Stroke Self-Management Support Improves Survivors' Self-Efficacy and Outcome Expectation of Self-Management Behaviors.

BACKGROUND AND PURPOSE: Evidence shows self-management programs are associated with improved recovery outcomes. This article reports on the effectiveness of a new nurse-led self-efficacy-based stroke self-management program. METHODS: A randomized controlled trial of participants recruited from 3 acute stroke units was conducted. The intervention group received the 4-week stroke self-management program. The control group received usual care. All participants were assessed at baseline and 8 weeks after randomization. Data were analyzed using generalized estimating equations. Outcomes included self-efficacy, outcome expectation, and satisfaction with performance of self-management behaviors. RESULTS: One hundred twenty-eight participants were randomized with mean age, 67.46 years (SD, 11.95); 59% men; and mean duration poststroke, 45 days (SD, 26.16). At 8 weeks of follow-up in the intention-to-treat population, the intervention group improved significantly in self-efficacy (95% confidence interval, 2.55-12.45; P<0.01), outcome expectation (95% confidence interval, 5.47-14.01; P<0.01), and satisfaction with performance of self-management behaviors (95% confidence interval, 3.38-13.87; P<0.01) compared with the control. Similar results were obtained at 8 weeks of follow-up in the per-protocol population. CONCLUSIONS: The stroke self-management program improved survivors' self-efficacy, outcome expectation, and satisfaction with performance of self-management behaviors. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02112955.

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 ).

Effectiveness of the cardiac-diabetes transcare program: protocol for a randomised controlled trial.

BACKGROUND: This paper presents a protocol for a randomised controlled trial of the Cardiac-Diabetes Transcare program which is a transitional care, multi-modal self-management program for patients with acute coronary syndrome comorbid with type 2 diabetes. Prior research has indicated people hospitalised with dual cardiac and diabetes diagnoses are at an elevated risk of hospital readmissions, morbidity and mortality. The primary aim of this study is to evaluate the effectiveness (and cost-effectiveness) of a Cardiac-Diabetes Transcare intervention program on 6-month readmission rate in comparison to usual care. METHODS/DESIGN: A two-armed, randomised controlled trial with blinded outcome assessment will be conducted to evaluate the comparative effectiveness of two modes of care, including a Usual Care Group and a Cardiac-Diabetes Transcare Intervention (in addition to usual care) Group. The primary outcome is 6-month readmission rate, although a range of secondary outcomes will be collected (including self-efficacy) at baseline, 1, 3 and 6 month reassessments. The intervention group will receive in-hospital education tailored for people recovering from an acute coronary syndrome-related hospital admission who have comorbid diabetes, and they will also receive home visits and telephone follow-up by a trained Research Nurse to reinforce and facilitate disease-management-related behaviour change. Both groups will receive usual care interventions offered or referred from participating hospital facilities. A sample size of 432 participants from participating hospitals in the Australian states of Queensland and Victoria will be recruited for 90% power based on the most conservative scenarios modelled for sample size estimates. DISCUSSION: The study outlined in this protocol will provide valuable insight into the effectiveness of a transitional care intervention targeted for people admitted to hospital with cardiac-related presentations commencing in the inpatient hospital setting and transition to the home environment. The purpose of theory-based intervention comprising face-to-face sessions and telephone follow up for patients with acute coronary syndrome and type 2 diabetes is to increase self-efficacy to enhance self-management behaviours and thus improve health outcomes and reduce hospital readmissions. TRIAL REGISTRATION: This study has been registered with the Australian New Zealand Clinical Trials Registry dated 16/12/2014: ACTRN12614001317684 .

Vietnamese Version of Diabetes Self-Management Instrument: Development and Psychometric Testing.

Self-management plays a vital role in diabetes management for adults with type 2 diabetes (T2DM). While there are many people with T2DM in Vietnam, clinical understanding of diabetes self-management (DSM) in this context is limited due to the lack of a valid measurement instrument. Translation and back-translation processes were used to translate the Diabetes Self-Management Instrument (DSMI) into Vietnamese. Then, translation equivalence, face validity, construct validity, and internal consistency were assessed in a sample of 198 Vietnamese adults with T2DM. The Cronbach's alpha of the V-DSMI was .92, with a number of significant inter-item correlations. The Vietnamese version of the Diabetes Self-Management Instrument (V-DSMI) retained the meaning of the original English version, and the language of the V-DSMI was clearly understandable to adults with T2DM in Vietnam. Confirmatory factor analysis supported the goodness of fit between the data and the previously identified factor structure. These results indicated that the V-DSMI is acceptable for use with Vietnamese adults with T2DM in further practice and research. However, future studies would be beneficial to determine the test-retest reliability and criterion validity of the V-DSMI. © 2016 Wiley Periodicals, Inc.

