Julie Winstanley

A randomised controlled trial of clinical supervision: selected findings from a novel Australian attempt to establish the evidence base for causal relationships with quality of care and patient outcomes, as an informed contribution to mental health nursing practice development

This paper reports on selected findings from a novel randomised controlled trial (RCT) conducted in mental health settings in Queensland, Australia. Several national and state reports recently revealed the sub-optimal state of Australian mental health service provision which have direct implications for mental health nursing, including the privately experienced cost of working and coping in these settings. Clinical supervision (CS), a structured staff support arrangement, has shown promise as a positive contribution to the clinical practice development agenda and is now found reflected in health policy themes elsewhere in the world. However, CS is underdeveloped in Australia and the empirical evidence base for the informed implementation of CS, per se, has remained elusive. Within the overall context of a RCT design, therefore, and supplemented by other data collection methods, this large and generously funded study attempted to make an incremental contribution to better understanding this demanding substantive domain. Whilst the substantive insights and theoretical propositions reported here were derived from, and may be limited by, a sub-specialty of nursing and a single geographic location, they were earthed in the personal self-reported experience of those directly involved with a clinical practice innovation. They may resonate with counterparts beyond mental health nursing and Queensland, Australia, respectively, therefore, and may assist in both conceptualising and operationalising CS research, education, management, policy and clinical practice development decision making in the future.

Early indicators and contributors to psychological distress in relatives during rehabilitation following severe traumatic brain injury: findings from the Brain Injury Outcomes Study.

ObjectivesTo develop a multivariate model of the dynamic interactions among key variables associated with relative distress and disrupted family functioning after traumatic brain injury (TBI). ParticipantsA relative sample (parents, spouses, close others; n = 134) derived from a statewide cohort of people with TBI recruited to the multicenter Brain Injury Outcomes Study. SettingA consecutive series of referrals over a 2-year period to the 11 adult units of the Brain Injury Rehabilitation Program in New South Wales, Australia. Main Outcome MeasuresRelative measures included General Health Questionnaire–28 (psychological distress), Family Assessment Device (family functioning), and BIOS Family Needs Questionnaire (perceived adequacy of support). The degree of impairment and level of participation of the person with TBI were assessed by the Mayo-Portland Adaptability Inventory and Sydney Psychosocial Reintegration Scale, respectively. AnalysisPath analysis examined the varying contribution of impairment, participation, and support variables to both relative distress and disturbances in family functioning. ResultsThe overall model accounted for substantial proportions of the variance in psychological distress and family functioning. Importantly, the distress experienced by relatives was not due to the direct impact of the neurobehavioral impairments, but the effect of these impairments was mediated by the degree of community participation achieved by the person with TBI. ConclusionsThe model highlights the impact on families when the person with TBI experiences restrictions in participation. Clinically, a greater focus on the provision of respite or case management services may assist in reducing relative distress.

Shift work and work injury in the New Zealand Blood Donors' Health Study

Objective: To investigate associations between work patterns and the occurrence of work injury. Methods: A cross sectional analysis of the New Zealand Blood Donors Health Study conducted among the 15 687 (70%) participants who reported being in paid employment. After measurement of height and weight, a self-administered questionnaire collected information concerning occupation and work pattern, lifestyle behaviour, sleep, and the occurrence of an injury at work requiring treatment from a doctor during the past 12 months. Results: Among paid employees providing information on work pattern, 3119 (21.2%) reported doing shift work (rotating with nights, rotating without nights, or permanent nights) and 1282 (8.7%) sustained a work injury. In unadjusted analysis, work injury was most strongly associated with employment in heavy manual occupations (3.6, 2.8 to 4.6) (relative risk, 95% CI), being male (1.9, 1.7 to 2.2), being obese (1.7, 1.5 to 2.0), working rotating shifts with nights (2.1, 1.7 to 2.5), and working more than three nights a week (1.9, 1.6 to 2.3). Snoring, apnoea or choking during sleep, sleep complaints, and excessive daytime sleepiness were also significantly associated with work injury. When mutually adjusting for all significant risk factors, rotating shift work, with or without nights, remained significantly associated with work injury (1.9, 1.5 to 2.4) and (1.8, 1.2 to 2.6), respectively. Working permanent night shifts was no longer significantly associated with work injury in the adjusted model. Conclusion: Work injury is highly associated with rotating shift work, even when accounting for increased exposure to high risk occupations, lifestyle factors, and excessive daytime sleepiness.

