Exploring the prevalence and management of wounds for people with dementia in long-term care.

The prevalence of wounds and comorbidities such as dementia increase with age. With an ageing population, the likelihood of overlap of these conditions is strong. This study aimed to determine the prevalence of wound types and current management strategies of wound care for people with dementia in long-term care (LTC). A scoping literature review, a cross-sectional observational and chart audit study of residents in dementia specific facilities in LTC were conducted. The scoping review indicated that people with dementia/cognitive impairment are often excluded from wound related studies andof the nine studies included in this review, none looked at the prevalence of types of wounds other then pressure injuries. In the skin audit, skin tears were noted as the most common wound type with some evidence-based practice strategies in place for residents. However, documentation of current wound occurred in less than a third of residents with wounds. This is the first study to note the prevalence of different wound types in people with dementia and current management strategies being used across two dementia-specific facilities and a lack of research in this area limits evidence in guiding practice.

Implementation of the Champions for Skin Integrity model to improve leg and foot ulcer care in the primary healthcare setting.

AIMS: To facilitate evidence-based leg and foot ulcer management through implementation of the Champions for Skin Integrity model to education in primary health care in Australia. BACKGROUND: Leg and foot ulcers are frequently seen wounds in general practice and wound care the most frequently performed activity by practice nurses. The literature reports the lack of evidence-based leg and foot ulcer assessment, management and prevention strategies in this setting, and previous research in regard to confidence and knowledge has indicated that general practice health professionals have the greatest need for education in wound care. DESIGN: Pre-post, nonequivalent group research design. METHODS: The Champions for Skin Integrity model of evidence-based wound management utilised strategies including workshops, development of Champions and use of resources. Pre- and post-implementation health professional surveys and patient clinical audits were completed. Descriptive statistics were calculated for all variables. Paired t tests identified statistically significant differences between the pre/post staff survey data. STROBE guidelines for reporting were followed (See Appendix S1). RESULTS: One hundred nine general practice healthcare professional staff attended the workshops. Significant outcomes were noted in increased levels of confidence in ability to assess, manage and prevent all types of leg and foot ulcers, as well as to apply evidence-based practice and change management following workshops. Pre- and post-skin audits also indicated an increase in evidence-based practices. CONCLUSION: Implementation of Champions for Skin Integrity strategies in this sample of primary healthcare professionals in general practice fostered a positive change in evidence-based wound management, assessment and prevention. RELEVANCE TO CLINICAL PRACTICE: The Champions for Skin Integrity model has supported increases in evidence-based practices in treatment and management of wounds in primary healthcare professionals, similar to the positive outcomes gained in the aged care setting. This is likely to lead to positive outcomes for those with wounds in this setting.

Transitional care interventions reduce unplanned hospital readmissions in high-risk older adults.

BACKGROUND: Acute hospital services account for the largest proportion of health care system budgets, and older adults are the most frequent users. As a result, older people who have been recently discharged from hospital may be at greater risk of readmission. This study aims to evaluate the comparative effectiveness of transitional care interventions on unplanned hospital readmissions within 28 days, 12 weeks and 24 weeks following hospital discharge. METHOD: The present study was a randomised controlled trial (ACTRN12608000202369). The trial involved 222 participants who were recruited from medical wards in two metropolitan hospitals in Australia. Participants were eligible for inclusion if they were aged 65 years and over, admitted with a medical diagnosis and had at least one risk factor for readmission. Participants were randomised to one of four groups: standard care, exercise program only, Nurse Home visit and Telephone follow-up (N-HaT), or Exercise program and Nurse Home visit and Telephone follow-up (ExN-HaT). Socio-demographics, health and functional ability were assessed at baseline, 28 days, 12 weeks and 24 weeks. The primary outcome measure was unplanned hospital readmission which was defined as any hospital admission for an unforeseen or unplanned cause. RESULTS: Participants in the ExN-HaT or the N-HaT groups were 3.6 times and 2.6 times respectively significantly less likely to have an unplanned readmission 28 days following discharge (ExN-HaT group HR 0.28, 95% CI 0.09-0.87, p = 0.029; N-HaT group HR 0.38, 95% CI 0.13-1.07, p = 0.067). Participants in the ExN-HaT or the N-HaT groups were 2.13 and 2.63 times respectively less likely to have an unplanned readmission in the 12 weeks after discharge (ExN-HaT group HR 0.47, 95% CI 0.23-0.97, p = 0.014; N-HaT group HR 0.38, 95% CI 0.18-0.82, p = 0.040). At 24 weeks after discharge, there were no significant differences between groups. CONCLUSION: Multifaceted transitional care interventions across hospital and community settings are beneficial, with lower hospital readmission rates observed in those receiving more transitional intervention components, although only in first 12 weeks. TRIAL REGISTRATION: Australian and New Zealand Clinical Trial Registry ( ACTRN12608000202369 ).

