A unified call to action from Australian nursing and midwifery leaders: ensuring that Black lives matter.

Nurses and midwives of Australia now is the time for change! As powerfully placed, Indigenous and non-Indigenous nursing and midwifery professionals, together we can ensure an effective and robust Indigenous curriculum in our nursing and midwifery schools of education. Today, Australia finds itself in a shifting tide of social change, where the voices for better and safer health care ring out loud. Voices for justice, equity and equality reverberate across our cities, our streets, homes, and institutions of learning. It is a call for new songlines of reform. The need to embed meaningful Indigenous health curricula is stronger now than it ever was for Australian nursing and midwifery. It is essential that nursing and midwifery leadership continue to build an authentic collaborative environment for Indigenous curriculum development. Bipartisan alliance is imperative for all academic staff to be confident in their teaching and learning experiences with Indigenous health syllabus. This paper is a call out. Now is the time for Indigenous and non-Indigenous nurses and midwives to make a stand together, for justice and equity in our teaching, learning, and practice. Together we will dismantle systems, policy, and practices in health that oppress. The Black Lives Matter movement provides us with a 'now window' of accepted dialogue to build a better, culturally safe Australian nursing and midwifery workforce, ensuring that Black Lives Matter in all aspects of health care.

Predicting Caries in Medical Settings: Risk Factors in Diverse Infant Groups.

Expanded partnership with the medical community is a promising strategy for reducing disparities in dental caries among young children. However, no validated caries risk instrument exists for use in primary health care settings. To help resolve this gap, a 52-item caries risk questionnaire was developed and targeted to primary caregivers (PCGs) to test in a 3-y prospective study. To begin to understand the validity of the questionnaire items, the purpose of this study was to compare responses to the questionnaire based on key demographic characteristics known to be associated with disparities in caries experience (e.g., race/ethnicity and insurance status). A total of 1,323 one-year-old children were recruited primarily through 3 medical research networks. Baseline questionnaire responses were analyzed via logistic regression. The sample was 49% female. Its racial/ethnic makeup was as follows: 13% Hispanic, 37% White, 37% Black, and 13% other or multiracial. Sixty-one percent were enrolled in Medicaid, and 95% resided in urban communities. Mothers represented 94% of PCGs. There were significant differences ( P < 0.05) in baseline responses based on Medicaid status and race/ethnicity. As compared with those not enrolled in Medicaid, children in the Medicaid group were significantly more likely (after adjusting for race/ethnicity) to 1) go to sleep while nursing or drinking something other than water, 2) eat sugary snacks between meals, 3) consume sugary drinks between meals, 4) receive topical fluoride from a health professional, 5) visit the dentist, and 6) not have an employed adult in the household. PCGs of children enrolled in Medicaid were significantly more likely to be the mother, have bleeding gums, eat sugary snacks between meals, consume sugary drinks between meals, eat or drink something other than water before going to bed, and not get regular dental checkups. In conclusion, there are significant differences in caries risk questionnaire responses based on Medicaid status and race/ethnicity that provide construct and criterion validity to the developed caries risk tool (ClinicalTrials.gov NCT01707797).

Preclinical Assessment of a Fully Automated Multiplex PCR Panel for Detection of Central Nervous System Pathogens.

We evaluated a multiplexed PCR panel for the detection of 16 bacterial, viral, and fungal pathogens in cerebrospinal fluid. Panel results were compared to routine testing, and discrepancies were resolved by additional nucleic acid amplification tests or sequencing. Overall, the positive and negative agreements across methods were 92.9% and 91.9%, respectively.

Development and testing of the Gait Assessment and Intervention Tool (G.A.I.T.): a measure of coordinated gait components.

