The cost-effectiveness of a telephone-based intervention to support caregivers of older people discharged from hospital.

BACKGROUND: A telephone intervention for caregivers of older people discharged from hospital was shown to improve preparedness to care, reduce caregiver strain and caregiver distress. No cost-effectiveness analysis has been published on this, or similar interventions. The study aims addressed here were to examine whether positive outcomes for caregivers resulting from the Further Enabling Care at Home (FECH) program changed the use and costs of health services by patients; and to assess cost-effectiveness. METHODS: A single-blind randomised controlled trial compared FECH to usual care. FECH involved a specially trained nurse addressing support needs of caregivers of older patients discharged from hospital. A minimum clinically important difference in preparedness to care was defined as an increase in Preparedness for Caregiving scale score of ≥ two points from baseline. Designated data collection was at: Time 1, within four days of discharge; Time 2, 15-21 days post-discharge; and Time 3, six weeks post-discharge. A last observation carried forward approach to loss to follow-up was used, with a sensitivity analysis including only those who completed all time points. Patient use of hospital, emergency department (ED) and ambulance services were captured for 12 weeks post-discharge using administrative data. Costs included nurse time supporting caregivers, resources used by the nurse, and time taken training the nurse to deliver FECH. Cost-effectiveness was assessed using decision trees for preparedness for caregiving. RESULTS: Sixty-two intervention dyads and 79 controls provided complete data. A significantly greater proportion of intervention group caregivers reported improved preparedness to care to Time 2 (36.4% v 20.9%, p = 0.029), though this was not sustained to Time 3. The intervention cost $AUD268.28 above usual care per caregiver. No significant differences were observed in health service use between groups. The incremental cost-effectiveness ratio for each additional caregiver reporting improved preparedness to care at Time 2 was $AUD1,730.84. CONCLUSIONS: To our knowledge this is the first work to calculate the cost-effectiveness of a telephone-delivered intervention designed to support caregivers of older people post-discharge, and will support decision-making regarding implementation. Further research should examine different settings, and assess impacts on health service use with larger samples and a longer follow-up. TRIAL REGISTRATION: Australian and New Zealand Clinical Trial Registry: ACTRN12614001174673 . Registered 07/11/2014.

Professional practice models for nursing: a review of the literature and synthesis of key components.

AIM: This review aimed to synthesise literature describing the development and/or implementation and/or evaluation of a professional practice model to determine the key model components. BACKGROUND: A professional practice model depicts nursing values and defines the structures and processes that support nurses to control their own practice and to deliver quality care. EVALUATION: A review of English language papers published up to August 2014 identified 51 articles that described 38 professional practice models. Articles were subjected to qualitative analysis to identify the concepts common to all professional practice models. KEY ISSUE: Key elements of professional practice models were theoretical foundation and six common components: leadership; nurses' independent and collaborative practice; environment; nurse development and reward; research/innovation; and patient outcomes. CONCLUSIONS: A professional practice model provides the foundations for quality nursing practice. This review is an important resource for nurse leaders who seek to advance their organisation in a journey for excellence through the implementation of a professional practice model. IMPLICATIONS FOR NURSING MANAGEMENT: This summary of published professional practice models provides a guide for nurse leaders who seek to develop a professional practice model. The essential elements of a professional practice model; theoretical foundation and six common components, are clearly described. These elements can provide the starting point for nurse leaders' discussions with staff to shape a professional practice model that is meaningful to direct care nurses.

Comparing new BSN RN self skills assessment to actual skills demonstration.

