Non-specialist Settings Research Articles

'Clinical Is the Pinnacle': Nurse Academics' Perspectives and Opinions of Their Students Undertaking Mental Health Clinical Placements.

Clinical placements form an integral and important part of preregistration nursing student learning. The theory-practice gap has been identified as problematic, with clinical experience being a key strategy to address this. Despite this, the perceptions of nurse academics teaching preregistration mental health nursing regarding clinical placements have not been widely explored. To garner perspectives and experiences of mental health clinical placements from nurse academics teaching mental health nursing to preregistration nursing students. A descriptive qualitative study involving 19 nurse academics from 13 metropolitan and regional Australian universities, who were involved in the design and delivery of preregistration mental health nursing content. Data were analysed thematically. The study adhered to the Standards for Reporting Qualitative Research (SRQR). Participants reported that inappropriate clinical placements generate negative student experiences. Furthermore, mental health placements in nonspecialist settings such as medical-surgical or aged care compromised student learning and posed a barrier to linking theory to practice. Increasing meaningful and appropriate mental health clinical placements in nurse education requires investment and support from multiple stakeholders. Nurse academics are crucial stakeholders in terms of understanding the impact of mental health clinical placements. Appropriate mental health clinical placements are central to effective comprehensive nurse education. Academics teaching mental health in preregistration curricula are significant stakeholders, and their informed perceptions are central to compel change.

Debate: Bridging the gap - role of nonspecialists in child and adolescent mental health care.

The first point of contact for patients and families seeking professional help for health problems is often in nonspecialist community healthcare settings that vary widely across the countries in funding sources, resources and support from specialist services. They typically involve general practitioners, family physicians, general and community paediatricians, and nonphysician health workers such as nurses, social workers and public health professionals. This article discusses the role of nonspecialists in addressing the challenges of limited resources in Child and Adolescent Mental Health (CAMH) care services as healthcare systems struggle to meet the high demand. Stakeholders and decision-makers need to reconsider traditional healthcare models and service delivery. Integrating nonspecialist community care can be a potential solution but is beset with ethical, geopolitical, practical and economic challenges. The urgency and complexity of the issue are highlighted, emphasising the need for global discussion around CAMH care.

Standards for the Implementation, Analysis, Interpretation, and Reporting of 24-hour Ambulatory Blood Pressure Monitoring Recommendations of the Italian Society of Hypertension.

Twenty-four-hour ambulatory blood pressure monitoring (ABPM) is recognized as a reference tool for accurately diagnosing hypertension. Until a few years ago, this technique was restricted to use by specialists. Recently, however, due to the need for wider availability and thanks to technological innovation, simplification of analysis processes, and increasing recognition of the importance of this tool for the diagnosis of hypertension, ABPM is now also being used in non-specialist settings. In such settings, ABPM is used with a two-pronged approach: (i) independently by a general practitioner with the possibility of specialist supervision for particular and complex cases; (ii) in the non-medical setting (community pharmacies, home care services, etc.) where the healthcare provider is trained in the proper use of the technique, with the understanding a physician must be responsible for the final clinical reporting. Unfortunately, due to the increasingly wide diffusion of ABPM, there has been considerable confusion about management roles and responsibilities in recent years. To clarify competencies and roles and standardize the processes related to the technique's implementation and proper management, experts of the Blood Pressure Monitoring Working Group of the Italian Society of Hypertension have drafted this document with the aim of providing a quick and easy reference guide for training healthcare professionals in the field.

Exploring palliative care practice and learning needs of allied health professionals in the Loddon Mallee region of Victoria: a cross-sectional survey.

