Mixed methods evaluation research for a mental health screening and referral clinical pathway.

RATIONALE: This study is an exemplar of mixed method evaluation research for development of a clinical pathway. AIM: To develop and evaluate an evidence-based, feasible mental health screening and referral clinical pathway for Department of Veterans' Affairs-funded community nursing care of war veterans and war widows in the Australian context. METHODS: Mixed methods were applied to formulate and clinically evaluate an appropriate pathway. The pathway was applied at urban and rural sites for the nursing care of 97 war veteran and war widow clients. Evaluative data were collected from clients, their informal carers, community nurses, and general practitioners. Chart auditing and pre-post measures were undertaken. Collaboration occurred with an interdisciplinary design team. RESULTS: The final modified six-page pathway includes use of validated screening tools (Kessler Psychological Distress Scale [K10]) and Alcohol Use Disorder Identification Test, appropriate referral information, directions for support and health-promoting education, and evidence-based guidelines. IMPLICATIONS FOR PRACTICE: The clinical pathway is a useful, tested, evidence-based guide for generalist community nurses to identify and suitably respond to common mental healthcare needs of war veterans and war widows. The pathway provides outcomes acceptable to clients and their carers, nurses and doctors. CONCLUSIONS: This study provides an evaluated clinical pathway for generalist community nurses to screen for mental health difficulties, make appropriate referrals as required and to support war veteran and war widow clients. However, the study also shows how research can be used to develop and evaluate practical, evidence-based clinical pathways.

An evaluation of a mental health screening and referral pathway for community nursing care: nurses' and general practitioners' perspectives.

AIMS AND OBJECTIVES: To evaluate a feasible, best practice mental health screening and referral clinical pathway for generalist community nursing care of war veterans and war widow(er)s in Australia. BACKGROUND: War veterans commonly experience mental health difficulties and do not always receive required treatment, as can also occur for war widow(er)s. Whenever opportunity arises, such as during community nursing care, it is vital to identify mental health problems in a health promotion framework. DESIGN: A clinical pathway was developed by literature review and consultation and then trialled and evaluated using mixed methods--quantitative and qualitative. METHODS: Community nurses who trialled the pathway completed an evaluation survey and attended focus groups. General practitioners responded to an evaluation survey. RESULTS: Most nurses found the pathway clear and easy to understand but not always easy to use. They emphasised the need to establish trust and rapport with clients prior to implementing the pathway. It was sometimes difficult to ensure effective referral to general practitioners for clients who screened positive for a mental health problem. When referral was accomplished, general practitioners reported adequate and useful information was provided. Some general practitioners also commented on the difficulty of achieving effective communication between general practitioners and nurses. CONCLUSIONS: Nurses and some general practitioners found the pathway useful for their practice. They offered several suggestions for improvement by simplifying the trialled pathway and accompanying guidelines and strategies to improve communication between nurses and general practitioners. This study adds understanding of how community nurses might productively screen for mental health difficulties. RELEVANCE TO CLINICAL PRACTICE: The trialled pathway, which was modified and refined following the study, is an evidence-based resource for community nurses in Australia and similar contexts to guide practise and maximise holistic care for war veterans and war widow(er)s and possibly other client groups.

A literature review of the application of the Geriatric Depression Scale, Depression Anxiety Stress Scales and Post-traumatic Stress Disorder Checklist to community nursing cohorts.

AIMS AND OBJECTIVES: To explore through literature review the appropriateness of three common tools for use by community nurses to screen war veteran and war widow(er) clients for depression, anxiety and post-traumatic stress disorder. BACKGROUND: War veterans and, to a lesser extent, war widow(er)s, are prone to mental health challenges, especially depression, anxiety and post-traumatic stress disorder. Community nurses do not accurately identify such people with depression and related disorders although they are well positioned to do so. The use of valid and reliable self-report tools is one method of improving nurses' identification of people with actual or potential mental health difficulties for referral to a general practitioner or mental health practitioner for diagnostic assessment and treatment. The Geriatric Depression Scale, Depression Anxiety Stress Scales and Post-traumatic Stress Disorder Checklist are frequently recommended for mental health screening but the appropriateness of using the tools for screening war veteran and war widow(er) community nursing clients who are often aged and have functional impairment, is unknown. DESIGN: Systematic review. CONCLUSIONS: Current literature informs that the Geriatric Depression Scale accurately predicts a diagnosis of depression in community nursing cohorts. The three Depression Anxiety Stress Scales subscales of depression, anxiety and stress are valid; however, no studies were identified that compared the performance of the Depression Anxiety Stress Scales in predicting diagnoses of depression or anxiety. The Post-traumatic Stress Disorder Checklist predicts post-traumatic stress disorder in community cohorts although no studies meeting the selection criteria included male participants. RELEVANCE TO CLINICAL PRACTICE: This review provides recommendations for the use of the Geriatric Depression Scale, Depression Anxiety Stress Scales and The Post-traumatic Stress Disorder Checklist based on examination of the published evidence for the application of these screening tools in samples approximated to community nursing cohorts. Findings and recommendations would guide community nurses, managers and health planners in the selection of mental health screening tools to promote holistic community nursing care.