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.

Cardiac-diabetes self-management program for Australians and Taiwanese: A randomized blocked design study.

Cardiac disease and type 2 diabetes are prevalent diseases globally. Cardiac rehabilitation and diabetes self-management programs empower patients' self-management to improve their health outcomes. However, inappropriate delivery modes and continuing low participation rates indicate some programs are less than optimal. A previous study demonstrated the feasibility of incorporating telephone and text messages into a cardiac-diabetes self-management program in Australia; however, the program did not specifically address patients' cultural backgrounds. This current study used a randomized blocked design to evaluate short-term efficacy of the cardiac-diabetes self-management program incorporating telephone and text-messaging across different cultural contexts in Australia and Taiwan in comparison to usual care. No significant differences between groups were observed for outcomes of self-care behavior, self efficacy, knowledge and health-related quality of life, with patients in both groups demonstrating improvements. Patient-reported outcomes indicated some evidence of an interaction effect between country of origin and group allocation. Findings indicated an improved tendency of outcome measures between the baseline and follow-up assessments within usual care and intervention groups. Further research is required to clarify components of the program work for each cultural group.

The effectiveness of psychosocial interventions for cognitive dysfunction in cancer patients who have received chemotherapy: a systematic review.

BACKGROUND: Chemotherapy-related cognitive dysfunction (CRCD) refers to problems with memory, attention span, or concentration, experienced by patients with cancer who have had chemotherapy. CRCD can have a significant negative effect on a patient's quality of life. The exact cause of CRCD is unknown but is presumed to be multifactorial. OBJECTIVE: To conduct a systematic review of the effectiveness of psychosocial interventions designed to treat CRCD. METHODS: Participants of interest to the review were over 18 years of age, diagnosed with cancer, and receiving chemotherapy or had received chemotherapy in the past. Interventions of interest were methods to improve cognitive function. Included study designs were randomized controlled trials, quasi-experimental trials, and quantitative observational studies. The primary outcome of interest was level of cognitive function. A three-step search strategy was utilized to identify studies published from 1985 to 2011 from a wide range of databases. Joanna Briggs Institute systematic review methods were used but findings were analyzed using the Cochrane Collaboration Review Manager 5.1 program. Weighted mean differences with 95% confidence intervals were calculated from the continuous data. RESULTS: Searching identified 3,109 potentially relevant articles and 120 full-text articles were retrieved. Two further papers were sourced from reference lists of retrieved articles. From 122 papers, six were suitable for critical appraisal and six were included in the analysis. Meta-analysis was conducted on two cognitive behavioral therapy (CBT) trials for the outcome of inability to concentrate. Significant effect was seen for one CBT intervention at 20 weeks (p = .004). Significant effect from CBT on quality of life was seen at 6-month follow-up (p < .05). CONCLUSIONS: Despite some evidence of an effect, there is insufficient evidence at this stage to strongly recommend any of the interventions to assist in decreasing the effects of CRCD, except in terms of improving quality of life.

A systematic review of the effectiveness of warming interventions for women undergoing cesarean section.

BACKGROUND: Women undergoing cesarean section are vulnerable to adverse effects associated with inadvertent perioperative hypothermia, but there has been a lack of synthesized evidence for temperature management in this population. This systematic review aimed to synthesize the best available evidence in relation to preventing hypothermia in mothers undergoing cesarean section surgery. METHODS: Randomized controlled trials meeting the inclusion criteria (adult patients of any ethnic background, with or without comorbidities, undergoing any mode of anesthesia for any type of cesarean section) were eligible for consideration. Active or passive warming interventions versus usual care or placebo, aiming to limit or manage core heat loss in women undergoing cesarean section were considered. The primary outcome was maternal core temperature. A comprehensive search with no language restrictions was undertaken of multiple databases from their inception until May 2012. Two independent reviewers using the standardized critical appraisal instrument for randomized controlled trials from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instruments (JBI-MASTARI) assessed retrieved papers for methodological quality and conducted data collection. Where possible, results were combined in a fixed effects meta-analysis using the Cochrane Collaboration Review Manager software. Due to heterogeneity for one outcome, random effects meta-analysis was also used. RESULTS: A combined total of 719 participants from 12 studies were included. Intravenous fluid warming was found to be effective at maintaining maternal temperature and preventing shivering. Warming devices, including forced air warming and under-body carbon polymer mattresses, were effective at preventing hypothermia. However, effectiveness increased if the devices were applied preoperatively. Preoperative warming devices reduced shivering and improved neonatal temperatures at birth. Intravenous fluid warming did not improve neonatal temperature, and the effectiveness of warming interventions on umbilical pH remains unclear. LINKING EVIDENCE TO ACTION: Intravenous fluid warming by any method improves maternal temperature and reduces shivering during and after cesarean section, as does preoperative body warming. Preoperative warming strategies should be utilized where possible. Preoperative or intraoperative warmed IV fluids should be standard practice. Warming strategies are less effective when intrathecal opioids are administered. Further research is needed to investigate interventions in emergency cesarean section surgery. Larger scale studies using standardized, clinically meaningful temperature measurement time points are required.