Objectives The objectives of this study were to examine the roles and needs of allied health professionals (AHPs) working in public healthcare settings in rural and regional Victoria, Australia in providing components of palliative care in their routine practice. Methods A cross-sectional study was conducted between March and May 2023. Surveys were collected from AHPs working in public healthcare settings in the Loddon Mallee region of Victoria, Australia. Clinicians reported on the frequency of provision of care to patients with terminal illness, and their self-reported skill and confidence in providing interventions to patients with palliative care needs. Results In total, 121 clinicians completed the survey. Almost every respondent reported they had provided care to patients with a terminal illness, with 41% of clinicians providing this care daily or weekly. The respondents were confident carrying out generalist interventions such as maintaining physical function but reported lower confidence in managing common symptoms of terminal illness such as loss of appetite, swallowing difficulties and changing communication needs. Two-thirds of respondents had not undertaken any training specific to palliative care, with many unaware of how to access palliative care-specific training. Conclusion AHPs in rural and remote areas regularly provide care to patients with terminal illness. As the number of patients seen in non-specialist palliative care settings is likely to increase in rural and regional areas, the low self-reported confidence in providing common components of care, and the low uptake of palliative care-specific training must be addressed to ensure AHPs can provide high-quality care to people with terminal illness.

A Wearable Device-Based System: The Potential Role in Real-time and Remote EEG Monitoring

Purpose: In recent years, the Electroencephalography (EEG)-based Brain-Computer Interface (BCI) application has been growing rapidly and has emerged as a technology with high translational potential since it allows disabled people to translate human intentions into control signals and to interact with the external environment without any kinesthetic movement. Individuals with significant health problems can benefit from this technology to improve their independence and facilitate participation in activities, thus improving general well-being and preventing impairments. The rapid advances in technology have led to optimal innovation in the context of wearable health monitoring and remote control solutions. Many wearable devices for capturing EEG signals in daily life have recently been released on the market. Our paper aims to present a wearable de-vice-based system for real-time and remote EEG monitoring, to describe the proposed system modules and the signal processing algorithms, to explore the functionalities of this wearable EEG solution, and to suggest its potential application for daily brain data recordings in the home environment. Materials and Methods: The validity of the Emotiv Epoc+ device in the continuous and real-time EEG signals acquisition and monitoring was demonstrated by means of preliminary test measurements during a resting state paradigm performed by a healthy control subject. Results: Our findings confirmed the Epoc+ reliability for event-related brain potential research and in measuring acceptable spectral EEG data. Conclusion: The described approach, focusing on the emerging area of remote monitoring sensors and wearable device applications, might be leveraged to measure complex health outcomes in non-specialist and remote settings.

Malawi Mental Health Guide: Overview and Evaluation of a Mental Health Quick Reference Guide and Phone App for Use in Non-specialist Settings

Malawi Mental Health Guide: Overview and Evaluation of a Mental Health Quick Reference Guide and Phone App for Use in Non-specialist Settings

Constructing the brief diagnostic criteria for temporomandibular disorders (bDC/TMD) for field testing.

Despite advances in temporomandibular disorders' (TMDs) diagnosis, the diagnostic process continues to be problematic in non-specialist settings. To complete a Delphi process to shorten the Diagnostic Criteria for TMD (DC/TMD) to a brief DC/TMD (bDC/TMD) for expedient clinical diagnosis and initial management. An international Delphi panel was created with 23 clinicians representing major specialities, general dentistry and related fields. The process comprised a full day workshop, seven virtual meetings, six rounds of electronic discussion and finally an open consultation at a virtual international symposium. Within the physical axis (Axis 1), the self-report Symptom Questionnaire of the DC/TMD did not require shortening from 14 items for the bDC/TMD. The compulsory use of the TMD pain screener was removed reducing the total number of Axis 1 items by 18%. The DC/TMD Axis 1 10-section examination protocol (25 movements, up to 12 sets of bilateral palpations) was reduced to four sections in the bDC/TMD protocol involving three movements and three sets of palpations. Axis I then resulted in two groups of diagnoses: painful TMD (inclusive of secondary headache), and common joint-related TMD with functional implications. The psychosocial axis (Axis 2) was shortened to an ultra-brief 11 item assessment. The bDC/TMD represents a substantially reduced and likely expedited method to establish (grouping) diagnoses in TMDs. This may provide greater utility for settings requiring less granular diagnoses for the implementation of initial treatment, for example non-specialist general dental practice.

