Nursing - Theses
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Clowns in the midst: understanding clown doctors at The Royal Children's Hospital Melbourne
Clown doctors are a feature in paediatric hospitals, visiting children and families, providing a welcome escape from the reality of hospitalisation. Though the use of humour to improve health and wellbeing has been widely researched, limited exploration of the clown doctors has occurred. This study aims to elucidate the work of clown doctors within a major paediatric hospital. This was an ethnographic study. Ethnography is an innovative approach to paediatric research, giving an intricate view that is otherwise difficult to attain. Participants for this study included the clown doctors employed at The Royal Children’s Hospital, and every person they had a meaningful encounter with during the course of their work, including patients, families, clinical and non-clinical staff. Data was collected via participant observation, with approximately 1,500 hours of ‘clown ward rounds’ documented over one year. Furthermore, 25 hour-long semi-structured interviews were conducted with a range of key informants. A constructivist framework was used to analyse emergent concepts. Constructivism explores how relationships and interactions create the individual’s understanding of the world. Furthermore, how different understanding, or meaning, can be derived from interactions based on individual context, background, culture and personal history. When asking people about the clown doctors, most ascribed a function, such as: distraction, anxiety reduction and procedural assistance; entertainment and making people laugh; emotional support and providing comfort; and communication, including translating clinical information to families. These functional elements of the clown doctors are the result of a more complex, intimate human connection that develops due to the nature of clown doctors being low-status, open, vulnerable and, in particular, existing as outsiders to the medical establishment. Clown doctors use humour to break down the emotional barriers created by illness, which they achieve through being person-centric and offsetting medically driven interactions the hospital often demands. They empower patients, returning a sense of control that is generally absent for hospitalised children. While almost universally acknowledged as a positive addition to the hospital, most people who encounter the clown doctors have little conception about the scope of their work. Although clown doctors are often described in concrete clinical terms, their real power lies in their ability to connect with people, and the psychosocial advantages that connection provides. The results of this descriptive study deliver valuable insight and a comprehensive understanding of clown doctors and the complexity of human relationships within a major paediatric hospital. Through this research we can identify what the clown doctors bring to the hospital environment, how paediatric staff can employ their unique skills more effectively, and finally give long-overdue credence to the notion that laughter, mirth, creativity and child-like wonder has as much place in a hospital as medicine.
Memory-making in neonatal end-of-life care
Experiencing the death of an infant places parents at risk of prolonged and profound grief, therefore providing appropriate psychosocial support for parents is crucial. Current perinatal palliative care guidelines recommend memory-making activities, such as collecting or creating mementos and spending time caring for the infant, as an important aspect of bereavement care. However, evidence to support such interventions is scant. This study used the grounded theory method described by Corbin and Strauss (2015) to explore bereaved parents’ experiences of memory-making in neonatal end-of-life care. Eighteen bereaved parents participated in extensive semi-structured interviews. The core psychosocial process underpinning parents’ experience of memory-making was identified as “Affirmed Parenthood”. This core category was supported by three key themes; “Being a parent”, “Creating evidence” and “Being guided”. “Being a parent” included spending time with the baby before and after death, touching and holding the baby, and providing physical care. “Creating evidence” captured parents’ efforts to collect or create tangible evidence of their baby’s life through photographs and other mementos, and by involving others with their baby to ensure that people outside the immediate family would have memories of their child. Finally, “Being guided” represented parents’ need to be supported and encouraged throughout the process of memory-making. Where all three key themes were addressed in bereavement care, parents experienced affirmation of the significance of their baby’s life, affirmation of the significance of their loss, and affirmation of their role as the baby’s parents.
