The effect of repositioning 3 hourly at night, using the 30 degree tilt, on the incidence of pressure ulcers, in older persons at risk of pressure ulcer development hospitalised in long-term care settings

Background: International best practice advocates the use of repositioning for the prevention of pressure ulcers; however, there is confusion surrounding the best method and frequency required. Therefore, a pragmatic, multi-centre, open label, prospective, cluster randomised controlled trial of repositioning for the prevention of pressure ulcers was undertaken. Aims: The aims of the study were to; compare the incidence of pressure ulcers among older persons in long-term care hospitals, nursed using two different repositioning regimes; identify pressure ulcer prevalence among older persons in long-term care, and to compare the cost implications of repositioning individuals using two different repositioning regimes. Methods: Ethical approval was received. Study sites (n=12) were randomly selected. Allocation to study groups was by cluster randomisation using remote randomisation. The experimental group (n=99) were repositioned 3-hourly at night, using the 30 degree tilt; the control group (n=114) received routine prevention. Data analysis was by intention-to-treat; follow up was for 4 weeks. For the prevalence study, participants comprised 1,100 older persons residing in the study settings. Data were collected using the Braden scale, the EPUAP minimum data set and the EPUAP pressure ulcer grading system. For the cost analysis, the focus was on the cost difference between the two study groups (in terms of the number of nurses needed per turn, the time per turn, the cost of a nurse per minute and the cost of dressing treatments and nurse time for dressing changes for pressure ulcers that developed during the study period). Results 1: For the prevalence study, all participants (n=1,100) were Irish Caucasian, 70% were female, and 75% were aged 80 years or older. Prevalence was 9%; 28% of pressure ulcers were grade 1, 33% grade 2, 15% grade 3 and 24% grade 4. The most common locations for pressure ulcers were the sacrum (58%) and the heel (25%). Seventy seven percent scored Braden low risk or not at risk, however, 53% were completely immobile/very limited mobility and 58% were chair/bedfast. There was a significant association between activity and mobility and pressure ulcer development (X2 45.50, p≤.0001 and X2 46.91, p≤.0001 respectively). Conversely, no association was found between nutrition and incontinence and pressure ulcer development (X2 15.96, p=.193 and X2 11.27, p=.506 respectively). Fifty percent had a pressure redistribution device in bed and 48% had one in use on the chair; although only 9% had a repositioning regimen planned for when in bed, and only 5% planned for when seated in the chair. Results 2: For the randomised controlled trial, all participants (n=213) were Irish Caucasian; 77% were female, and 65% were aged 80 years or older. Routine prevention for the control group was identified as turning during the night, on average, every six hours, using 90 degree lateral rotation. Three patients (3%) developed a pressure ulcer in the experimental group (3-hourly turning), whereas 13 patients (11%) developed a pressure ulcer in the control group (6-hourly turning), this difference was statistically significant (X2 5.347, p=.021). All pressure ulcers were grade 1 (44%) or grade 2 (56%). Results 3: For the economic analysis, the mean time-per-turn was 3.01 minutes (experimental), and 5.93 minutes (control). The mean number of nurses needed for each turn was 1.51 (experimental), and 2.02 nurses (control). The mean daily nurse time was 18.5 minutes (experimental) and 24.5 minutes (control) (p≤.0001). The daily mean difference between the groups was -6.00 minutes (95% CI -3.71 to -8.48). The cost per patient was €207.4 (experimental) and €274.3 (control) (p≤.0001). The mean difference between the groups is -€66.90 (95% CI –€24.68 to –€81.03). In the experimental group, 96.6% of participants remained free of pressure ulcers, 88.1% of patients remained pressure ulcer free in the control group (p=0.030). The incremental cost effectiveness ratio is -€787, thus the intervention is a dominant option (costs are lower for better outcomes). For the total study period, the cost of repositioning was €19,958.40 (experimental) and €31,270.20 (control). Total pressure ulcer dressing treatment was €3.87 (experimental) and €100.36 (control). Total costs were €19,962.27 (experimental) and €31,370.56 (control). The cost difference between the two positioning regimens was -€11,408.29. Projected annual costs of repositioning were estimated for those who would require repositioning of all individuals who where hospitalised across the study sites, using the 30 degree tilt compared to repositioning using standard care. Of these individuals, 53.5% would require repositioning based on Braden mobility scores. Costs for use of the 30 degree tilt were estimated as €258,402.48, these costs were estimated as €509,078.64 for standard care. The annual cost difference is -€250,676.16. Conclusion: This study reports on a ‘low-technological’ intervention that has shown to have a direct effect on pressure ulcer incidence. Repositioning older persons at risk of pressure ulcers every three hours at night, using the 30 degree tilt, reduces the incidence of pressure ulcers when compared to usual care. It is also less time consuming, requires less personnel and is more cost effective when compared with standard care. The study also reports on the first ever pressure ulcer prevalence survey conducted in long-term care in Ireland and results provide significant insights into decision-making and use of resources in the prevention of pressure ulcers

