No ordinary consultation - a qualitative inquiry of hospital palliative care consultation services

PURPOSE

Considering the great need for palliative care in hospitals, it is essential for hospital staff to have palliative care knowledge. Palliative consultations have been shown to have positive effects on in-hospital care. However, barriers to contact with and uptake of palliative consultation advice are reported, posing a need for further knowledge about the process of palliative consultations. The purpose of this study therefore was to examine how palliative consultations in hospitals are practised, as perceived by consultants and health care professionals on receiving wards.

DESIGN/METHODOLOGY/APPROACH

Focus groups with palliative care consultation services, health care personnel from receiving wards and managers of consultation services. Interpretive description and constant comparative method guided the analysis.

FINDINGS

Variations were seen in several aspects of practice, including approach to practice and represented professions. The palliative consultants were perceived to contribute by creating space for palliative care, adding palliative knowledge and approach, enhancing cooperation and creating opportunity to ameliorate transition. Based on a perception of carrying valuable perspectives and knowledge, a number of consultation services utilised proactive practices that took the initiative in relation to the receiving wards.

ORIGINALITY/VALUE

A lack of policy and divergent views on how to conceptualise palliative care appeared to be associated with variations in consultation practices, tentative approaches and a bottom-up driven development. This study adds knowledge, implying theoretical transferability as to how palliative care consultations can be practised, which is useful when designing and starting new consultation services.

First initiatives in prehospital care-Basing assessments on incomplete preliminary information

Rationale and aim: Ambulance staff, i.e. registered nurses and assistant nurses, receive assignments from emergency dispatch centres including information on level of priority, address and patient’s care requirements. One problem is that the preliminary information the dispatcher gives to the ambulance staff may be incomplete. The purpose of this study was to determine how ambulance staff base their assessments on incomplete preliminary information when assessing care requirements.Methods: Fifteen ambulance staff working at seven ambulance stations were interviewed for this study. Interviews were transcribed and analysed using content analysis.Results: Incomplete preliminary information means that ambulance staff may be misdirected. This means that if the preliminary information from the dispatcher is incomplete, the ambulance staff need to reassess, and this is perceived to be difficult. Ambulance staff tend to stick to the first initiative that is taken after they receive an alert from the dispatcher.Conclusions: When ambulance staff receive incomplete preliminary information, they need to consider the possibility of conducting a reassessment. Based on the results, there is a need for new procedures to improve preparedness to conduct a reassessment after receiving incomplete preliminary information.

Doctors’ functional leadership in psychiatric healthcare teams – a reversible leadership logic

Purpose

– The purpose of this paper was to study how psychiatric doctors practise leadership in multidisciplinary healthcare teams. The paper seeks to answer the question: How do psychiatric doctors lead multidisciplinary teams during treatment conferences?

Design/methodology/approach

– Six psychiatric teams were studied at a university hospital. Each team was observed over a period of 18 months, and data were collected during four years (2008-2011). Data were collected through interviews with doctors (n = 19) and observations (n = 30) of doctors’ work in multidisciplinary psychiatric teams.

Findings

– Doctors in a multidisciplinary team use either self-imposed or involuntary leadership style. Oscillating between these two extremes was a strategy for handling the internal tensions of the team.

Research limitations/implications

– The study was a case study, performed during treatment conferences at psychiatric wards in a university hospital. This limitation means that there is cause for some caution in generalising the results.

Practical implications

– The results are useful for understanding leadership in multidisciplinary medical teams. By understanding the reversible logic of leadership, cooperation and knowledge sharing can be gained, which means that a situation of mere peaceful coexistence can be avoided. Understanding the importance of the informal contract makes it possible to switch leadership among team members. A reversible leadership with an informal contract makes the team less vulnerable. The team’s professionals can thus easily handle difficult situations and internal tensions, facilitating leadership and management of multidisciplinary teams.

Originality/value

– Doctors in multidisciplinary psychiatric teams use reversible leadership logic.

Internal temperature increase during photothermal tumour ablation in mice using gold nanorods

Laser ablation (LA) is gaining large acceptance in the treatment of tumor. One of the main risks of this treatment is damaging the healthy tissue around the tumor. Among the solutions proposed to improve the selectivity of the LA and to localize heating to tumor tissue, the use of gold nanoparticles is one of the most promising. The aim of this work is threefold: i) to measure the temperature increase within the tumor during plasmonic photothermal therapy using gold nanorods; ii) to investigate the influence of nanorods concentration and laser settings on both the intra-tumoral temperature and the tumor surface temperature; iii) and to establish the nanorods concentrations able to cause tumor resorption at a defined laser settings. Two sets of trials were performed: i) 16 mice were divided in four groups with different treatment time (i.e., 5 min, 2 min, 1 min, and 30s), with constant gold nanorods amount (i.e., 12.5 μg) and laser power (i.e., 3 W·cm(-2)); ii) 16 mice were divided in four groups treated with different amount of gold nanorods (i.e., control, 12.5 μg, 25 μg, 50 μg) for 5 min at 2 W·cm(-2). Results show significant differences between internal and surface temperatures. We also demonstrate that this temperature difference increases with nanoparticle concentrations, decreases with laser power, and is not influenced by treatment time. This information is critical to improve the theoretical models that will guide future study designs in sensitive orthotopic tumor models.