The effectiveness of hyperbaric oxygen therapy for healing chronic venous leg ulcers: A randomized, double-blind, placebo-controlled trial.

Over 30% of venous leg ulcers do not heal despite evidence-based treatment. This study aimed to determine the effectiveness of Hyperbaric Oxygen Therapy (HBOT) as an adjunct treatment for nonhealing venous leg ulcers. A randomized, double-blind, parallel group, placebo-controlled trial was undertaken in three hyperbaric medicine units. Adults with a venous leg ulcer, Transcutaneous Oxygen Measurement indicative of a hypoxic wound responsive to oxygen challenge, and without contraindications for HBOT; were eligible. Of 84 eligible patients, 10 refused and 74 enrolled. 43 participants achieved over 50% ulcer Percent Area Reduction (PAR) after four weeks of evidence-based care and were thus excluded from the intervention phase. Thirty-one participants were randomized to either 30 HBOT treatments (100% oxygen at 2.4 atmospheres absolute (ATA) for 80 minutes), or 30 "placebo" treatments, receiving a validated "sham" air protocol, initially pressurized to 1.2ATA, then cycled between 1.05-1.2ATA for eight minutes before settling at 1.05ATA. The primary outcome was numbers in each group completely healed. Secondary outcomes were ulcer PAR, pain and quality of life, 12 weeks after commencing interventions. The participants' mean age was 70 years (standard deviation (SD) 12.9) and median ulcer duration at enrolment was 62 weeks (range 4-3120). At 12 weeks, there was no significant difference between groups in the numbers completely healed. The HBOT intervention group had a mean of 95 (SD 6.53) ulcer PAR, compared to 54 (SD 67.8) mean PAR for the placebo group (t = -2.24, p = 0.042, mean difference -40.8, SE 18.2) at 12 weeks. HBOT may improve refractory healing in venous leg ulcers, however patient selection is important. In this study, HBOT as an adjunct treatment for nonhealing patients returned indolent ulcers to a healing trajectory.

Predicting the likelihood of venous leg ulcer recurrence: The diagnostic accuracy of a newly developed risk assessment tool.

The aim of this study was to validate a newly developed tool for predicting the risk of recurrence within 12 months of a venous leg ulcer healing. Performance of the tool to predict recurrence within a 12-month period was assessed using Area Under the Receiver Operating Characteristic Curve (AUC) analysis. Multi-site retrospective and prospective longitudinal studies were undertaken to validate a risk assessment tool for the recurrence of venous leg ulcers within 12 months. In the retrospective study (n = 250), 55% of venous leg ulcers recurred within 12 months, and the risk assessment total score had excellent discrimination and goodness of fit with an AUC of 0.83 (95% CI, 0.76-0.90, P < .001). The prospective study (n = 143) observed that 50.4% (n = 63) of venous leg ulcers recurred within 12 months of healing. Participants were classified using the risk assessment tool as being at low risk (28%), moderate risk (59%), and high risk (13%); the proportion of wounds recurring at 12 months was 15%, 61%, and 67% for each group, respectively. Validation results indicated good discrimination and goodness of fit, with an AUC of 0.73 (95% CI, 0.64-0.82, P < .001). Validation of this risk assessment tool for the recurrence of venous leg ulcers provides clinicians with a resource to identify high-risk patients and to guide decisions on adjunctive, tailored interventions to address the specific risk factors to decrease the risk of recurrence.

