Developing physiotherapy student safety skills in readiness for clinical placement using standardised patients compared with peer-role play: a pilot non-randomised controlled trial

BACKGROUND

Using simulated learning environments with standardised patients (SPs) provides a way to scaffold the development of skills for patient safety in a low risk environment. There are no data regarding whether adding SP interactions in early years of physiotherapy training improves safe performance on clinical placement. We assessed the feasibility of recruiting and collecting data from junior physiotherapy students during an SP workshop with a pilot non-randomised trial, also assessing time, cost and scheduling information.

METHODS

Second year physiotherapy students were invited to participate and allocated to either the SP workshop in a simulated hospital environment (with and without video feedback) or usual teaching comprising peer role play. The main outcome measures were participant recruitment, retention and survey response rates, whether the training and workshops were delivered as scheduled and costs for SPs and staff training and workshop attendance. Students self-reported confidence, communication, preparedness for clinic and satisfaction was measured using pre-post surveys.

RESULTS

The pilot trial proved feasible, with 108 students recruited (100%) and high retention (95%) and survey response rates (85%). The training sessions and SP workshops were delivered as scheduled, costing $4700AUD. Students rated their confidence and preparedness for clinical placement higher post intervention (p < 0.001) with high levels of satisfaction with the SP interactions (mean score 9.3/10).

CONCLUSIONS

In this setting the SP workshop was feasible. Further research incorporating a randomised trial investigating the integration of SPs for the development and assessment of patient safety skills in physiotherapy education is recommended.

TRIAL REGISTRATION

ANZCTR no: 12,615,000,686,505.

The Experience of Acupuncture Care from the Perspective of People with Chronic Low Back Pain: A Grounded Theory Study

Objectives

To explore the experience of acupuncture care from the perspective of people with chronic low back pain.

Methods

A grounded theory, qualitative study using indepth interviews was undertaken with 11 people who had received acupuncture care for chronic low back pain. Interviews were audio-recorded and transcribed verbatim. Initial, focused and theoretical coding were used to identify a core category and several other categories.

Results

The core category, Reclaiming Control, was related to the sense of well-being experienced by most of the participants as a result of undergoing acupuncture care. The other categories were Gaining Sanctuary, Gaining Trust and Working Together. These categories reflected the processes of participants entering an aesthetically appealing, calm and relaxing space; developing confidence in the acupuncturists’ ability to care for them; and negotiating strategies and sharing decision-making with acupuncturists about their care.

Conclusions

Clinicians using acupuncture as a management strategy for low back pain may elicit an immediate sense of calmness in patients with subsequent well-being benefits. A sense of calmness may also be enhanced through providing a relaxing physical environment. The transactional and interpersonal processes of establishing trust and rapport, and shared decision-making are important for clients. Shared decision-making can be improved by clinicians carefully considering the explanation of issues and plans to a particular patient, especially by developing an understanding of each patient's worldview and using language that the suits each individual's healthcare orientation. Our findings should be interpreted cautiously as the results may be generalisable only to private practice in affluent countries, and whether the findings are representative beyond this setting remains unclear.

Physical activity habits and preferences in the month prior to a first-ever stroke

Background. Physical inactivity is a powerful risk factor for stroke and other chronic diseases. The aim of this study was to explore physical activity habits and preferences in the month leading up to a first-ever stroke, and to determine whether participants were aware of the link between stroke and physical activity.

Methods. We undertook an observational study with 81 participants recently admitted to a stroke unit. Participants reported their pre-morbid physical activity preferences and habits and completed the Barriers to Physical Activity and Disability Survey. Data were analysed with summative content analysis and descriptive statistics.

Results. Only 31% of participants were aware that physical inactivity was associated with stroke. Most participants defined physical activity with examples of instrumental activities of daily living (IADL) and walking (48% of responses), and IADLs constituted their most frequent regular physical activity (38% of responses). The barriers to physical activity reported by participants most frequently were lack of motivation (52%), lack of interest (50%) and lack of energy (42%).

Conclusions. Regular physical activity is important to prevent stroke and other chronic diseases but adults at risk of stroke have little awareness of the risks of physical inactivity and little motivation to undertake regular exercise.

