Patricia Nicholson

The use of scoring rubrics to determine clinical performance in the operating suite

UNLABELLED This research evolved out of the need to examine the validity and inter-rater reliability of a set of performance-based scoring rubrics designed to measure competencies within the operating suite. METHOD Both holistic and analytical rubrics were developed aligned to the ACORN Standard [Australian College of Operating Room Nurses Standard NR4, 2004. ACORN Competency Standards for Perioperative Nurses: Standard NR4: The Instrument Nurse in the Perioperative Environment. Australian College of Operating Room Nurses Ltd, Adelaide] and underpinned by the Dreyfus model (1981). Three video clips that captured varying performance of nurses performing as instrument nurses in the operating suite were recorded and used as prompts by expert raters, who judged the performance using the rubrics. RESULTS The study found that the holistic rubrics led to more consistent judgments than the analytical rubrics, yet the latter provided more diagnostic information for intervention purposes. Despite less consistency, the Analytical Observation Form had sufficient construct validity to satisfy the requirements of criterion referencing as determined by the Item Separation Index (Rasch, 1960), including high internal consistency and greater inter-rater reliability when average ratings were used. CONCLUSION The study was an empirical investigation of the use of concomitant Analytical and Holistic Rubrics to determine various levels of performance in the operating suite including inter-rater reliability. The methodology chosen was theoretically sound and sufficiently flexible to be used to develop other competencies within the operating suite.

Barriers, enablers and challenges to initiating end-of-life care in an Australian intensive care unit context.

BACKGROUND Patients admitted to Australian intensive care units are often critically unwell, and present the challenge of increasing mortality due to an ageing population. Several of these patients have terminal conditions, requiring withdrawal of active treatment and commencement of end-of-life (EOL) care. OBJECTIVES The aim of the study was to explore the perspectives and experiences of physicians and nurses providing EOL care in the ICU. In particular, perceived barriers, enablers and challenges to providing EOL care were examined. METHODS An interpretative, qualitative inquiry was selected as the methodological approach, with focus groups as the method for data collection. The study was conducted in Melbourne, Australia in a 24-bed ICU. Following ethics approval intensive care physicians and nurses were recruited to participate. Focus group discussions were discipline specific. All focus groups were audio-recorded then transcribed for thematic data analysis. RESULTS Five focus groups were conducted with 11 physicians and 17 nurses participating. The themes identified are presented as barriers, enablers and challenges. Barriers include conflict between the ICU physicians and external medical teams, the availability of education and training, and environmental limitations. Enablers include collaboration and leadership during transitions of care. Challenges include communication and decision making, and expectations of the family. CONCLUSIONS This study emphasised that positive communication, collaboration and culture are vital to achieving safe, high quality care at EOL. Greater use of collaborative discussions between ICU clinicians is important to facilitate improved decisions about EOL care. Such collaborative discussions can assist in preparing patients and their families when transitioning from active treatment to initiation of EOL care. Another major recommendation is to implement EOL care leaders of nursing and medical backgrounds, and patient support coordinators, to encourage clinicians to communicate with other clinicians, and with family members about plans for EOL care.

Identifying pedagogy and teaching strategies for achieving nationally prescribed learning outcomes

ABSTRACT With the globalisation of university education, national frameworks are commonly used to prescribe standardised learning outcomes and achieve accountability. However, these frameworks are generally not accompanied by guiding pedagogy to support academics in adjusting their teaching practices to achieve the set outcomes. This paper reports the results of a scoping review of health science literature aimed at identifying pedagogy and teaching strategies relevant to achieve the learning outcomes specified by the Australian Qualifications Framework at a masters degree level. Eight practical teaching messages emerged from the review and three broad pedagogical trends were identified: the need to use authentic disciplinary-based learning activities; ensure that students are able to discover different perspectives about future practice and bring student reflection about their own knowledge into curricula. More critically, the review highlights that academics attempting to translate national learning outcome frameworks into their teaching practices face a complex and time-consuming task which may involve searching beyond their own disciplinary focus to identify practical teaching strategies to meet prescribed learning outcomes.

Medication adherence in pregnant women with human immunodeficiency virus receiving antiretroviral therapy in sub-Saharan Africa: a systematic review

