Mary D. Courtney

Fewer Emergency Readmissions and Better Quality of Life for Older Adults at Risk of Hospital Readmission: A Randomized Controlled Trial to Determine the Effectiveness of a 24-Week Exercise and Telephone Follow-Up Program

OBJECTIVES: To evaluate the effect of an exercise‐based model of hospital and in‐home follow‐up care for older people at risk of hospital readmission on emergency health service utilization and quality of life.

A comparison of activities undertaken by enrolled and registered nurses on medical wards in Australia: An observational study

BACKGROUND The past decade has seen increasing patient acuity and shortening lengths of stays in acute care hospitals, which has implications for how nursing staff organise and provide care to patients. OBJECTIVE The aim of this study was to describe the activities undertaken by enrolled nurses (ENs) and registered nurses (RNs) on acute medical wards in two Australian hospitals. DESIGN This study used structured observation, employing a work sampling technique, to identify the activities undertaken by nursing staff in four wards in two hospitals. Nursing staff were observed for two weeks. The data collection instrument identified 25 activities grouped into four categories, direct patient care, indirect care, unit related activities and personal activities. SETTING Two hospitals in Queensland, Australia. RESULTS A total of 114 nursing staff were observed undertaking 14,528 activities during 482h of data collection. In total, 6870 (47.3%) indirect, 4826 (33.2%) direct, 1960 (13.5%) personal and 872 (6.0%) unit related activities were recorded. Within the direct patient care activities, the five most frequently observed activities (out of a total of 10 activities) for all classifications of nursing staff were quite similar (admission and assessment, hygiene and patient/family interaction, medication and IV administration and procedures), however the absolute proportion of Level 2 RN activities were much lower than the other two groups. In terms of indirect care, three of the four most commonly occurring activities (out of a total of eight activities) were similar among groups (patient rounds and team meetings, verbal report/handover and care planning and clinical pathways). The six unit related activities occurred rarely for all groups of nurses. CONCLUSION This study suggests that similarities exist in the activities undertaken by ENs and Level 1 RNs, supporting the contention that role boundaries are no longer clearly delineated.

A randomised controlled trial of a community nursing intervention: improved quality of life and healing for clients with chronic leg ulcers

AIMS AND OBJECTIVE The negative impact of chronic leg ulcers on quality of life is well documented. The aim of this study was to determine the effectiveness of a new community nursing model of care on quality of life, morale, depression, self-esteem, social support, healing, pain and functional ability of clients with chronic venous leg ulcers. BACKGROUND Venous leg ulcers are slow to heal, frequently recur and are associated with pain, restricted mobility and decreased quality of life. Although chronic wound care consumes a large proportion of community nursing time and health care resources, there is little evidence available on the effectiveness of differing models of community care for this population. DESIGN Randomised controlled trial. METHODS We recruited a sample of 67 participants with venous leg ulcers referred for care to a community nursing organisation in Queensland, Australia after obtaining informed consent. Participants were randomised to either the Lindsay Leg Club model of care (n = 34), emphasising socialisation and peer support; or the traditional community nursing model (n = 33) consisting of individual home visits by a registered nurse. Participants in both groups were treated by a core team of nurses using identical research protocols based on short-stretch compression bandage treatment. Data were collected at baseline, 12 and 24 weeks from commencement. RESULTS Participants who received care under the Leg Club model demonstrated significantly improved outcomes in quality of life (p = 0.014), morale (p < 0.001), self-esteem (p = 0.006), healing (p = 0.004), pain (p = 0.003) and functional ability (p = 0.044). CONCLUSION In this sample, the evaluation of the Leg Club model of care shows potential to improve the health and well-being of clients who have chronic leg ulcers. RELEVANCE TO CLINICAL PRACTICE These results suggest further evaluation and implementation of this model is warranted by community health organisations involved in the care of this population.

The impact of rural clinical placement on student nurses' employment intentions.

Commonwealth Government health policy and professional organisations have indicated that successful recruitment and retention strategies are crucial to address the shortage of health professionals in rural and remote areas. This research study aimed to evaluate the effectiveness of a Clinical Placement Support Scheme for nursing students as a recruitment strategy for rural and remote health care services, and to develop an increased awareness of the employment opportunities available in these areas. The population consisted of final year Bachelor of Nursing students enrolled in either a rural or metropolitan clinical placement in 2000. A pre-post test survey design was used. Analysis of pre- and post-test data found a 12% increase (to 89%) in the number of students intending to seek employment in a rural setting, compared to a 5% increase (to 46%) in students who undertook a metropolitan placement. One-third of the students who chose a rural placement had no previous experience of a rural lifestyle and over half of these students indicated their intention to work in a rural setting following their clinical placement. These results support the theory that undergraduate rural clinical experience can have a positive influence on the recruitment of health professionals to rural areas.