Predicting delayed healing: The diagnostic accuracy of a venous leg ulcer risk assessment tool.

The aim of this study was to validate a newly developed tool that can predict the risk of failure to heal of a venous leg ulcer in 24 weeks. The risk assessment tool was validated, and performance of the tool was assessed using Area Under the Receiver Operating Characteristic Curve (AUC) analysis. Retrospective and prospective validation was conducted through multi-site, longitudinal studies. In the retrospective study (n = 318), 30% of ulcers did not heal within 24 weeks, with the tool demonstrating an AUC of 0.80 (95% CI, 0.68-0.93, P < .001) for the total score. In the prospective study across 10 clinical sites (n = 225), 31% (n = 68) of ulcers did not heal within 24 weeks. Participants were classified with the RAT at enrolment as being at low risk (27%), moderate risk (53%) or high risk (20%) of delayed healing; the proportion of wounds unhealed at 24 weeks was 6%, 29% and 59%, respectively. Validation results of the total score indicated good discrimination and goodness of fit with an AUC of 0.78 (95% CI, 0.71-0.85, P < .001). Validation of this risk assessment tool offers assurance that realistic outcomes can be predicted for patients, and scores can guide early decisions on interventions to address specific risk factors for failing to heal, thus promoting timely healing.

Predicting the Likelihood of Delayed Venous Leg Ulcer Healing and Recurrence: Development and Reliability Testing of Risk Assessment Tools.

Venous leg ulcers are characterized by a long healing process and repeated cycles of ulceration. A secondary analysis of data from multisite longitudinal studies was conducted to identify risk factors for delayed healing and recurrence of venous leg ulcers for development of risk assessment tools, and a single-site prospective study was performed to as- sess the new tools' interrater reliability (IRR). The development of the risk assessment tools was based on results from previous multivariate analyses combined with further risk factors documented in the literature from systematic reviews, randomized controlled trials, and cohort studies with regard to delayed healing and recurrence. The delayed healing tool contained 10 items, including patient demographics, living status, use of high-compression therapy, ulcer area, wound bed tissue type, and percent reduction in ulcer area after 2 weeks. The recurrence tool included 8 items, including his- tory of deep vein thrombosis, duration of previous ulcer, history of previous ulcers, body mass index, living alone, leg elevation, walking, and compression. Using consensus procedures, content validity was established by an advisory group of 21 expert multidisciplinary clinicians and researchers. To determine intraclass correlation (ICC) and IRR, 3 rat- ers assessed 26 patients with an open ulcer and 22 with a healed ulcer. IRR analysis indicated statistically signi cant agreement for the delayed healing tool (ICC 0.84; 95% con dence interval [CI], 0.70-0.92; P <.001) and the recurrence tool (ICC 0.88; 95% CI, 0.75-0.94; P <.001). The development and reliability results of these risk assessment tools meet the recommendations for evidence-based, reliable tools and may bene t clinicians and patients in the management of venous leg ulcers. Studies to examine the items with low ICC scores and to determine the predictive validity of these tools are warranted.

Reduced prevalence and severity of wounds following implementation of the Champions for Skin Integrity model to facilitate uptake of evidence-based practice in aged care.

AIMS AND OBJECTIVES: To evaluate the implementation of the Champions for Skin Integrity model on facilitating uptake of evidence-based wound management and improving skin integrity in residents of aged care facilities. BACKGROUND: The incidence of skin tears, pressure injuries and leg ulcers increases with age, and such wounds can be a serious issue in aged care facilities. Older adults are not only at higher risk for wounds related to chronic disease but also injuries related to falls and manual handling requirements. DESIGN: A longitudinal, pre-post design. METHODS: The Champions for Skin Integrity model was developed using evidence-based strategies for transfer of evidence into practice. Data were collected before and six months after implementation of the model. Data on wound management and skin integrity were obtained from two random samples of residents (n = 200 pre; n = 201 post) from seven aged care facilities. A staff survey was also undertaken (n = 126 pre; n = 143 post) of experience, knowledge and evidence-based wound management. Descriptive statistics were calculated for all variables. Where relevant, chi-square for independence or t-tests were used to identify differences between the pre-/postdata. RESULTS: There was a significant decrease in the number of residents with a wound of any type (54% pre vs 43% post, χ2 4·2, p = 0·041), as well as a significant reduction in specific wound types, for example pressure injuries (24% pre vs 10% post, χ2 14·1, p < 0·001), following implementation of the model. An increase in implementation of evidence-based wound management and prevention strategies was observed in the postimplementation sample in comparison with the preimplementation sample. This included use of limb protectors and/or protective clothing 6% pre vs 20% post (χ2 17·0, p < 0·001) and use of an emollient or soap alternative for bathing residents (50% pre vs 74% post, χ2 13·9, p = 0·001). CONCLUSIONS: Implementation of the model in this sample fostered an increase in implementation of evidence-based wound management and prevention strategies, which was associated with a decrease in the prevalence and severity of wounds. RELEVANCE TO CLINICAL PRACTICE: This study suggests the Champions for Skin Integrity model has the potential to improve uptake of evidence-based wound management and improve skin integrity for older adults.