Regular group exercise is associated with improved mood but not quality of life following stroke

Purpose. People with stroke living in the community have an increased prevalence of depression and lower quality of life than healthy older adults. This cross-sectional observational study investigated whether participation in regular exercise was associated with improved mood and quality of life.

Methods. We recruited three groups of community dwelling participants: 13 healthy older adults, 17 adults post-stroke who regularly participated in group exercise at a community fitness facility and 10 adults post-stroke who did not regularly exercise. We measured mood using the Depression, Anxiety, Stress Scale (DASS) and quality of life using the Assessment of Quality of Life (AQoL) scale.

Results. Levels of stress and depression were significantly greater in the people with stroke who did not undertake regular exercise (p = 0.004 and p = 0.004 respectively), although this group had more recent strokes (p < 0.001). Both stroke groups had lower quality of life scores (p = 0.04) than the healthy adults.

Conclusions. This small, community-based study confirms that people following stroke report poorer quality of life than stroke-free individuals. However, those who exercise regularly have significantly lower stress and depression compared to stroke survivors who do not. Future research should focus on the precise type and amount of exercise capable of improving mood following stroke.

'I understand all the major things': how older people with limited English proficiency decide their need for a professional interpreter during health care after stroke

OBJECTIVE

To explore the process of decision-making of older people with limited English proficiency (LEP) about using a professional interpreter during their health care after stroke.

DESIGN

A constructivist grounded theory approach was used. Up to two in-depth interviews were conducted with 13 older people with LEP from seven different language groups, and one older person who preferred to speak English, who had recently received health care after an acute stroke. Professional interpreters assisted with 19 of the 24 study interviews. Data were analysed and theoretical processes developed using a constant comparative method.

RESULTS

Professional interpreters were not a strong presence in the health care experience after stroke for participants. The use of professional interpreters was a complex decision for participants, influenced by their perception of the language and health care expertise of themselves and others, their perceived position to make the decision and whom they trusted. Getting by in English allowed participants to follow rules-based talk of health professionals, but did not enable them to understand detailed information or explanation, or to engage in the management of their condition in a meaningful way.

CONCLUSION

Health professionals have an opportunity and a mandate to demonstrate leadership in the interpreter decision by providing knowledge, opportunity and encouragement for people with LEP, to use an interpreter to engage in, and understand, their health care after stroke. Health professionals may need to advise when interpretation is needed for health care situations, when communication difficulties may not be anticipated by the person with LEP.

Snakes and ladders: the barriers and facilitators of elective hip- and knee-replacement surgery in Australian public hospitals

OBJECTIVES

Waiting lists for elective surgery are a persistent problem faced by health systems. The progression through elective surgery waiting lists can be likened to a game of snakes and ladders where barriers (snakes) delay access to surgery and facilitators (ladders) expedite access. The aim of the present study was to describe the barriers and facilitators to delivery of total hip- and total knee-replacement surgery in South Australian public-funded hospitals.

METHODS

Semistructured interviews with staff, direct observation of administrative processes and documentation analysis were combined under a systems theory framework.

RESULTS

System barriers (snakes) were grouped into five categories: resources, workload, hospital engagement, community engagement and system processes. Inadequate resources was the most prominent barrier, patient cancellations resulted in one-third of administrative tasks being repeated and there was a perceived lack of engagement to maximising efficiency. Interestingly, despite a lack of resources being perceived to be the biggest problem, additional resources without system change was not considered an effective long-term strategy.

CONCLUSIONS

Given the complexity of the elective surgery system, it is not surprising that single-item reforms have not created lasting reductions in waiting times. Multifaceted, whole-system reforms may be more successful. WHAT IS KNOWN ABOUT THE TOPIC? Waiting lists and waiting times for surgery are controversial, associated with frequent reforms and negative emotive headlines. We know from existing literature and anecdotal reports that individuals frequently experience lengthy delays before receiving elective surgery. Anecdotal reports also suggest that there are inefficiencies within elective surgery systems that contribute to these delays and result in cancellations, patient deterioration and poor overall satisfaction with the public health system in Australia. What isn't clear is whether this perception is accurate and what inefficiencies do exist that could be specifically targeted for reform. WHAT DOES THIS PAPER ADD? This paper adds weight to the argument that some inefficiencies exist within elective surgery systems, and identifies specific barriers to the delivery of total hip- and total knee-replacement surgery in South Australian public hospitals. It also identifies several strategies that could improve system function, some of which have already been implemented at a local level in response to stress on the system, and some of which require broad region- or state-wide change. In contrast to existing research, the level of detail provided in the present paper should allow for targeted reforms with the potential to improve system function and the efficiency with which joint-replacement surgery can be delivered. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS? All clinicians aim to provide the best intervention for their patients. Should the findings of this study be used to inform elective surgery system changes, patients and clinicians should experience a more streamlined approach to referral for and receipt of elective surgery in public hospitals. The consistency with which barriers and facilitators were identified across the four hospitals involved in this research supports the generalisability of the results. This further suggests that although specific to hip and knee replacement, many of the same barriers and facilitators could be in place across numerous surgical and non-surgical disciplines.

