Heather Gibb

An environmental scan of an aged care workplace using the PARiHS model: assessing preparedness for change.

AIM The environmental scan aimed to deepen our understanding of the aged care work culture and to ascertain the readiness of the workers to advance towards team-based quality care provision. BACKGROUND The workplace context was a high-care unit within a large residential aged care facility. METHODS We used the Promoting Action on Research Implementation in Health Services (PARiHS) framework to assess workplace readiness via interviews, individual surveys and observation of practice. RESULTS A profile of current culture emerged as mutually supportive and task focused, but at the same time lacking corporate team features of shared decision-making and feedback for practice improvement. However, latent within the frontline leaders and personal care staff, there was evidence of some embedded knowledge and capacity for corporate team performance. CONCLUSIONS This study has validated an evidence-based method for conducting environmental scanning in aged care, recommended before any major change is introduced. IMPLICATIONS FOR NURSING MANAGEMENT Environmental scanning helps gauge workforce capacity and limitations; this information can enable managers to capitalize on identified cultural strengths to fortify change and avoid pitfalls of personal and collective vulnerabilities.Aim  The environmental scan aimed to deepen our understanding of the aged care work culture and to ascertain the readiness of the workers to advance towards team-based quality care provision. Background  The workplace context was a high-care unit within a large residential aged care facility. Methods  We used the Promoting Action on Research Implementation in Health Services (PARiHS) framework to assess workplace readiness via interviews, individual surveys and observation of practice. Results  A profile of current culture emerged as mutually supportive and task focused, but at the same time lacking corporate team features of shared decision-making and feedback for practice improvement. However, latent within the frontline leaders and personal care staff, there was evidence of some embedded knowledge and capacity for corporate team performance. Conclusions  This study has validated an evidence-based method for conducting environmental scanning in aged care, recommended before any major change is introduced. Implications for nursing management  Environmental scanning helps gauge workforce capacity and limitations; this information can enable managers to capitalize on identified cultural strengths to fortify change and avoid pitfalls of personal and collective vulnerabilities.

Exploring the role of music therapy in cardiac rehabilitation after cardiothoracic surgery: a qualitative study using the Bonny Method of Guided Imagery and Music

Background:Cardiac rehabilitation integrates physical, psychological, and vocational strategies to restore and sustain optimal health. Objective:An innovative study using music therapy (Bonny Method of Guided Imagery and Music [BMGIM]) explored the experiences of cardiac rehabilitation participants in an outpatient setting at 2 major metropolitan teaching hospitals. Methods:Commencing 6 to 15 weeks after cardiothoracic surgery, 6 study participants were recruited for 6 weekly music therapy (BMGIM) sessions. Qualitative analysis of the patient narrative within a semiotic framework demonstrated that patients used music therapy to spontaneously explore their recovery process. Results:Five grand themes emerged: (1) looking through the frame, (2) feeling the impact, (3) spiralling into the unexpected, (4) sublime plateau, and (5) rehearsing new steps. The themes related to physical changes, adjustment after surgery, and anticipated lifestyle. Conclusions:This study demonstrates that music therapy (BMGIM) may be used to access and understand the internal recovery process of postcardiothoracic surgical patients, providing an additional clinical tool to augment the external rehabilitation process.

The use of behavioural reinforcement in the management of behaviours of concern associated with dementia