Implementation of a Quality Initiative in Higher Education - Peer Observation of Teaching

The change chosen for this project was the introduction of a pilot of peer observation of teaching. This was a joint project between the writer and a colleague. The rationale for choosing this project was the drive for enhanced quality assurance in teaching and learning within the writer’s organisation. The ultimate aim of this drive is that teaching and learning should be provided to the highest standards, and these standards should be continuously evaluated. Peer observation of teaching is one method of such evaluation; however developments were in an embryonic phase. Kotter’s change model and the CIPP evaluation model provided guidance throughout the project. A survey was sent to 66 undergraduate teaching staff to elicit perceptions of peer observation of teaching. Education was then provided to staff volunteers, following which they undertook one peer observation of teaching session, 5 staff acted as observers and 5 acted as observees. Focus group interviews were then held with the volunteers (n=7). Results from both the survey and focus groups were in congruence with each other and also with the literature, staff welcome the implementation of peer observations of teaching, favour a formative, developmental model, and suggest a structured observation tool with possibility for open ended comments. Staff had no previous training in giving or receiving feedback, or in use of formal reflection methods. The evaluation of the project provided the writer with guidance for the development of a model for the full roll out of peer observation within the organisation

Competition and Facilitation: Contrasting Effects of Artemisia Tridentata on Desert vs Montane Pines

Circumstantial evidence suggests that Artemisia tridentata may out-compete Pinus ponderosa and P. jefferyi for water at ecotones between shrub steppe and montane forest vegetation in the Great Basin. Other studies indicate that within the shrub steppe Artemisia may act as a nurse plant for a third species of pine, P. monophylla. We used field experiments to study these contrasting effects of Artemisia on P, ponderosa and P. monophylla within the contest of the distributional patterns in western Nevada of all three species on andesite, and on sites where hydrothermal activity has altered the andesite. At intermediate elevations in the Great Basin Artemisia and P. monophylla are restricted to unaltered desert soils, whereas P. ponderosa is restricted to acidic, nutrient-poor altered andesite. Although mature P. monophylla were virtually absent in our study plots on altered andesite, first- and second-year seedlings were common. On adjacent unaltered andesite, all size classes of P. monophylla occurred, and P. monophylla seedlings were associated with Artemisia shrubs. Pinus ponderosa and P. jefferyi adults and seedlings were rare on unaltered andesite, but a wide range of size classes was found on altered andesite. In experiments, all P. ponderosa seedlings on unaltered andesite were consumed by predators regardless of positive or negative spatial association with shrubs. Of the P, monophylla seedlings that germinated on unaltered andesite, all that were under shrubs survived, but only 6% of those that germinated in the intershrub spaces survived, On the open altered andesite the mortality of P. monophylla seedlings due to abiotic stress was high, with a final survival of only 3%, whereas 25% of P, ponderosa seedlings survived the iir-st growing season on altered andesite. On unaltered andesite, survival and conductance of P. ponderosa saplings was enhanced by shrub removal, but P. monophylla survival was significantly higher under shrubs than in shrub-removal plots or in intershrub spaces, In Artemisia-removal experiments, we found that Artemisia competed with P. ponderosa seedlings and saplings for water. Removal of Artemisia decreased water use efficiency (WUE) of P. monophylla seedlings. The absence of Artemisia may restrict Pinus monophylla from out-crops of altered andesite in the Great Basin, but provide refuges for P. ponderosa

Experiences of Interventions Aiming to Improve the Mental Health and Wellbeing of Children and Young People with a Long-Term Physical Condition: A Systematic Review and Meta-ethnography

This is the author accepted manuscript. The final version is available from Wiley via the DOI in this recordBackground Children and young people with long term physical health conditions are at increased risk of experiencing mental health and wellbeing difficulties. However, there is a lack of research that explores the experiences of, and attitudes towards interventions aiming to improve their mental health and wellbeing. This systematic review seeks to address this gap in the literature by exploring what children and young people with long term conditions, their caregivers and health practitioners perceive to be important aspects of interventions aiming to improve their mental health and wellbeing. Methods An information specialist searched five academic databases using pre‐defined criteria for qualitative evaluations of interventions aiming to improve the mental health or wellbeing of children with long term physical conditions. Reviewers also performed supplementary citation and grey literature searches. Two reviewers independently screened titles, abstracts and full texts which met the inclusion criteria and conducted data extraction and quality assessment. Meta‐ethnography was used to synthesise the findings. Results Screening identified 60 relevant articles. We identified five overarching constructs through the synthesis: i) Getting In and Staying In, ii) Therapeutic Foundation, iii) Social Support, iv) A Hopeful Alternative and v) Empowerment. The line of argument which links these constructs together indicates that when interventions can provide an environment that allows young people to share their experiences and build empathetic relationships; it can enable participants to access social support and increase feelings of hope and empowerment. Conclusion These findings may provide a framework to inform the development of mental health interventions for this population, and evaluate existing interventions which already include some of the components or processes identified by this research. Further research is needed to establish which of the constructs identified by the line of argument are most effective in improving the mental wellbeing of young people living with long term conditions.National Institute for Health Research (NIHR

