Barriers and facilitators to opportunistic chronic kidney disease screening by general practice nurses.

AIM: Opportunistic screening in general practice (GP) is a cost-effective and viable approach to the early identification of chronic kidney disease (CKD). This study sought to identify the barriers and facilitators to CKD screening practices of GP nurses working in a regional area of New South Wales, Australia. METHODS: An eight-item elicitation questionnaire informed by the Theory of Planned Behaviour was administered to a convenience sample of 26 GP nurses. RESULTS: Participants identified that the advantages of CKD screening were its early detection and treatment, the reduction of disease burden, and the opportunity to increase awareness and provide disease prevention education. These positive attitudinal beliefs were offset by negative beliefs about the impost of opportunistic screening on nursing time, particularly when there were other competing clinical priorities. Participants reported that practice doctors were wary of the financial costs associated with additional non-claimable services and believed that unfunded services, regardless of patient benefit, were difficult to justify in a private business environment. Screening was enabled in GP settings with existing screening protocols or initiatives, and when patients presented with known risk factors. Barriers to screening were more frequently described and illustrated a strong focus on financial aspects of GP. Without reimbursement through the Medicare Benefits Scheme, screening was not considered an economical use of nursing time. Other competing and billable clinical services took precedence. CONCLUSION: The findings of this study can be used to inform the development and evaluation of interventions that target opportunistic CKD screening in the GP setting.

Home care packages: insights into the experiences of older people leading up to the introduction of consumer directed care in Australia.

This paper reports phase one, conducted from March to June 2015, of a two-phase, qualitative descriptive study designed to explore the perceptions and experiences of older people before and after the introduction of consumer directed care (CDC) to home care packages (HCP) in Australia. Eligible consumers with a local HCP provider were mailed information about the study. Data collection occurred before the introduction of CDC and included face-to-face, in-depth interviews, summaries of interviews, field notes and reflective journaling. Semi-structured questions and 'emotional touchpoints' relating to home care were used to guide the interview conversation. Line-by-line data analysis, where significant statements were highlighted and clustered to reveal emergent themes, was used. Five older people, aged 81 to 91 years, participated in the study. The four emergent themes were: seeking quality and reciprocity in carer relationships; patchworking services; the waiting game; and technology with utility. Continuity of carers was central to the development of a trusting relationship and perceptions of care quality among older consumers. Care coordinators and workers should play a key role in ensuring older people receive timely information about CDC and their rights and responsibilities. Participants' use of contemporary technologies suggests opportunities to improve engagement of HCP clients in CDC.

Mum's absence(s): conceptual insights into absence as loss during a loved one's delirium.

AIMS AND OBJECTIVES: To examine qualitative research findings about family experiences of absence or loss during older person delirium, and provide a critical discussion of the similarities and differences in these experiences with conceptual understandings of absence and loss. BACKGROUND: Families who care for older people with chronic illnesses experience many losses. However, the nondeath loss experiences of family during an older loved one's delirium, an acute condition accompanied by marked changes in demeanour, have received little consideration. DESIGN: Discursive position paper. METHODS: The findings from two qualitative research studies about family experiences during an older loved one's delirium are discussed in relation to the concepts of absence and nondeath loss. RESULTS: The uncharacteristic behaviours and cognitive changes that accompany delirium may estrange family who, despite the older person's corporeal presence, sense the profound absence or loss of their loved one. Although the notion of absence, a nondeath loss, is similar to the experiences of family of people with chronic conditions, there are differences that distinguish these encounters. The similarities and differences between absence during delirium and the concepts of psychological absence, nonfinite loss and psychosocial death are discussed. Psychosocial death, reversibility/irreversibility and partial marked change, are suggested as conceptual descriptions for the absence families experience during an older loved one's delirium. CONCLUSIONS: The sense of absence or loss that family may experience during their older loved one's delirium needs to be recognised, understood and addressed by healthcare staff. Understanding or appreciating conceptualisations of absence, as a nondeath loss, may enhance understandings of family member needs during delirium and enable better support strategies. RELEVANCE TO CLINICAL PRACTICE: Conceptualisations of absence enhance understandings of family distress and needs during their older loved one's delirium. The potential for family members to experience their loved one's absence during delirium, a nondeath loss, needs to be considered by healthcare staff. Family experiences of absence during delirium need to be recognised by healthcare staff, acknowledged as a potential source of distress, and considered when involving family in the older person's care. Nurses are ideally placed to respond compassionately and provide appropriate family member re-assurance, support and information during delirium. Information should include possible impacts on family and coping strategies.

Reflexivity and exploring the meaning of delirium through media depictions: Methodological insights from a phenomenological study.