Five additional mobility and locomotor items to improve responsiveness of the FIM in wheelchair-dependent individuals with spinal cord injury

Study design:Repeated-measures design.Objectives:To assess the validity and responsiveness of five additional mobility and locomotor (5-AML) items when used in conjunction with the Functional Independence Measure (FIM) for assessing the mobility and locomotor function of individuals with spinal cord injury (SCI).Setting:Specialised acute spinal and rehabilitation units in Sydney, Australia.Methods:A previously published scale comprising five key mobility and locomotor skills was further refined. The five items included a bed mobility and vertical (floor-to-chair) transfer item and three wheelchair propulsion items (pushing 200 m over flat ground, pushing up a ramp and negotiating a kerb). A total of 43 eligible patients with SCI (ASIA A–C impairment) admitted consecutively to two acute SCI units in Sydney between 1999 and 2002 were recruited, with four being lost to follow-up. Locomotor and mobility outcomes were measured at regular intervals for up to 6 months with the FIM and the 5-AML. Construct validity of the 5-AML was assessed by testing ability of items to discriminate between different impairment groups (tetraplegia and paraplegia). Item responsiveness was assessed by analysing ability to detect changes in mobility and locomotor function over time. Factor analysis techniques were used to test the hypothesis that the 5-AML, when used in conjunction with the FIM, provides a more sensitive measure of mobility and locomotor function than the FIM alone.Results:The 5-AML items were shown to be valid and responsive, measuring aspects of ‘real world’ mobility and locomotor function not reflected by the FIM. The bed mobility item was highly responsive to change over time for the tetraplegic group, but quickly reached a ceiling in the paraplegic group. The vertical (floor-to-chair) transfer item showed greater responsiveness over time and less ceiling effect for the paraplegic group than any of the FIM locomotor or mobility items. The three wheelchair propulsion items better discriminated between people with tetraplegia and paraplegia, and were more sensitive to changes in locomotor ability over the 6-month period than FIM locomotor items. Results of a preliminary factor analysis indicated that the 5-AML items measure different aspects of mobility and locomotor function than the FIM.Conclusion:The 5-AML items, when used in conjunction with the FIM, provides better delineation of function between people with tetraplegia and paraplegia and provides a more responsive measure of change in function over time than the FIM alone.

The MCSS-26: revision of the Manchester Clinical Supervision Scale using the Rasch Measurement Model.

Background: Previously published accounts of the evaluation of the effects of clinical supervision, a structured system to support health service staff, have been mainly contained to small scale qualitative studies. Over the past decade, the 36-item Manchester Clinical Supervision Scale (MCSS) has transformed the evaluation landscape and has been used as a quantitative outcome measure in upward of 90 licensed studies in 12 countries worldwide. The factor structure has been replicated by other researchers and the psychometric properties have been found robust. However, it had not been previously tested empirically using newly available and sophisticated statistical analyses. Purpose: This study tested the original factor structure and response format of the MCSS for goodness of fit to the Rasch model, using Rasch Unidimensional Measurement Model (RUMM) 2030 software, and investigated the validity of the questionnaire for both nursing and allied health (AH) staff. Methods: A series of Rasch analyses were conducted on the seven subscales of the MCSS. The default procedure for RUMM software uses the partial credit model, which allows items to have varying numbers of response categories and does not assume the distance between response thresholds is uniform. Results: Detailed Rasch analyses indicated that the 36-item version of the MCSS could be reduced to 26 items and result in improved fit statistics for six subscales rather than seven. Conclusions: This study reconfirmed the established psychometric properties of the MCSS, now renamed the MCSS-26.