Identifying risk factors and protective factors for venous leg ulcer recurrence using a theoretical approach: A longitudinal study.

BACKGROUND: The high recurrence rate of chronic venous leg ulcers has a significant impact on an individual's quality of life and healthcare costs. OBJECTIVES: This study aimed to identify risk and protective factors for recurrence of venous leg ulcers using a theoretical approach by applying a framework of self and family management of chronic conditions to underpin the study. DESIGN: Secondary analysis of combined data collected from three previous prospective longitudinal studies. SETTING: The contributing studies' participants were recruited from two metropolitan hospital outpatient wound clinics and three community-based wound clinics. PARTICIPANTS: Data were available on a sample of 250 adults, with a leg ulcer of primarily venous aetiology, who were followed after ulcer healing for a median follow-up time of 17 months after healing (range: 3-36 months). METHODS: Data from the three studies were combined. The original participant data were collected through medical records and self-reported questionnaires upon healing and every 3 months thereafter. A Cox proportion-hazards regression analysis was undertaken to determine the influential factors on leg ulcer recurrence based on the proposed conceptual framework. RESULTS: The median time to recurrence was 42 weeks (95% CI 31.9-52.0), with an incidence of 22% (54 of 250 participants) recurrence within three months of healing, 39% (91 of 235 participants) for those who were followed for six months, 57% (111 of 193) by 12 months, 73% (53 of 72) by two years and 78% (41 of 52) of those who were followed up for three years. A Cox proportional-hazards regression model revealed that the risk factors for recurrence included a history of deep vein thrombosis (HR 1.7, 95% CI 1.07-2.67, p=0.024), history of multiple previous leg ulcers (HR 4.4, 95% CI 1.84-10.5, p=0.001), and longer duration (in weeks) of previous ulcer (HR 1.01, 95% CI 1.003-1.01, p<0.001); while the protective factors were elevating legs for at least 30min per day (HR 0.33, 95% CI 0.19-0.56, p<0.001), higher levels of self-efficacy (HR 0.95, 95% CI 0.92-0.99, p=0.016), and walking around for at least 3h/day (HR 0.66, 95% CI 0.44-0.98, p=0.040). CONCLUSIONS: Results from this study provide a comprehensive examination of risk and protective factors associated with leg ulcer recurrence based on the chronic disease self and family management framework. These results in turn provide essential steps towards developing and testing interventions to promote optimal prevention strategies for venous leg ulcer recurrence.

Scoping study into wound management nurse practitioner models of practice.