Protocol for a randomised blocked design study using telephone and text-messaging to support cardiac patients with diabetes: a cross cultural international collaborative project.

BACKGROUND: The prevalence of type 2 diabetes is rising internationally. Patients with diabetes have a higher risk of cardiovascular events accounting for substantial premature morbidity and mortality, and health care expenditure. Given healthcare workforce limitations, there is a need to improve interventions that promote positive self-management behaviours that enable patients to manage their chronic conditions effectively, across different cultural contexts. Previous studies have evaluated the feasibility of including telephone and Short Message Service (SMS) follow up in chronic disease self-management programs, but only for single diseases or in one specific population. Therefore, the aim of this study is to evaluate the feasibility and short-term efficacy of incorporating telephone and text messaging to support the care of patients with diabetes and cardiac disease, in Australia and in Taiwan. METHODS/DESIGN: A randomised controlled trial design will be used to evaluate a self-management program for people with diabetes and cardiac disease that incorporates the use of simple remote-access communication technologies. A sample size of 180 participants from Australia and Taiwan will be recruited and randomised in a one-to-one ratio to receive either the intervention in addition to usual care (intervention) or usual care alone (control). The intervention will consist of in-hospital education as well as follow up utilising personal telephone calls and SMS reminders. Primary short term outcomes of interest include self-care behaviours and self-efficacy assessed at baseline and four weeks. DISCUSSION: If the results of this investigation substantiate the feasibility and efficacy of the telephone and SMS intervention for promoting self management among patients with diabetes and cardiac disease in Australia and Taiwan, it will support the external validity of the intervention. It is anticipated that empirical data from this investigation will provide valuable information to inform future international collaborations, while providing a platform for further enhancements of the program, which has potential to benefit patients internationally. TRIAL REGISTRATION: ACTRN 12611001196932.

Delineating the practice profile of advanced practice nursing: a cross-sectional survey using the modified strong model of advanced practice.

AIMS: To test a model that delineates advanced practice nursing from the practice profile of other nursing roles and titles. BACKGROUND: There is extensive literature on advanced practice reporting the importance of this level of nursing to contemporary health service and patient outcomes. Literature also reports confusion and ambiguity associated with advanced practice nursing. Several countries have regulation and delineation for the nurse practitioner, but there is less clarity in definition and service focus of other advanced practice nursing roles. DESIGN: A statewide survey. METHODS: Using the modified Strong Model of Advanced Practice Role Delineation tool, a survey was conducted in 2009 with a random sample of registered nurses/midwives from government facilities in Queensland, Australia. Analysis of variance compared total and subscale scores across groups according to grade. Linear, stepwise multiple regression analysis examined factors influencing advanced practice nursing activities across all domains. RESULTS: There were important differences according to grade in mean scores for total activities in all domains of advanced practice nursing. Nurses working in advanced practice roles (excluding nurse practitioners) performed more activities across most advanced practice domains. Regression analysis indicated that working in clinical advanced practice nursing roles with higher levels of education were strong predictors of advanced practice activities overall. CONCLUSION: Essential and appropriate use of advanced practice nurses requires clarity in defining roles and practice levels. This research delineated nursing work according to grade and level of practice, further validating the tool for the Queensland context and providing operational information for assigning innovative nursing service.

A randomized controlled trial of self-management programme improves health-related outcomes of older people with heart failure.