Procedural pain assessment in infants and young children: identifying a suitable behavioural assessment scale
Infants and young children frequently experience pain as a consequence of medical procedures associated with their healthcare. Pain management is often suboptimal, and this is in part due to the difficulties associated with assessment of pain of infants and children too young to self-report pain intensity. Observable behaviours indicative of pain have long been considered a viable alternative and scales comprised of these behaviours have proliferated in the literature. However, it remains unclear which scales are best suited for procedural pain assessment and whether they are well supported by psychometric data. The aims of this project were to: identify behavioural observation scales potentially suitable for procedural pain assessment, summarise available psychometric data and prospectively test the psychometric properties of potentially suitable scales when used to assess procedural pain in infants and young children. These aims were addressed in three phases of work: i) a thorough interrogation of the literature to identify scales considered potentially suitable for assessing procedural pain in infants and children, ii) a series of systematic reviews to summarise the evidence supporting the psychometric properties of the identified scales and iii) a prospective observational study to test the psychometric properties of these scales used to assess procedural pain in infants and young children. Three scales, the Face, Legs, Activity, Cry and Consolability Scale (FLACC), the Modified Behavioral Pain Scale (MBPS) and the Visual Analogue Scale for observers (VASobs), met predefined criteria and were considered potentially suitable for inclusion in this project. The systematic reviews showed that available psychometric data was insufficient to recommend these scales for procedural pain assessment of infants and children. There was data to tentatively support the MBPS and to a lesser extent the VASobs for assessing immunisation related pain. The data regarding the FLACC scale was inconclusive. The results of the prospective study confirmed that all scales were sensitive to pain. The FLACC scale and MBPS scores were reliable (intraclass correlation (ICC) 0.92 and 0.87, respectively) but VASobs scores were less reliable (ICC 0.55). The FLACC scores showed the highest sensitivity (94.9%) and specificity (72.5%) for procedure type (painful vs non-painful) at the lowest cut-off score (pain score 2, area under the curve (AUC 0.83)). Similar results were achieved at a MBPS cut-off score of 4 (sensitivity 91.5%, specificity 77.5%, AUC 0.85). The FLACC scale resulted in more incomplete scores (p < 0.000) and was changed more often than other scale scores. Reviewers liked the VASobs most, considered it the quickest and easiest to apply, but judged the FLACC scale and MBPS to be more likely to be useful. In conclusion, three behavioural observational pain scales to assess procedural pain in infants and young children were identified and included in systematic reviews. This work culminated in a prospective study, the results of which support use of the FLACC scale, but not without reservation as there are practical limitations when used to assess procedural pain. These results build on promising existing evidence that suggests that the FLACC scale may currently be a suitable scale for procedural pain assessment in infants and young children.
Modelling residential aged care in Australia: entry and exit
Ageing of the Australian population affects the residential aged care system, yet the structure and dynamics of the system remain uncertain. A comprehensive model of residential care based on the individual perspective of residential aged care events is missing. Thus, older Australians, government and care providers have only a limited model of aged care actions. This study uses big administrative unit record data on aged care assessments (ACAP), aged care appraisals (ACFI) and unit record survey data (SDAC) to identify factors associated with aged care events in older persons’ trajectories towards and through residential care. To achieve this goal and broaden understanding of Australian residential care, this study uses the following steps: (1) modelling of the probability of entry to and exit from residential care, with a multi-state model of transitions between levels of care needs; (2) modelling the applications for aged care and approvals for entry to residential care; (3) derivation of transition and mortality assumptions for individual care needs that can be used in a projection model; (4) estimation of life expectancy in residential care based on needs for assistance; and (5) assessing the quality of Australian data on aged care for statistical modelling and projections of residential care demand. The results show that health factors, above all needs for assistance, determine the speed and direction of a person’s progression towards institutional care. Probabilities of aged care events, transition rates and life expectancy estimates, derived in this study, provide a comprehensive picture of Australian residential aged care. These findings are expected to have important implications for residential aged care policies in Australia in terms of having better understanding and more accurate predictive power for the future of aged care.