OBJECTIVES: The primary objective of this research was to investigate wound management nurse practitioner (WMNP) models of service for the purposes of identifying parameters of practice and how patient outcomes are measured. METHODS: A scoping study was conducted with all authorised WMNPs in Australia from October to December 2012 using survey methodology. A questionnaire was developed to obtain data on the role and practice parameters of authorised WMNPs in Australia. The tool comprised seven sections and included a total of 59 questions. The questionnaire was distributed to all members of the WMNP Online Peer Review Group, to which it was anticipated the majority of WMNPs belonged. RESULTS: Twenty-one WMNPs responded (response rate 87%), with the results based on a subset of respondents who stated that, at the time of the questionnaire, they were employed as a WMNP, therefore yielding a response rate of 71% (n=15). Most respondents (93%; n=14) were employed in the public sector, with an average of 64 occasions of service per month. The typical length of a new case consultation was 60 min, with 32 min for follow ups. The most frequently performed activity was wound photography (83%; n=12), patient, family or carer education (75%; n=12), Doppler ankle-brachial pressure index assessment (58%; n=12), conservative sharp wound debridement (58%; n=12) and counselling (50%; n=12). The most routinely prescribed medications were local anaesthetics (25%; n=12) and oral antibiotics (25%; n=12). Data were routinely collected by 91% of respondents on service-related and wound-related parameters to monitor patient outcomes, to justify and improve health services provided. CONCLUSION: This study yielded important baseline information on this professional group, including data on patient problems managed, the types of interventions implemented, the resources used to accomplish outcomes and how outcomes are measured.

Testing the effectiveness of a self-efficacy based exercise intervention for adults with venous leg ulcers: protocol of a randomised controlled trial.

BACKGROUND: Exercise and adequate self-management capacity may be important strategies in the management of venous leg ulcers. However, it remains unclear if exercise improves the healing rates of venous leg ulcers and if a self-management exercise program based on self-efficacy theory is well adhered to. METHOD/DESIGN: This is a randomised controlled in adults with venous leg ulcers to determine the effectiveness of a self-efficacy based exercise intervention. Participants with venous leg ulcers are recruited from 3 clinical sites in Australia. After collection of baseline data, participants are randomised to either an intervention group or control group. The control group receive usual care, as recommended by evidence based guidelines. The intervention group receive an individualised program of calf muscle exercises and walking. The twelve week exercise program integrates multiple elements, including up to six telephone delivered behavioural coaching and goal setting sessions, supported by written materials, a pedometer and two follow-up booster calls if required. Participants are encouraged to seek social support among their friends, self-monitor their weekly steps and lower limb exercises. The control group are supported by a generic information sheet that the intervention group also receive encouraging lower limb exercises, a pedometer for self-management and phone calls at the same time points as the intervention group. The primary outcome is the healing rates of venous leg ulcers which are assessed at fortnightly clinic appointments. Secondary outcomes, assessed at baseline and 12 weeks: functional ability (range of ankle motion and Tinetti gait and balance score), quality of life and self-management scores. DISCUSSION: This study seeks to address a significant gap in current wound management practice by providing evidence for the effectiveness of a home-based exercise program for adults with venous leg ulcers. Theory-driven, evidence-based strategies that can improve an individual's exercise self-efficacy and self-management capacity could have a significant impact in improving the management of people with venous leg ulcers. Information gained from this study will provide much needed information on management of this chronic disease to promote health and independence in this population. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12612000475842.

The effectiveness of a four-layer compression bandage system in comparison with Class 3 compression hosiery on healing and quality of life in patients with venous leg ulcers: a randomised controlled trial.

An increasing number of compression systems available for treatment of venous leg ulcers and limited evidence on the relative effectiveness of these systems are available. The purpose of this study was to conduct a randomised controlled trial to compare the effectiveness of a four-layer compression bandage system and Class 3 compression hosiery on healing and quality of life (QL) in patients with venous leg ulcers. Data were collected from 103 participants on demographics, health, ulcer status, treatments, pain, depression and QL for 24 weeks. After 24 weeks, 86% of the four-layer bandage group and 77% of the hosiery group were healed (P = 0·24). Median time to healing for the bandage group was 10 weeks, in comparison with 14 weeks for the hosiery group (P = 0·018). The Cox proportional hazards regression found participants in the four-layer system were 2·1 times (95% CI 1·2-3·5) more likely to heal than those in hosiery, while longer ulcer duration, larger ulcer area and higher depression scores significantly delayed healing. No differences between groups were found in QL or pain measures. Findings indicate that these systems were equally effective in healing patients by 24 weeks; however, a four-layer system may produce a more rapid response.

Improved functional ability and independence in activities of daily living for older adults at high risk of hospital readmission: a randomized controlled trial.