The purpose of the study was to compare the self-skills assessment with the skill competence during an actual skills demonstration of newly hired bachelor of science in nursing (BSN) registered nurse graduates. This retrospective study included 32 randomly selected BSN registered nurse graduates from January 2010 to December 31, 2010. The participants were already hired into a midwest health system. Because this was a retrospective study, no demographic data were collected, and no consent from participants was needed. This study included a clinical skills check list where the participants rated themselves on specific skills utilizing a Likert scale ranging from 1 (no knowledge) to 4 (able to perform independently). The same clinical check list was utilized by an expert registered nurse when the skill was demonstrated. This study compared the difference between the subject's self-rating of skills and the clinical demonstration of the skills. We used t tests in the analysis to demonstrate the differences between the participant's self-rating of skills and the expert evaluation of the clinical demonstration of the skills. The data were inserted into the Statistical Package for the Social Sciences 19 software program to assist in the analysis process. The study demonstrated 17 significant differences in the skills ratings between the participant and competency demonstration of new BSN graduates. These significant results (2 tailed) ranged from .000 to .048.The 17 out of 46 specific skills where differences were noted included the following: staple removal, nasal pharyngeal suctioning, urinary catheter specimen collection, site care dressing change, urinary catheter irrigation, Juzo application and measurement, 5-lead telemetry, oral airway insertion, hemovac/Jackson Pratt, oral pharyngeal suctioning, urinary catheter insertion, dry suction chest drainage, bed to cart/slider board, urinary catheter removal, antiembolism stockings, measurement and application, removal of iv and sit-and-stand alarm. Overall, the participants rated their skill levels lower in 15 out of 17 significant skills when compared with their competency assessment (t test: -3.284, df = 31, P = .003). In two skill ratings (urinary catheter specimen collection and oral pharyngeal suction), the participants rated themselves higher than the competency demonstration. Two skills that had a mean participant and expert score between 1 (no knowledge) and 2 (able to perform with 1-to-1 coaching) were oral airway insertion and dry suction chest drainage. Some possible reasons why the participants rated themselves lower could be the use of different or unfamiliar terms or uncertainty of the procedure at a different health institution. Some newly graduated BSN nurses may have not performed the skills on a regular basis or only in simulation.

Soluble cell adhesion molecules in late-life depression.

BACKGROUND: Late-life depression has been associated with vascular diseases and with increases in circulating cytokines and cell adhesion molecules in the prefrontal cortex. We hypothesized that soluble intercellular adhesion molecule-1 (sICAM-1) and soluble vascular cell adhesion molecule-1 (sVCAM-1) would be increased in late-life major depression. METHODS: Serum levels of sICAM-1 and sVCAM-1 were measured in subjects over 60 with major depression (N = 23), subsyndromal depression (N = 20) and controls (N = 25). Depression severity was assessed using the Montgomery-Asberg (MDRS) and Geriatric Depression (GDS) rating scales. RESULTS: There was no significant increase in sICAM-1 (p = 0.240) or sVCAM-1 (p = 0.600) in depression nor was there any correlation of either molecule with depression severity. Adjusting for differences in cognitive impairment did not alter these findings. There was also no difference between subjects with an early onset of depression (before 60) and those with late-onset depression. CONCLUSIONS: These findings do not provide evidence that previously reported increases in serum cytokines in depression are due to peripheral vascular disease. Although we assessed subjects for vascular diseases it is possible that subtle but important differences between groups may still have been present and may have contributed to our negative findings. Our results suggest central nervous system mechanisms, such as related to HPA axis activation, may be responsible for the enhanced inflammatory response in depression.

Increase in interleukin-1beta in late-life depression.

OBJECTIVE: Depression has been associated with increases in circulating cytokines in younger adults, and there is evidence for prefrontal inflammation in late-life depression. The authors tested the hypothesis that levels of cytokine interleukin-1beta (IL-1beta) would be higher in subjects with late-life major depression. METHOD: Serum levels of IL-1beta were measured in three groups of subjects who were older than 60: 19 subjects with major depression, 20 subjects with subsyndromal depression, and 21 healthy comparison subjects. The Montgomery-Asberg Depression Rating Scale and the Geriatric Depression Scale were used to assess severity of depression. RESULTS: Compared with healthy subjects, those with major depression had significantly higher levels of IL-1beta (170%); the higher levels of IL-1beta strongly correlated with current depression severity. There were no significant differences between subjects with subsyndromal depression and the other two groups. CONCLUSIONS: These findings support the existence of an inflammatory response, which may be state dependent, in late-life depression.

Health informatics education for clinicians and managers--what's holding up progress?

This paper reports outcomes of a national survey of health informatics (HI) education and training carried out in the UK. A questionnaire to elicit details of HI and IT skills teaching was derived from a national consensus document (Learning to Manage Health Information, LtMHI). Forms were sent to all pre-qualification medical and nursing schools and to a stratified sample of postgraduate and post-registration programmes. Three case studies were carried out in acute hospital trusts to gain insight into opportunities for continuing professional development in health informatics and IT. Our evidence suggests that in the UK, health informatics is not yet integrated into the clinical curriculum. Nearly all the pre-qualification courses made some provision for teaching IT skills. Nonetheless, many respondents felt that students did not receive sufficient training. There was considerable variation in the amount of HI teaching provided in the different educational sectors. The case studies suggested very little HI training was provided for clinical staff and take-up of provision was not monitored. A number of factors are holding up progress, the most important being a lack of staff with the knowledge and skills to provide academic leadership. The paper outlines some steps that need to be taken to ensure health informatics is embedded in all clinical curricula.