Asymptomatic thrombosis following the use of central venous catheters in children
Central venous catheters (CVCs) are the major cause of thrombosis in acutely unwell neonates and children. This thesis reports the outcomes of a prospective study of 189 children in a paediatric intensive care unit (PICU) that aimed to determine the frequency of asymptomatic CVC-related thrombosis during hospital admission, and the incidence of residual CVC-related thrombosis and clinically significant post thrombotic syndrome (PTS) two years following CVC placement. The study also sought to identify risk factors predictive of CVC-related thrombosis and clinically significant PTS and determine the utility of ultrasound screening for asymptomatic CVC-related thrombosis in acutely unwell children. This study is distinct from previous work as children in this cohort identified to have asymptomatic CVC-related thrombosis were not treated and were followed for two years to determine the natural history of asymptomatic thrombosis. The incidence of asymptomatic CVC-related thrombus during hospital admission was 21.2% (n=31), despite over 80% of the cohort having received thromboprophylaxis. One child had a symptomatic CVC-related thrombosis. Sixteen children had new or residual thrombus identified on the follow-up ultrasound, performed a mean of 26 months post CVC placement. Of 126 PTS assessments completed at follow-up, 10.3% of children were diagnosed with mild PTS as classified by both the Manco-Johnson instrument and Modified Villalta scale. Only two children were identified to have clinically significant PTS (Manco-Johnson instrument only), one of whom had a symptomatic CVC-related thrombosis. Whilst over one fifth of the cohort had asymptomatic CVC-related thrombosis, only one of these children developed clinically significant PTS. There were no clinical embolic phenomenon or deaths attributable to CVC-related thrombosis. These findings suggest that ultrasound screening for asymptomatic CVC-related thrombosis is not indicated in children in PICU as, despite no treatment (in all but one child), the incidence of any thrombosis-associated morbidity was extremely low. In addition, the study’s findings support previous evidence that thromboprophylaxis provides no protection against CVC-related thrombosis in children. Neither D-dimer nor Factor VIII were predictive of CVC-related thrombosis. However, this study identified that children with femoral CVCs had a significantly higher incidence of residual thrombosis and thrombosis-associated morbidity. Children with femoral CVCs were also significantly more likely to have a higher PIM2 probability of death, cardiac arrest, hypotension, elevated D-dimer and Factor VIII compared to children with jugular CVCs. Whether the placement of the CVC in the femoral veins or the apparent higher acuity of this sub-group of patients is the mediator of increased risk (residual thrombosis and morbidity) compared to jugular CVC placement remains unclear. This study contributes novel insights into the natural history of asymptomatic CVC-related thrombosis, demonstrating a very low morbidity associated with jugular CVC placement. This study informs future clinical research targeting children most at risk of long-term CVC-related thrombosis associated morbidity. Specifically, further investigation of similar cohorts of children to those in whom femoral CVC placement occurred in this study is needed to elucidate risk factors for poor outcomes and the potential for a risk stratified approach to the treatment of asymptomatic CVC related thrombosis.
An exploration of the nursing role in a telehealth based stroke secondary prevention program
This research study set out to explore a specialist nursing role in the field of Telehealth for chronic disease management. This study aimed to explore the role of the nurse through measurement of nursing activity during the one-year period of participant follow-up. The study aimed to effect long-term secondary prevention of stroke through an evidence based approach to the management of modifiable cardiovascular risk factors and post stroke depression in the community setting. Research suggests that up to 80% reduction of risk of successive stroke can be achieved if recommendations from evidence-based guidelines are implemented. Notwithstanding these findings a gap exists in the implementation of preventative strategies for stroke survivors in the community. Results from previous research indicate that Telehealth is cost effective and potentially may significantly reduce socioeconomic burden and the probability of successive stroke. A small number of studies have highlighted potential mechanisms through which Telehealth can benefit the stroke survivor, carers, families and health professionals. Researchers have recommended more research into Telehealth in order to develop and to define effective interventions. A pilot randomised controlled trial (RCT) conducted at two metropolitan hospitals showed positive results in risk factor and depression outcomes. Integral to this model of care was the role of the nurse. In the current nurse-led, nested multicentre RCT, study nurses gained increased telephone access, to follow-up and support stroke survivors and their General Practitioners. There were 93 participants (43 intervention) recruited from four metropolitan hospitals over a period of two years. Nursing staff were integrated with the multidisciplinary team in designated stroke centres and General Practitioners in the community. Specialists were available to participate in shared care. Telephone follow-up was initially attenuated by risk for second stroke, with high-risk individuals receiving a greater frequency of follow-up. The results indicated that nurses engaged in both fundamental nursing process and advanced activities to assist stroke survivors through transitions across the health landscape after stroke. Case management, assessment and care planning were frequent fundamental activities and occupied a relatively large percentage of the nurse’s time. The mean difference in outcome systolic blood pressure was significantly improved in the intervention group. The mean difference in post stroke depression screening score was significantly better for the intervention group. Lifestyle modification in particular physical activity was better in the intervention group. The results add support to the place of nursing in the ongoing care of stroke survivors in the community setting.
