home visits from community nurses within 30 days of hospital discharge. Data were collected at baseline before discharge and 30 days after discharge. FINDINGS Patients in the study group were statistically significantly more satisfied with their care. There were no statistically significant differences in other outcomes, including readmission rate, ADL score, self-perceived life satisfaction and self-perceived health. Regression analysis revealed that self-perceived life satisfaction, self-perceived health and disease category other than general symptoms were three statistically significant variables predicting hospital readmissions. CONCLUSION Preventive home visits were not effective in reducing hospital readmissions, but satisfaction with care was enhanced. Subjective well-being is a key variable that warrants attention in the planning and evaluation of postdischarge home care.

Comparison of effects between home visits with telephone calls and telephone calls only for transitional discharge support: a randomised controlled trial

Background: home visits and telephone calls are two often used approaches in transitional care but their differential effects are unknown. Objective: to examine the overall effects of a transitional care programme for discharged medical patients and the differential effects of telephone calls only. Design: randomised controlled trial. Setting: a regional hospital in Hong Kong. Participants: patients discharged from medical units fitting the inclusion criteria (n = 610) were randomly assigned to: control (‘control’, n = 210), home visits with calls (‘home’, n = 196) and calls only (‘call’, n = 204). Intervention: the home groups received alternative home visits and calls and the call groups calls only for 4 weeks. The control group received two placebo calls. The nurse case manager was supported by nursing students in delivering the interventions. Results: the home visit group (after 4 weeks 10.7%, after 12 weeks 21.4%) and the call group (11.8, 20.6%) had lower readmission rates than the control group (17.6, 25.7%). Significance differences were detected in intention-to-treat (ITT) analysis for the home and intervention group (home and call combined) at 4 weeks. In the per-protocol analysis (PPA) results, significant differences were found in all groups at 4 weeks. There was significant improvement in quality of life, self-efficacy and satisfaction in both ITT and PPA for the study groups. Conclusions: this study has found that bundled interventions involving both home visits and calls are more effective in reducing readmissions. Many of the transitional care programmes use all-qualified nurses, and this study reveals that a mixed skills model seems to bring about positive effects as well.

Effects of a postdischarge transitional care programme for patients with coronary heart disease in China: a randomised controlled trial

AIM To test the effects of a postdischarge transitional care programme among patients with coronary heart disease. BACKGROUND . Coronary heart disease is a leading cause of death worldwide. Effective postdischarge care can help patients maintain a healthy lifestyle and thereby control the risk factors. Transitional care is under-developed in mainland China. DESIGN A randomised controlled trial. METHOD The control group (n = 100) received routine care and the study group (n = 100) received the postdischarge transitional care programme, which consisted of predischarge assessment, structured home visits and telephone follow-ups within four weeks after discharge. Subjects were recruited in 2002-2003, with data collected at baseline before discharge, two days and four and 12 weeks after discharge. RESULTS Participants in the study group had significantly better understanding in diet, medications and health-related lifestyle behaviour at day 2 and in weeks 4 and 12 and better understanding in exercise at weeks 4 and 12. There were significant differences between the control and study groups in diet and health-related lifestyle at day 2 and weeks 4 and 12, in medication at weeks 4 and 12 and exercise at week 12. There was no difference in hospital readmission between the two groups. The study group was very satisfied with the care. There was no difference in willingness to pay for nurse follow-up services between groups. CONCLUSION This study is an original effort to establish and test a nurse-led transitional care model in China. Results demonstrate that transitional care is effective in mainland China, concurring with studies done elsewhere. RELEVANCE TO CLINICAL PRACTICE This study has constructed a transitional care model for patients with coronary heart disease in the context of the Chinese population which is effective in enhancing healthy lifestyle among these patients.

Effects of a health-social partnership transitional program on hospital readmission: A randomized controlled trial

Hospital readmission is an indicator of care quality. Studies have been conducted to test whether post-discharge transitional care programs can reduce hospital readmission, but results are not conclusive. The contemporary development of post-discharge support advocates a health and social partnership approach. There is a paucity of experimental studies examining the effects of such efforts. This study designed a health-social transitional care management program (HSTCMP) and subjected it to empirical testing using a randomized controlled trial in the medical units of an acute general hospital with 1700 beds in Hong Kong during the period of February 2009 to July 2010. Results using per-protocol analysis revealed that the HSTCMP significantly reduced readmission at 4-weeks (study 4.0%, control 10.2%, χ(2) = 7.98, p = 0.005). The intention-to-treat result also showed a lower readmission rate with the study group but the result was not significant (study 11.5%, control 14.7%, χ(2) = 1.53, p = 0.258). There was however significant improvement in quality of life, self-efficacy and satisfaction in the study group in both per-protocol and intention-to-treat analyses. The study suggests that a health-social partnership, using volunteers as substitutes for some of the professional care, may be effective for general medical patients.