OBJECTIVE: During hospitalization older people often experience functional decline which impacts on their future independence. The objective of this study was to evaluate a multifaceted transitional care intervention including home-based exercise strategies for at-risk older people on functional status, independence in activities of daily living (ADLs) and walking ability. METHODS: A randomized controlled trial was undertaken in a metropolitan hospital in Australia with 128 patients (64 intervention, 64 control) aged over 65 years with an acute medical admission and at least one risk factor for hospital readmission. The intervention group received an individually tailored programme for exercise and follow-up care which was commenced in hospital and included regular visits in hospital by a physiotherapist and a registered nurse, a home visit following discharge and regular telephone follow-up for 24 weeks following discharge. The programme was designed to improve health-promoting behaviours, strength, stability, endurance and mobility. Data were collected at baseline, then 4, 12 and 24 weeks following discharge using the Index of ADL, Instrumental Activities of Daily Living (IADL) and the Walking Impairment Questionnaire (WIQ; modified). RESULTS: Significant improvements were found in the intervention group in IADL scores (P < 0.001), ADL scores (P < 0.001) and WIQ scale scores (P < 0.001) in comparison to the control group. The greatest improvements were found in the first 4 weeks following discharge. CONCLUSIONS: Early introduction of a transitional model of care incorporating a tailored exercise programme and regular telephone follow-up for hospitalized at-risk older adults can improve independence and functional ability.

A randomised controlled trial to prevent hospital readmissions and loss of functional ability in high risk older adults: a study protocol.

BACKGROUND: Older people have higher rates of hospital admission than the general population and higher rates of readmission due to complications and falls. During hospitalisation, older people experience significant functional decline which impairs their future independence and quality of life. Acute hospital services comprise the largest section of health expenditure in Australia and prevention or delay of disease is known to produce more effective use of services. Current models of discharge planning and follow-up care, however, do not address the need to prevent deconditioning or functional decline. This paper describes the protocol of a randomised controlled trial which aims to evaluate innovative transitional care strategies to reduce unplanned readmissions and improve functional status, independence, and psycho-social well-being of community-based older people at risk of readmission. METHODS/DESIGN: The study is a randomised controlled trial. Within 72 hours of hospital admission, a sample of older adults fitting the inclusion/exclusion criteria (aged 65 years and over, admitted with a medical diagnosis, able to walk independently for 3 meters, and at least one risk factor for readmission) are randomised into one of four groups: 1) the usual care control group, 2) the exercise and in-home/telephone follow-up intervention group, 3) the exercise only intervention group, or 4) the in-home/telephone follow-up only intervention group. The usual care control group receive usual discharge planning provided by the health service. In addition to usual care, the exercise and in-home/telephone follow-up intervention group receive an intervention consisting of a tailored exercise program, in-home visit and 24 week telephone follow-up by a gerontic nurse. The exercise only and in-home/telephone follow-up only intervention groups, in addition to usual care receive only the exercise or gerontic nurse components of the intervention respectively. Data collection is undertaken at baseline within 72 hours of hospital admission, 4 weeks following hospital discharge, 12 weeks following hospital discharge, and 24 weeks following hospital discharge. Outcome assessors are blinded to group allocation. Primary outcomes are emergency hospital readmissions and health service use, functional status, psychosocial well-being and cost effectiveness. DISCUSSION: The acute hospital sector comprises the largest component of health care system expenditure in developed countries, and older adults are the most frequent consumers. There are few trials to demonstrate effective models of transitional care to prevent emergency readmissions, loss of functional ability and independence in this population following an acute hospital admission. This study aims to address that gap and provide information for future health service planning which meets client needs and lowers the use of acute care services. TRIAL REGISTRATION NO: Australian & New Zealand Clinical Trials Registry ACTRN12608000202369.

Paediatric fever management: continuing education for clinical nurses.