Recent neuroscience methods have provided the basis upon which to develop effective gait training methods for recovery of the coordinated components of gait after neural injury. We determined that there was not an existing observational measure that was, at once, adequately comprehensive, scored in an objectively-based manner, and capable of assessing incremental improvements in the coordinated components of gait. Therefore, the purpose of this work was to use content valid procedures in order to develop a relatively inexpensive, more comprehensive measure, scored with an objectively-based system, capable of incrementally scoring improvements in given items, and that was both reliable and capable of discriminating treatment response for those who had a stroke. Eight neurorehabilitation specialists developed criteria for the gait measure, item content, and scoring method. In subjects following stroke (>12 months), the new measure was tested for intra- and inter-rater reliability using the Intraclass Correlation Coefficient; capability to detect treatment response using Wilcoxon Signed Ranks Test; and discrimination between treatment groups, using the Plum Ordinal Regression. The Gait Assessment and Intervention Tool (G.A.I.T.) is a 31-item measure of the coordinated movement components of gait and associated gait deficits. It exhibited the following advantages: comprehensive, objective-based scoring method, incremental measurement of improvement within given items. The G.A.I.T. had good intra- and inter-rater reliability (ICC=.98, p=.0001, 95% CI=.95, .99; ICC=.83, p=.007, 95% CI=.32, .96, respectively. The inexperienced clinician who had training, had an inter-rater reliability with an experienced rater of ICC=.99 (p=.0001, CI=.97, .999). The G.A.I.T. detected improvement in response to gait training for two types of interventions: comprehensive gait training (z=-2.93, p=.003); and comprehensive gait training plus functional electrical stimulation (FES; z=-3.3, p=.001). The G.A.I.T. was capable of discriminating between two gait training interventions, showing an additive advantage of FES to otherwise comparable comprehensive gait training (parameter estimate=1.72, p=.021; CI, .25, 3.1).

Clinical leadership in contemporary clinical practice: implications for nursing in Australia.

BACKGROUND: Leadership in the clinical practice environment is important to ensure both optimal patient outcomes and successive generations of motivated and enthusiastic clinicians. AIM: The present paper seeks to define and describe clinical leadership and identify the facilitators and barriers to clinical leadership. We also describe strategies to develop clinical leaders in Australia. Key drivers to the development of nursing leaders are strategies that recognize and value clinical expertise. These include models of care that highlight the importance of the nursing role; evidence-based practice and measurement of clinical outcomes; strategies to empower clinicians and mechanisms to ensure participation in clinical decision-making. KEY ISSUES: Significant barriers to clinical leadership are organizational structures that preclude nurses from clinical decision making; the national shortage of nurses; fiscal constraints; absence of well evaluated models of care and trends towards less skilled clinicians. CONCLUSIONS: Systematic, strategic initiatives are required to nurture and develop clinical leaders. These strategies need to be collegial collaborations between the academic and health care sectors in order to provide a united voice for advancing the nursing profession.

The effects of strain heterology on the epidemiology of equine influenza in a vaccinated population.

We assess the effects of strain heterology (strains that are immunologically similar but not identical) on equine influenza in a vaccinated population. Using data relating to individual animals, for both homologous and heterologous vaccinees, we estimate distributions for the latent and infectious periods, quantify the risk of becoming infected in terms of the quantity of cross-reactive antibodies to a key surface protein of the virus (haemagglutinin) and estimate the probability of excreting virus (i.e. becoming infectious) given that infection has occurred. The data suggest that the infectious period, the risk of becoming infected (for a given vaccine-induced level of cross-reactive antibodies) and the probability of excreting virus are increased for heterologously vaccinated animals when compared with homologously vaccinated animals. The data are used to parameterize a modified susceptible, exposed, infectious and recovered/resistant (SEIR) model, which shows that these relatively small differences combine to have a large effect at the population level, where populations of heterologous vaccinees face a significantly increased risk of an epidemic occurring.

Addressing the burden of heart failure in Australia: the scope for home-based interventions.

The growing burden of heart failure (HF) challenges health practitioners to implement and evaluate models of care to facilitate optimal health related outcomes. Australia supports a publicly funded universal health insurance system with a strong emphasis on primary care provided by general practitioners. The burden of chronic HF, and a social and political framework favoring community-based, noninstitutionalized care, represents an ideal environment in which home-based HF programs can be implemented successfully. Cardiovascular nurses are well positioned to champion and mentor implementation of evidence-based, patient-centered programs in Australian communities. This paper describes the facilitators and barriers to implementation of best practice models in the Australian context. These include the challenge of providing care in a diverse, multicultural society and the need for clinical governance structures to ensure equal access to the most effective models of care.