AIMS: This paper is a report on the effectiveness of a self-management programme based on the self-efficacy construct, in older people with heart failure. BACKGROUND: Heart failure is a major health problem worldwide, with high mortality and morbidity, making it a leading cause of hospitalization. Heart failure is associated with a complex set of symptoms that arise from problems in fluid and sodium retention. Hence, managing salt and fluid intake is important and can be enhanced by improving patients' self-efficacy in changing their behaviour. DESIGN: Randomized controlled trial. METHODS: Heart failure patients attending cardiac clinics in northern Taiwan from October 2006-May 2007 were randomly assigned to two groups: control (n = 46) and intervention (n = 47). The intervention group received a 12-week self-management programme that emphasized self-monitoring of salt/fluid intake and heart failure-related symptoms. Data were collected at baseline as well as 4 and 12 weeks later. Data analysis to test the hypotheses used repeated-measures anova models. RESULTS: Participants who received the intervention programme had significantly better self-efficacy for salt and fluid control, self-management behaviour and their heart failure-related symptoms were significantly lower than participants in the control group. However, the two groups did not differ significantly in health service use. CONCLUSION: The self-management programme improved self-efficacy for salt and fluid control, self-management behaviours, and decreased heart failure-related symptoms in older Taiwanese outpatients with heart failure. Nursing interventions to improve health-related outcomes for patients with heart failure should emphasize self-efficacy in the self-management of their disease.

Advanced practice nursing role development: factor analysis of a modified role delineation tool.

AIM: This study reports the use of exploratory factor analysis to determine construct validity of a modified advanced practice role delineation tool. BACKGROUND: Little research exists on specific activities and domains of practice within advanced practice nursing roles, making it difficult to define service parameters of this level of nursing practice. A valid and reliable tool would assist those responsible for employing or deploying advanced practice nurses by identifying and defining their service profile. This is the third article from a multi-phase Australian study aimed at assigning advanced practice roles. METHODS: A postal survey was conducted of a random sample of state government employed Registered Nurses and midwives, across various levels and grades of practice in the state of Queensland, Australia, using the modified Advanced Practice Role Delineation tool. Exploratory factor analysis, using principal axis factoring was undertaken to examine factors in the modified tool. Cronbach's alpha coefficient determined reliability of the overall scale and identified factors. RESULTS: There were 658 responses (42% response rate). The five factors found with loadings of ≥400 for 40 of the 41 APN activities were similar to the five domains in the Strong model. Cronbach's alpha coefficient was 0·94 overall and for the factors ranged from 0·83 to 0·95. CONCLUSION: Exploratory factor analysis of the modified tool supports validity of the five domains of the original tool. Further investigation will identify use of the tool in a broader healthcare environment.

Psychometric properties of the Chinese version of State Self-Esteem Scale: an analysis of data from a cross-sectional survey of patients in the first four months after stroke.

AIM: To establish the psychometric properties of the Chinese version of the State Self-Esteem Scale in stroke patients. BACKGROUND: Self-esteem is seen to enhance peoples' ability to cope with disease: low self-esteem may inhibit participation in rehabilitation and thus result in poor health and social outcomes. Although the Chinese version of the State Self-Esteem Scale has been used as an outcome measure for stroke rehabilitation, no study has examined its factor structure in this patient group. DESIGN: A cross-sectional design. METHODS: A convenience sample of 265 Chinese stroke patients (mean age 71·4, SD 10·3 years), with a minimum score of 18 out of a possible 30 for the Mini Mental State Exam recruited from two regional rehabilitation hospitals in Hong Kong. An exploratory factor analysis and an internal consistency analysis of the State Self-Esteem Scale were conducted. Pearson's correlation coefficients were calculated between the State Self-Esteem Scale and the Geriatric Depression Scale to determine convergent validity. RESULTS: The final factor solution comprised a three-factor model with correlated constructs and accounted for 49·5% of the total variance. Significant negative correlations were found between the Geriatric Depression Scale and the State Self-Esteem Scale subscale scores (r-0·31 to -0·55, p < 0·01), indicating that the State Self-Esteem Scale had acceptable convergent validity. The new three-factor structure had higher Cronbach's alphas when compared with the original three-factor structure. RELEVANCE TO CLINICAL PRACTICE: The State Self-Esteem Scale appears to be a useful measure for assessing state self-esteem in stroke patients. To establish the concurrent, discriminative and construct validities, the factor structure of the SSES could be further developed and tested.

Development and pilot test of a peer-support based Cardiac-Diabetes Self-Management Program: a study protocol.

