Mental health nurses’ support to caregivers of older adults with severe mental illness : a qualitative study

Background: Literature has shown the serious impact of severe mental illness on the daily life of caregivers. We studied reported caregiver support practices by mental health nurses for use in the development of a nursing intervention. We aimed to explore current caregiver support practices by mental health nurses. Methods: Twenty-one participants completed semi-structured interviews, and 17 participants attended two focus groups. All interviews were audio-taped, transcribed and coded for qualitative analysis. Results: The diversity in caregiver support could best be described by three prototypes: the tolerator, the preventer and the concerner, representing three approaches of involvement with caregivers. At one end of the spectrum are mental health nurses (MHN) who are essentially only concerned with the wellbeing of the care recipient and see the caregiver as a potential impediment in reaching the client’s goals. We call these the tolerators. At the other end of the spectrum are the MHNs who see the caregiver and the care recipient as inextricably connected with each other. In these cases the MHN directs her/his intervention towards both the informal caregiver and the care recipient. We call these the concerners. In the middle position are MHNs who realize that caregivers are important agents in the achievement of the client’s goals, and therefore consider preventing them from becoming overburdened as an important goal. We call these the preventers. Conclusions: Based on the extent to which the MHNs believe that the informal caregiver plays a necessary role in the client’s support system, and the degree to which they feel responsible for the caregiver’s wellbeing, three MHN prototypes can be distinguished. These prototypes determine how the nurses’ vision directs their understanding of their role and responsibilities and the content of their behaviour. This implies that a change in behaviour needs to be preceded by a change in vision. Therefore, promoting family support cannot be achieved by one-size-fits-all-programmes

The functional ability and health related quality of life of survivors of critical iliness after hospital discharge