An invitation to grieve: reconsidering critical incident responses by support teams in the school setting

This paper proposes that consideration could be given to an invitational intervention rather than an expectational intervention when support personnel respond to a critical incident in schools. Intuitively many practitioners know that it is necessary for guidance/counselling personnel to intervene in schools in and following times of trauma. Most educational authorities in Australia have mandated the formulation of a critical incident intervention plan. This paper defines the term critical incident and then outlines current intervention processes, discussing the efficacy of debriefing interventions. Recent literature suggests that even though it is accepted that a planned intervention is necessary, there is scant evidence as to the effectiveness of debriefing interventions in stemming later symptoms of post traumatic stress disorder. The authors of this paper advocate for an expressive therapy intervention that is invitational rather than expectational, arguing that not all people respond to trauma in the same way and to expect that they will need to recall and retell what has happened is most likely a dangerous assumption. A model of invitation using Howard Gardner’s (1983) multiple intelligences is proposed so that students are invited to grieve and understand emotionally what is happening to them following a critical incident

Simpson's paradox and calculation of number needed to treat from meta-analysis

BACKGROUND: Calculation of numbers needed to treat (NNT) is more complex from meta-analysis than from single trials. Treating the data as if it all came from one trial may lead to misleading results when the trial arms are imbalanced. DISCUSSION: An example is shown from a published Cochrane review in which the benefit of nursing intervention for smoking cessation is shown by formal meta-analysis of the individual trial results. However if these patients were added together as if they all came from one trial the direction of the effect appears to be reversed (due to Simpson's paradox). Whilst NNT from meta-analysis can be calculated from pooled Risk Differences, this is unlikely to be a stable method unless the event rates in the control groups are very similar. Since in practice event rates vary considerably, the use a relative measure, such as Odds Ratio or Relative Risk is advocated. These can be applied to different levels of baseline risk to generate a risk specific NNT for the treatment. SUMMARY: The method used to calculate NNT from meta-analysis should be clearly stated, and adding the patients from separate trials as if they all came from one trial should be avoided

Let me take the wheel: Illusory control and sense of agency

Illusory control refers to an effect in games of chance where features associated with skilful situations increase expectancies of success. Past work has operationalized illusory control in terms of subjective ratings or behaviour, with limited consideration of the relationship between these definitions, or the broader construct of agency. This study used a novel card-guessing task in 78 participants to investigate the relationship between subjective and behavioural illusory control. We compared trials in which participants (a) had no opportunity to exercise illusory control, (b) could exercise illusory control for free, or (c) could pay to exercise illusory control. Contingency Judgment and Intentional Binding tasks assessed explicit and implicit sense of agency, respectively. On the card-guessing task, confidence was higher when participants exerted control than in the baseline condition. In a complementary model, participants were more likely to exercise control when their confidence was high, and this effect was accentuated in the pay condition relative to the free condition. Decisions to pay were positively correlated with control ratings on the Contingency Judgment task, but were not significantly related to Intentional Binding. These results establish an association between subjective and behavioural illusory control and locate the construct within the cognitive literature on agency.J.T.W. is funded by a Cambridge Australia Poynton Scholarship. L.C., E.L.O. and M.R.F.A. were funded by a Medical Research Council [grant number G1100554/1]. C.M.G. is funded by a Sir Henry Welcome Postdoctoral Fellowship [grant number 101521/ Z/12/Z]

Baryon Washout, Electroweak Phase Transition, and Perturbation Theory

We analyze the conventional perturbative treatment of sphaleron-induced baryon number washout relevant for electroweak baryogenesis and show that it is not gauge-independent due to the failure of consistently implementing the Nielsen identities order-by-order in perturbation theory. We provide a gauge-independent criterion for baryon number preservation in place of the conventional (gauge-dependent) criterion needed for successful electroweak baryogenesis. We also review the arguments leading to the preservation criterion and analyze several sources of theoretical uncertainties in obtaining a numerical bound. In various beyond the standard model scenarios, a realistic perturbative treatment will likely require knowledge of the complete two-loop finite temperature effective potential and the one-loop sphaleron rate.Comment: 25 pages, 9 figures; v2 minor typos correcte