Common incentives for teamwork – the unspoken contract's significance

Purpose

– The aim of this paper was to identify and study common incentives for teamwork.

Design/methodology/approach

– The study was designed as a case study. The case consists of teamwork at a university hospital. At the hospital, ten psychiatric teams were studied for a period of four years (2008-2011). Each team was followed for 12-18 months. Data were collected through interviews (n=48) and observations (n=52) of the teamwork at treatment conferences.

Findings

– The common incentives identified consist of shared responsibility, appreciation and long-sightedness. The incidence of a silent contract is highlighted as an explanation for the team's cohesion.

Research limitations/implications

– The study is conducted in a public organisation within one field. The results should therefore be interpreted with some caution.

Practical implications

– The study is useful for practitioners to understand the importance of common incentives as a collective driving force. By developing well-adapted common incentives, the practical work can be developed, refined and improved.

Originality/value

– The significance of common incentives and the unspoken contract in the team is identified.

Cultural camouflage--a critical study of how artefacts are camouflaged and mental health policy subverted

This study identifies hidden artefacts in a public organisation. In contrast to earlier studies, it focuses on artefacts as concealing rather than conveying meaning. Negligent behaviour caused by an unpopular culture was recognised in five psychiatric wards at a Swedish university hospital. Data comprising observations (87 h) and interviews (n = 60) were collected over a period of 48 months (2008-2011). Four different items used in everyday work representing a deeper meaning of the organisation were identified during the observations. The items selected were work attire, nametags, keys and restraint beds. These were considered particularly promising when it came to the aim of the study, namely, to find out how artefacts are camouflaged. The observations and the interviews revealed that these were controversial and contested artefacts in the organisation. The study uses the term 'cultural camouflage' for behaviour that ignores and consciously conceals symbols that have negative values. This concept contrasts with previous research that shows how artefacts are emphasised and how they contribute to the character of the activity in a transparent way. Conservative and backward-looking behaviour among staff provided one explanation as to why artefacts were concealed. Another was the need to establish harmonious internal interactions.

Synchronous work: myth or reality? A critical study of teams in health and medical care

RATIONALE, AIMS AND OBJECTIVES

In this article, ideal conceptions about teamwork are tested. The research question posed is: How are teams in psychiatry formed? Three theoretical concepts that distinguish groups from teams are presented: sequentiality, parallelism and synchronicity. The presumption is that groups cooperate sequentially and teams synchronously, while the parallel work mode is a transitional form between group and team.

METHODS

Three psychiatric outpatient teams at a university hospital specialist clinic were studied. Data were collected through 25 personal interviews and 82 hours of observations. The data collection was carried out over 18 months (2008-2009).

RESULTS

Results show: (1) that the three theoretical distinctions between group and team need to be supplemented with two intermediate forms, semiparallel and semisynchronous teamwork; and (2) that teamwork is not characterized by striving towards a synchronous ideal but instead is marked by an adaptive interaction between sequential, parallel and synchronous working modes.

CONCLUSIONS

The article points to a new intermediate stage between group and team. This intermediate stage is called semiparallel teamwork. The study shows that practical teamwork is not characterized by a synchronous ideal, but rather is about how to adaptively find acceptable solutions to a series of practical problems. The study emphasizes the importance of the team varying between different working modes, so-called semisystematics.

The 20-minute team--a critical case study from the emergency room

RATIONALE

In this article, the difference between team and group is tested empirically. The research question posed is How are teams formed? Three theoretical concepts that distinguish groups from teams are presented: sequentiality, parallelism and synchronicity. The presumption is that groups cooperate sequentially and teams synchronously, while parallel cooperation is a transition between group and team.

METHODS

To answer the question, a longitudinal case study has been made of a trauma team at a university hospital. Data have been collected through interviews and direct observations. Altogether the work of the trauma team has been studied for a period of 5 years (2002-2006).

RESULTS

The results indicate that two factors are of central importance for the creation of a team. The first is related to its management and the other to the forms of cooperation. To allow for a team to act rapidly and to reduce friction between different members, clear leadership is required.

CONCLUSIONS

The studied team developed cooperation with synchronous elements but never attained a level that corresponds to idealized conceptions of teams. This is used as a basis for challenging ideas that teams are harmonious and free from conflicts and that cooperation takes place without friction.