Self-treatment of wounds: a mixed methods study
A chronic wound is a disruption of the structure and function of the skin associated with protracted healing. Chronic wounds affect 2% of Australians and cost US$2.85 billion per annum. Chronic wounds have a negative effect on the physical, emotional, social, lifestyle and financial domains of quality of life. Wound treatment involves wound assessment, wound cleansing, debridement of devitalised tissue and the application of wound dressings. Individuals often seek professional services for wound treatment, however the researchers experience and some published evidence suggests that patients sometimes self-treat. Successful self-treatment of chronic wounds has the potential to improve wound healing and the individual’s well-being. A self-care approach to wound treatment may also help to relieve pressure on healthcare services and reduce the economic burden of this condition. The aim of this research was to investigate self-treatment of chronic wounds among people living in the community to inform the development of educational resources and supports for this group. The objectives of this research were to describe the characteristics of people who self-treat, to determine their self-treatment practices and to explore the effect of self-treatment on quality of life. A sequential explanatory design mixed methods study was conducted in Australia and Wales. Data collection involved participants completing one survey (n=113), and a sub-group of the sample completed one in-depth interview (n=25), and one observation of their self-treatment (n=8). The sample was 63.6 years of age on average, self-treated wounds that were 109 weeks duration on average and more than three quarters (n=89, 78.8%) had a leg wound. Health-related quality of life was sub-optimal, 6/10 (ave.) according to the Cardiff Wound Impact Schedule. The majority of self-treaters reported conducting wound cleansing (n=103, 91.2%), wound dressing removal (n=101, 89.4%), wound dressing application (n=100, 88.5%), and wound assessment (n=94, 83.2%). Wound imaging (n=38, 33.6%) and wound debridement (n=46, 40.7%) were conducted by less than half of the sample. The most common reasons for self-treating were to be independent (n=66, 58.4%) and to do the treatment at a time that suited (n=62, 56.6%). Few self-treaters reported receiving structured education to assist them to self-treat (n=6, 5.3%). Self-treaters had spent on average AU$2475 on wound dressing products since the wound started, and AU$121.82 in the most recent 4 weeks which represented 12% of their disposable income. Observations of self-treatment identified that participants conducted the above mentioned self-treatment activities however often not in the most effective manner. The interviews conducted in this study suggested that the effect of self-treatment on quality of life was mainly positive, in particular it improved pain, reduced worry about infection, had financial benefits, and allowed the individual to recapture time lost when receiving professional care. This research has demonstrated the need to develop educational resources and supports for people who self-treat chronic wounds. These resources should include a tool to appraise self-treatment capacity and an e-learning education program to teach patients and their significant other how to self-treat. These resources also have the potential to guide and standardise the practices of healthcare professionals who educate and support self-treaters, and encourage a shared care approach to this self-treatment practice.
Missed nursing care - a nurse's perspective: an exploratory study into the who, what and why of missed care
BACKGOUND: Exploration of missed or delayed nursing care has become increasingly prevalent in international nursing literature over the past ten years. Evidence demonstrates that missed nursing care, or care that is left undone or passed on to the following shift, is common and the factors that lead to missed care are complex and numerous. Critically, patients report poorer experiences of care in hospitals where more nursing care is left undone. Despite strong international evidence, there has been little research to explore missed nursing care in Australia, and no papers focusing specifically on missed nursing care in the cancer setting. The aims of this study were to (i) explore nurses’ perceptions of what care is missed in one haematology/oncology in-patient setting in Victoria, Australia, and (ii) to identify factors contributing to missed care. METHODS: This study employed an exploratory mixed-methods approach that included an on-line survey of nurses’ views of missed care and factors leading to missed care, a description of the environment of care during the data collection period, and focus groups to explore, in depth, factors nurses believe result in missed care. RESULTS: Survey data were collected from 17 of 50 eligible nurses (34%) working on a haematology/oncology ward over a three week period in September, 2015. During the data collection period, 103 patients were cared for on the ward. The most common areas of missed care reported were: talking to patients (n=15, 88.2%), developing and updating nursing care plans (n=13, 76.5%), and educating patients and family (n=11, 64.7%). Data from the focus groups indicated acute awareness of missed care and multiple factors leading to missed care were identified. These included staff skill mix, organisation of nursing work, and non-nursing duties that detracted from time with patients. During the focus groups, nurses described considerable discomfort at being unable to provide emotional care they wanted to deliver to patients and their families. They also talked about the inability to take care of themselves. CONCLUSION: This preliminary, exploratory study offers an insight into missed nursing care and its consequences on patients and nurses in one Australian cancer setting. Data reflect the findings of earlier international studies and indicated potentially modifiable factors for reduction of missed nursing care. Multi-site research is needed to further explore missed care in cancer settings to better understand and make recommendations for optimal environments of care, caring and staff wellbeing.