‘Far Away from Home’: adolescent inpatient admissions far from home, out of area or to adult wards: a national surveillance study

BackgroundThe increasing prevalence and acuity of mental disorders among children and adolescents have placed pressure on services, including inpatient care, and resulted in young people being admitted at-distance or to...

Abstract 12512: Predictive Factors of Right Heart Catheterization to Diagnose Pulmonary Arterial Hypertension Using Least Absolute Shrinkage Selection Operator (LASSO) Regression

Introduction: Right Heart Catheterization (RHC) is the gold standard diagnostic test to confirm Pulmonary Arterial Hypertension (PAH). However, not all patients receive a RHC to confirm diagnosis. Hypothesis: This study analyzed a real-world PAH dataset to understand factors predictive of RHC being used to confirm diagnosis. Methods: Data were analyzed from the 2022 Adelphi PAH Disease Specific Programme™ containing physician-provided patient information for PAH patients in the US, France, Germany, Italy, Spain, UK and Japan. As our outcome (RHC at diagnosis) is binary, logistic regression was used behind LASSO for 113 covariates (predictors). LASSO regression inputs many covariates, only those associated with the outcome are presented. Each covariate is tested individually and against all others. In LASSO an odds ratio (OR) is generated. An OR > 1 or more indicates a predictor is associated with a higher likelihood of RHC at diagnosis, an OR < 1 indicates a lower likelihood. RHC at diagnosis was physician-confirmed from patient records. Results: A total of 529 PAH patients with complete data for all covariates were analyzed. Mean age was 55 and 51% were female. Overall, 75% received a RHC at diagnosis. Patient refusal (34%) and deemed unnecessary by managing physician due to other testing (29%) were the most frequently cited reasons for lack of RHC. Of the 113 initial predictors, 24 were considered important in predicting RHC ( Figure 1 ). The leading predictors for RHC at diagnosis were patients classified as functional class (FC) III, those experiencing symptoms of dyspnea, palpitations and cyanosis, and those diagnosed at an accredited expert pulmonary hypertension (PH) center. Conclusions: Results indicate that RHC is more likely to be used for patients presenting with a higher FC, key PAH symptoms and diagnosed at PH expert centers. Further emphasis should be placed on RHC at diagnosis particularly within non-specialist settings to help achieve accurate diagnosis.

Nasal sprays: commonly used medications that are often misunderstood.

Sinonasal inflammatory disease is very common and all clinicians who care for these patients should understand the topical treatment options available. This article reviews the utility and application of steroidal, saline, decongestant, antihistamine and anticholinergic preparations for the treatment of sinonasal disease, with a particular focus on evidence-based guidelines for use in both specialist and non-specialist healthcare settings.

Patient pathways for rare diseases in Europe: ataxia as an example

BackgroundProgressive ataxias are rare and complex neurological disorders that represent a challenge for the clinicians to diagnose and manage them. This study explored the patient pathways of individuals attending specialist ataxia centres (SAC) compared with non–specialist settings. We investigated specifically how diagnosis was reached, the access to healthcare services, treatments, and care satisfaction. The focus of this study was on early intervention, coordination of treatment to understand the care provision in different countries.MethodsA patient survey was done in the UK, Germany and Italy to gather information about diagnosis and management of the ataxias in specialist (SAC) and non-specialist settings, utilisation of other primary and secondary health care services, and patients’ satisfaction of received treatment.ResultsPatients gave positive feedback about the role of SAC in understanding their condition, ways to manage their ataxia (p < 0.001; UK) and delivering care adapted to their needs (p < 0.001; UK), in coordinating referrals to other healthcare specialists, and in offering opportunities to take part in research studies. Similar barriers for patients were identified in accessing the SACs among the selected countries, UK, Germany, and Italy.ConclusionsThis study provides crucial information about the ataxia patients care pathways in three European countries. Overall, the results showed a trend in patients’ satisfaction being better in SAC compared to non-SAC. The outcomes can be used now for policy recommendations on how to improve treatment and care for people with these very rare and complex neurological diseases across Europe.

Registered Nurses' beliefs about end-of-life care: A mixed method study.

