Diabetic foot ulcers - predictors of healing time and aspects of telemedicine

Background: A diabetic foot ulcer (DFU) is a feared complication of diabetes. Both duration and severity of ulcer before start of treatment in specialist health care are factors that can effect healing time for patient with DFUs. More research about duration and severity of DFUs before seeking care as predictors of healing time might contribute to knowledge of importance for clinical interventions. Treatment of DFUs puts pressure on the health care system in terms of utilization of available resources. Moreover, the prevalence of diabetes is increasing dramatically and, as a result, longterm diabetes-related complications are also likely to increase. Telemedicine can be one way to address these issues, because telemedicine follow up may enable more integrated care pathways across health care levels. Telemedicine has been used in different settings, but knowledge of telemedicine’s effect on clinical outcomes and patients’ experiences among patients with DFUs is limited. Aims: The overall aim of this study was to provide new knowledge about predictors of healing time in patients with a DFU and to assess the effect of and experience with a telemedicine intervention for patients with a DFU. To achieve the overall aim, three specific aims were established: 1) to investigate whether A) duration of ulcer before start of treatment in specialist health care, and B) severity of ulcer according to the University of Texas (UT) classification system at the start of treatment (baseline), are independent predictors of healing time; 2) to evaluate whether telemedicine follow up of patients with DFUs treated in primary health care, in collaboration with hospital outpatient specialist care, is noninferior to standard outpatient care in terms of ulcer healing time. Further, to assess for superior whether amputations, death, consultations and patient satisfaction are different from telemedicine follow up compared to standard outpatient care; and, 3) to explore the experiences of patients with DFUs receiving telemedicine compared to patients receiving standard outpatient care health care delivered in the context of a cluster randomised controlled trial. Methods: Three different study designs were used. Study I: A retrospective cohort study included data from electronic medical records system of 105 patients with new DFUs from two outpatient clinics in Western Norway during 2009-2011. Competing risk regression with adjustment for potential confounders was used to evaluate the associations of duration and severity of the ulcer with healing time. Study II: In this pragmatic cluster randomised controlled non-inferiority trial, 182 patients (94/88 in telemedicine/standard outpatient care; 42 clusters) with a new DFU were recruited from three hospital outpatient clinics in Western Norway (from September 2012 to June 2016). The primary endpoint was healing time and secondary endpoints included amputation, death, number of consultations per month, and patient satisfaction. Study III: In the qualitative study individual interviews were conducted with 24 adults recruited from the cluster randomised controlled non-inferiority trial (n=13/ n=11 from the telemedicine /standard outpatient care group) in the period March 2014-May 2015. Results: Study 1: Of the 105 adults, 48 (45.7%) achieved ulcer healing, 38 (36.2%) underwent amputations, 10 (9.5%) died before ulcer healing and 9 (8.5%) were lost to follow up. For those who healed, mean healing time was 3.8 months (113 days), measured from start of treatment in the specialist health care to end of follow up. Time from patient-reported ulcer onset to referral by general practitioner (GP) to specialist health care was found to be a strong predictor of healing time. Patients who were referred to specialist health care by a GP ≥ 52 days after ulcer onset had a 58% (Sub hazard ratio (SHR) 0.42, CI 0.18, 0.98) decreased healing rate compared with patients who were referred earlier. Ulcers with the highest severity i.e. ulcer penetrating to tendon or bone (grade 2/3) and peripheral arterial disease with and without infection (stage C/D) according to the UT classification system had an 86% (SHR 0.14, CI 0.05, 0.43) decreased healing rate compared with low severity i.e. superficial ulcer (grade 1) with infection (stage A/B) or ulcer penetration to tendon/capsula (grad 2) and clean ulcer (stage A). Study II: Of 182 patients, 142 (78.9%) achieved complete ulcer healing, and 75 (79.8%) healed in the telemedicine group and 67 (76.1%) in the standards outpatient care group. Mean healing including only those who healed was 3.4 months and 3.8 months in the telemedicine group and standard outpatient group, respectively. Telemedicine was non-inferior to standard outpatient care regarding healing time (mixed-effects regression analysis: (mean difference –0.43 months, 95% CI –1.50, 0.65). This finding persisted also after taking into account competing risk from death and amputation (SHR 1.16, 95% CI 0.85, 1.59). There were no significant differences between the telemedicine follow up and standard outpatient care related to the effect estimate of the secondary outcomes, except for significantly fewer amputations in the telemedicine group. Study III: Three themes emerged from the analysis: 1) competence of health care professionals, 2) continuity of care, and 3) easy access, i.e. to receive treatment and follow up near home or at their home. Group allocation seemed to have limited impact on the patients’ follow-up experiences. Competence of health care professionals and continuity of care were important, because they could either enhance or impair wound care. When telemedicine functioned as intended, it was an advantage in the treatment. Easy access was important for the participants, but the importance of accessibility appeared only when competence among health care professionals and continuity of care were present. Conclusions: Early referral to specialist health care if an ulcer occurs is crucial for optimal ulcer healing and has a clear implication for routine care. Grade and stage severity are also important predictors for healing time, and early screening to assess the severity and initiation of prompt treatment is important. Telemedicine can be an alternative but also a supplement to usual care for patients with DFUs, at least for patients with more superficial ulcers. As the number of outpatient clinic consultations in the telemedicine group did not differ from the standard care group, there is need to focus on organisational aspects to facilitate the use of telemedicine. Health care professionals’ competence, continuity of care and easy access to health care services were essential for patients with DFUs, and telemedicine may compensate for lack of these factors