Falls after stroke

Falls are common at all stages after stroke, occurring in the acute, rehabilitative, and chronic phases. Consequences of falls include death or serious injury, minor injuries, functional limitations, reduced mobility and activity, and fear of falling. These consequences can have implications for independence and quality of life after stroke. The high frequency of falls may be due to a combination of existing falls risk factors prior to the stroke as well as impairments from the stroke, such as decreased strength and balance, hemineglect, perceptual problems, and visual problems. This paper reviews the magnitude of the problem of falls in people with stroke, highlights risk factors, and summarizes the limited randomized controlled trial evidence on falls prevention in this population. There is a need for further high quality research investigating the effectiveness of interventions to reduce falls and injury in people with stroke from onset through to the chronic stage.

Effects of a multifactorial falls prevention program for people with stroke returning home after rehabilitation: a randomized controlled trial

OBJECTIVES

To determine whether a multifactorial falls prevention program reduces falls in people with stroke at risk of recurrent falls and whether this program leads to improvements in gait, balance, strength, and fall-related efficacy.

DESIGN

A single blind, multicenter, randomized controlled trial with 12-month follow-up.

SETTING

Participants were recruited after discharge from rehabilitation and followed up in the community.

PARTICIPANTS

Participants (N=156) were people with stroke at risk of recurrent falls being discharged home from rehabilitation.

INTERVENTIONS

Tailored multifactorial falls prevention program and usual care (n=71) or control (usual care, n=85).

MAIN OUTCOME MEASURES

Primary outcomes were rate of falls and proportion of fallers. Secondary outcomes included injurious falls, falls risk, participation, activity, leg strength, gait speed, balance, and falls efficacy.

RESULTS

There was no significant difference in fall rate (intervention: 1.89 falls/person-year, control: 1.76 falls/person-year, incidence rate ratio=1.10, P=.74) or the proportion of fallers between the groups (risk ratio=.83, 95% confidence interval=.60-1.14). There was no significant difference in injurious fall rate (intervention: .74 injurious falls/person-year, control: .49 injurious falls/person-year, incidence rate ratio=1.57, P=.25), and there were no significant differences between groups on any other secondary outcome.

CONCLUSIONS

This multifactorial falls prevention program was not effective in reducing falls in people with stroke who are at risk of falls nor was it more effective than usual care in improving gait, balance, and strength in people with stroke. Further research is required to identify effective interventions for this high-risk group.

Aerobic exercise to improve cognitive function in adults with neurological disorders: a systematic review

OBJECTIVE

To evaluate whether aerobic exercise improves cognition in adults diagnosed with neurologic disorders.

DATA SOURCES

The Cochrane Central Register of Controlled Clinical Trials, MEDLINE, CINAHL, PubMed, EMBASE, PEDro, AMED, SPORTDiscus, PsycINFO, ERIC, and Google Scholar, with the last search performed in December 2010.

STUDY SELECTION

We included controlled clinical trials and randomized controlled trials with adults diagnosed with a neurologic disorder. Studies were included if they compared a control group with a group involved in an aerobic exercise program to improve cardiorespiratory fitness and if they measured cognition as an outcome.

DATA EXTRACTION

Two reviewers independently extracted data and methodologic quality of the included trials.

DATA SYNTHESIS

From the 67 trials reviewed, a total of 7 trials, involving 249 participants, were included. Two trials compared the effectiveness of yoga and aerobic exercise in adults with multiple sclerosis. Two trials evaluated the effect of exercise on patients with dementia, and 2 trials evaluated the effectiveness of exercise to improve cognition after traumatic brain injury. One trial studied the effect of a cycling program in people with chronic stroke. Lack of commonality between measures of cognition limited meta-analyses. Results from individual studies show that aerobic exercise improved cognition in people with dementia, improved attention and cognitive flexibility in patients with traumatic brain injury, improved choice reaction time in people with multiple sclerosis, and enhanced motor learning in people with chronic stroke.

