An Appreciative Inquiry into Medication Administration by Registered Nurses: The Untold Story

Registered nurses (RNs) worldwide are educated and authorised to administer medications as part of their role. The framework used to guide the practice of safely administering the right dose of the right medication by the right route to the right patient at the right time is known internationally as the 'five rights'. The five rights framework is pervasive in the nursing literature and has underpinned a plethora of research studies focused on medication error identification and management. Most of these studies seek error rates and causes and rarely explore the actions or experiences of nurses who administer medications, other than in relation to their adherence to the five rights framework. This study offers a different perspective. This two-phase qualitative, appreciative inquiry used Medication Services Queensland's (2009a) rights framework as the basis for observing the medication administration practices of RNs in a regional hospital in Queensland, Australia. The five rights framework in this region has been extended for public health system employees by the addition of a sixth right that requires the nurse to offer the patient the right to refuse the medication. The observation phase provided a rich contextual backdrop for the next phase, in which the participants were interviewed about their experiences. The participants were asked to explain their observed practices. The study found that by taking an appreciative inquiry approach to medication administration, person-centred nursing practices that contribute to the safe administration of medication emerged. This alternate view of medication administration has the potential to encourage further research and development of hidden strengths in nursing practices such as coordination and management of medication related processes

Interventions for drug-using offenders with co-occurring mental illness: : A systematic review and economic appraisal

Background: Drug-using offenders with co-occurring mental health problems are common in the criminal justice system. A combination of drug use and mental health problems makes people more likely to be arrested for criminal involvement after release compared to offenders without a mental health problem. Previous research has evaluated interventions aimed broadly at those with a drug problem but rarely with drug use and mental health problems. This systematic review considers the effectiveness of interventions for drug-using offenders with co-occurring mental health problems. Methods: We searched 14 electronic bibliographic databases up to May 2014 and five Internet resources. The review included randomised controlled trials designed to reduce, eliminate, or prevent relapse of drug use and/or criminal activity. Data were reported on drug and crime outcomes, the identification of mental health problems, diagnoses and resource information using the Drummond checklist. The systematic review used standard methodological procedures as prescribed by the Cochrane collaboration. Results: Eight trials with 2058 participants met the inclusion criteria. These evaluated: case management (RR, 1.05, 95 % CI 0.90 to 1.22, 235 participants), motivational interviewing and cognitive skills, (MD-7.42, 95 % CI-0.20.12 to 5.28, 162 participants) and interpersonal psychotherapy (RR 0.67, 95 % CI 0.3 to 1.5, 38 participants). None of these trials reported significant reductions in self-report drug misuse or crime. Four trials evaluating differing therapeutic community models showed reductions in re-incarceration (RR 0.28, 95 % CI 0.13 to 0.63, 139 participants) but not re-arrest (RR 1.65, 95 % CI 0.83 to 3.28, 370 participants) or self-report drug use (RR 0.73, 95 % CI 0.53 to 1.01, 370 participants). Mental health problems were identified across the eight trials and 17 different diagnoses were described. Two trials reported some resource information suggesting a cost-beneficial saving when comparing therapeutic communities to a prison alternative. Conclusions: Overall, the studies showed a high degree of variation, warranting a degree of caution in the interpretation of the magnitude of effect and direction of benefit for treatment outcomes. Specifically, tailored interventions are required to assess the effectiveness of interventions for drug-using offenders with co-occurring mental health problems

IMPaCT Back study protocol. Implementation of subgrouping for targeted treatment systems for low back pain patients in primary care: a prospective population-based sequential comparison.

BACKGROUND: Prognostic assessment tools to identify subgroups of patients at risk of persistent low back pain who may benefit from targeted treatments have been developed and validated in primary care. The IMPaCT Back study is investigating the effects of introducing and supporting a subgrouping for targeted treatment system in primary care. METHODS/DESIGN: A prospective, population-based, quality improvement study in one Primary Care Trust in England with a before and after design. Phases 1 and 3 collect data on current practice, attitudes and behaviour of health care practitioners, patients' outcomes and health care costs. Phase 2 introduces and supports the subgrouping for targeted treatment system, via a multi-component, quality improvement intervention that includes educational courses and outreach visits led by opinion leaders, audit/feedback, mentoring and organisational support to embed the subgrouping tools within IT and clinical management systems.We aim to recruit 1000 low back pain patients aged 18 years and over consulting 7 GP practices within one Primary Care Trust in England, UK. The study includes GPs in participating practices and physiotherapists in associated services. The primary objective is to determine the effect of the subgrouping for targeted treatment system on back pain related disability and catastrophising at 2 and 6 months, comparing data from phase 1 with phase 3. Key secondary objectives are to determine the impact on: a) GPs' and physiotherapists' attitudes and behaviour regarding low back pain; b) The process of care that patients receive; c) The cost-effectiveness and sustainability of the new clinical system. DISCUSSION: This paper details the rationale, design, methods, planned analysis and operational aspects of the IMPaCT Back study. We aim to determine whether the new subgrouping for targeted treatment system is implemented and sustained in primary care, and evaluate its impact on clinical decision-making, patient outcomes and costs. STUDY REGISTRATION: International Standard Randomised Controlled Trial Number Register ISRCTN55174281.RIGHTS : This article is licensed under the BioMed Central licence at http://www.biomedcentral.com/about/license which is similar to the 'Creative Commons Attribution Licence'. In brief you may : copy, distribute, and display the work; make derivative works; or make commercial use of the work - under the following conditions: the original author must be given credit; for any reuse or distribution, it must be made clear to others what the license terms of this work are