How do patients with lung cancer experience radiation induced oesophagitis?
Patients with lung cancer who receive radiotherapy to their chest may experience the specific treatment toxicity of radiation induced oesophagitis (RIO) if the oesophagus is included in the radiotherapy treatment field. RIO causes significant pain and distress to patients. There is a lack of evidence to guide appropriate management. There is also a lack of information on how patients experience this toxicity. This qualitative, exploratory study examined the experience of RIO described by patients with lung cancer who received RT to the chest, either alone or in combination with chemotherapy. The aims of this project were to: • identify the properties and characteristics of RIO as experienced by the patient having radiotherapy to the chest for lung cancer, • understand how these properties and characteristics change over time, • understand the patient experience of ongoing symptoms following completion of radiotherapy, • identify aspects of the RIO experience amenable to nursing interventions that will assist in the management of RIO and, • establish research questions to test specific nursing interventions for RIO. The Theory of Unpleasant Symptoms (TOUS) was chosen as the conceptual framework for the development of the semi-structured interviews and analysis. Two cohorts of patients were recruited to address the research questions used in this study. Cohort 1 consisted of patients who were actively receiving cancer treatment and experiencing RIO. This cohort provided insight into the experience of RIO in the acute setting, including onset and progression. Cohort 2 consisted of patients who completed treatment for primary lung cancer within the last six months and who experienced Grade 3 RIO at some stage during their treatment. Cohort 2 provided insight into the recovery trajectory following RIO, including long term changes. Semi-structured patient interviews were used to capture the patients experience and recovery of RIO. The interviews sought to identify the properties and characteristics of the pain and swallowing difficulties as described by all patients as well as other relevant features of the experience. Content analysis was used to analyse interview data. Four patient stories were chosen from the interviews to illustrate the overall experience of RIO and recovery as a means of providing context to the findings of this study. These vignettes illustrate the increasing impact on daily life as the severity of RIO increased. The extracted statements identified from the interviews were organised into the four central predetermined categories to describe the experience of RIO: (1) pain, (2) swallowing, (3) management and (4) the impact or bother of the experience of RIO. TOUS provided a framework to capture the symptom dimensions of quality, intensity, duration and associated distress of RIO for each of these categories as experienced by the patients. The patient statements extracted from the interviews were organised into four categories to describe the experience of recovery from Grade 3 RIO. The four categories were (1) memory of pain and swallowing difficulties, (2) time to recovery, (3) long term effects on swallowing and (4) advice for future patients. New knowledge of RIO gained from this study shows that experience changes across the trajectory of RIO, that pain and swallowing are inter-related and require combined therapeutic approaches and that while healing occurs, some swallowing difficulty can persist for some patients.
Effectiveness of Primary Health Care Services in New Zealand for Minority Refugee Populations: A Case Study of Bhutanese Refugee Women
A significant number of people have been displaced from their country of origin and become refugees, mostly due to armed conflicts, political violence and human rights abuse. Refugees’ traumatic past and uncertain future, together with complex health needs, present significant challenges for resettlement in their host country. Bhutanese refugees are Bhutanese citizens of Nepali origin. During 1991–1992, more than 100,000 Nepali- Bhutanese became refugees. After spending more than 18 years in refugee camps in Nepal, most of these refugees have now been resettled in various countries including New Zealand and Australia. The aim of this thesis is to examine the effectiveness of primary health care services in meeting the health needs of Bhutanese refugee women resettled in New Zealand. The conceptual framework of this study was guided by the globally accepted philosophy and principles underpinning the Declaration of Alma-Ata for Primary Health Care and the Ottawa Charter for Health Promotion. This qualitative exploratory study was conducted in two phases; the first phase comprised focus group discussions with 32 Bhutanese women and eight Bhutanese men; and the second phase involved individual interviews with 12 health service providers including four general practitioners, five nurses and three midwives. All focus groups with the Bhutanese sample were completed in Nepali, and were later transcribed in Nepali and translated to English. Phase one of the study revealed that resettlement in New Zealand had mixed impacts on Bhutanese women’s health. In general, there had been an improvement in physical health, however, their self-esteem and overall mental health status had deteriorated due to compounding stressors related to their traumatic refugee journey as well as resettlement challenges that they had been enduring. In addition, these women faced a number of barriers in accessing and utilising health services in New Zealand. In phase two of the study, health professionals identified common attributes of Bhutanese women that could impact positively or negatively in addressing their health needs and articulated a number of challenges and some enablers in addressing their health needs. Overall, the findings of this study have revealed that there have been inadequacies and constraints in the provision of culturally safe and effective primary health care services to Bhutanese refugee women and provide evidence for recommendations to address these inadequacies. These findings demonstrated that although New Zealand has had a powerful and enduring primary health care policy commitment, there are limitations in the implementation of this policy in practice. While this study was undertaken with one specific group of people, the results are likely to be transferrable to other minority refugee populations. It is anticipated that the results of this study will contribute in planning and implementing future strategies to better address the health needs of minority refugee populations in New Zealand.