In the course of a phenomenological study that explored the experiences of family members during their older loved one's delirium, a range of delirium experiences depicted in artistic, creative, and linguistic media were reviewed. The search for, and compilation of, media sources for reflection during data analysis is described in this paper. In doing so, the researcher reveals how attentiveness and openness to varied depictions of lived experiences, as well as a valuing attitude toward challenging subjective perspectives, can enhance researcher reflexivity and appreciation of interpretive meanings. Turning to media depictions of delirium offered alternative perspectives on the experience. It challenged the researcher's assumptions, enhanced phenomenological reflection, promoted critique of evolving interpretations, and suggested meanings that might not have otherwise been realized. The approach used is a potent, although often overlooked, way to differentiate the nature of phenomena shared through lived experience data. Media-based methods and their use in phenomenology continue to be explored. Illustrations of how to integrate media sources, as well as discussion about the benefits and alternatives to more common uses, are needed.

Adult family member experiences during an older loved one's delirium: a narrative literature review.

AIMS AND OBJECTIVES: To provide a narrative literature review about family experiences during older person delirium. BACKGROUND: Delirium is a common and serious condition which manifests when older people are unwell. Family members of older people are likely to encounter their loved one and become involved in care during delirium. DESIGN: Narrative literature review. METHODS: Electronic database and Google Scholar(™) searches were conducted using search terms for delirium, family, experience and older people. RESULTS: Though family members are important partners in the care of older people, there has been little exploration of their experiences during delirium. Current literature identifies that family members experience unexpected, rapid and unpredictable changes in their older loved one, absence of the person they know, distress, not knowing about delirium nor how to help, and supportive and unsupportive relationships with health care staff. CONCLUSIONS: Health care staff need understanding about what it means for family to have someone close to them have delirium. Without understanding, it is difficult for staff to respond with compassion, provide support and appropriately include family in the older person's care. There is a need to mitigate family distress and provide support, including information which addresses family concerns. RELEVANCE TO CLINICAL PRACTICE: The distress family members experience, the impact of losing connection to their loved one, and the difficulty family face in sustaining hope for their loved one's return needs to be recognised and addressed by health care staff, particularly nurses, during the older person's care.

Existential Absence: The Lived Experience of Family Members During Their Older Loved One's Delirium.

When older people develop delirium, their demeanor changes; they often behave in ways that are out of character and seem to inhabit another world. Despite this, little is known about the experiences of family members who are with their older loved one at this time. This article reports a phenomenological study that involved in-depth interviews with 14 women whose older loved one had delirium. Analysis and interpretation of the data depict the women's experiences as "Changing family portraits: Sudden existential absence during delirium," capturing the way family members lose the taken-for-granted presence of their familiar older loved one and confront a stranger during delirium.

Orientation strategies during delirium: are they helpful?

AIM: This paper critiques literature that reports older person experiences of orientation strategies in relation to current recommendations for the management of older person delirium and makes recommendations for future research. BACKGROUND: Delirium is a common syndrome in hospitalised older people and a difficult syndrome for health care staff to manage. During delirium, older people describe experiencing altered states of reality and use of orientation strategies as part of their care. Orientation, a non-pharmacological approach to the management of delirium, is recommended as a care strategy in evidence-based guidelines and protocols. METHOD: Discursive paper. DISCUSSION: This paper considers published research into the experiences of hospitalised older people during an episode of delirium and questions the appropriateness of orientation strategies. How care strategies are experienced by older people is emphasised. An approach to care which is a flexible balance of reality orientation and validation therapy, synchronised with the changing reality and reactions of the older person, is identified as a care recommendation from research. CONCLUSION: When delirium is experienced during hospitalisation, health care staff have a responsibility to provide care that is person-centred and sensitive to the older person's needs. It has been assumed that no harm comes from the use of orientation approaches, and delirium management guidelines have recommended this approach. However, orientation strategies can lead to mistrust of, and distancing from, health care staff and family, so impeding their relationships with carers. Care practices that consider the older person to be unique and that synchronise with the older person's changing experiences of reality are suggested for further research. RELEVANCE TO CLINICAL PRACTICE: Caring for an older person in delirium is challenging for health care staff. Reconsideration of, and research into, care strategies during delirium has the potential to improve the quality of care for hospitalised older people.

Experiences of older people following the introduction of consumer-directed care to home care packages: A qualitative descriptive study.