Housing, social support and people with schizophrenia: a grounded theory study

The aim of this study was to develop a substantive grounded theory describing the relationship among housing, social support, and the mental health of people with schizophrenia. To achieve this aim, data were collected from people with schizophrenia living in boarding houses and living in their own home. Semi-structured in-depth interviews were conducted with 13 people with schizophrenia to explore their experiences and views regarding the impact of their housing on their mental health. Findings indicate a strong desire among all participants to live in their own home. When they do they feel they belong, they feel safe and most importantly they have greater opportunities to make and maintain supportive social relationships.

Relationships between preventive activities, psychosocial factors and recurrence of venous leg ulcers: a prospective study

AIM The aim of this study was to identify relationships between preventive activities, psychosocial factors and leg ulcer recurrence in patients with chronic venous leg ulcers. BACKGROUND Chronic venous leg ulcers are slow to heal and frequently recur, resulting in years of suffering and intensive use of healthcare resources. METHODS A prospective longitudinal study was undertaken with a sample of 80 patients with a venous leg ulcer recruited when their ulcer healed. Data were collected from 2006 to 2009 from medical records on demographics, medical history and ulcer history; and from self-report questionnaires on physical activity, nutrition, preventive activities and psychosocial measures. Follow-up data were collected via questionnaires every 3 months for 12 months after healing. Median time to recurrence was calculated using the Kaplan-Meier method. A Cox proportional-hazards regression model was used to adjust for potential confounders and determine effects of preventive strategies and psychosocial factors on recurrence. RESULTS There were 35 recurrences in a sample of 80 participants. Median time to recurrence was 27 weeks. After adjustment for potential confounders, a Cox proportional hazards regression model found that at least an hour/day of leg elevation, 6 or more days/week in Class 2 (20-25 mmHg) or 3 (30-40 mmHg) compression hosiery, higher social support scale scores and higher General Self-Efficacy scores remained significantly associated (P < 0·05) with a lower risk of recurrence, while male gender and a history of deep vein thrombosis remained statistically significant risk factors for recurrence. CONCLUSION Results indicate that leg elevation, compression hosiery, high levels of self-efficacy and strong social support will help prevent recurrence.

Routine changing of intravenous administration sets does not reduce colonization or infection in central venous catheters.

OBJECTIVE To determine the effect of routine intravenous (IV) administration set changes on central venous catheter (CVC) colonization and catheter-related bacteremia. DESIGN Prospective, randomized, controlled trial. SETTING Eighteen-bed intensive care unit (ICU) in a large metropolitan hospital. PARTICIPANTS Two hundred fifty-one patients with 404 chlorhexidine gluconate and silver sulfadiazine-coated multi-lumen CVCs. INTERVENTIONS CVCs inserted in the ICU and in situ on day 4 were randomized to have their IV administration sets changed on day 4 (n = 203) or not at all (n = 201). Use of fluid containers and blood product administration sets was limited to 24 hours. CVCs were removed when not required, infection was suspected, or in place on day 7. Catheter cultures were performed on removal by blinded laboratory staff. Catheter-related bacteremia was diagnosed by a blinded intensivist using strict definitions. Data were collected regarding catheter duration, site, Acute Physiology and Chronic Health Evaluation (APACHE) II score, patient age, diagnosis, hyperglycemia, hypoalbuminemia, immune status, number of fluid containers and IV injections, and administration of propofol, blood, total parenteral nutrition, or lipid infusion. RESULTS There were 10 colonized CVCs in the group receiving a set change and 19 in the group not receiving one. This difference was not statistically significant on Kaplan-Meier survival analysis. There were 3 cases of catheter-related bacteremia per group. Logistic regression found that burns diagnosis and increased ICU stay significantly predicted colonization. CONCLUSION IV administration sets can be used for 7 days in patients with short-term, antiseptic-coated CVCs.