An evaluation of violence risk screening at triage in one Australian emergency department
Background: There is an increasing focus in the published literature on the problem of patient violence in hospital emergency departments (ED). Patient violence negatively impacts staff safety and ultimately the quality of care provided to patients. Research and clinical practice guidelines indicate that the prevention of patient violence in hospital EDs requires a systematic process for identifying patients who are at risk; however the evidence supporting the implementation of risk screening processes in practice is limited. This research was conducted to evaluate the processes and outcomes of a violence risk screening decision support process at triage in one Australian ED. A decision support process for identifying patients at risk of becoming violent was developed and integrated into usual patient assessment practices at point of entry (triage). An evaluation of the risk screen process was then conducted to measure its influence on staff, patient, and organisational outcomes. Design : A mixed methods design incorporating both qualitative and quantitative approaches was utilised. Three studies were sequentially conducted to; explore the feasibility and need for a risk screening process, implement a brief risk screening process and evaluate its influence on the use of security and clinical responses to incidents of patent violence (Code Grey events). Setting: The study site was a level one trauma centre located in Melbourne, Australia. This ED has an annual census of 60,000 presentations with a 40% admission rate. Methods: Study One was conducted to explore the need for, and feasibility of, violence risk screening in practice. Semi-structured observations of triage nurses conducting routine patient assessments were made at the study site. In addition, a retrospective analysis of Code Grey responses matched with demographic and clinical information was performed to characterise the patients and situations in which Code Grey responses were activated. Patient and carer interviews were performed to explore the public perceptions and acceptability of violence risk screening at triage. In Study Two, the violence risk screening decision support process was developed and pilot tested. Levels of agreement between independent raters was determined using the risk screening process for a series of triage assessments. In Study Three, a before and after evaluation was conducted of the risk screening process for its influence on Code Grey responses and access to clinical care. Analysis of the predictive ability of the risk screening process including estimates of its sensitivity and specificity, likelihood ratios and predictive values were performed. Matched pair analysis compared triage nurse self-efficacy before and after the intervention. Results : In Study One structured observations of routine patient assessment at triage (N=167) found nurses used the existing triage process to identify at risk individuals. Based on their assessments the nurses identified a small number of patients requiring risk assessment (6%:10/167) This integrated approach to determining risk was observed to be used in all cases and deviated from standard operating procedure that recommended the use of pre-scripted questions. The 12-month retrospective review of Code Grey responses (N= 1959) identified a high risk group of patients who attended the ED on more than one occasion and required a Code Grey response for violence. Although this group represented 12% (105/857) of patients, they accounted for 32% (577/1796) of all Code Grey events audited. Of the 950 presentations requiring a Code Grey, 67% (639/950) were male, 66% (623/950) arrived by ambulance and 36% (350/950) were referred for a mental health assessment. Factors such as arriving escorted by police and requiring a mental health assessment significantly increased the risk of an individual having a Code Grey response while in the ED (OR=18.88; 95%CI=12.9,27.97; OR=11.68, 95%CI=9.13,14.94 respectively). Analysis of the Code Grey data showed that 25% (500/1959) of events occur at entry points to ED and 50% of a Code Grey responses occurred within the 77 minutes of arrival to the ED. Patient and carer interviews found there is a community expectation that patients at risk of violence are identified to allow an opportunity for prevention and improve safety (N=19). In Study Two, pilot testing of the risk screening process showed that triage nurses correctly identified 52% (122/233) of the patients who required a Code Grey response. Emergency department nurses (n=6) reviewed the triage notes for a sample (n=29) of patients not correctly identified at risk of violence. There was an acceptable level of agreement between triage nurses 69-82%, (kappa .25-.65). Of the 29 presentations of patients who required a Code Grey but were not identified at triage, 45% (13/29) did not have warning signs for violence at triage. In Study Three following the introduction of the violence risk screening decision support process, the proportion of Code Grey response at triage reduced from 29% before (258/904) to 22% after (200/897) implementation p<.001. The median duration of Code Grey events decreased from 14 