BACKGROUND: People with cardiac disease and type 2 diabetes have higher hospital readmission rates (22%) compared to those without diabetes (6%). Self-management is an effective approach to achieve better health outcomes; however there is a lack of specifically designed programs for patients with these dual conditions. This project aims to extend the development and pilot test of a Cardiac-Diabetes Self-Management Program incorporating user-friendly technologies and the preparation of lay personnel to provide follow-up support. METHODS/DESIGN: A randomised controlled trial will be used to explore the feasibility and acceptability of the Cardiac-Diabetes Self-Management Program incorporating DVD case studies and trained peers to provide follow-up support by telephone and text-messaging. A total of 30 cardiac patients with type 2 diabetes will be randomised, either to the usual care group, or to the intervention group. Participants in the intervention group will received the Cardiac-Diabetes Self-Management Program in addition to their usual care. The intervention consists of three face-to-face sessions as well as telephone and text-messaging follow up. The face-to-face sessions will be provided by a trained Research Nurse, commencing in the Coronary Care Unit, and continuing after discharge by trained peers. Peers will follow up patients for up to one month after discharge using text messages and telephone support. Data collection will be conducted at baseline (Time 1) and at one month (Time 2). The primary outcomes include self-efficacy, self-care behaviour and knowledge, measured by well established reliable tools. DISCUSSION: This paper presents the study protocol of a randomised controlled trial to pilot evaluates a Cardiac-Diabetes Self-Management program, and the feasibility of incorporating peers in the follow-ups. Results of this study will provide directions for using such mode in delivering a self-management program for patients with both cardiac condition and diabetes. Furthermore, it will provide valuable information of refinement of the intervention program. TRIAL REGISTRATION NUMBER: ACTRN12611000086965.

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.

ICU nurses' experiences and perspectives of caring for obstetric patients in intensive care: a qualitative study.

AIMS AND OBJECTIVES: The aim of this study was to gain an understanding of the experiences and perspectives of intensive care nurses caring for critically ill obstetric patients. BACKGROUND: Current literature suggests critically ill obstetric patients need specialised, technically appropriate care to meet their specific needs with which many intensive care nurses are unfamiliar. Furthermore, there is little research and evidence to guide the care of this distinct patient group. DESIGN: This study used a descriptive qualitative design. METHODS: Two focus groups were used to collect data from 10 Australian intensive care units nurses in May 2007. Open-ended questions were used to guide the discussion. Latent content analysis was used to analyse the data set. Each interview lasted no longer than 60 minutes and was recorded using audio tape. The full interviews were transcribed prior to in-depth analysis to identify major themes. RESULTS: The themes identified from the focus group interviews were competence with knowledge and skills for managing obstetric patients in the intensive care unit, confidence in caring for obstetric patients admitted to the intensive care unit and acceptance of an expanded scope of practice perceived to include fundamental midwifery knowledge and skills. CONCLUSION: The expressed lack of confidence and competence in meeting the obstetric and support needs of critically ill obstetric women indicates a clear need for greater assistance and education of intensive care nurses. This in turn may encourage critical care nurses to accept an expanded role of clinical practice in caring for critically ill obstetric patients. RELEVANCE TO CLINICAL PRACTICE: Recognition of the issues for nurses in successfully caring for obstetric patients admitted to an adult intensive care setting provides direction for designing education packages, ensuring specific carepaths and guidelines are in place and that support from a multidisciplinary team is available including midwifery staff.

Validation of scales measuring self-efficacy and outcome expectancy in evidence-based practice.

BACKGROUND: Evidence-based practice (EBP) is embraced internationally as an ideal approach to improve patient outcomes and provide cost-effective care. However, despite the support for and apparent benefits of EBP, it has been shown to be complex and difficult to incorporate in the clinical setting. Research exploring implementation of EBP has highlighted many internal and external barriers including clinicians' lack of knowledge and confidence to integrate EBP into their day-to-day work. Nurses in particular often feel ill-equipped with little confidence to find, appraise and implement evidence. AIMS: This study aimed to undertake preliminary testing of the psychometric properties of tools that measure nurses' self-efficacy and outcome expectancy in regard to EBP. METHODS: A survey design was used in which nurses who had either completed an EBP unit or were randomly selected from a major tertiary referral hospital in Brisbane, Australia, were sent two newly developed tools: (1) Self-Efficacy in EBP (SE-EBP) scale and (2) Outcome Expectancy for EBP (OE-EBP) scale. RESULTS: Principal Axis Factoring found three factors with eigenvalues above 1 for the SE-EBP explaining 73% of the variance and one factor for the OE-EBP scale explaining 82% of the variance. Cronbach's alpha for SE-EBP, three SE-EBP factors and OE-EBP were all >0.91 suggesting some item redundancy. The SE-EBP was able to distinguish between those with no prior exposure to EBP and those who completed an introductory EBP unit. CONCLUSIONS: While further investigation of the validity of these tools is needed, preliminary testing indicates that the SE-EBP and OE-EBP scales are valid and reliable instruments for measuring health professionals' confidence in the process and the outcomes of basing their practice on evidence.