Dissertation submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in fulfillment of the requirements for the degree of Master of Science in Physiotherapy Johannesburg, 2016Background: Critically ill patients face physical, psychological, and health-related quality of life (HRQOL) problems. Factors relating to the intensive care unit (ICU) stay of a critically ill patient may affect a patient’s HRQOL after discharge from hospital and may include the development of acute respiratory distress syndrome (ARDS) and sepsis, prolonged length of mechanical ventilation (MV) and prolonged periods of immobility. Organ dysfunction and multiple organ failure (MOF) influence a patient’s QOL after hospital discharge. The presence of chronic diseases such as chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM), and obesity may also contribute to the development of and severity of critical illness. Survivors of critical illness may be confronted with major problems during their recovery from critical illness. Limited South African data is available regarding the QOL of survivors of critical illness and limited research evidence is available to support rehabilitation services for this population after hospital discharge.The population of South Africa is a complex society and therefore has its own unique challenges that patients may face on a daily basis after a period of critical illness. These challenges may result in patients experiencing functional problems and a reduced HRQOL after critical illness. The aim of this study was to determine the functional ability and HRQOL of survivors of critical illness when assessed in the first six months after discharge from hospitals in South Gauteng. Methods: A prospective, observational, and longitudinal study was conducted using patients, who met the inclusion criteria for the study, in the ICU’s of a private hospital in Johannesburg. The acute physiology and chronic health evaluation II (APACHE II) and simplified acute physiology score II (SAPS II) were calculated and recorded for enrolled participants, as well as duration of MV, ICU length of stay (LOS) and hospital LOS. The physical function in ICU test scored (PFIT-s) was performed at the time of discharge from ICU and repeated at discharge from hospital. At one and six months after discharge from hospital, participants’ peripheral muscle strength was measured using a handheld dynamometer (HHD), exercise endurance was assessed using the six minute walking test (6MWT), and participants completed the short form 36 (SF-36) questionnaire, EuroQol Group 5 dimension (EQ-5D) questionnaire, patient health questionnaire (PHQ-9) and recent physical activity questionnaire (RPAQ). Results and Discussion: Twenty-four participants were enrolled into the study. The mean age was 51 (± 13.8) years, the majority were male (n=19, 79.2%), and most participants were employed (n=20, 83.3%) prior to the onset of critical illness. Half of the participants in this study presented with pre-existing disease prior to critical illness (n=12; 50%). Majority of participants underwent surgical interventions (n=19, 79.2%) which led to ICU admission and half of participants (n=12, 50%) reported having pre-morbid disease. All participants in the current study received physiotherapy treatment for the duration of their hospital stay. A significant change between mean PFIT-s interval scores (p=0.02) at ICU discharge and hospital discharge was found with a 0.4 points (± 0.7) change in interval scores. This change was not clinically significant, suggesting that not all the rehabilitation needs of these participants, who were recovering from critical illness, were met before their discharge from hospital. The increase in median 6MWT distance achieved was 65 meters, this being of clinical significance. There was no significant change in mean 6MWT distance achieved (53 meters ± 74.9).The limited mean distances that participants in this study were able to achieve during the 6MWT suggests that their endurance is impaired, which may impact their ability to perform activities of daily living. A marginally significant relationship was found between 6MWT distance at one month follow-up and SF-36 mental component score (MCS) at six months (p=0.05). Significant mean changes in peripheral muscle strength over six months after discharge were observed for right-sided (dominant side in all participants) elbow flexion (17.3 ±15.7, p=0.00), elbow extension (32.6 ± 37, p=0.02), hip abduction (53.4 ± 52.3, p=0.01), knee extension (59.9 ± 40.3, p=0.00), knee flexion (42.4 ± 31.3, p=0.00) and ankle dorsiflexion (29.9 ± 36.9, p=0.02), left-sided hip abduction (36.4 ± 45.2, p=0.02), knee flexion (40 ± 43.3, p=0.01), and ankle dorsiflexion (43.3 ± 48.1, p=0.03). The fact that majority of participants in this study lived alone may account for the improvements in muscle strength observed as they would be dependent on themselves for performing daily activities.The median PHQ-9 score showed an improvement of 2 points between one month and six months follow-up. A significant change in mean SF-36 physical component score (PCS) of 8.8 points (± 7.6, p=0.00) was observed over the six months period. This relates to improvements in the physical domain of HRQOL over the first six months after discharge from hospital following critical illness. The significant improvement in HRQOL related to PCS in the current study may be due to the fact that most participants lived alone and were self-dependent for daily activities even though they had some form of support from family and friends, and some of them had also returned to work by six months following discharge. Participants in the current study had several co-morbidities which may also have contributed to the lower observed mean PCS scores at six months. Significant changes in mean SF-36 domain scores were observed over six months for the role physical (RP) (p=0.00), bodily pain (BP) (p=0.05), general health (GH) (p=0.00), vitality (VT) (p=0.01) and the social functional (SF) (p=0.00). A significant mean change of 14.6 points (± 9.7) in EQ-5D visual analogue scale (VAS) scores was observed over six months after discharge. Participants’ abilities to mobilise, care for themselves and participate in usual activities (measured using the EQ-5D) improved over time as they continued to recover from critical illness. Large reduction in level of pain and discomfort experienced at six months as measured with the EQ-5D questionnaire may be due to wound healing that took place as the majority of participants underwent surgery. A significant relationship was found between the SF-36 PCS at one month follow-up and severity of illness (SAPS II) scores.Very weak and weak relationships were found between the SF-36 PCS and APACHE II scores (r=0.036) and SAPS II scores (r= 0.31) and moderate strength relationships were found between SF-36 PCS and PHQ-9 scores (r= -0.49) and 6MWT distance (r= 0.54) at six months follow-up. None of these relationships were statistically significant. Moderate strength negative relationships which were statistically significant, were identified between the SF-36 MCS and ICU LOS (r= -0.56; p=0.04) and hospital LOS (r= -0.56; p=0.04) at six month follow-up. A strong negative relationship was found between the SF-36 MCS at six months follow-up and duration of MV which was statistically significant (r= -0.7; p= 0.01). A strong negative relationship was found between SF-36 MCS scores and PHQ-9 scores at six months after discharge from hospital which was statistically significant (r= -0.72; p= 0.01). The main reasons reported by participants for not returning to work were pensioner status and physical weakness; however, at six months more than half of participants had returned to employment. The presence of depressive disorders did not directly influence return to work. The relatively good return to work rate observed may be attributed to the significant increases in muscle strength and PCS observed as well as the reduction in problems reported in relation to mobility, self-care, pain or discomfort and participation in usual activities over the first six months following discharge. Length of MV, SF-36 MCS and SF-36 PCS scores had no statistically significant relationship with exercise endurance at six months after hospital discharge. Limitations to this study include the small sample size and high drop-out rates. Conclusion: Survivors of critical illness in Gauteng province suffered from limitations in functional abilities at ICU discharge and improvements observed at hospital discharge were not clinically significant. Even though peripheral muscle strength improved significantly for participants in the six months following discharge, they still presented with limitations in exercise endurance. Significant improvements were observed in QOL related to physical functioning but little improvements were observed for QOL related to mental health. Some participants presented with symptoms of depression. More than half of participants returned to employment by six months following discharge. Findings from this study suggest that survivors of critical illness don’t recover fully on their own after an episode of acute illness. These results should be used to motivate for implementation of structured rehabilitation programmes, including counselling, to aid the physical, emotional and mental recovery of survivors of critical illness in the long term after hospital discharge.MT201