To examine registered nurses' (RNs) behavioural, normative and control beliefs about end-of-life care for patients who are diagnosed with advanced and life-limiting illnesses; and to identify the barriers and facilitators they experience when providing end-of-life care. A sequential explanatory mixed methods study. An online cross-sectional survey was conducted using the Care for Terminally Ill Patient tool among 1293 RNs working across five hospitals in the Kingdom of Saudi Arabia. Online individual semi-structured interviews with a subgroup of survey respondents were then undertaken. Data were collected between October 2020 to February 2021. A total of 415 RNs completed the online survey, with 16 of them participating in individual interviews. Over half of the participants expressed the belief that end-of-life care is most efficiently delivered through multidisciplinary team collaboration. The majority of participants also believed that discussing end-of-life care with patients or families leads to feelings of hopelessness. Paradoxically, the study revealed that more than half of the participants held the negative belief that patients at the end of life should optimally receive a combination of both curative and palliative care services. The results showed that nurses' beliefs were significantly associated with their age, religion, ward type, level of education and frequency of providing end-of-life care. Data from the qualitative interviews identified four themes that explored RNs' beliefs and its related factors. The four themes were 'holistic care', 'diversity of beliefs', 'dynamics of truth-telling' and 'experiences of providing end-of-life care.' Wherever possible, patients at the end-of-life should be cared for in specialist settings by multidisciplinary teams to ensure effective, high-quality care. Where this is not possible, organisations should ensure that teams of multidisciplinary staff, including nurses, receive education and resources to support end-of-life care in non-specialist settings. Hospitals that employ foreign-trained nurses should consider providing targeted education to enhance their cultural competence and reduce the impact of different beliefs on end-of-life care.

Mobile audiometry for hearing threshold assessment: A systematic review and meta-analysis.

Technological advancements in mobile audiometry (MA) have enabled hearing assessment using tablets and smartphones. This systematic review (PROSPERO ID: CRD42021274761) aimed to identify MA options available to health providers, assess their accuracy in measuring hearing thresholds, and explore factors that might influence their accuracy. A systematic search of online databases including PubMed, Embase, Cochrane, Evidence Search and Dynamed was conducted on 13th December 2021, and repeated on 30th October 2022, using appropriate Medical Subject Headings (MeSH) terms. Eligible studies reported the use of MA to determine hearing thresholds and compared results to conventional pure-tone audiometry (CA). Studies investigating MA for hearing screening (i.e. reporting just pass/fail) were ineligible for inclusion. Two authors independently reviewed studies, extracted data, and assessed methodological quality and risk of bias using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. Adults and children, with and without diagnosis of hearing impairment. A meta-analysis was performed to obtain the mean difference between thresholds measured using MA and CA in dB HL. Searches returned 858 articles. After systematic review, 17 articles including 1032 participants were analysed. The most used software application was ShoeboxTM (6/17) followed by Hearing TestTM (3/17), then HearTestTM (2/17). Tablet computers were used in ten studies, smartphones in six, and a computer in one. The mean difference between MA and CA thresholds was 1.36 dB (95% CI, 0.07-2.66, p = 0.04). Significant differences between mobile audiometry (MA) and conventional audiometry (CA) thresholds were observed in thresholds measured at 500Hz, in children, when MA was conducted in a sound booth, and when MA was self-administered. However, these differences did not exceed the clinically significant threshold of 10 decibels (dB). Included studies exhibited high levels of heterogeneity, high risk of bias and low concerns about applicability. MA compares favourably to CA in measuring hearing thresholds and has role in providing access to hearing assessment in situations where CA is not available or feasible. Future studies should prioritize the integration of pure-tone threshold assessment with additional tests, such as Speech Recognition and Digits-in-Noise, for a more rounded evaluation of hearing ability, assesses acceptability and feasibility, and the cost-effectiveness of MA in non-specialist settings.

Qualitative evidence regarding the experience of receiving and providing care for mental health conditions in non-specialist settings in low-income and middle-income countries: a systematic review of reviews

QuestionThis review of reviews synthesises qualitative evidence on the experiences of receiving and providing care and treatment for mental health conditions in non-specialist settings in low-income and middle-income countries (LMICs),...