CONCLUSIONS

There is limited evidence to support the use of aerobic exercise to improve cognition in adults with neurologic disorders. Of the 67 studies retrieved, less than half included cognition as an outcome, and few studies continued the aerobic exercise program long enough to be considered effective. Further studies investigating the effect of aerobic exercise interventions on cognition in people with neurologic conditions are required.

The FLASSH study: protocol for a randomised controlled trial evaluating falls prevention after stroke and two sub-studies

Background

Falls are common in stroke survivors returning home after rehabilitation, however there is currently a lack of evidence about preventing falls in this population. This paper describes the study protocol for the FLASSH (FaLls prevention After Stroke Survivors return Home) project.

Methods and design

This randomised controlled trial aims to evaluate the effectiveness of a multi-factorial falls prevention program for stroke survivors who are at high risk of falling when they return home after rehabilitation. Intervention will consist of a home exercise program as well as individualised falls prevention and injury minimisation strategies based on identified risk factors for falls. Additionally, two sub-studies will be implemented in order to explore other key areas related to falls in this population. The first of these is a longitudinal study evaluating the relationship between fear of falling, falls and function over twelve months, and the second evaluates residual impairment in gait stability and obstacle crossing twelve months after discharge from rehabilitation.

Discussion

The results of the FLASSH project will inform falls prevention practice for stroke survivors. If the falls prevention program is shown to be effective, low cost strategies to prevent falls can be implemented for those at risk around the time of discharge from rehabilitation, thus improving safety and quality of life for stroke survivors. The two sub-studies will contribute to the overall understanding and management of falls risk in stroke survivors.

Trial registration

This trial is registered with the Australian and New Zealand Clinical Trials Registry (ACTRN012607000398404).

Balance Score and a History of Falls in Hospital Predict Recurrent Falls in the 6 Months Following Stroke Rehabilitation

OBJECTIVE

To investigate predictors of recurrent falls in adults who return to community dwelling after stroke rehabilitation.

DESIGN

Prospective observational study.

SETTING

Community.

PARTICIPANTS

Fifty-five adults with stroke (mean age +/- standard deviation, 68.1+/-12.8y).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Baseline measures included balance, gait speed, muscle strength and tone, activity level, hemianopia, visual contrast sensitivity, hemineglect, medication use, fear of falling, and depression. Participants kept a 6-month prospective falls diary after discharge from rehabilitation.

RESULTS

Twenty-five (45%) participants reported falling, 12 had recurrent falls (> or =2 falls), and 13 fell once. Participants who fell recurrently had histories of falling during hospitalization or rehabilitation, poorer physical function measures, were taking more medications, and were more likely to have hemineglect than participants who fell once or did not fall (P<.05). A history of falling in the hospital or during rehabilitation, combined with poor balance (either Berg Balance Scale score <49 or step test score <7), predicted recurrent falls with sensitivity and specificity values greater than 80%.

CONCLUSIONS

Falls are a common occurrence after stroke. The predictive model developed can be used to identify people who are likely to have recurrent falls in the 6 months after stroke rehabilitation.

Gait aid use by ambulatory older people in a residential setting: a descriptive exploration

The aim of this study was to describe the use of gait aids by ambulatory older people in a residential care setting. A cross-sectional exploration generating both qualitative and quantitative data was undertaken in a South Australian low-care population (n = 31). Demographic data were collected via case note review. Type of aid, mode of use and reasons for gait aid use were investigated via a structured face-to-face interview.

Results identified four discrete groups of gait aid users in this population: those who used no aid (n = 5), those who used a stick only (n = 7), those who used a frame only (n = 13) and those who used both a stick and a frame (n = 6). In total, 31% of gait aids were self-prescribed and 33% of frames were used inappropriately. A vast range of psychosocial and behavioural factors was described by subjects to influence gait aid type and use. These findings suggest that self-prescription by older people may indicate alternative underlying needs that may be better met by therapeutic interventions other than gait aid prescription.