A systematic review of the effectiveness of in-home community nurse led interventions for the mental health of older persons.

AIMS AND OBJECTIVES: The aim was to systematically review evidence about the effectiveness of in-home community nurse-led interventions for older persons with, or at risk of, mental health disorders, to inform best practice nursing care with this focus. The primary review question was 'How effective are in-home community nurse-led interventions for older persons with or at risk of mental health disorders for improving mental health?' The outcome indices of interest were nursing actions to determine incidence or prevalence of mental health disorders, any change in a patient's attitude towards their mental health condition, any change in objective measurement of mental health, or a change in diagnostic status. BACKGROUND: The rising incidence of mental health disorders in older persons is a major concern for community nurses in developed countries. Effectively facilitating improved mental health for older persons is necessary in this era of ageing populations with increased demands on health funding. Disseminating systematically reviewed evidence for in-home community nursing that positively impacts on the mental health of older persons is crucial to ensure effective care is provided to this vulnerable patient group. RESULTS: This review reveals that there is evidence to support the superiority of applying validated screening tools for mental health disorders over relying on community nurses' opinions and non-validated tools about this matter. DESIGN: Systematic review. METHODS: Search of electronic databases. CONCLUSION: A clear need for replication and multi-centre trials of reviewed pertinent studies is identified. Relevance to clinical practice. Community nurses should consider using validated screening tools for this focus. Until such time as higher quality evidence is available about other nursing interventions, the reviewers suggest that the prime nursing action should be the identification of whether older persons receiving community nursing care might have a mental health disorder and, if so, then collaborative referral is made to appropriate services.

Compression bandaging for venous leg ulcers: the essentialness of a willing patient.

AIM: To describe and explore reasons for use or non-use by district nurses of compression bandaging, a best practice component of venous leg ulcer management. BACKGROUND: Leg ulcers are costly to both individuals and communities. The most prevalent of leg ulcers are venous leg ulcers, which are common wounds treated by district nurses. Compression bandaging is the best practice for the treatment of venous leg ulcers with considerable evidence that this aids healing in an effective and timely manner. It is anecdotally known that compression bandaging is not always used by district nurses when treating venous leg ulcers, yet little is known as to why this is so. METHOD: A qualitative descriptive/exploratory study was used; interview data were collected with constant comparative data analysis applied until data saturation was obtained. FINDINGS: As could be anticipated, several basic elements need to be present for a district nurse to use compression bandaging, like knowing that compression bandaging is best practice, knowing how to use compression bandaging and being able to determine that the ulcer is venous in nature. However, the major finding is the essentialness of having a patient willing for compression bandaging to be applied and sustained; the study explored what determines willingness or non-willingness and strategies that can be used to encourage willingness. CONCLUSION: A prime enabler of the use of compression bandaging is having a patient willing to agree to the commencement of this treatment and for this to be sustained. Consequent recommendations are offered. Evidence-based nursing requires not only knowledge of cause and effect evidence but also evidence that provides understanding about human responses and choices when there is a health challenge. RELEVANCE TO CLINICAL PRACTICE: The relevance of the findings for clinical practice is that knowledge is provided about what factors may constrain a patient's willingness for compression bandaging to be applied and sustained as treatment for a venous leg ulcer and about what actions can be tried to facilitate willingness.

Where does practice nursing fit in primary health care?