A rollercoaster of emotions: An integrative review of emotions and its impact on health professional students' learning in simulation-based education

publishedVersio

The affective component of learning in simulation-based education – facilitators’ strategies to establish psychological safety and accommodate nursing students’ emotions

This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visithttp://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data..Background: Active learning situations such as simulation-based education (SBE) are found to trigger a wide range of emotions among students. Facilitators have an important educational role in SBE which include being attentive and adaptive to students’cognitive and afective responses. Although the importance of emotions in SBE is recog nized in facilitator guidelines, little is known about how facilitators accommodate student afect. Hence, this study explores facilitators’ strategies for addressing students’ emotions in SBE. Method: Individual interviews with nine facilitators were performed and transcripts were subjected to qualitative analyses in accordance with interpretive description approach. Results: Findings show that facilitators are attentive to and continuously assess students’ emotional responses in SBE. Both positive emotions, such as interest and surprise, and negative emotions such as anxiety are cultivated, yet adapted to the perceived needs of the individual student. Psychological safety was seen as a prerequisite for optimal learning, regardless of the students’ previous level of knowledge. Furthermore, signifcant learning was seen as some thing that might also arise from uncomfortable experiences, such as students realizing their own mistakes or uncer tainty. Hence facilitators were found to balance levels of difculty, emotional arousal and psychological safety during the various phases of SBE. Conclusion: Facilitators recognize the emotional dimension of learning in SBE and have numerous strategies for accommodating students’ emotions. This study highlights the complexity of the facilitator’s role in adapting training to individual cognitive and emotional needs. These fndings have implications for facilitator training which should include awareness of the role of emotions in learning and strategies for observing and accommodating training to meet emotional needs.publishedVersio

The affective component of learning in simulation-based education – facilitators’ strategies to establish psychological safety and accommodate nursing students’ emotions

Background Active learning situations such as simulation-based education (SBE) are found to trigger a wide range of emotions among students. Facilitators have an important educational role in SBE which include being attentive and adaptive to students’cognitive and affective responses. Although the importance of emotions in SBE is recognized in facilitator guidelines, little is known about how facilitators accommodate student affect. Hence, this study explores facilitators’ strategies for addressing students’ emotions in SBE. Method Individual interviews with nine facilitators were performed and transcripts were subjected to qualitative analyses in accordance with interpretive description approach. Results Findings show that facilitators are attentive to and continuously assess students’ emotional responses in SBE. Both positive emotions, such as interest and surprise, and negative emotions such as anxiety are cultivated, yet adapted to the perceived needs of the individual student. Psychological safety was seen as a prerequisite for optimal learning, regardless of the students’ previous level of knowledge. Furthermore, significant learning was seen as something that might also arise from uncomfortable experiences, such as students realizing their own mistakes or uncertainty. Hence facilitators were found to balance levels of difficulty, emotional arousal and psychological safety during the various phases of SBE. Conclusion Facilitators recognize the emotional dimension of learning in SBE and have numerous strategies for accommodating students’ emotions. This study highlights the complexity of the facilitator’s role in adapting training to individual cognitive and emotional needs. These findings have implications for facilitator training which should include awareness of the role of emotions in learning and strategies for observing and accommodating training to meet emotional needs.publishedVersio

Culture crash regarding nursing students' experience of implementation of EBP in clinical practice

Dette er en pdf av forlagets publiserte versjon etter avtale. Tidsskriftets side: http://www.vardinorden.no/vin/forsideAims: The aim of this study was to examine nursing students’ experiences of the implementation of evidence-based practice (EBP) in a clinical setting. Background: Educating students in EBP is a challenge to both faculties and clinical practices, because EBP educational interventions may improve knowledge but do not ensure application of EBP in clinical settings. Becoming skilled in the application of EBP requires practice and nurses that motivate students to use EBP. Methods: Fourteen second-year students were divided into three focus groups according to the ward in which they undertook their clinical practice. Each group contained 4–5 students. Findings: The students were able to implement EBP according to the goals of the syllabus, but encountered a clinical setting that was insufficiently prepared, both structurally and in terms of knowledge, to mentor them regarding EBP. The findings indicate a culture crash between the students’learning goals of EBP at the faculty and the application of EBP in practice. Conclusion: The results of this study demonstrated that EBP is feasible in clinical practice, but highlighted the various factors obstructing its implementation. There is a need to find pathways to reduce hindrance in implementation of EBP

Health professional students’ self-reported emotions during simulation-based education: An interpretive descriptive study