Infant exposure to environmental tobacco smoke: a prevalence study in Australia.

OBJECTIVE: To determine: the prevalence of exposure to environmental tobacco smoke among infants aged 0-12 months in two child health care settings; the accuracy of parent report indicators of exposure; and the factors associated with exposure to environmental tobacco smoke. METHOD: Samples of consecutive parents of infants 12 months of age or younger who attended Hunter Region public child health and immunisation clinics were approached to complete a questionnaire and to allow a urine sample to be obtained from their infant during December and January 1998/99. Infant urine samples were analysed for cotinine and information obtained regarding the smoking status of household members, infant exposure to environmental tobacco smoke during the previous three days, and parent and infant characteristics and demographics. RESULTS: 85 (47%) [95% CI 40-54] infants in the combined sample had detectable levels of cotinine. Sensitivity of reported infant exposure of 86% was achieved through the combined measure of parent report of exposure and smoking status of households. The odds of exposure for infants of smoking parents were 14 times that of infants of nonsmokers [CI 5.26-50.0]. CONCLUSIONS: Almost half of the infants in this study had detectable levels of cotinine in their urine. Future interventions targeting infant exposure to environmental tobacco smoke should incorporate quit smoking strategies for both parents and other household members, as well as strategies for changing the pattern of smoking behaviour around infants. IMPLICATIONS: These findings suggest that existing community education strategies and passive smoking public policies are failing to protect this vulnerable population group.

Predictors of dropout among men who batter: a review of studies with implications for research and practice.

Identifying the characteristics of men who drop out of batterers' programs is crucial for prevention, intervention, and research. This article reviews studies of program attrition to establish a description of men who fail to complete group-based batterers' interventions. Studies indicate that men who drop out are more likely to be unemployed, be unmarried and/or childless, have lower incomes, and less education than men who remain. Dropouts are also more likely to have a criminal history, to report substance abuse or related problems, and to present with particular relationship concerns or orientations. The relationship between court referral and dropout was inconsistent across studies and may vary according to socioeconomic status. Psychopathology is consistently related to dropout, but may be associated with other factors (e.g., comorbidity or referral source). Age, race, childhood exposure to violence, and battering history are all inconsistently associated with dropping out. The implications of these findings for research and program development are discussed.

The anatomy and relations of evidence-based medicine.

Current tensions between evidence-based medicine (EBM) and some clinicians are counterproductive and unnecessary. The most contentious issues concern (a) the limitations of efficacy data from randomised trials as evidence; (b) differences in attitudes to medical diagnosis and clinical judgement; and (c) political concerns about the use of the concept of clinical evidence and guidelines to restrict physician autonomy. Health services research has evolved in response to a bureaucratic need to study health care, including clinical practice, in order to improve its effectiveness (defined mainly in terms of technological interventions), and to contain costs. Its perspective is from the top-down representing the interests of bureaucracy and managed care, and articulates with political demands for professional accountability and cost-containment. EBM has established its place as an important contributor to the methodological toolbox for health services research. There is a need for a corresponding coherent programme of clinical practice research which would locate EBM in the clinical environment beside quality assurance, the study of the appropriateness and effectiveness of interventions, and multidisciplinary research related to the art of medicine and supportive aspects of clinical care. EBM would then be seen as one organ in relation to many others making their contribution to the body of knowledge needed for clinical decisions and policy making. A 'centre for the study of clinical practice' would be an appropriate structure to support such a comprehensive programme of clinical practice research in a tertiary hospital. The bottom-up perspective of clinical practice research would complement the current top-down perspective of most health services research, providing information to doctors, patients and administrators concerning local quality of care and health outcomes, information which could also be aggregated for guidance of health policy makers. It would also represent the voice of the clinician in policy debates. Such a programme, located in the practice environment, would also foster mutual understanding, respect and cooperation between workers from different backgrounds.