BackgroundThe use of antiretroviral therapy (ART) is a core strategy proposed by the World Health Organization in preventing mother to child transmission (MTCT) of HIV. This systematic review aimed to examine the enablers and barriers of medication adherence among HIV positive pregnant women in sub-Saharan Africa.MethodsWe used the following keywords: HIV AND (Pregnancy OR Pregnant*) AND (PMTCT OR “PMTCT Cascade” OR “Vertical Transmission” OR “Mother-to-Child”) AND (Prevent OR Prevention) AND (HAART OR “Antiretroviral Therapy” OR “Triple Therapy”) AND (Retention OR Concordance OR Adherence OR Compliance) to conduct electronic searches in the following databases: MEDLINE Complete (1916-Dec 2017), Embase (1947-Dec 2017), Global Health (1910-Dec 2017) and CINAHL Complete (1937-Dec 2017). Of the four databases searched, 401 studies were identified with 44 meeting the inclusion criteria. Seven studies were added after searching reference lists of included articles, resulting in 51 articles in total.ResultsThe review demonstrated that stigma, cost of transportation, food deprivation and a woman’s disclosure or non-disclosure of her HIV status to a partner, family and the community, could limit or define the extent of her adherence to prescribed antiretroviral drugs during pregnancy. Furthermore, the review indicated that knowledge of HIV status, either before or during pregnancy, was significantly associated with medication adherence. Women who knew their HIV status before pregnancy demonstrated good adherence while women who found out their HIV infection status during pregnancy were linked with non-adherence to ART.ConclusionThis review revealed several barriers and enablers of adherence among pregnant women taking ART in sub-Saharan Africa. Major barriers included the fear of HIV infection status disclosure to partners and family members, stigma and discrimination. A major enabler of adherence in women taking ART was women’s knowledge of their HIV status prior to becoming pregnant. Enhanced effort is needed to facilitate women’s knowledge of their HIV status before pregnancy to enable disease acceptance and management, and to support pregnant women and her partner and family in dealing with fear, stigma and discrimination about HIV.

A meta-analysis of effectiveness of interventions to improve adherence in pregnant women receiving antiretroviral therapy in sub-Saharan Africa

OBJECTIVE We evaluated the effectiveness of interventions aimed at improving antiretroviral therapy (ART) adherence during pregnancy in sub-Saharan Africa. METHODS For this meta-analysis, the following databases were searched: MEDLINE Complete, Embase, Global Health, CINAHL Complete, and Google Scholar. Randomized and nonrandomized studies were considered for inclusion if they involved an intervention with the intent of improving medication adherence among pregnant women taking ART in sub-Saharan Africa. Databases were searched from inception to the end of August 2017. The primary outcome assessed was adherence to ART, defined as the proportion of women adherent to treatment in the control and intervention groups. Risk ratios and random effect meta-analysis were undertaken, and heterogeneity was examined with the I2 statistic. RESULTS The systematic search of databases yielded a total of 402 articles, of which 19 studies were selected for meta-analysis with a total of 27,974 participants. Nine types of interventions were identified in the 19 studies to improve ART adherence. The test for the subgroup differences showed that there was a statistically significant difference among the 9 subgroups of interventions, χ2 (8)=102.38; p=0.00001. Collectively, in the meta-analysis, the various intervention types made a significant impact on improving medication adherence. The overall effect estimate with 95% CI was as follows: 1.25 (95% CI=1.03, 1.52, p=0.03). The following risk ratio results for meta-analysis were obtained for the three interventions that showed significant impact on adherence; namely social support and structural support, 1.58 (95% CI=1.36, 1.84, p<0.00001); education, social support and structural support=2.60 (95% CI=1.95, 3.45, p<0.00001); and device reminder=1.13 (95% CI=1.05, 1.20, p=0.0004). The proportion of women who were adherent to ART as a result of the interventions was 59.3% compared with 22.5% in the control groups. CONCLUSION The use of device reminder, a combination of social support and structural support, and education, social support and structural support has the potential to improve ART adherence during pregnancy. Good quality prospective observational studies and randomized control trials are needed in sub-Saharan Africa to determine the most effective interventions.

Communication and Decision-Making About End-of-Life Care in the Intensive Care Unit

Background Clinicians in the intensive care unit commonly face decisions involving withholding or withdrawing life‐sustaining therapy, which present many clinical and ethical challenges. Communication and shared decision‐making are key aspects relating to the transition from active treatment to end‐of‐life care. Objectives To explore the experiences and perspectives of nurses and physicians when initiating end‐of‐life care in the intensive care unit. Methods The study was conducted in a 24‐bed intensive care unit in Melbourne, Australia. An interpretative, qualitative inquiry was used, with focus groups as the data collection method. Intensive care nurses and physicians were recruited to participate in a discipline‐specific focus group. Focus group discussions were audio‐recorded, transcribed, and subjected to thematic data analysis. Results Five focus groups were conducted; 17 nurses and 11 physicians participated. The key aspects discussed included communication and shared decision‐making. Themes related to communication included the timing of end‐of‐life care discussions and conducting difficult conversations. Implementation and multidisciplinary acceptance of end‐of‐life care plans and collaborative decisions involving patients and families were themes related to shared decision‐making. Conclusions Effective communication and decisionmaking practices regarding initiating end‐of‐life care in the intensive care unit are important. Multidisciplinary implementation and acceptance of end‐of‐life care plans in the intensive care unit need improvement. Clear organizational processes that support the introduction of nurse and physician end‐of‐life care leaders are essential to optimize outcomes for patients, family members, and clinicians.