Lymph Node Ratio Provides Prognostic Information in Addition to American Joint Committee on Cancer N Stage in Patients With Melanoma, Even If Quality of Surgery Is Standardized

Objective:To investigate whether lymph node ratio (LNR) gives additional prognostic information to American Joint Committee on Cancer (AJCC) N stage in a melanoma treatment center where regional lymph node dissection (RLND) techniques are standardized. Background:Lymph node ratio is the ratio of involved lymph nodes to total number of lymph nodes removed at RLND. It is a predictor of survival for melanoma patients. One possible explanation of this is variation in surgical quality. Methods:Regional lymph node dissection procedures performed between 1993 and 2006 were identified from a prospective melanoma database. Patients having axilla, groin, and neck (≥4 levels) RLNDs were allocated to both AJCC N stage groupings and LNR groupings using thresholds A 10% and less, B more than 10% to 25%, and C more than 25%. Results:Lymph nodes retrieval for surgeons was equivalent or exceeded existing standards. For all RLNDs combined (n = 1514) and for the separate regions N1 and LNR A, N2 and LNR B, and N3 and LNR C all had similar numbers of patients allocated to each group with similar survival. The significant factors on multivariate analysis were LNR, primary melanoma Breslow thickness (but only when assessing AJCC stage T0–T3 vs T4), ulceration, AJCC N stage, age less than 50 years/50 years and more, and lymph node basin (groin better than axilla and neck). Lymph node ratio also allowed substaging of AJCC stage N3 patients. Conclusions:Standardized techniques for RLNDs result in LNR and AJCC N stage having similar percentages of cases in each grouping with similar survival. However, LNR is still an independent predictor in prognosis in these melanoma patients. Substaging may account for some of these observations.

The importance of adequate primary tumor excision margins and sentinel node biopsy in achieving optimal locoregional control for patients with thick primary melanomas.

Objective:This study sought to investigate the impact of histopathologically measured excision margins and SNB on local and locoregional disease control in patients with primary cutaneous melanomas more than 4 mm thick. Background:Most current guidelines recommend at least a 2-cm surgical margin (which corresponds to a 16-mm histopathologic margin). These guidelines are based on limited evidence, mostly obtained in patients who did not have an SNB. Methods:Histopathologic tumor excision margins for clinically lymph node-negative patients with melanomas more than 4 mm thick, treated at Melanoma Institute Australia (1992–2009), were determined. Clinicopathologic predictors of local and locoregional disease-free survival were investigated. Results:There were 632 patients eligible for the study; of these, 397 (62.8%) had an SNB. The median histopathologic excision margin was 15 mm (interquartile range, 11.0–19.5 mm). After a median follow-up of 37 months, local and locoregional recurrences were observed in 48 (7.6%) and 159 (25.2%) patients, respectively. Excision margin as a continuous variable was a significant predictor of local [hazard ratio (HR), 0.91; P < 0.001) and locoregional (HR, 0.97; P = 0.042) tumor control on multivariate analyses. Patients with histopathologic margins 16 mm or less had worse local disease-free survival (HR, 2.41; P = 0.01). Patients who did not have an SNB were at higher risk of locoregional recurrence (HR, 1.67; P = 0.003). Conclusions:Histopathologically determined primary tumor excision margins more than 16 mm, corresponding to 2-cm surgical margins, were associated with better local control in patients with melanomas more than 4 mm thick. Patients achieved the best local and locoregional control when SNB was coupled with a more than 16-mm histologic excision margin.

Sentinel node positive melanoma patients: prediction and prognostic significance of nonsentinel node metastases and development of a survival tree model.