PURPOSE: This study examined the influence of level of practice, additional paediatric education and length of paediatric and current experience on nurses' knowledge of and beliefs about fever and fever management. METHOD: Fifty-one nurses from medical wards in an Australian metropolitan paediatric hospital completed a self-report descriptive survey. RESULTS: Knowledge of fever management was mediocre (Mean 12.4, SD 2.18 on 20 items). Nurses practicing at a higher level and those with between one and four years paediatric or current experience were more knowledgeable than novices or more experienced nurses. Negative beliefs that would impact nursing practice were identified. Interestingly, beliefs about fever, antipyretic use in fever management and febrile seizures were similar; they were not influenced by nurses' knowledge, experience, education or level of practice. CONCLUSIONS: Paediatric nurses are not expert fever managers. Knowledge deficits and negative attitudes influence their practice irrespective of additional paediatric education, paediatric or current experience or level of practice. Continuing education is therefore needed for all paediatric nurses to ensure the latest clear evidence available in the literature for best practice in fever management is applied.

Fever management: paediatric nurses' knowledge, attitudes and influencing factors.

AIMS: This paper describes Australian paediatric nurses' knowledge of and attitudes toward fever and its management and the predictors of their intentions to administer paracetamol to a febrile child. BACKGROUND: Despite evidence-based support for the beneficial effects of fever over the past three decades, health professionals' negative attitudes toward fever and their reliance on antipyretics to reduce it have persisted and continue to be reported in the literature. METHODS: A self-report questionnaire was used. An instrument was developed, piloted by test-retest and revised prior to data collection. Fifty-one paediatric nurses working in medical wards of a metropolitan paediatric hospital in Australia participated. RESULTS: Nurses' mean knowledge score about the physiology of fever, general fever management and antipyretics was 62%, which was not as high as expected. Participants reported positive attitudes toward the benefits of fever, the necessity for its reduction in children with pre-existing cardiac or respiratory conditions and towards regular antipyretic administration masking the infective process. Negative attitudes included disbelief that temperature is often unrelated to illness severity. Conflicting attitudes toward febrile convulsions were highlighted by beliefs that antipyretic therapy prevents these and that antipyretics do not prevent initial febrile convulsions. Predictors of intentions to administer paracetamol were beliefs about the effectiveness of paracetamol and nurses' beliefs about the expectations of others in relation to paracetamol administration. Nurses reported strong intentions to administer paracetamol to the next febrile child they cared for. Limitations of the study include the use of a nurse manager for recruitment and collecting the data at only one site. CONCLUSIONS: Fever management is an integral aspect of paediatric nursing. For its consistent rational management, nurses must have appropriate knowledge and positive attitudes. This highlights the need for continuing education in fever management.

Fever management audit: Australian nurses' antipyretic usage.

Do nurses manage fevers of children hospitalized for a febrile illness ritualistically or rationally? Nurses recorded temperatures more frequently during the first 8 hours in the ward with a mean frequency of 13.36 (SD = 4.76, range 5 to 24) during the first 24 hours following admission. In the majority of cases, there was a strong second hourly pattern of temperature monitoring according to the time of day (e.g., 0600 hr, 0800 hrs, 1000 hr). Seventy-six percent (51) of the children received at least one antipyretic. The mean temperature when antipyretics were administered was 38.34 degrees C (SD = 1.02, range 35.9 degrees C to 40.8 degrees C). The highest antipyretic administration occurred during the daytime, and the highest temperature recording occurred during the nighttime. Antipyretic administration and mean temperatures generally followed a similar pattern, except at 0800 and 1600 hours when antipyretic administration was high and mean temperatures low. This study revealed a need to further investigate the knowledge, attitudes, and decision-making criteria of nurses toward fever management.

Barriers to effective cancer pain management: a survey of hospitalized cancer patients in Australia.

The purpose of this study was to examine attitudinal barriers to effective pain management in a consecutively recruited cohort of 114 cancer patients from four Australian hospitals. When surveyed, 48% of this sample reported experiencing pain within the previous 24 hours. Of these, 56% reported this pain to be "distressing, horrible or excruciating," with large proportions indicating that this pain had affected their movement, sleep and emotional well-being. Three factors were identified as potentially impacting on patients' responses to pain-poor levels of patient knowledge about pain, low perceived control over pain, and a deficit in communication about pain. A trend for older patients to experience more severe pain was also identified. These older patients reported being more willing to tolerate pain and perceive less control over their pain. Suggestions are made for developing patient education programs and further research using concepts drawn from broader social and behavioral models.