Personality Disorder Diagnoses in ICD-11: Transforming Conceptualisations and Practice.

Until the advent of the ICD-11, classification of personality disorders was based on categorical prototypes with a long history. These prototypes, whilst familiar, were not based in the science of personality. Prototypical classifications were also complex to administer in non-specialist settings requiring knowledge of many signs and symptoms. This article introduces the new structure of ICD-11 for personality disorders, describing the different severity levels and trait domain specifiers. Case studies illustrate the main aspects of the classification. The new ICD-11 system acknowledges the fundamentally dimensional nature of personality and its disturbances whilst requiring clinicians to make categorical decisions on the presence or absence of personality disorder and severity (mild, moderate or severe). The connection between normal personality functioning and personality disorder is established by identifying five trait domain specifiers to describe the pattern of a person's personality disturbance (negative affectivity, detachment, dissociality, disinhibition, and anankastia) that connect to the Big 5 personality traits established in the broader study of personality. Whilst new assessment measures have been and are in development, the success of the new system will rely on clinicians and researchers embracing the new system to conceptualise and describe personality disturbances and to utilise the classification in the investigation of treatment outcome.

Evaluating an implementation model of evidence-based therapy for eating disorders in non-specialist regional mental health settings

BackgroundMany people with eating disorders (EDs) either do not access treatment, access it well after symptoms first start, or drop out of treatment. This study evaluated ways to improve early access to evidence-based interventions for those with EDs in a non-specialist community setting.MethodsIn an Australian regional community, links were formed between general medical practitioners and treatment providers (psychologists, mental health social workers and dietitians), who received ongoing training, feedback and support. Service users had access to 20–40 subsidised treatment sessions. Data were collected from 143 patients over 18 months. Our outcomes are reported according to the RE-AIM implementation framework: Reach (we measured uptake and treatment completion); Effectiveness (impact on disordered eating cognitions, body mass index, remission, and moderators of effectiveness including illness duration, previous treatment, presence of comorbidities, presence of a normative level of disordered eating, presence of any ED behaviours, weighing in treatment, multidisciplinary case conferencing, number of dietetic sessions); Adoption (drop-out and predictors); Implementation (barriers encountered); Maintenance (subsequent activity designed to embed new practices).ResultsTreatment was completed by 71%; significant large decreases in eating disorder cognitions were achieved; remission was obtained by 37% (intent-to-treat). Treatment completion was predicted by lower baseline levels of disordered eating, uptake of ≥ 3 dietetic sessions, and ≥ 2 team case conferences. Greater improvement over time was predicted by regular case conferencing and in-session weighing.ConclusionsImplementation of this model in a regional community setting produced completion rates and outcomes comparable to those found in specialist clinical trials of ED treatments. Service providers identified care coordination as the most important factor to connect users to services and help navigate barriers to ongoing treatment.Trial Registration: This research was an invited evaluation of a project implemented by the Australian Department of Health. The project did not introduce any new clinical practice but sought to improve access to evidence-based multidisciplinary treatment for people with EDs by removing four known systemic barriers: securing an accurate diagnosis, availability of multidisciplinary treatment, cost of treatment, and intensity of treatment. As such, the project did not require trial registration. Notwithstanding, this evaluation obtained ethics approval (Bellberry Human Research Ethics Committee, Application No: 2018-09-728-FR-1).

The efficacy of family treatments for adolescent anorexia nervosa in specialist versus non-specialist settings: protocol for a systematic review and meta-analysis

