Improving management of fever in neutropenic children with cancer across multiple sites.

OBJECTIVE: To evaluate the effectiveness of a clinical pathway in achieving antibiotic administration in less than 60 minutes for children with cancer, presenting with fever and neutropenia. Secondary objectives were to determine association between time to antibiotics (TTA) and other variables including fever duration, location of care and intravenous access types. METHODS: Following introduction of the clinical pathway, we collected prospective data about management of all cases that did and did not use the pathway across multiple sites over 16 months. A follow-up audit was conducted after 12 months. RESULTS: We evaluated a total of 453 presentations. Use of the clinical pathway was significantly associated with achieving TTA in less than 60 minutes (RR 0.69, 95% CI 0.56-0.85, p = <0.001). Despite varying use of the pathway over time, the median time to antibiotics was achieved in both the initial study period (57 minutes) and sustained at follow-up (60 minutes). TTA was also associated with types of intravenous access device and location of care and with length of stay. We did not find any association between TTA and any other variables. CONCLUSION: Clinical pathways improve fever management in this patient cohort. Ongoing education and auditing to identify factors which impact processes of care are necessary.

Student evaluations of teaching (SET): implications for medical education in psychiatry and an approach to evaluating SET and student performance.

OBJECTIVE: We present reflections on student evaluation of teaching (SET) in the context of recent higher educational research that assesses SET, as well as concurrent and/or subsequent student performance. CONCLUSIONS: In a sense, there is in-built cynicism in SET, with more favourable SET for easier assessment. There is emerging evidence that SET is inversely proportional to the performance of students in subsequent courses, i.e. the higher the ratings, the poorer the students perform in subsequent studies. It is proposed that SET should be combined with contemporaneous formative and summative assessments of student performance in medical school settings, especially in psychiatry education.

A systematic review of the approaches to multi-level learning in the general practice context, using a realist synthesis approach: BEME Guide No. 55.

Background: Recent global increases in medical student numbers and shifts in medical education from teaching hospitals to community settings call for effective strategies to meet the demand for general practice teaching placements. It has been proposed that "multi-level learning" (MLL), in which learning and teaching are shared across different levels of learners, may provide teaching efficiencies and valuable experiences for learners and teachers. Aims: To identify, evaluate and synthesize the evidence related to the types, benefits, challenges, and facilitators of MLL in community-based general practice, and the underlying mechanisms and associated contexts to explain the reported outcomes. Method: A realist synthesis approach guided the systematic review. Results: Fifteen papers were identified, providing primary evaluation data predominantly from interviews with or surveys of key stakeholders. Generally, all levels of learners reported overall satisfaction with their MLL experiences. Medical students appreciated learning from prevocational doctors and registrars due to social and cognitive congruence. Mechanisms and contexts that supported our hypotheses regarding successful MLL outcomes were identified, with "a strong teaching culture" being a major mechanism. Conclusions: The findings can help inform practices considering the implementation or enhancement of MLL initiatives in general practice. Further research should include measuring defined learning outcomes.

A self-report of the Healer's art by junior doctors: does the course have a lasting influence on personal experience of humanism, self-nurturing skills and medical counterculture?

BACKGROUND: Healer's Art (HA) is a voluntary course offered during medical school. The course aims to address the growing loss of meaning and commitment experienced by doctors through the exploration of compassion, empathy and awe in medicine, and early exposure to a supportive community of practice. This project aimed to evaluate the potential influence of HA on junior doctor graduates. METHODS: Junior doctors who had undertaken HA during their medical studies were interviewed. A thematic analysis was performed on the results of these semi-structured interviews. RESULTS: Ten junior doctors who had undertaken the HA course participated in interviews. All interviewees described the HA as a positive and enlightening experience in their medical education. The thematic analysis identified four major themes: developing empathy in the doctor-patient journey, self-care and self-awareness, the creation of a supportive community, and coping with the challenging medical culture. CONCLUSIONS: HA provides experiential learning that enables participants to explore humanistic medicine. Self-selected junior doctors recall the course as a positive experience, and perceive themselves to be continuing to employ the techniques from HA in the healthcare setting. The concepts taught in the HA course appear to have a lasting personal impact on some junior doctors, who identify the course as influencing their self-reported positive patient-doctor relationships and supportive relationships with medical peers.

The "Golden Angels": effects of trained volunteers on specialling and readmission rates for people with dementia and delirium in rural hospitals.