Household disposal of pharmaceuticals: Attitudes and risk perception in a UK sample

Pharmaceuticals can enter the environment through disposal in toilets, sinks and general waste. In the UK, household medicines are correctly disposed of by returning them to a pharmacy. This study examined household patterns of medicine waste, storage and disposal practices via a cross-sectional survey with 663 UK adults. Multiple regression was used to explore the contribution of key variables on self-reported medicines disposal behaviour. Analysis demonstrated that age, information, awareness, probability, attitude and intention all predicted correct disposal behaviour. Results indicate that multiple factors influence different disposal destinations uniquely. Affect and age increase disposal in sink/toilet but reduce disposal in bin. Presence of children increase bin and sink/toilet disposal but decrease pharmacy returns. Awareness and received information on correct disposal reduce bin disposal and increase pharmacy returns. The results suggest people use different mental models for each destination with disposal in sink/toilets and bins considered quicker and safer in the presence of children or for those feeling anxious. It is important to understand the capability, opportunity and motivation people have to return medicines to the pharmacy in addition to raising awareness of correct medicine disposal

Optimising outcomes of exercise and corticosteroid injection in patients with subacromial pain (impingement) syndrome: a factorial randomised trial

Objectives: To compare the clinical effectiveness of (1) physiotherapist-led exercise versus an exercise leaflet, and (2) ultrasound-guided subacromial corticosteroid injection versus unguided injection for pain and function in subacromial pain (formerly impingement) syndrome (SAPS).Methods: This was a single-blind 2×2 factorial randomised trial. Adults with SAPS were randomised equally to one of four treatment groups: (1) ultrasound-guided corticosteroid injection and physiotherapist-led exercise, (2) ultrasound-guided corticosteroid injection and an exercise leaflet, (3) unguided corticosteroid injection and physiotherapist-led exercise and (4) unguided corticosteroid injection and an exercise leaflet. The primary outcome was the Shoulder Pain and Disability Index (SPADI), collected at 6 weeks, 6 and 12 months and compared at 6 weeks for the injection interventions and 6 months for the exercise interventions by intention to treat.Results: We recruited 256 participants (64 treatment per group). Response rates for the primary outcome were 94% at 6 weeks, 88% at 6 months and 80% at 12 months. Greater improvement in total SPADI score was seen with physiotherapist-led exercise than with the exercise leaflet at 6 months (adjusted mean difference -8.23; 95% CI -14.14 to -2.32). There were no significant differences between the injection groups at 6 weeks (-2.04; -7.29 to 3.22), 6 months (-2.36; -8.16 to 3.44) or 12 months (1.59; -5.54 to 8.72).Conclusions: In patients with SAPS, physiotherapist-led exercise leads to greater improvements in pain and function than an exercise leaflet. Ultrasound guidance confers no additional benefit over unguided corticosteroid injection

Comparison of two modern vaccines and previous influenza infection against challenge with an equine influenza virus from the Australian 2007 outbreak

During 2007, large outbreaks of equine influenza (EI) caused by Florida sublineage Clade 1 viruses affected horse populations in Japan and Australia. The likely protection that would be provided by two modern vaccines commercially available in the European Union (an ISCOM-based and a canarypox-based vaccine) at the time of the outbreaks was determined. Vaccinated ponies were challenged with a representative outbreak isolate (A/eq/Sydney/2888-8/07) and levels of protection were compared. A group of ponies infected 18 months previously with a phylogenetically-related isolate from 2003 (A/eq/South Africa/4/03) was also challenged with the 2007 outbreak virus. After experimental infection with A/eq/Sydney/2888-8/07, unvaccinated control ponies all showed clinical signs of infection together with virus shedding. Protection achieved by both vaccination or long-term immunity induced by previous exposure to equine influenza virus (EIV) was characterised by minor signs of disease and reduced virus shedding when compared with unvaccinated control ponies. The three different methods of virus titration in embryonated hens’ eggs, EIV NP-ELISA and quantitative RT-PCR were used to monitor EIV shedding and results were compared. Though the majority of previously infected ponies had low antibody levels at the time of challenge, they demonstrated good clinical protection and limited virus shedding. In summary, we demonstrate that vaccination with current EIV vaccines would partially protect against infection with A/eq/Sydney/2888-8/07-like strains and would help to limit the spread of disease in our vaccinated horse population