Interventions for preventing and managing aggressive patients admitted to an acute hospital setting: a systematic review.

BACKGROUND: Violence in health care has been widely reported and health care workers, particularly nurses in acute care settings, are ill-equipped to manage patients who exhibit aggressive traits. AIM: The aim of this systematic review was to establish best practice in the prevention and management of aggressive behaviours in patients admitted to acute hospital settings. DATA SOURCES: An extensive search of the major databases was conducted from 1990 to 2007. The search included published and unpublished studies and papers in English. REVIEW METHODS: This review considered any quantitative research study design that evaluated the effectiveness of interventions in the prevention and management of patients who exhibit aggressive behaviours in an acute hospital setting. Each included study was quality assessed by two independent reviewers and data were extracted using the relevant tools developed by the Joanna Briggs Institute. RESULTS: Ten studies met the inclusion criteria and were included in the review. The evidence identified from the studies includes: the benefit of education and training of acute care nurses in aggression management techniques; use of "as required" medications is effective in minimising harm to patients and staff; and that specific interventions such as physical restraint may play a role in managing aggressive behaviours from patients in the acute care setting. CONCLUSIONS: This review makes several recommendations for the prevention and management of aggressive behaviours in acute hospital patients. However, due to the lack of high-quality studies conducted in the acute care setting there is huge scope for future research in this area.

National regulation in Australia: a time for standardisation in roles and titles.

BACKGROUND: The past few years has seen a growth in the number of new nursing roles and position titles in many countries, including Australia. The Australian situation is unique due to the lack of professional engagement and debate in determining the purpose of some of these new positions. Often these new roles have been poorly defined, and there is no national consistency in nomenclature. The recent move to a national nursing registration system provides an opportunity for change. METHOD: Discursive paper. RESULTS: New roles arise for a number of reasons, including a change in function or title for a preexisting role or in response to the establishment a completely new position. However, the lack of a co-ordinated approach to introduction of new roles may lead to role proliferation (the rapid increase or spread of new positions and position titles), role blurring (where the boundaries of different positions become less distinct) and role confusion (where both nurses and health system clients experience a lack of clarity regarding the precise scope of roles). CONCLUSION: Professional nursing practice is defined by the impact on patient outcomes, not by position titles. As such, the potential positive impact of a new role on patient outcomes should be the primary consideration when considering its introduction. National regulation of the profession provides an opportunity for the profession to debate and determine some consistency in position titles, responsibilities and areas of specialty practice.

A Delphi study to validate an advanced practice nursing tool.

AIM: This paper is a report of a study conducted to validate an instrument for measuring advanced practice nursing role delineation in an international contemporary health service context using the Delphi technique. BACKGROUND: Although most countries now have clear definitions and competency standards for nurse practitioners, no such clarity exists for many advanced practice nurse roles, leaving healthcare providers uncertain whether their service needs can or should be met by an advanced practice nurse or a nurse practitioner. The validation of a tool depicting advanced practice nursing is essential for the appropriate deployment of advanced practice nurses. This paper is the second in a three-phase study to develop an operational framework for assigning advanced practice nursing roles. METHOD: An expert panel was established to review the activities in the Strong Model of Advanced Practice Role Delineation tool. Using the Delphi technique, data were collected via an on-line survey through a series of iterative rounds in 2008. Feedback and statistical summaries of responses were distributed to the panel until the 75% consensus cut-off was obtained. RESULTS: After three rounds and modification of five activities, consensus was obtained for validation of the content of this tool. CONCLUSION: The Strong Model of Advanced Practice Role Delineation tool is valid for depicting the dimensions of practice of the advanced practice role in an international contemporary health service context thereby having the potential to optimize the utilization of the advanced practice nursing workforce.