BackgroundCompletion lymph node dissection (CLND) following positive sentinel node biopsy (SNB) for melanoma detects additional nonsentinel node (NSN) metastases in approximately 20% of cases. This study aimed to establish whether NSN status can be predicted, to determine its effect on survival, and to develop survival tree models for the sentinel node (SN) positive population.Materials and MethodsSydney Melanoma Unit (SMU) patients with at least 1 positive SN, meeting inclusion criteria and treated between October 1992 and June 2005, were identified from the Unit database. Survival characteristics, potential predictors of survival, and NSN status were assessed using the Kaplan–Meier method, Cox regression model, and logistic regression analyses, respectively. Classification tree analysis was performed to identify groups with distinctly different survival characteristics.ResultsA total of 323 SN-positive melanoma patients met the inclusion criteria. On multivariate analysis, age, gender, primary tumor thickness, mitotic rate, number of positive NSNs, or total number of positive nodes were statistically significant predictors of survival. NSN metastasis, found at CLND in 19% of patients, was only predicted to a statistically significant degree by ulceration. Multivariate analyses demonstrated that survival was more closely related to number of positive NSNs than total number of positive nodes. Classification tree analysis revealed 4 prognostically distinct survival groups.ConclusionsPatients with NSN metastases could not be reliably identified prior to CLND. Prognosis following CLND was more closely related to number of positive NSNs than total number of positive nodes. Classification tree analysis defined distinctly different survival groups more accurately than use of single-factor analysis.

Clinical supervision for nurses working in mental health settings in Queensland, Australia: a randomised controlled trial in progress and emergent challenges:

Abstract Several national and state-based inquiry documents have reported long-standing and major concerns about mental health service provision in Australia. In particular, accounts of the difficult circumstances that surround the recruitment and retention of high-quality mental health nurses have clearly emerged, independent of jurisdiction. However, the privately experienced cost of working and coping in contemporary mental health settings, especially when the resilience of nursing staff is tested remains poorly understood. Clinical supervision (CS), a structured staff support arrangement, has shown promise as a positive contribution to the clinical governance agenda and is now found reflected in central policy themes elsewhere in the world. However, the concept of CS remains underdeveloped in Australia. The background to a unique randomised controlled trial (RCT), currently in progress in Queensland, Australia, has been described in this study. The efficacy of the most widely adopted model of CS that may address the promotion of standards and clinical audit issues, the development of skills and knowledge and the personal well-being of the supervisee will be tested. This study, funded by the Queensland Treasury/Golden Casket Foundation, will focus not only on the outcomes for individual mental health nurses but also examine the quality of care they provide and the effects of both on patient outcomes. This study will seek to establish a sustainable, strategically significant contribution to the knowledge base both for the mental health nursing workforce in Queensland (and beyond) and the patients they seek to serve.

Chronic Care Team Profile: a brief tool to measure the structure and function of chronic care teams in general practice

AIM At a time when workforce shortages in general practices are leading to greater role substitution and skill-mix diversification, and the demand on general practices for chronic disease care is increasing, the structure and function of the general practice team is taking on heightened importance. To assist general practices and the organizations supporting them to assess the effectiveness of their chronic care teamworking, we developed an interview tool, the Chronic Care Team Profile (CCTP), to measure the structure and function of teams in general practice. This paper describes its properties and potential use. METHOD An initial pool of items was derived from guidelines of best-practice for chronic disease care and performance standards for general practices. The items covered staffing, skill-mix, job descriptions and roles, training, protocols and procedures within the practice. The 41-item pool was factor analysed, retained items were measured for internal consistency and the reduced instruments face, content and construct validity were evaluated. RESULTS A three-factor solution corresponding to non-general practitioner staff roles in chronic care, administrative functions and management structures provided the best fit to the data and explained 45% of the variance in the CCTP. Further analyses suggested that the CCTP is reliable, valid and has some utility. DISCUSSION The CCTP measures aspects of the structure and function of general practices which are independent of team processes. It is associated with the job satisfaction of general practice staff and the quality of care provided to patients with chronic illnesses. As such, the CCTP offers a simple and useful tool for general practices to assess their teamworking in chronic disease care.