Chondronecrosis of the hip. The protective role of the ossific nucleus in an animal model

The presence of the ossific nucleus and its role in reducing the risk of ischemic necrosis in developmental dysplasia of the hip remains a matter of controversy. Ischemic necrosis of the pre-osseous capital femoral epiphysis, defined as chondronecrosis, was evaluated in a rabbit model. Histologic evidence of chondronecrosis after casting in maximum abduction was greater in 1-day-old New Zealand White rabbits before the radiographic appearance of the ossific nucleus, compared with 16-day-old New Zealand White rabbits with an ossific nucleus already present. This preliminary study supports the hypothesis that the ossific nucleus may decrease the risk of intracapsular compressive ischemic injury to the developing capital femoral epiphysis in a rabbit model.

Effect of topical nasal azelastine on the symptoms of rhinitis, sleep, and daytime somnolence in perennial allergic rhinitis

BACKGROUND

Recent data suggested that daytime somnolence in patients with allergic rhinitis was secondary to disrupted sleep caused by nasal congestion. Medications, which decreased congestion, would be expected to improve sleep and daytime somnolence. Previously, we demonstrated that nasal steroids improved all three symptoms. The effect of topical nasal antihistamines on these symptoms has yet to be studied.

OBJECTIVE

The objective of this 8-week, double-blind, placebo-controlled study was to determine whether topical nasal azelastine was effective at decreasing congestion, daytime somnolence, and improving sleep.

METHODS

We recruited 24 subjects with perennial allergic rhinitis and randomized them in a double-blinded, crossover fashion, to receive placebo or azelastine two sprays BID, using Balaam's design. Questionnaires, daily diary, and Epworth Sleepiness Scale were used as tools. The last 2 weeks of each 4-week treatment period were summarized, scored, and compared by PROC MIXED in SAS.

RESULTS

The analysis of the Rhinitis Severity Score showed significant improvement only of rhinorrhea in the azelastine group (P = .03). The symptom severity of nasal congestion and daytime somnolence was not significantly different between placebo and azelastine. Subjects considered azelastine effective at improving their sleep (P = .04), but daytime somnolence (P = .06) and congestion (P = .09) were not statistically improved.

CONCLUSION

Azelastine is effective in reducing rhinorrhea and improving sleep quality. We were unable to demonstrate that azelastine can significantly reduce the severity of congestion or daytime somnolence.

Efficacy of a steroid nasal spray compared with an antihistamine nasal spray in the treatment of perennial allergic rhinitis

Allergic rhinitis is a common disease with a lifetime prevalence of 20% among the United States population. The cost of medication alone to manage allergic rhinitis in the United States was estimated to be $3.1 billion. The two most commonly prescribed classes of medications are antihistamines and topical nasal steroids. The data on comparing the efficacy of a commonly used antihistamine (azelastine hydrochloride) with that of topical steroids, however, are conflicting. Therefore, the reported study was undertaken to determine the efficacy of azelastine with that of a topical nasal steroid (flunisolide) in treating patients for the symptoms of perennial allergic rhinitis. Forty-four subjects were enrolled in a double-blind, placebo-controlled study using Balaam's design. In one group, patients were treated with topical nasal corticosteroids or placebo. In the other group, patients were treated with the antihistamine nasal spray or placebo. Subjective data were collected by the use of questionnaires and a daily diary, which focused on nasal symptoms, sleep, and daytime sleepiness. The results demonstrated that the topical nasal corticosteroid performed superiorly to the antihistamine nasal spray in improving sleep, daytime sleepiness, sneezing, ocular and nasal pruritus, and nasal congestion. Thus, the topical nasal corticosteroid was found to be more effective than antihistamine nasal spray in reducing symptoms of allergic rhinitis. This study provides further support for the use of topical nasal corticosteroids as first-line treatment for perennial allergic rhinitis.

The contribution of the ossific nucleus to the structural stiffness of the capital femoral epiphysis: a porcine model for DDH

The preosseous femoral head is thought to be vulnerable to compressive ischemic injury during the treatment of developmental dysplasia of the hip. The ossific nucleus has been proposed to increase the mechanical strength of the capital femoral epiphysis (CFE) and to decrease the risk of avascular necrosis. Sixty mixed-breed fetal and postgestational femoral head specimens were evaluated for structural stiffness in relation to the size of the ossific nucleus within the CFE. The structural stiffness of the CFE in the porcine model was found to increase exponentially with the size of the ossific nucleus. A finite-element model revealed that the presence of an ossific nucleus occupying 40% of the epiphyseal volume reduced the compressive strain in the region of the posterior-superior branch of the medial circumflex artery by an average of 54%. The results of this study support the hypothesis that the presence of the ossific nucleus may protect the CFE from compressive ischemic injury in the treatment of DDH.