Improved functional ability and independence in activities of daily living for older adults at high risk of hospital readmission: a randomized controlled trial

OBJECTIVE During hospitalization older people often experience functional decline which impacts on their future independence. The objective of this study was to evaluate a multifaceted transitional care intervention including home-based exercise strategies for at-risk older people on functional status, independence in activities of daily living (ADLs) and walking ability. METHODS A randomized controlled trial was undertaken in a metropolitan hospital in Australia with 128 patients (64 intervention, 64 control) aged over 65 years with an acute medical admission and at least one risk factor for hospital readmission. The intervention group received an individually tailored programme for exercise and follow-up care which was commenced in hospital and included regular visits in hospital by a physiotherapist and a registered nurse, a home visit following discharge and regular telephone follow-up for 24 weeks following discharge. The programme was designed to improve health-promoting behaviours, strength, stability, endurance and mobility. Data were collected at baseline, then 4, 12 and 24 weeks following discharge using the Index of ADL, Instrumental Activities of Daily Living (IADL) and the Walking Impairment Questionnaire (WIQ; modified). RESULTS Significant improvements were found in the intervention group in IADL scores (P < 0.001), ADL scores (P < 0.001) and WIQ scale scores (P < 0.001) in comparison to the control group. The greatest improvements were found in the first 4 weeks following discharge. CONCLUSIONS Early introduction of a transitional model of care incorporating a tailored exercise programme and regular telephone follow-up for hospitalized at-risk older adults can improve independence and functional ability.

Factors that affect health outcomes in adults with type 2 diabetes: A cross-sectional study

BACKGROUND Factors that individually influence blood sugar control, health-related quality of life, and diabetes self-care behaviors have been widely investigated; however, most previous diabetes studies have not tested an integrated association between a series of factors and multiple health outcomes. OBJECTIVES The purposes of this study are to identify risk factors and protective factors and to examine the impact of risk factors and protective factors on adaptive outcomes in people with type 2 diabetes. DESIGN A descriptive correlational design was used to examine a theoretical model of risk factors, protective factors, and adaptive outcomes. SETTINGS This study was conducted at the endocrine outpatient departments of three hospitals in Taiwan. PARTICIPANTS A convenience sample of 334 adults with type 2 diabetes aged 40 and over. METHODS Data were collected by a self-reported questionnaire and physiological examination. Using the structural equation modeling technique, measurement and structural regression models were tested. RESULTS Age and life events reflected the construct of risk factors. The construct of protective factors was explained by diabetes symptoms, coping strategy, and social support. The construct of adaptive outcomes comprised HbA1c, health-related quality of life, and self-care behaviors. Protective factors had a significant direct effect on adaptive outcomes (beta=0.68, p<0.001); however, risk factors did not predict adaptive outcomes (beta=-0.48, p=0.118). CONCLUSIONS Identifying and managing risk factors and protective factors are an integral part of diabetes care. This theoretical model provides a better understanding of how risk factors and protective factors work together to influence multiple adaptive outcomes in people living with type 2 diabetes.

Diarrhoea risk factors in enterally tube fed critically ill patients: A retrospective audit

OBJECTIVE Diarrhoea in the enterally tube fed (ETF) intensive care unit (ICU) patient is a multi-factorial problem. Diarrhoeal aetiologies in this patient cohort remain debatable; however, the consequences of diarrhoea have been well established and include electrolyte imbalance, dehydration, bacterial translocation, peri anal wound contamination and sleep deprivation. This study examined the incidence of diarrhoea and explored factors contributing to the development of diarrhoea in the ETF, critically ill, adult patient. METHOD After institutional ethical review and approval, a single centre medical chart audit was undertaken to examine the incidence of diarrhoea in ETF, critically ill patients. Retrospective, non-probability sequential sampling was used of all emergency admission adult ICU patients who met the inclusion/exclusion criteria. RESULTS Fifty patients were audited. Faecal frequency, consistency and quantity were considered important criteria in defining ETF diarrhoea. The incidence of diarrhoea was 78%. Total patient diarrhoea days (r=0.422; p=0.02) and total diarrhoea frequency (r=0.313; p=0.027) increased when the patient was ETF for longer periods of time. Increased severity of illness, peripheral oxygen saturation (Sp02), glucose control, albumin and white cell count were found to be statistically significant factors for the development of diarrhoea. CONCLUSION Diarrhoea in ETF critically ill patients is multi-factorial. The early identification of diarrhoea risk factors and the development of a diarrhoea risk management algorithm is recommended.