ABSTRACTObjectives:Evaluate the clinical outcomes for patients with dementia, delirium, or at risk for delirium supported by the person-centered volunteer program in rural acute hospitals. DESIGN: A non-randomized, controlled trial. PARTICIPANTS: Older adults admitted to seven acute hospitals in rural Australia. Intervention (n = 270) patients were >65 years with a diagnosis of dementia or delirium or had risk factors for delirium and received volunteer services. Control (n = 188) patients were admitted to the same hospital 12 months prior to the volunteer program and would have met eligibility criteria for the volunteer program, had it existed. INTERVENTION: Trained volunteers provided 1:1 person-centered care with a focus on nutrition and hydration support, hearing and visual aids, activities, and orientation. MEASURES: Medical record audits provided data on volunteer visits, diagnoses, length of stay (LOS), behavioral incidents, readmission, specialling, mortality, admission to residential care, falls, pressure ulcers, and medication use. RESULTS: Across all sites, there was a significant reduction in rates of 1:1 specialling and 28 day readmission for patients receiving the volunteer intervention. LOS was significantly shorter for the control group. There were no differences in other patient outcomes for the intervention and control groups. CONCLUSION: The volunteer intervention is a safe, effective, and replicable way to support older acute patients with dementia, delirium, or risk factors for delirium in rural hospitals. Further papers will report on cost effectiveness, family carer, volunteer, and staff experiences of the program.

Between SET and ASP: balancing the scales of student evaluation of teaching (SET) and teachers' assessments of student performance (ASP) for medical school education in psychiatry.

OBJECTIVES:: We explore the relative roles of student evaluation of teaching (SET) and teachers' assessment of student performance (ASP) in medical school education in psychiatry. CONCLUSIONS:: We conclude that SET and ASP need to be better researched as outcome measures, and input from both processes needs to be balanced in evaluating psychiatric medical education.

Help-seeking intentions for anxiety among older adults.

Mental health practices are not working for older people with anxiety in residential care, as there is a persistent lack of recognition and treatment. This suggests that alternative ways of reaching and meeting the needs of this population need to be explored. One possibility involves enabling older adults themselves to seek help. The current work explored various factors impacting on help-seeking behaviours. In total, 105 participants from independent living units in a residential care setting completed a questionnaire focusing on attitudes and stigma towards anxiety, likelihood to seek help, help-seeking barriers and literacy around the symptoms of anxiety. Participants in the main did not hold negative attitudes towards other people with anxiety, despite concerns that other people could view them negatively if they were experiencing anxiety. Barriers to help-seeking included: difficulties recognising physical anxiety symptoms as being indicative of anxiety; the effectiveness of treatments; costs; misdiagnosis; privacy; medication usage and the associated side-effects; and, uneasiness about the skills and knowledge of health professionals. Although concerns were not held by all participants, the fact remains that anxiety is largely undiagnosed and untreated for this population and these stoppages to appropriate care must be addressed.

Gfap-positive radial glial cells are an essential progenitor population for later-born neurons and glia in the zebrafish spinal cord.

Radial glial cells are presumptive neural stem cells (NSCs) in the developing nervous system. The direct requirement of radial glia for the generation of a diverse array of neuronal and glial subtypes, however, has not been tested. We employed two novel transgenic zebrafish lines and endogenous markers of NSCs and radial glia to show for the first time that radial glia are essential for neurogenesis during development. By using the gfap promoter to drive expression of nuclear localized mCherry we discerned two distinct radial glial-derived cell types: a major nestin+/Sox2+ subtype with strong gfap promoter activity and a minor Sox2+ subtype lacking this activity. Fate mapping studies in this line indicate that gfap+ radial glia generate later-born CoSA interneurons, secondary motorneurons, and oligodendroglia. In another transgenic line using the gfap promoter-driven expression of the nitroreductase enzyme, we induced cell autonomous ablation of gfap+ radial glia and observed a reduction in their specific derived lineages, but not Blbp+ and Sox2+/gfap-negative NSCs, which were retained and expanded at later larval stages. Moreover, we provide evidence supporting classical roles of radial glial in axon patterning, blood-brain barrier formation, and locomotion. Our results suggest that gfap+ radial glia represent the major NSC during late neurogenesis for specific lineages, and possess diverse roles to sustain the structure and function of the spinal cord. These new tools will both corroborate the predicted roles of astroglia and reveal novel roles related to development, physiology, and regeneration in the vertebrate nervous system. GLIA 2016;64:1170-1189.