Comparison of sorbitol MacConkey agar and a two-step method which utilizes enzyme-linked immunosorbent assay toxin testing and a chromogenic agar to detect and isolate enterohemorrhagic Escherichia coli.

Enterohemorrhagic Escherichia coli (EHEC) and specifically serotype O157:H7 are a significant cause of hemorrhagic gastrointestinal disease and the hemolytic uremic syndrome. Methods currently used in clinical microbiology labs, such as sorbitol-MacConkey (SMAC) agar, reliably detect only O157:H7. We have evaluated a two-step method that has the potential to identify and isolate all EHEC serotypes, including serotype O157:H7. This method utilizes a chromogenic selective-differential medium for the isolation of E. coli together with an enzyme-linked immunosorbent assay (ELISA) that detects the Shiga-like toxins Stx1 and Stx2. Both are commercially available and usable in a wide range of clinical microbiology laboratories. Compared to a Vero cell cytotoxic assay, SMAC had sensitivities of 23.5% for the identification of all EHEC serotypes and of 50.0% for the identification of O157:H7 alone. The two-step method had sensitivities of 76.5 and 100%, respectively. The ELISA alone had a sensitivity of 82.4% in the detection of Stx1 and Stx2. The specificity was 100% in all cases. Overall, 14 EHEC isolates were obtained: 8 (58%) O157:H7, 2 (14%) O26, 2 (14%) O111:NM, 1 (7%) O103:H2, and 1 (7%) O121:H19. All but one were isolated during the months of May to September. The two-step method was found to be considerably more expensive than SMAC for both positive and negative samples.

Use of multidimensional assessment to provide testimony on behalf of residents in a life-care home.

City administrators challenged a life-care home's tax-exempt status. A successful, empirically-based case was made based on data collected by gerontological nurses using the Iowa Self-Assessment Inventory (ISAI) and related instruments (Mini-Mental State Examination [MMSE], Instrumental Activities of Daily Living Scale [IADLS], and Physical Self-Maintenance Scale [PSMS]) to describe the life-care population. Testimony by gerontological nurses included comparisons between these life-care residents and statewide data on elderly individuals currently residing in nursing homes and in the community. The data they presented showed not only that this life-care home provided a high quality of life, but also saved society substantial amounts of money in government-funded services that would otherwise be provided to residents of this home. The judge ruled in favor of continuing tax-exempt status for this life-care home because credible evidence clearly demonstrated that taxpayer savings from the services provided to life-care home residents and the life-care commitment dramatically outweighed the taxpayer costs associated with lost tax revenues.

Early postoperative enteral feeding following major upper gastrointestinal surgery.

For a variety of reasons, enteral feeding is frequently delayed following major abdominal surgery. The purpose of this study was to evaluate prospectively the feasibility and tolerance of early jejunal feeding following major upper gastrointestinal surgery. Beginning on postoperative day 1, patients (n = 167) received a full-strength enteral formula at the rate of 25 ml/hr through a jejunal feeding tube. Diets were advanced to the calculated target rate (25 kcal/kg/day) by postoperative day 4. Complications of tube feeding, calories received, and patient symptoms were recorded daily. There were no major complications or deaths resulting from placement of a jejunal tube or from early enteral feeding. Patients had abdominal symptoms such as cramping, distention, nausea, and diarrhea on 9%, 18%, 4%, and 24% of all feeding days, respectively. The majority of these symptoms, with the exception of diarrhea, were graded as mild. Patients undergoing surgery for pancreatic malignancy had significantly more diarrhea than patients undergoing esophagectomy or gastrectomy. Despite these differences in symptoms, patients received an average of 78% of their targeted caloric goal by postoperative day 4 and maintained this level throughout the study. Early enteral feeding for patients undergoing esophageal, gastric, or pancreatic resections is both safe and feasible despite the occurrence of predominantly mild gastrointestinal symptoms.

A study of the educational and research priorities of registered nurses in rural Australia.

This study set out to identify the educational and research priorities of registered nurses practising in rural and remote areas of Australia. It included two groups of participants, one which identified as rural and another which identified as remote. The findings for the rural cohort in the study are presented in this article. Research participants represented a national sample. The Delphi method was used to obtain the most reliable consensus of the nurse participants. In the final phase of the study, 13 high priorities were identified. Study findings highlight perceived needs for clinical nursing research and continuing education for nurses practising in rural Australia.