OBJECTIVE: To explore the experiences of older people receiving home care package (HCP) support following the introduction of consumer-directed care (CDC) by the Australian government on 1 July 2015. METHODS: Thirty-one older people with existing HCP support from two service providers in regional New South Wales, Australia, participated in a face-to-face interview and/or a qualitative survey. RESULTS: Analysis revealed the theme of Choices: Preferences, constraints, balancing and choosing. Participants described choosing to live at home with HCP support; however, they were constrained by poor communication and information about service changes and options, personal budgets and access to future care. HCP services remained largely unchanged during transition to CDC. CONCLUSION: Many aspects of the initial implementation of CDC were challenging for older people. Clear, relevant and timely communication and information about CDC and its consequences for consumers appear to be needed to enhance CDC.

PP2A-B' holoenzyme substrate recognition, regulation and role in cytokinesis.

Protein phosphatase 2A (PP2A) is a major Ser/Thr phosphatase; it forms diverse heterotrimeric holoenzymes that counteract kinase actions. Using a peptidome that tiles the disordered regions of the human proteome, we identified proteins containing [LMFI]xx[ILV]xEx motifs that serve as interaction sites for B'-family PP2A regulatory subunits and holoenzymes. The B'-binding motifs have important roles in substrate recognition and in competitive inhibition of substrate binding. With more than 100 novel ligands identified, we confirmed that the recently identified LxxIxEx B'α-binding motifs serve as common binding sites for B' subunits with minor variations, and that S/T phosphorylation or D/E residues at positions 2, 7, 8 and 9 of the motifs reinforce interactions. Hundreds of proteins in the human proteome harbor intrinsic or phosphorylation-responsive B'-interaction motifs, and localize at distinct cellular organelles, such as midbody, predicting kinase-facilitated recruitment of PP2A-B' holoenzymes for tight spatiotemporal control of phosphorylation at mitosis and cytokinesis. Moroever, Polo-like kinase 1-mediated phosphorylation of Cyk4/RACGAP1, a centralspindlin component at the midbody, facilitates binding of both RhoA guanine nucleotide exchange factor (epithelial cell transforming sequence 2 (Ect2)) and PP2A-B' that in turn dephosphorylates Cyk4 and disrupts Ect2 binding. This feedback signaling loop precisely controls RhoA activation and specifies a restricted region for cleavage furrow ingression. Our results provide a framework for further investigation of diverse signaling circuits formed by PP2A-B' holoenzymes in various cellular processes.

Predicting runoff-induced pesticide input in agricultural sub-catchment surface waters: linking catchment variables and contamination.

An urgent need exists for applicable methods to predict areas at risk of pesticide contamination within agricultural catchments. As such, an attempt was made to predict and validate contamination in nine separate sub-catchments of the Lourens River, South Africa, through use of a geographic information system (GIS)-based runoff model, which incorporates geographical catchment variables and physicochemical characteristics of applied pesticides. We compared the results of the prediction with measured contamination in water and suspended sediment samples collected during runoff conditions in tributaries discharging these sub-catchments. The most common insecticides applied and detected in the catchment over a 3-year sampling period were azinphos-methyl (AZP), chlorpyrifos (CPF) and endosulfan (END). AZP was predominantly found in water samples, while CPF and END were detected at higher levels in the suspended particle samples. We found positive (p < 0.002) correlations between the predicted average loss and the concentrations of the three insecticides both in water and suspended sediments (r between 0.87 and 0.94). Two sites in the sub-catchment were identified as posing the greatest risk to the Lourens River mainstream. It is assumed that lack of buffer strips, presence of erosion rills and high slopes are the main variables responsible for the high contamination at these sites. We conclude that this approach to predict runoff-related surface water contamination may serve as a powerful tool for risk assessment and management in South African orchard areas.

Wetlands in changed landscapes: the influence of habitat transformation on the physico-chemistry of temporary depression wetlands.

Temporary wetlands dominate the wet season landscape of temperate, semi-arid and arid regions, yet, other than their direct loss to development and agriculture, little information exists on how remaining wetlands have been altered by anthropogenic conversion of surrounding landscapes. This study investigates relationships between the extent and type of habitat transformation around temporary wetlands and their water column physico-chemical characteristics. A set of 90 isolated depression wetlands (seasonally inundated) occurring on coastal plains of the south-western Cape mediterranean-climate region of South Africa was sampled during the winter/spring wet season of 2007. Wetlands were sampled across habitat transformation gradients according to the areal cover of agriculture, urban development and alien invasive vegetation within 100 and 500 m radii of each wetland edge. We hypothesized that the principal drivers of physico-chemical conditions in these wetlands (e.g. soil properties, basin morphology) are altered by habitat transformation. Multivariate multiple regression analyses (distance-based Redundancy Analysis) indicated significant associations between wetland physico-chemistry and habitat transformation (overall transformation within 100 and 500 m, alien vegetation cover within 100 and 500 m, urban cover within 100 m); although for significant regressions the amount of variation explained was very low (range: ∼2 to ∼5.5%), relative to that explained by purely spatio-temporal factors (range: ∼35.5 to ∼43%). The nature of the relationships between each type of transformation in the landscape and individual physico-chemical variables in wetlands were further explored with univariate multiple regressions. Results suggest that conservation of relatively narrow (∼100 m) buffer strips around temporary wetlands is likely to be effective in the maintenance of natural conditions in terms of physico-chemical water quality.