Executive summary Introduction People with dementia often require high‐level care due to behaviours that are associated with dementia such as verbal and physical aggression. Behavioural therapies that utilise approaches such as behavioural reinforcement are one possible strategy to manage such behaviours. Aims The objective of this review was to synthesise the best available evidence in relation to the use of behavioural reinforcement in the management of behaviours associated with dementia. Inclusion criteria Types of participants Participants were adults aged over 60 years who had a clinical diagnosis of dementia and who exhibited any of the following behaviours associated with dementia e.g. verbal and physical aggression, vocalisations and wandering. Types of intervention Any behaviour therapy modality that used reinforcement techniques was considered. Types of outcomes The outcome of interest was a change in the behaviour associated with dementia. Types of studies Any quantitative or qualitative study designs were considered. In the absence of high quality studies, designs such as case series were considered. Search strategy The search strategy aimed to find both published and unpublished studies using a three‐step approach. Papers were limited to the English language and a date restriction of 1990 to 2009 was set. Methods of review Critical appraisal Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review. Disagreements that arose between the reviewers were resolved through discussion. Data extraction Quantitative data was extracted from papers included in the review using a standardised data extraction tool. Data synthesis Only quantitative papers met the reviews inclusion criteria and were subsequently included. Due to the heterogeneity in the study design, populations, interventions and outcomes of papers, meta‐analyses could not be undertaken. A narrative summary of each paper is thus provided. Results Only five papers were included; one repeated measures quasi‐experimental study, three case series and one case report. Priority was given to the quasi‐experimental study due to its design and quality score. The methodological quality of the other papers was weak. In total only eleven subjects were included that focussed on different schedules of reinforcement and different behaviours. The quasi‐experimental study did not demonstrate significant results between presenting a visual stimulus continuously or intermittently and wandering. The preliminary evidence from the case series/report all reported a reduction in the undesirable behaviour following implementation of a reinforcement method. Conclusions Due to the evidence currently available, the utilisation of reinforcement approaches to assist in reducing or eliminating behaviours associated with dementia can be neither recommended nor refuted. Implications for practice There is weak evidence to suggest that implementing a reinforcement schedule may reduce behaviours such as physical or verbal aggression and vocalisations. The evidence for wandering is equivocal. Making a decision to utilise this type of behavioural approach should be based on clinical judgement, the preference of the patient or family and the context in which the care is delivered. Implications for research Due to the limited available evidence on this topic that can only provide weak empirical evidence, further experimental investigations such as controlled trials should be conducted to test the hypothesis that reinforcement strategies may assist in reducing or eliminating behaviour/s associated with dementia.

In pursuit of clinical excellence: the role of evidence

The tireless pursuit of clinical excellence demonstrated by health practitioners from all disciplines, across the world, never ceases to amaze me. This determination to ensure that the quality of healthcare is of the highest possible standard, despite the challenges and exigencies that plague its delivery, is truly a testimony to the strength and professionalism of those involved. This volume of the journal draws together a range of perspectives and approaches in addressing the challenge of continuous quality improvement through the analysis and application of evidence to inform clinical decision-making. It could be described as a volume committed to ‘down to earth aspects’ of healthcare. The systematic reviews in this volume include an analysis of evidence for patient simulation as an alternative to traditional clinical encounters, as the basis for student learning;1 the relative effectiveness of different fluid regimens in colostomy irrigation2 and an analysis of the relative effectiveness of a low toxicity treatment in osteoarthritis, through the use of ginger.3 A practice implementation project is outlined in the ‘Evidence Utilisation’ section regarding the use of physical restraint as a safety measure in residential aged care.4 In this same vein, two articles are included which relate to the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) software. It has long been argued that ‘a pluralistic approach when considering “what counts as evidence” for health care practices’ is required.5 Thus, the JBI-QARI software was designed within the Joanna Briggs Institute to provide a framework to manage, appraise, analyse and synthesise the findings of qualitative research as part of a systematic review. This resource therefore offers opportunity for synthesising experiences and perspectives in a systematic way to further inform clinical decision-making in practice. The first of the papers related to JBI-QARI is a systematic review that examines the experiences of young people with chronic illness.6 The other paper reports on the researcher experience of using JBI-QARI to examine the views and experiences of older people in relation to falls.7 As the authors emphasise, the capacity to include reviews of qualitative data of this kind, ensures that care delivery is both evidencebased and consumer informed. This edition of the journal highlights the importance of ensuring that quality improvement initiatives consider the best available evidence in line with the context of care, client preference and professional clinical expertise. It acknowledges that the pursuit of clinical excellence is the sum total of these individual but equally important elements and recognises the unique and inimitable relationship between those who provide and those who use health services.