Do interventions with staff in long-term residential facilities improve quality of care or quality for life people with dementia? A systematic review of the evidence.

BACKGROUND: Common sense suggests and research indicates relationships between staff factors in residential dementia care and quality of life (QOL) for residents, with poor care increasing suffering. However, we do not have a coherent picture of which staff interventions have an impact on quality of care (QOC) or resident QOL. METHODS: A comprehensive search of 20 years' peer-reviewed literature using Medline, PsycINFO, Embase, PubMed, CINAHL, and the Cochrane, Campbell Collaboration identified 4,760 studies meriting full text review. Forty-six met the inclusion criteria, namely interventions in long-term facilities helping staff develop their capacity to provide better care and/or QOL for residents with dementia. Thirty-five other papers comprised an associated predictor review. RESULTS: Conclusions from these limited data are further compromised because nine studies failed to measure effects on residents and only half assessed effects after the project team withdrew. Of these, excellent studies produced change over the medium (3-4 months) or longer term, including reduction in challenging behavior and restraint use but this applied only to a minority. A number of studies failed to measure effects on QOC, limiting conclusions about mechanisms underlying change. CONCLUSION: In general, level of intervention required depended on the target. For outcomes like restraint use, structured education sessions with some support appear adequate. Programs to reduce pain require more support. For complicated issues like challenging behavior and increasing co-operation in showering, detailed, supportive, on-site interventions are required. Improvements in restraint and staff/resident interactions were the most promising findings. (Review registration number: PROSPERO 2014:CRD42014015224).

How do staff influence the quality of long-term dementia care and the lives of residents? A systematic review of the evidence.

BACKGROUND: Research suggests and common sense indicates that there are relationships between staff variables in residential dementia care and the quality of life (QOL) of residents, with poor care due to staff factors increasing resident suffering. Despite these indications, we do not have a coherent picture of these relationships, which variables are important, and where to intervene in order to minimize suffering for people with dementia. METHODS: This systematic review examined associations between staff variables, quality of care (QOC), and QOL for residents, using published peer-reviewed literature from the last 20 years. A comprehensive search was conducted using an exhaustive list of search terms, leading to the identification of 33,204 unique papers, which was reduced to 35 on-topic papers. RESULTS: In the main, we were able to provide collective evidence to suggest there are relationships between potentially adjustable staff variables and QOC on to QOL. When staff treat and interact empathetically and humanely in care, there is a relationship with better mood for residents, delayed functional dependence and better food intake. Where staff are more skilled and educated, there is less psychotropic medication use. Unlimited empathy about the risk of residents falling or being in pain is not enough; staff need to know about the dangers of restraint. CONCLUSIONS: Confidence in these indicative links is weakened by a lack of high-quality prospective longitudinal studies focusing on potentially adjustable staff variables, with a bias towards cross-sectional studies including only variables that are fixed or unlikely to change. (Review registration no. PROSPERO 2014:CRD42014015224).

General practice trainees face practice ownership with fear.

Objectives The aim of the present secondary analysis of data collected in a grounded theory study was to explore the perceptions of Registrars and new Fellows to practice ownership and management. Methods Focus groups and interviews with Registrars and recent Fellows were undertaken to explore the desire to become an owner, facilitators and barriers to practice ownership and delivery models for practice ownership education. A secondary thematic analysis was conducted to understand emerging concepts related to perceptions of general practice ownership. Results A surprisingly strong theme of fear was evident across focus group and interview participants. Expressed fear was specifically related to financial concerns, lack of relevant knowledge and skills and concern over balancing different roles. Moderating factors included previous life and educational experiences, as well as role modelling. Conclusions Graduation of a cohort of new general practitioners (GPs) who express fear towards practice ownership is concerning. Creating more positive learning environments and opportunity for open discussion regarding practice management and ownership is an important step in providing adequate support for new GPs to give serious consideration to career options. What is known about the topic? The traditional model of general practice ownership has been for a doctor to own and/or manage the practice. Fewer new GPs are taking on the role of owning a general practice, and disinterest has been presumed to play a significant role in this trend. It has been reported that current curricula provide insufficient focus on providing learning opportunities for general practice trainees on ownership and management models; however, recent research has shown that general practice trainees have a strong interest in receiving this knowledge during their training. What does this paper add? The present qualitative research evaluated the emotional response that general practice trainees (Registrars) expressed when they considered practice ownership. GP Registrars expressed fear when asked about the prospect of owning their own practice. This may be influenced by the role modelling they receive during their training. What are the implications for practitioners? Supervisors involved in general practice training should ensure their trainees have the opportunity to learn about practice ownership during their training. Supervisors should also be aware that their own behaviour and attitudes towards practice ownership is observed by their trainees and it can colour the emotional response the trainee has when considering owning a practice.