Practice nursing is an integral and growing part of primary health care internationally and increasingly within the Australian health care system. The potential for practice nursing being considered as a specialty of community nursing, boundary issues in community nursing, and defining characteristics of practice nursing as a model of community-based nursing are discussed in this paper. As the author has worked as a practice nurse, personal reflections on the evolving practice nurse role are provided. Practice nursing is a dynamic entity and will continue to evolve in the primary health care setting. In order for practice nursing to meet the primary health care agenda, there is a need to incorporate a social model of health with the medical model of health and to promote research and scholarship to support this goal.

Developing a web-based information resource for palliative care: an action-research inspired approach.

BACKGROUND: General Practitioners and community nurses rely on easily accessible, evidence-based online information to guide practice. To date, the methods that underpin the scoping of user-identified online information needs in palliative care have remained under-explored. This paper describes the benefits and challenges of a collaborative approach involving users and experts that informed the first stage of the development of a palliative care website 1. METHOD: The action research-inspired methodology included a panel assessment of an existing palliative care website based in Victoria, Australia; a pre-development survey (n = 197) scoping potential audiences and palliative care information needs; working parties conducting a needs analysis about necessary information content for a redeveloped website targeting health professionals and caregivers/patients; an iterative evaluation process involving users and experts; as well as a final evaluation survey (n = 166). RESULTS: Involving users in the identification of content and links for a palliative care website is time-consuming and requires initial resources, strong networking skills and commitment. However, user participation provided crucial information that led to the widened the scope of the website audience and guided the development and testing of the website. The needs analysis underpinning the project suggests that palliative care peak bodies need to address three distinct audiences (clinicians, allied health professionals as well as patients and their caregivers). CONCLUSION: Web developers should pay close attention to the content, language, and accessibility needs of these groups. Given the substantial cost associated with the maintenance of authoritative health information sites, the paper proposes a more collaborative development in which users can be engaged in the definition of content to ensure relevance and responsiveness, and to eliminate unnecessary detail. Access to volunteer networks forms an integral part of such an approach.

A grounded theory: seeking relief from flatus as relevant client-nurse action and interaction.

Flatus problems are not uncommon among gastroenterological clients and those in other care settings. Yet what clients and nurses do productively about those problems in regard to their actions and interactions and why they do so has not previously been the focus of research. Holistic health management requires trustworthy qualitative evidence to guide best practice in this regard. This study systematically developed a substantive grounded theory that details and explains the trajectory of the basic social process: seeking relief from being discommoded (inconvenienced, troubled) by flatus in the situational context of client-nurse interactions. In the theory, there is also a focus on the context of nursing care situations, possible constraints, and likely outcomes. Grounded theory method was applied. Data were collected through semistructured individual interviews, nonparticipant observation, and document analysis regarding incidents and situations involving 38 participants-clients and registered nurses. The results show that clients, when trying to do something about the situation, can be severely discommoded by flatus problems and are hampered by embarrassment and the social taboo about admitting that one is bothered by flatus. The individual may or may not disclose the problem to a nurse, and nurses may or may not be attuned to these problems. There are ways for nurses to be helpful in these situations and possible remedies are identified in this article.

Screening for depression in older district nursing clients: feasibility study.

Depression is a common condition among older district nursing clients. This two-cycle feasibility study trialled a process for depression screening by using the 15-item Geriatric Depression Scale (GDS) with a sample of older clients in an Australian district nursing organization. An education session about depression and use of the GDS preceded the screening process. The trial found that a number of barriers existed among participant nurses regarding screening for depression, although generally they acknowledged depression as a common problem among older clients and most believed that they potentially had a important role in the identification and support of clients with this condition. Lack of knowledge emerged as a major constraint, as did uneasiness about entering the mental health area, with some reluctance to use the GDS because of the type of questions included and not wanting to be intrusive regarding the 'emotional matters' of clients. Recommendations are offered about screening for depression with this client population.

Health-promoting education needs of middle-aged persons in a rural community in Taiwan.

The purpose of this study was to identify the health-promoting education needs of middle-aged people in a rural community of Taiwan. A randomized sample of 1100 potential respondents was mailed a survey questionnaire with a response rate of 29.7%. The questionnaire was a unique 'needs analysis' tool developed by the researchers. Data were analysed using descriptive and inferential statistics. The results indicated that many respondents were already experiencing at least one chronic disease with physical and mental health moderate in status overall, though varying between men and women. The five highest ranked education needs from an extensive list were: healthy diet, family communication, relating to adult children, fitness and exercise, and cancer prevention. The findings, supplemented by the results from other needs analysis methods that also applied, have provided important insights for the design of a relevant health-promoting education programme for middle-aged people in that community.