Are Non-Pharmacological Interventions Effective in Reducing Drug Use and Criminality? : A Systematic and Meta-Analytical Review with an Economic Appraisal of These Interventions

Background: The numbers of incarcerated people suffering from drug dependence has steadily risen since the 1980s and only a small proportion of these receive appropriate treatment. A systematic review to evaluate the effectiveness and economic evidence of non-pharmacological interventions for drug using offenders was conducted. Methods: Cochrane Collaboration criteria were used to identify trials across 14 databases between 2004 and 2014. A series of meta-analyses and an economic appraisal were conducted. Results: 43 trials were identified showing to have limited effect in reducing re-arrests RR 0.97 (95% CI 0.89-1.07) and drug use RR 0.90 (95% CI 0.80-1.00) but were found to significantly reduce re-incarceration RR 0.70 (95% CI 0.57-0.85). Therapeutic community programs were found to significantly reduce the number of re-arrests RR 0.70 (95% CI 0.56-0.87). 10 papers contained economic information. One paper presented a cost-benefit analysis and two reported on the cost and cost effectiveness of the intervention. Conclusions: We suggest that therapeutic community interventions have some benefit in reducing subsequent re-arrest. We recommend that economic evaluations should form part of standard trial protocols

Convergent evolution of floral signals underlies the success of Neotropical orchids

The great majority of plant species in the tropics require animals to achieve pollination, but the exact role of floral signals in attraction of animal pollinators is often debated. Many plants provide a floral reward to attract a guild of pollinators, and it has been proposed that floral signals of non-rewarding species may converge on those of rewarding species to exploit the relationship of the latter with their pollinators. In the orchid family (Orchidaceae), pollination is almost universally animal-mediated, but a third of species provide no floral reward, which suggests that deceptive pollination mechanisms are prevalent. Here, we examine floral colour and shape convergence in Neotropical plant communities, focusing on certain food-deceptive Oncidiinae orchids (e.g. Trichocentrum ascendens and Oncidium nebulosum) and rewarding species of Malpighiaceae. We show that the species from these two distantly related families are often more similar in floral colour and shape than expected by chance and propose that a system of multifarious floral mimicry—a form of Batesian mimicry that involves multiple models and is more complex than a simple one model–one mimic system—operates in these orchids. The same mimetic pollination system has evolved at least 14 times within the species-rich Oncidiinae throughout the Neotropics. These results help explain the extraordinary diversification of Neotropical orchids and highlight the complexity of plant–animal interactions

Accountability and rural development partnerships: a study of Objective 5b EAGGF funding in South West England

Author's pre-print version. Final version available online at http://www.sciencedirect.com/Funding for Rural Development Partnerships has signalled a shift in rural policy, towards actively involving the rural population in determining the direction and implementation of change. However, early experience with partnerships has indicated that the funding bodies have retained significant control. One reason for this is that they are constrained by their accountability requirements. Furthermore, with not all members of the partnership accountable to the same degree, the funding bodies bear a significant proportion of the risk of new ventures which can result in conservative decisions. A study of the EAGGF component of an EU Objective 5b Programme in the South West of England highlights the tensions that can arise in a partnership from existing accounting arrangements. The lack of a trusting relationship between state and citizens resulted in excessively formal accountability requirements, creating difficulties for applicants, and producing risk-averse decisions by state administrative bodies. However, the case study demonstrates that through the development of networks, both accountability and thereby project responsibility and risk could be more widely spread, creating opportunities for locally shaped, novel and flexible development

Characterizing uncertainty of the hydrologic impacts of climate change

The high climate sensitivity of hydrologic systems, the importance of those systems to society, and the imprecise nature of future climate projections all motivate interest in characterizing uncertainty in the hydrologic impacts of climate change. We discuss recent research that exposes important sources of uncertainty that are commonly neglected by the water management community, especially, uncertainties associated with internal climate system variability, and hydrologic modeling. We also discuss research exposing several issues with widely used climate downscaling methods. We propose that progress can be made following parallel paths: first, by explicitly characterizing the uncertainties throughout the modeling process (rather than using an ad hoc “ensemble of opportunity”) and second, by reducing uncertainties through developing criteria for excluding poor methods/models, as well as with targeted research to improve modeling capabilities. We argue that such research to reveal, reduce, and represent uncertainties is essential to establish a defensible range of quantitative hydrologic storylines of climate change impacts