The process of practice redesign in delirium care for hospitalised older people: a participatory action research study.

BACKGROUND: In 2007 three researchers completed a 6-month study in one 32-bed acute care medical ward in a large hospital in New South Wales, Australia. The problem drawn to the attention of researchers was that approximately 60% of older people were delirious on arrival or develop incident delirium during their hospital stay. Lack of recognition, underreporting and inadequate care responses to delirium in hospitalised older people signalled a major practice problem. AIM: To collaboratively explore ways in which clinical practice could be improved. METHOD: We selected Participatory Action Research (PAR) as the methodology to involve health practitioners in practice redesign. PAR is a process in which 'we', researchers and participants, systematically work together in cycles of 'looking, thinking and acting'. Delirium and the high percentage of older people who succumb to this condition was the main practice problem requiring a response. Eight volunteer clinicians and three researchers met weekly as a group for 13 sessions over 6 months. Clinicians set the agenda for redesign of practice. Raising awareness about delirium and its prevention were the selected action strategies. A delirium alert protocol was developed for implementation by the clinicians and later evaluation as a separate study. FINDINGS: There was evidence that practice had changed. Physical and chemical restraints had not been used for 3 months subsequent to the study's completion. The nurse manager reported that early detection strategies had prevented episodes of acute hyperactive delirium. Whilst there continued to be older people admitted with a diagnosis of delirium, there were fewer incidences of delirium developing on the ward and there was less disruption to other patients, especially at night. The strategy of raising the awareness of delirium in older people was successful. We are confident that working collaboratively with practitioners is the way to bring evidence to practice in delirium care for older people in acute care settings.

Delirium and older people: what are the constraints to best practice in acute care?

An Australian research team conducted a six-month acute care pilot study in a medical ward of a large hospital in New South Wales. Aim. To explore ways health practitioners might redesign their practice to include prevention, early detection and management of delirium in older people based on the best current practice. Method and design. Participatory action research (PAR) was selected as the best approach for involving ward staff to make sustainable clinical practice decisions. The PAR group comprised research academics and eight clinicians from the ward. Thirteen PAR sessions were held over 5 months. Clinicians described care of patients with delirium. Stories were analysed to identify constraints to best practice. Following PAR group debate about concerns and issues, there were actions toward improved practice taken by clinicians. Relevance to clinical practice. The following constraints to best practice were identified: delayed transfer of patients from the Emergency Department; routine ward activities were not conducive to provision of rest and sleep; assisting with the patient's orientation was not possible as relatives were not able to accompany and/or stay with the older patient. Underreporting of delirium and attributing confusion to dementia was viewed as an education deficit across disciplines. A wide range of assessment skills was identified as prerequisites for working in this acute care ward, with older people and delirium. Clinicians perceived that management driven by length of a patient's stay was incongruent with best practice delirium care which required more time for older patients to recover from delirium. Two significant actions towards practice improvement were undertaken by this PAR group: (i) development of a draft delirium alert prevention protocol and (ii) a separate section of the ward became a dedicated space for the care of patients with delirium. A larger study is being planned across a variety of settings.

Patients' understanding and participation in a trial designed to improve the management of anti-psychotic medication: a qualitative study.

BACKGROUND: Combining qualitative methods alongside randomised controlled trials in the health field has been advocated but has only been used rarely in mental health services research. The aim of this study was to illuminate patients' understanding of the nature and purpose and outcomes of a trial designed to improve the management of neuroleptic medication. METHODS: Qualitative interviews were carried out with a group of patients participating in a trial comparing a psycho-educational and therapeutic alliance intervention in managing anti-psychotic medication. RESULTS: Our findings highlighted aspects of the experience, process and outcome of the trial, which remain latent in the quantitative assessment. The issue of enlarged selfefficacy emerging when patients were involved in communications with professionals in the trial was important. Whilst the participants provided positive feedback about their involvement in the trial, they struggled to recall the details of the intervention to which they had been exposed. Patients did not readily identify the content and concepts characterising each condition; rather they prioritised the opportunity for communication and contact with the researchers. CONCLUSIONS: Qualitative research accompanying trials illuminates and adds to the quantitative outcomes. The key to interpreting participants' accounts of the process and outcomes of this trial suggests the need to give greater emphasis to participants' past and current experience of service contact.