Elevation of cell adhesion molecule immunoreactivity in the anterior cingulate cortex in bipolar disorder.

BACKGROUND: Neuroimaging reports of increases in signal hyperintensities in white and deep gray matter and other work indicate that there might be an inflammatory response in affective disorders. METHODS: The microvascular immunoreactivity of intercellular adhesion molecule-1 and vascular cell adhesion molecule-1 was measured with image analysis in postmortem tissue from the anterior cingulate cortex (ACC) and dorsolateral prefrontal cortex (DLPFC) from 15 unipolar and 15 bipolar subjects and compared with each other and with 15 subjects with schizophrenia and 15 control subjects. RESULTS: Intercellular adhesion molecule-1 immunoreactivity in gray and white matter of the ACC in bipolar subjects was increased compared with control subjects (gray: p =.001; white: p <.001) and schizophrenic subjects (gray: p =.016; white: p =.025) and modestly increased in white matter compared with unipolar subjects (p =.049). No such differences were found in the DLPFC. CONCLUSIONS: These findings are consistent with the presence of an inflammatory response in the ACC in bipolar disorder.

Enrolled nurse medication administration.

This paper describes an initiative undertaken at Sir Charles Gairdner Hospital in Perth, Western Australia to enhance the professional development of enrolled nurses to allow them to administer medications without the direct supervision of a registered nurse. This practice change proved to be a positive step for the hospital and for enrolled nurses. Benefits for patients were identified as greater continuity of care and increased timeliness of medication admiuistrqtion. The benefits for enrolled nurses were increased job satisfaction, improved morale and self esteem while the main benefit for registered nurses was decreased stres and workload.

Chronic glial activation, neurodegeneration, and APP immunoreactive deposits following acute administration of double-stranded RNA.

Several neurodegenerative disorders, including Alzheimer's and Parkinson's diseases, are associated with immunocompetent microglia, leading to the suggestion that chronic glial-mediated inflammation contributes to the neurodegeneration seen in these diseases. Little direct evidence supports this hypothesis, and no suitable rodent models exist that do not involve the use of blunt trauma or ischaemia, events that are infrequently encountered in the human disease state. In the present study, we report that administration of double-stranded RNA, a classical inducer of interferon-gamma (IFN-gamma), causes rapid and persistent activation of microglia and astrocytes, as well as induction of interleukin-1beta (IL-beta) and nitric oxide synthase. In close temporal succession to glial activation, there is neurodegeneration, with neuron loss involving apoptosis in selected brain regions including the septal nucleus, hippocampus, cortex and thalamus, along with hippocampal atrophy. This neuronal loss is accompanied by punctate deposits of material that are immunoreactive for amyloid precursor protein, beta-amyloid peptide (Abeta), and apolipoprotein E. The findings may have clinical relevance, since the administration of the nonsteroidal antiinflammatory agent (NSAID) ibuprofen markedly reduces the neurodegeneration observed in the absence of significant glial inhibition. These findings may be relevant to the pathogenesis of Alzheimer's disease in particular, and to other neurodegenerative diseases involving inflammation.

Communicating with families of patients in an acute hospital with advanced cancer: problems and strategies identified by nurses.

After pain management, poor communication with health professionals creates the most distress for families of patients with cancer. Difficulties communicating with families also have been identified as potentially stressful for nurses. This is particularly the case for nurses working in acute care settings. However, little research has been undertaken to examine the specific problems and challenges confronting nurses who endeavor to communicate with families of patients with cancer in a hospital setting. The purpose of this study was to describe nurses' perceptions of communication issues, potential barriers, and strategies associated with nurse-family interactions in an acute cancer hospital setting. Focus groups were conducted with nurses from two cancer wards at an Australia hospital. Four distinct themes emerged. First, all nurses described communication difficulties they encountered when interacting with families. Second, team factors appeared to be a central determinant of the quality of nurse-family communication. Third, nurses described difficulties associated with the delivery of bad news and treatment plans that are not clearly defined for the patient. Finally, the effects of poor communication on nurses were notably and vividly described. In this report, recommendations for clinical practice and subsequent research are offered.

Ischemic basis for deep white matter hyperintensities in major depression: a neuropathological study.