Improved neutrino point source search method for IceCube's high energy starting event sample

High Energy Neutrino Astronomy is a new field that has the potential to solve the mystery of the origin of cosmic ray particles, the highest energy particles that have been observed. The IceCube Neutrino Observatory has recently discovered the existence of a high energy astrophysical neutrino flux. We are able to calculate for our "track-like" sub-population of events a directional origin to within a square degree, yet it remains difficult to establish whether these neutrinos come from bright distinguishable sources or a sea of individual weak neutrino producers. The current goal of neutrino point source analyses is the observation of a bright neutrino source above expected background rates of neutrinos, in our case both from a uniform distribution of astrophysical neutrino sources and background neutrino events produced in cosmic ray interactions with our own atmosphere. This thesis presents a new form of point source analysis that tests the data under the model of the combination of multiple background hypotheses and a single point source hypothesis, where the predicted background distributions can be produced through simulation. We apply this analysis to the High Energy Starting Event sample produced by IceCube, and show how this analysis differs to previous analyses on these events. We find that the fit using a background in the likelihood that does not match the distribution of the events can result in a bias in the fitted strength of a point source, and that the relative power of the analysis compared to the previous point source analysis can depend on the point source location, where the power is seen to be comparable in the southern sky but improved in the northern sky. Our results from applying our new form of point source analysis to the data do not show strong evidence for a point source hypothesis, with p-values of 0.468 for all events in our sample and 0.922 for a subset of shower topology events in our sample.Thesis (Ph.D.) -- University of Adelaide, School of Physical Sciences, 201

A journey into causes of corporate misbehaviour:Why corporate legal disciplines and regulation need to be structurally reformed

Corporations are the most powerful economic entities in contemporary society. The main finding in this thesis is that existing regulatory approaches in corporate law, corporate governance and corporate social responsibility are methodologically suboptimal and politically biased. Their continued use entrenches corporate power and undermines our ability to properly deal with the social, economic and environmental effects of corporate misbehaviour. This conclusion draws on insights from twelve disciplines: law, political economics, economics, psychology, anthropology, management studies, sociology, political science, criminology, theology, media studies and philosophy. The resolution of global crises such as climate change, biodiversity loss and inequality requires us to urgently reform corporate law, corporate governance and corporate social responsibility. The reform chapter outlines how such an overhaul can be achieved without fundamental shocks to the economy

Constraints on Minute-Scale Transient Astrophysical Neutrino Sources

High-energy neutrino emission has been predicted for several short-lived astrophysical transients including gamma-ray bursts (GRBs), core-collapse supernovae with choked jets, and neutron star mergers. IceCube’s optical and x-ray follow-up program searches for such transient sources by looking for two or more muon neutrino candidates in directional coincidence and arriving within 100 s. The measured rate of neutrino alerts is consistent with the expected rate of chance coincidences of atmospheric background events and no likely electromagnetic counterparts have been identified in Swift follow-up observations. Here, we calculate generic bounds on the neutrino flux of short-lived transient sources. Assuming an E^−2.5 neutrino spectrum, we find that the neutrino flux of rare sources, like long gamma-ray bursts, is constrained to <5% of the detected astrophysical flux and the energy released in neutrinos (100 GeV to 10 PeV) by a median bright GRB-like source is <10^52.5 erg. For a harder E^−2.13 neutrino spectrum up to 30% of the flux could be produced by GRBs and the allowed median source energy is <10^52  erg. A hypothetical population of transient sources has to be more common than 10^−5   Mpc^−3 yr^−1 (5×10^−8   Mpc^−3 yr^−1 for the E^−2.13 spectrum) to account for the complete astrophysical neutrino flux

Old-Age Exclusion: Active Ageing, Ageism and Agency (Editorial)

This editorial serves a double purpose. It introduces the articles and commentary comprising this thematic issue on old-age exclusion, and simultaneously aims to make a concise contribution to the discussion on the relation between agency of older people and old-age exclusion. While indeed it is clear that limitations of agency due to a lack of resources in old age or age discrimination lead to exclusion of older people, the relationship between reduced agency and exclusion is less clear in the case of internalized age norms. It ends with a plea for surveys studying older populations to pay more attention to older people's identities and life goals, opinions and reasons for action