to 13 minutes p<.009. The proportion of planned Code Greys increased from 52% (468/904) before to 62% after (556/897) p<.001. The sensitivity of the risk screening process was estimated at 56% and the specificity 97%. The total number of coercive interventions (physical restraint, medication given during the Code Grey and mechanical restraint) increased from 822 before to 1007 after p<.001. The median time from triage to first Code Grey increased from 71 minutes before (IQR=7-226) to 124 after (IQR=21-304) p<.001. Patients who required a Code Grey response were seen more quickly by medical staff (Median= 47, IQR=19-106) compared to baseline data (Median=51, IQR=14-114) p<.002. The revised violence risk screen resulted in ED nursing and medical staff being alerted to risk of violence by the electronic alert symbol for 61% (494/817) of Code Grey responses. Conclusion : On arrival to ED, the risk for violence was determined by the triage nurse using clinical judgement. This process was found to be feasible, acceptable to clinical staff, integrated into current triage processes, and reflected the public’s expectations of care. Communication of risk was facilitated using the existing clinical information system and normal work flow within the ED. High risk patient groups and locations were identified. Not all patients who require a Code Grey response were found to have observable warning signs at triage. Following the intervention there was an overall reduction in time staff engaged in emergency responses for aggression. Access to care was unchanged following the introduction of the risk screening; however the increase in the use of coercive practices following implementation of the risk screening process is of concern and warrants further exploration.
Development of a guideline to inform the content of a summarized patient information form regarding cancer clinical trials
Ethical review processes support the need to present comprehensive information to enable patients with cancer make informed decisions about whether or not to participate in a clinical trial. However, evidence indicates that patients do not always understand information given to them about the requirements and purpose of clinical trials, raising concerns about the status of consent given. Researchers have attempted to enhance patients’ understanding through implementation of diverse interventions, but these have had mixed outcomes. The thesis started with a systematic review to explore the efficacy of interventions developed to improve patient understanding of clinical trials. The findings of the systematic review suggested limited impact of the interventions on patient understanding. Likely reasons for the limited success were: 1) only a small element of the communication process was addressed by the studies; 2) studies lacked a theoretical framework; 3) studies lacked a detailed description of the intervention development process; 4) studies did not draw on evidence to inform the inclusion of essential information as part of interventions being tested to enable informed consent; and 5) studies lacked reliable and valid outcome measures to measure the impact of interventions on patients’ knowledge of trial purposes and requirements. This PhD set out to develop a guideline for health professionals to inform the creation of the Summarized Patient Information Forms (SPIFs); a document designed to complement the lengthy and often complex Participant Information and Consent Forms (PICFs) given to patients eligible for cancer clinical trials. The purpose of the PhD was to develop a resource to help address documented limitations in patients’ understanding of cancer clinical trial consent forms. Habermas’ Theory of Communicative Action (TCA) was chosen as the theoretical framework to inform the study design. In Stage I, a Delphi process was adopted to generate an exhaustive list of information regarded as important to support informed clinical trial participation and then to reduce this information, through a consensus process, to essential items for inclusion in a SPIF. The Delphi consensus process produced 14 statements regarded as essential information to be included in a SPIF. Stage II involved the development of a guideline for health professionals to inform the production of a SPIF to support patients’ understanding of cancer trial participation requirements during the informed consent process. The SPIF also has the potential to support patients to ask questions or voice concerns during the informed consent process as a result of providing information in an accessible and familiar language. This PhD has produced a robust guideline for health professionals with which to inform the development of a SPIF; a short and concise document as an adjunct to the full PICF to enhance the informed consent process. Once developed, a SPIF can be used to enhance communication of essential information between health professionals and patients. The SPIF has the potential to help professionals share information in an understandable way, to ensure patients understand what clinical trial participation involves and thus, address international concerns about the status of consent currently being achieved with patients recruited to cancer clinical trials.