Effects of a transitional palliative care model on patients with end-stage heart failure: a randomised controlled trial

Objective To examine the effects of home-based transitional palliative care for patients with end-stage heart failure (ESHF) after hospital discharge. Methods This was a randomised controlled trial conducted in three hospitals in Hong Kong. The recruited subjects were patients with ESHF who had been discharged home from hospitals and referred for palliative service, and who met the specified inclusion criteria. The interventions consisted of weekly home visits/telephone calls in the first 4 weeks then monthly follow-up, provided by a nurse case manager supported by a multidisciplinary team. The primary outcome measures were any readmission and count of readmissions within 4 and 12 weeks after index discharge, compared using χ2 tests and Poisson regression, respectively. Secondarily, change in symptoms over time between control and intervention groups were evaluated using generalised estimating equation analyses of data collected using the Edmonton Symptom Assessment Scale (ESAS). Results The intervention group (n=43) had a significantly lower readmission rate than the control group (n=41) at 12 weeks (intervention 33.6% vs control 61.0% χ2=6.8, p=0.009). The mean number (SE) of readmissions for the intervention and control groups was, respectively, 0.42 (0.10) and 1.10 (0.16) and the difference was significant (p=0.001). The relative risk (CI) for 12-week readmissions for the intervention group was 0.55 (0.35 to 0.88). There was no significant difference in readmissions between groups at 4 weeks. However, when compared with the control group, the intervention group experienced significantly higher clinical improvement in depression (45.9% vs 16.1%, p<0.05), dyspnoea (62.2% vs 29.0%, p<0.05) and total ESAS score (73.0% vs 41.4%, p<0.05) at 4 weeks. There were significant differences between groups in changes over time in quality of life (QOL) measured by McGill QOL (p<0.05) and chronic HF (p<0.01) questionnaires. Conclusions This study provides evidence of the effectiveness of a postdischarge transitional care palliative programme in reducing readmissions and improving symptom control among patients with ESHF. Trial registration number HKCTR-1562; Results.

Effects of 8 weeks sustained follow-up after a nurse consultation on hypertension: A randomised trial

BACKGROUND The prevalence of hypertension is high, but the overall control rate is low. Poor control of, hypertension is associated with a number of diseases, such as stroke, heart and renal failure, and high, mortality rates. Studies have shown the separate effects of nurse clinics and telephone follow-up on, blood pressure control, but the incremental effect of combining the two interventions is unknown. OBJECTIVES This study examines whether there is an incremental effect on blood pressure control when using a nurse clinic combined with telephone follow-up. METHODS This was a randomised controlled trial. The primary outcome measure was blood pressure reading. The secondary outcome measures included adherence to home blood pressure monitoring, exercise, diet, medication, and satisfaction with care. RESULTS There were no significant differences in the baseline measures between the control and study groups. Significant differences were found at 8 weeks after intervention was initiated between groups in, systolic blood pressure (control -7.97 vs study -19.03, t=2.35, p=0.022, CI 1.66-20.47) and diastolic, blood pressure (control -3.72 vs study -11.68, t=3.02, p=0.004, CI 2.68-13.24). Other variables with a significant between-group differences (p<0.05) were blood pressure control rate, adherence, to home blood pressure monitoring, exercise and satisfaction with care. Further analysis using, regression showed that home blood pressure monitoring is the most significant predictor for improved, systolic blood pressure. CONCLUSIONS This study showed that nurse clinics have positive effects on blood pressure control and adherence to healthy lifestyle, but telephone follow-up after such clinics augments the effects of the clinic consultation. This combined mode of services is worth considering for other chronic disease, management programmes.

Educating nurses to care for the dying in Hong Kong: a problem-based learning approach.

Caring for dying patients is an essential and major aspect of nursing care. However, previous studies have revealed that nurses felt uncomfortable and inadequate in dealing with the dying patients and their families. This study reports the effectiveness of a problem-based learning approach in death education among a group of registered nurses in Hong Kong. Three problems, with three segmented scenarios related to cancer nursing, were used. Students went through the problem-based learning process and documented their learning throughout the course in journals. A total of 72 sets of journals were collected and analyzed. The strategies of within case and cross-case analysis were employed. The within case analysis explored the learning development of students for each problem. The cross-case analysis compared and contrasted findings of the within case analysis. Three themes have been derived from the findings. They were: nurses acknowledging their emotions in facing death and dying, a need for the nurses to be better equipped in communication and counseling, and a holistic and family-centered approach to care. This study provides evidence showing that problem-based learning is an effective strategy to enhance nurses’ self-awareness of death and dying issues, and to stimulate nurses to formulate a plan that addresses the physical, psychological, and social aspects of care. Findings also reveal that nurses need to take into account the particular reactions of death and dying in the Chinese culture when planning care.