Volunteers improving person-centred dementia and delirium care in a rural Australian hospital.

INTRODUCTION: The aim of the present study was to address the challenges faced by staff in an acute rural hospital in Australia when providing person-centred care for patients with dementia and/or delirium. This was done by training volunteers to provide personal support to these patients, then measuring the outcomes of this intervention. METHODS: Volunteers were given training, then allocated patients with dementia/delirium or at risk of delirium. A quasi-experimental pre-post design assessed outcomes of the intervention. Quantitative measures were clinical outcome data for the 64 patients who passed through the program; questionnaire data related to the stress and attitudes of the 18 participating nurses; and attitudes, knowledge and confidence of the 18 volunteers. Qualitative measures assessed acceptability and feasibility of the intervention to staff and volunteers. RESUTLS: There was a significant reduction over time in length of stay for patients, and an increase in the use of analgesic medications. Only one patient fell while volunteers were on duty. There were no effects on the stress of nursing staff or their attitudes to dementia. Volunteers gained significantly in confidence and attitudes to dementia. The program was highly acceptable, with 96% of staff and 100% of volunteers perceiving the program as beneficial for patients, staff and volunteers. The program has continued and is now being expanded to other rural sites. CONCLUSIONS: It is feasible to introduce and then sustain a relatively inexpensive program to improve quality of care for people with dementia and/or delirium in an acute rural hospital. Reasons for the program's effectiveness are canvassed in the paper, but further research is needed to investigate the effectiveness of a similar program in urban hospitals.

The Development of the strain in dementia care scale (SDCS).

BACKGROUND: Though many staff gain satisfaction from working with people with dementia in residential facilities, they also experience significant stress. This is a serious issue because this in turn can affect the quality of care. There is, however, a lack of instruments to measure staff strain in the dementia-specific residential care environment, and the aim of this study, accordingly, was to develop the "Strain in Dementia Care Scale." METHODS: The instrument was developed in three steps. In the first step, items were derived from six focus group discussions with 35 nurses in the United Kingdom, Australia, and Sweden concerning their experience of strain. In the second step, a preliminary 64-item scale was distributed to 927 dementia care staff in Australia and Sweden, which, based on exploratory factor analysis, resulted in a 29-item scale. In the final step, the 29-item scale was distributed to a new sample of 346 staff in Sweden, and the results were subjected to confirmatory factor analysis. RESULTS: The final scale comprised the following 27 items producing a five-factor solution: Frustrated empathy; difficulties understanding and interpreting; balancing competing needs; balancing emotional involvement; and lack of recognition. CONCLUSIONS: The scale can be used (a) as an outcome measurement in residential care intervention studies; (b) to help residential facilities identify interventions needed to improve staff well-being, and, by extension, those they care for; and

Beyond prevalence to process: the role of self and identity in medical student well-being.

CONTEXT: Problematic stress levels among medical students have been well established. This stress can lead to depression, suicidal ideation, substance abuse, burnout and cynicism, having a negative effect on students and their patients. METHODS: We propose to move towards examining the processes underlying well-being in some medical students and vulnerability in others. We draw upon social psychological literature to propose that self-complexity, medical student identity and associated norms all have the capacity to influence medical students' well-being in both positive and negative ways. RESULTS: We identify two key dilemmas facing medical students with regard to the social psychological factors investigated. First, a diverse set of interests and a high level of self-complexity is thought to buffer against the effects of stress and might also be beneficial for medical practitioners, but the intensive nature of medical education makes it difficult for students to pursue outside interests, leading to a strongly focused identity. Second, a strong group identity is associated with high levels of social support and improved well-being, but unhealthy group norms may have a greater influence on individuals who have a strong group identity, encouraging them to engage in behaviours that place their well-being at risk. A model is proposed outlining how these potentially contradictory social psychological processes may combine to impact upon medical students' well-being. CONCLUSIONS: There is great scope for investigating the role of self-complexity, identity and norms in the medical education context, with room to investigate each of these factors alone and in combination. We highlight how our proposed model can inform medical educators as to the students who may be most vulnerable to the effects of stress and the potential interventions from which they may benefit. We conclude that social psychological factors make a valuable contribution to understanding the complex issue of well-being in medical education.