Psychiatric complications and comorbidities in medical inpatients: the inadequacy of attestation at discharge.

The determination of an appropriate level of prospective payment for inpatient medical services requires consideration and documentation of psychiatric problems which impact on resource utilization. A major source of information for reimbursement planning is the list of secondary diagnoses referred to as "complications and comorbidities" (CCs) taken from the medical record. If psychiatry problems are omitted on the attestation sheet, they are unlikely to be included in any reimbursement formulae. This study was designed to look at actual hospital experience in terms of how often psychiatric diagnoses were attested to on the medical record. Of the 100 patients evaluated, 25 were found to have 33 psychiatric complications and CCs. Of the 33 psychiatric CCs, only 9 (24%) were recorded on the attestation sheet. Reasons for and implications of this low rate of attestation are discussed. The complete and accurate attestation of psychiatric problems may be the single most important priority for psychiatrists in general hospitals. Even when the DRG system is replaced by capitation payment, the importance of accurate diagnostic recording and recognition will remain paramount to making rate analyses and adjustments.

A study of clinical nursing research priorities of renal specialist nurses caring for critically ill people.

The aim of this pilot research project was to identify priority areas for clinical nursing research for renal specialist nurses practising in general critical care. Research participants in the study included Clinical Nurse Specialists (CNSs) and Clinical Nurse Consultants (CNCs), n = 12. The study sample was national with representation from a number of major metropolitan teaching hospitals in Australia. The Delphi technique was used to obtain the most reliable consensus of the specialist nurses. Research priorities emerged in four areas: 1) clinical research which is of highest value to patients; 2) clinical research which is of highest value to CNSs/CNCs; 3) clinical research which would provide improved community care and 4) research that would be of value for CNSs/CNCs professional needs. In the final phase of the study nine high priorities were identified. The findings of the study suggest directions for clinical nursing research which would benefit renal specialist nurses and their patients.

Clinical nursing research priorities in Australian critical care: a pilot study.

The aims of this research project were to identify areas for research in Australian critical care nursing with potential for improvement in patient care, and to advise nursing research policy and priorities with relevance to areas of patients' needs. Research participants represented a national sample of clinical nurse specialists (CNSs) and clinical nurse consultants (CNCs). The Delphi method was used to obtain the most reliable consensus of the specialist nurses, and over 238 research priorities were identified initially. In the final phase of the research nine high priorities were identified. The findings of this study suggest directions for clinical nursing research in critical care.

The impact of posthospital home care on patients with cancer.

Symptom distress, mental health status, enforced social dependency and health perceptions were measured in two groups of cancer patients, one receiving home care services (n = 49) and the other receiving no such services (n = 11). Data were obtained at hospital discharge and 3 months later. Patients receiving home care demonstrated statistically significant improvement on mental health and social dependency; patients not receiving home care did not improve on any variable. After controlling for baseline scores, the home care group had significantly higher mental health status at the second interview than the no home care group.

The impact of psychiatric comorbidity on Medicare reimbursement for inpatient medical care.

Funding for psychiatric consultation-liaison (C-L) services has been a difficult problem. It has been suggested that the identification of psychiatric co-morbidities in Medicare patients on medical services could generate incremental hospital revenue by moving patients from a lower to a higher paying Diagnostic Related Group (DRG). This increased revenue could be used as a means of supporting the psychiatric C-L service. This study documents the financial impact of screening for and documenting psychiatric co-morbidities on a general acute medical service. We clinically assessed 100 consecutive Medicare admissions and found 25 psychiatric co-morbidities in 20 patients. In only one case did the psychiatric diagnosis result in moving the case to a higher DRG. However, the need for psychiatric consultation remains evident as there was significant lack of recognition and documentation of the psychiatric diagnoses by the medical team. The authors discuss both the financial and clinical implications of screening medical inpatients for psychiatric co-morbidities and propose directions for further studies in this area.