The experience of flatus incontinence from a bowel ostomy: a hermeneutic phenomenology.

OBJECTIVE: To interpret and present possible meanings in the stories of people with bowel ostomies about their experience of impact of flatus incontinence on their life and being. DESIGN: Hermeneutic phenomenology guided by a Gadamerian perspective. SETTING AND SUBJECTS: Six people with a bowel ostomy were recruited from a city in Australia. METHODS: In-depth, nonstructured interviews generated rich text. Interviews were videotaped. A variety of interpretive, hermeneutic techniques were applied for text interpretation RESULTS: Nine existential themes of meaning emerged: I am undignified, I am a secret, I am always with gas, I am not myself alone, I am without choice, I am a seeker of control, I am the smell, I am not normal, and I am living a life-sort of. Through symbiotic interpretation, writing, and re-writing, themes were encompassed in a short story: a creative synthesis of actual events and interpreted understandings for ostomates about possible meanings of experiencing flatus incontinence. CONCLUSION: Flatus incontinence for people with bowel ostomies can be quite discommoding and impact on their interactions, self-image, sexuality, social activity, and psychological well-being. Nurses need to understand this for empathetic interaction, patient assessment, intervention selection, research planning, and pertinent education.

Triangulation of qualitative approaches: hermeneutical phenomenology and grounded theory.

AIM: In this paper, suggestions are offered about the appropriate use of hermeneutic phenomenology and grounded theory in one study. BACKGROUND: As an alternative to selecting only one qualitative research approach to illuminate a topic of interest about which little is known, two qualitative approaches could be used in a study. Fear of 'method slurring' may prevent this alternative being used. Occasionally, however, credible qualitative researchers have advocated using various research approaches in one study, for example using hermeneutical phenomenology and grounded theory in triangulation. However, if pursuing this direction, several advances in thinking about using qualitative research approaches should be considered. DISCUSSION: An experience is presented of deciding to use grounded theory and hermeneutic phenomenology in one study. Cautions, practical considerations and alternative options are offered for using these approaches in one study, and the implications of some other possible ways to 'triangulate' qualitative approaches are discussed. CONCLUSION: Different research approaches can be creatively and successfully used in one study if there has been adequate consideration of vital factors that determine if there is a good 'fit' of the approaches not only with the research problem and question, but also with each other, while also maintaining the integrity of each approach.

A Delphi study of district nursing research priorities in Australia.

This study, using a Delphi approach, sought the opinion of a self-selected panel of 320 district nurses regarding research priorities for district nursing in Australia. Over three rounds of questionnaires, the 419 research clinical problem areas requiring research as suggested by the panel were each rated in importance by the panel and then ranked through analysis from high to low average rating scores, thereby, whittling down the list to the top 15% (68) research questions and to a final list of the top 10 research priorities overall. Research questions focusing on discharge planning are dominant in these top 10 priorities, with documentation issues the second most common focus. Other foci in the top 10 priorities are staffing, aged care, palliative care, and assessment. The organization-specific top 10 research priorities focus on wound care, funding, education, and communication issues. Additionally, the top 68 priorities, which are either finitely practice-based or contextual-issues research questions, were categorized into 20 themes. The results will hopefully lead to scarce human and financial resources being directed to practice-relevant research programs that will facilitate improved health for district nursing (primarily home-nursing) clients in Australia and elsewhere.

Constipation and the preached trio: diet, fluid intake, exercise.

A survey of 90 older community-dwelling people's constipation experience is reported in part. The focus is the participants' efforts to use diet, fluid intake and exercise as preventive strategies. Most feel that they have been preached to in this regard. However, constraints may prevent full adherence to the trio and although some have gained from diet adjustment, the majority is disillusioned about these strategies. Nurses should be aware that scientific and medical literature is discussing evidence that dietary fibre intake preventing constipation is not proven, that fluid intake does not necessarily determine stool bulk or speed colon transit time, and that there is no proven link between exercise levels and chronic constipation.