BACKGROUND: White matter hyperintensities on magnetic resonance imaging are increased in major depression in the deep white matter, especially in frontal areas. These lesions have been hypothesized to be ischemic in origin, but there have been no previous neuropathological studies in depression. We investigated the neuropathological basis of these lesions in depression, hypothesizing that they would be more frequently ischemic in origin in depressed subjects. METHODS: We carried out in vitro magnetic resonance imaging on 3 slices of brain tissue (2 frontal, 1 occipital) from 20 elderly subjects who had a history of major depression and 20 elderly controls. The films were blindly rated, and sections were prepared for neuropathological analysis from the same slices and stained conventionally and by means of immunohistochemistry for microglia, macrophages, and astroglia. Lesions on the films were identified in the tissue, blindly described neuropathologically, and subsequently divided into ischemic and nonischemic lesions. RESULTS: All the deep white matter hyperintensities in the depressed group were found to be ischemic, compared with less than a third of those in the control group, a highly significant difference (P<.001). This difference was due to smaller punctate lesions (<3 mm), which were predominantly ischemic in depressed subjects but not in control subjects. Larger lesions were usually ischemic in both groups. Compared with control subjects, ischemic lesions were significantly more likely to be in the dorsolateral prefrontal cortex compared with the anterior cingulate cortex (P =.003) and the occipital cortex (P =.01) in the depressed subjects. CONCLUSIONS: Deep white matter hyperintensities are more frequently due to cerebral ischemia, and such ischemic lesions are more frequently located at the level of dorsolateral prefrontal cortex in depressed subjects. Our findings strongly support the "vascular depression" hypothesis of late-life depression.

Cell adhesion molecule expression in the dorsolateral prefrontal cortex and anterior cingulate cortex in major depression in the elderly.

BACKGROUND: Neuroimaging studies have demonstrated changes in the dorsolateral prefrontal cortex (DLPFC) and anterior cingulate cortex (ACC) in major depression. AIMS: We investigated the expression of cell adhesion molecules (CAMs) in the prefrontal cortex in depression. METHOD: Immunohistochemistry to localise CAMs in post-mortem tissue from 20 subjects with major depression and 20 controls, and image analysis to quantify their expression. RESULTS: We found significant increases in CAMs in the grey matter of the DLPFC in the depression group but no comparable differences in the ACC or occipital cortex. In the white matter there was a non-significant increase in intercellular adhesion molecule-I in the DLPFC in the depression group but no increase in the other areas or for vascular cell adhesion molecule-I in any area. Paired tests showed specificity for the DLPFC in the depression group only. CONCLUSIONS: The increase in CAM expression in the DLPFC suggests an inflammatory reaction and is consistent with ischaemia.

Protection of striatal neurons by joint blockade of D1 and D2 receptor subtypes in an in vitro model of cerebral hypoxia.

Massive increases in extracellular dopamine have been reported in the ischemic rodent striatum, implicating this neurotransmitter in toxic events. We have examined whether dopamine receptor antagonists are protective against hypoxic insult, using brain slices containing the rostral striatum obtained from adult male C57/BLIcrfa(t) mice. Slices were subjected in vitro to 20 min nitrogen hypoxia, with or without addition of: (i) 50 microM haloperidol (D2 receptor antagonist and sigma ligand), (ii) 10 microM SCH23390 (selective D1 receptor antagonist), (iii) 10 microM eticlopride (selective D2 receptor antagonist), (iv) 10 microM SCH23390 and 10 microM eticlopride in combination, and (v) 10 microM MK-801 (noncompetitive NMDA receptor antagonist). Subsequently, slices were reoxygenated, fixed 2 h postinsult, and processed for light microscopy. Damage was assessed by calculating pyknotic profiles as a percentage of total neuronal profiles present. No pyknotic profiles were detected in normoxic control tissue, but this phenotype predominated in most slices subject to hypoxia alone (60.1 +/- 30.6% pyknotic profiles). Marked protection was produced by haloperidol (7.1 +/- 7.6%, P = 0.002), MK-801 (8.6 +/- 6.9%, P = 0.007), and the combined application of SCH23390 and eticlopride (5.9 +/- 9.4%, P = 0.001). No protection was demonstrated for SCH23390 or eticlopride when applied separately. These data suggest that hypoxic damage in the rostral mouse striatum is mediated via NMDA, D1, and D2 receptors. Protection against hypoxic damage by dopamine receptor antagonists requires the combined blockade of both classes of dopamine receptor.