Looking beyond personal stressors: an examination of how academic stressors contribute to depression in Australian graduate medical students.

BACKGROUND: Medical school is a challenging environment that requires students to deal effectively with stress borne out of the medical education environment, as well as their personal lives. Previous research has not systemically distinguished between academic and personal sources of stress, and in particular has not explored the independent contribution that academic stressors make to medical student depression. PURPOSES: This study aimed to investigate whether academic stressors make a unique contribution to the level of depressive symptoms in medical students, over and above the contribution made by personal stressors alone. METHODS: Sixty-seven medical students completed an online questionnaire designed to measure the total number of recent life events (personal and academic), and their perceived impact, using a modified version of the Psychiatric Epidemiology Research Interview Life Events Scale. Depressive symptoms were measured using the Centre for Epidemiological Studies Depression Scale. RESULTS: Both the total number of personal stressors, r(67) = .363, p = .003, and their perceived impact, r(67) = .412, p = .001, were found to be positively related to depressive symptoms. A positive relationship was also observed between depressive symptoms and the total number of academic stressors, r(67) = .321, p = .008, and their perceived impact, r(67) = .489, p < .001. In addition, it was found that the perceived impact of academic stressors was able to explain higher levels of depressive symptoms in medical students over and above the effect afforded by personal stressors alone. CONCLUSION: The findings of this study suggest that stress borne out of the medical school environment contributes to depressive symptoms in medical students over and above the contribution made by personal stressors alone. This indicates that although it is important to help students cope with stress borne out of their personal lives, interventions by medical schools aimed at reducing the impact of academic stressors on medical student depression may also be of great importance.

The learner's perspective in GP teaching practices with multi-level learners: a qualitative study.

BACKGROUND: Medical students, junior hospital doctors on rotation and general practice (GP) registrars are undertaking their training in clinical general practices in increasing numbers in Australia. Some practices have four levels of learner. This study aimed to explore how multi-level teaching (also called vertical integration of GP education and training) is occurring in clinical general practice and the impact of such teaching on the learner. METHODS: A qualitative research methodology was used with face-to-face, semi-structured interviews of medical students, junior hospital doctors, GP registrars and GP teachers in eight training practices in the region that taught all levels of learners. Interviews were audio-recorded and transcribed. Qualitative analysis was conducted using thematic analysis techniques aided by the use of the software package N-Vivo 9. Primary themes were identified and categorised by the co-investigators. RESULTS: 52 interviews were completed and analysed. Themes were identified relating to both the practice learning environment and teaching methods used.A practice environment where there is a strong teaching culture, enjoyment of learning, and flexible learning methods, as well as learning spaces and organised teaching arrangements, all contribute to positive learning from a learners' perspective.Learners identified a number of innovative teaching methods and viewed them as positive. These included multi-level learner group tutorials in the practice, being taught by a team of teachers, including GP registrars and other health professionals, and access to a supernumerary GP supervisor (also termed "GP consultant teacher"). Other teaching methods that were viewed positively were parallel consulting, informal learning and rural hospital context integrated learning. CONCLUSIONS: Vertical integration of GP education and training generally impacted positively on all levels of learner. This research has provided further evidence about the learning culture, structures and teaching processes that have a positive impact on learners in the clinical general practice setting where there are multiple levels of learners. It has also identified some innovative teaching methods that will need further examination. The findings reinforce the importance of the environment for learning and learner centred approaches and will be important for training organisations developing vertically integrated practices and in their training of GP teachers.

A pilot study of an intergenerational program for people in residential aged care with cognitive impairment and children from a co-located early learning centre during COVID-19.

Intergenerational programs in residential aged care may improve well-being and combat loneliness and social isolation in older people with cognitive impairment. This pilot study investigated the effects of a semi-structured intergenerational group, including children from a co-located early learning centre and people living in residential aged care with cognitive impairment. This 9-week study used a mixed methods pre- and post-program design. Sessions were designed and delivered once per week by Occupational Therapists and took into account residents' interests and children's developmental needs and interests, identified in pre-program interviews. Nine older people with cognitive impairment and 13 children participated. The program was well attended despite disruptions and complications caused by COVID-19 and weather conditions. Older people valued the opportunity to engage with the children. Children were observed to gain confidence in communicating and forming friendships with older people with different levels of ability. There did not appear to be any change in loneliness or neuropsychiatric symptoms. The intergenerational program benefited participants and received strong support from family members and staff of the early learning centre and aged care home.