This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)Aim: This study aimed to explore active students’ experiences of emotions during simulation-based education (SBE) sequences when a simulation was performed as a part of formal curriculum in natural educational settings and to consider the practical educational implications of the findings. Background: An SBE approach is used widely in nursing education. Emotions are necessary for learning to take place and some of these can prevent or promote learning. This is an active and affective learning activity that can trigger various emotions. Previous research in SBE has studied student anxiety, which has been frequently measured quantitatively. An understanding of students’ emotions can give valuable insight into the learning process and improve nursing educational practice. Methods: The study took place in four Norwegian universities. It was guided by interpretive descriptions, which involve qualitative methodology. This study was approved by the Norwegian Centre for Research Data (No: 59059). Data were collected using an interpersonal process interview with eight healthcare professional students after participating in SBE. Results: The results show that students experienced coexisting and changing emotions during the shifting academic scenes in the simulations. During briefing, scenario and debriefing, students experienced being activated and had coexisting pleasant and unpleasant emotions. Unpleasant emotions were found to decrease during the simulation. Numerous identified emotions were found to be valuable for learning. Conclusion: The insight into students’ experience of arousal, negative emotions and the potential for SBE to trigger students’ comprehensive academic emotions have implications for nurse educators when planning and facilitating simulations.publishedVersio

Characteristics of a self-management support programme applicable in primary health care: a qualitative study of users’ and health professionals’ perceptions

BACKGROUND: Development of more self-management support programmes in primary health care has been one option used to enhance positive outcomes in chronic disease management. At present, research results provide no consensus on what would be the best way to develop support programmes into new settings. The aim of the present study was therefore to explore users’ and health professionals’ perceptions of what would be the vital elements in a self - management support programme applicable in primary health care, how to account for them, and why. METHODS: Four qualitative, semi-structured focus group interviews were conducted in Central Norway. The informants possessed experience in development, provision, or participation in a self-management support programme. Data was analysed by the Systematic Text Condensation method. RESULTS: The results showed an overall positive expectation to the potential benefits of development of a self-management support programme in primary health care. Despite somewhat different arguments and perspectives, the users and the health professionals had a joint agreement on core characteristics; a self-management support programme in primary health care should therefore be generic, not disease specific, and delivered in a group- based format. A special focus should be on the everyday- life of the participants. The most challenging aspect was a present lack of competence and experience among health professionals to moderate self-management support programmes. CONCLUSIONS: The development and design of a relevant and applicable self-management support programme in primary health care should balance the interests of the users with the possibilities and constraints within each municipality. It would be vital to benefit from the closeness of the patients’ every-day life situations. The user informants’ perception of a self-management support programme as a supplement to regular medical treatment represented an expanded understanding of the self-management support concept. An exploring approach should be applied in the development of the health professionals’ competence in practice. The effect of a self-management support programme based on the core characteristics found in this study needs to be evaluated

Nursing staff’s knowledge and attitudes towards Dementia in an Indian nursing home: A qualitative interview study

Background: Despite the increased prevalence of dementia in India, there is reported to be little awareness of the disease. This could lead to a late diagnosis, a reduced number of choices regarding future care, and misinterpretation of the symptoms or neglect. Taking into consideration that most nurses caring for older people in the future will work with people with dementia, there is concern that they may not be able to meet the needs of this group of patients unless they have the necessary knowledge and a positive attitude. Aim: To explore the knowledge about and attitude towards dementia among nursing staff working in residential care facilities for older people in India. Method: An explorative and descriptive qualitative design was used. Two semistructured focus group interviews were conducted with nursing staff working in 6 nursing homes in India. Qualitative content analysis was used. Ethical approval was granted by the Norwegian Social Science Data Services. Findings: The participants highlighted the following 3 dimensions in relation to their knowledge of and attitudes toward dementia in residential care facilities in India: (1) people with dementia – a walking mystery; (2) we need to go along with them, but it is challenging; and (3) if we know, we can care for them in a better way. Conclusion: The findings revealed a wide range of differences in attitude towards and inadequate knowledge of dementia among nursing staff. However, their overall attitudes toward people with dementia was positive.publishedVersio

Ringvirkninger av petroleumsnæringen i norsk økonomi

Denne rapporten studerer hvordan aktiviteten i ulike næringer i norsk økonomi påvirkes direkte av etterspørselen fra petroleumsnæringen gjennom næringenes leveranser av varer og tjenester. Det er to typer av leveranser som identifiseres: 1. De direkte leveransene fra ulike norske næringer og utlandet til petroleumsnæringen i form av investeringsvarer og produktinnsats. Dette er næringenes produksjon som leveres direkte til petroleumsnæringen. 2. Summen av de direkte og indirekte leveransene fra ulike norske næringer til petroleumsnæringen i form av bruttoprodukt (verdiskapning) i næringene og den tilhørende sysselsettingen. Denne analysen ser ikke bare på de direkte leveransene, men også på summen av direkte og indirekte leveranser. Det benyttes en kryssløpsmodell med tall fra produktkryssløpet i nasjonalregnskapet for å tallfeste leveransene til petroleumsnæringen. Vi beregner andelen av verdiskapningen i hver enkelt næring som kan knyttes til leveransene til petroleumsnæringen, og hvor mye denne andelen utgjør av petroleumsnæringens samlede etterspørsel.Prosjektet er delfinansiert av Norges Bank