BackgroundAnorexia nervosa (AN) is often diagnosed in adolescence, and most evidence-based treatments for AN in young people involve the family. Family therapies for AN are intensive, outpatient treatments that utilise the parents as the primary resource in the young person’s recovery. Research regarding family treatment for AN is often conducted in specialist settings—with relatively little data reporting the translation of this specialised treatment into real-world, non-specialist settings. This systematic review and meta-analysis aims to determine the efficacy of family treatments for adolescents with AN in specialist settings versus non-specialist settings.MethodsThis systematic review and meta-analysis will be conducted according to the preferred reporting items for systematic reviews and meta-analyses guidelines. Retrospective cohort studies, pilot studies, case series, randomised controlled trials and qualitative investigations that present original data and investigated the efficacy of family treatments for adolescents with AN in either a specialist or non-specialist setting will be included in the review. Data will be extracted by two reviewers and study quality will be assessed. The primary outcome, change in weight, will be used to determine via meta-analysis and, depending on study heterogeneity, subgroup analysis or meta-regression whether there is a statistically significant subgroup difference between specialist and non-specialist treatment settings. The review will also consider changes in eating disorder symptomology and related constructs.DiscussionResults from this review will help determine if there is a difference in the efficacy of family treatments for adolescent AN in specialist versus non-specialist treatment settings, primarily in relation to weight recovery. This, in turn, will inform the translation of evidence-based interventions that are generally studied and implemented within specialist centres into the non-specialist health care system.

Menopausal status, ultrasound and biomarker tests in combination for the diagnosis of ovarian cancer in symptomatic women.

Menopausal status, ultrasound and biomarker tests in combination for the diagnosis of ovarian cancer in symptomatic women.

Strategies for knowledge translation of a palliative approach outside specialized palliative care services: a scoping review

ObjectivesResearch suggests palliative care to be translated and integrated in non-specialized palliative care services throughout the palliative care continuum across populations and settings. A need has been identified to build on the existing research literature in order to design strong knowledge translation strategies that can be evaluated in future research. The aim was to map strategies for knowledge translation of a palliative approach to care into non-specialized palliative care services for adult patients. The objectives were to explore the primary research activities, the specific type of knowledge translation strategies used, the research designs and study settings for such evaluations along with the major results thereof, and to identify major research gaps in this area.MethodsA scoping review was performed to map the volume and characteristics of research literature (project registered in PROSPERO #2018 CRD42018100663). The ten-year period 2010 to 2019 was searched in six major databases for original articles published in English in which the knowledge translation of a palliative approach for adult patients was evaluated in non-specialized palliative healthcare settings, and all type of empirical data-based research designs. We excluded non-English, non-empirical articles, non-evaluation of knowledge translations, specialized palliative care settings, and other types of publications (i.e. non-original articles).ResultsMost of the 183 included articles focused on patients with cancer who were dying in hospitals and in high income countries. Only 13 articles focused on early palliative care. A palette of different strategies was used to implement palliative care in non-specialist palliative settings; no strategy was identified as outstanding. The majority of the articles had unspecified essential components of the research designs.ConclusionPrevious suggestions for utilization of implementation science for knowledge translation of a palliative approach to care into non-specialized palliative care services are confirmed, and established knowledge translation theories can strengthen the field. To advance this specific field of knowledge, meticulously detailed reporting of studies is required as related to research designs, clarifications of contextual influences and mechanisms at work. Specific systematic reviews and meta-syntheses in the field are merited.

"Palliative Syringe Driver"? A Mixed-Methods Study in Different Hospital Departments on Continuous Infusions of Sedatives and/or Opioids in End-of-Life Care.

ObjectivesContinuous infusions of sedatives and/or opioids (continuous infusions) are frequently used in end-of-life care. Available data indicate challenges in nonspecialist palliative care settings. We aimed to assess the use of continuous infusions during the last week of life in different hospital departments.MethodsIn a sequential mixed-methods design, a retrospective cohort study was followed by consecutive qualitative interviews in 5 German hospital departments. Medical records of 517 patients who died from January 2015 to December 2017 were used, and 25 interviews with physicians and nurses were conducted. Recorded sedatives were those recommended in guidelines for “palliative sedation”: benzodiazepines, levomepromazine, haloperidol (≥5 mg/d), and propofol. Exploratory statistical analysis (R 3.6.1.) and framework analysis of interviews (MAXQDA 2018.2) were performed.ResultsDuring the last week of life, 359 of 517 deceased patients (69%) received continuous infusions. Some interviewees reported that continuous infusions are a kind of standard procedure for “palliative” patients. According to our interviewees’ views, equating palliative care with continuous infusion therapy, insufficient experience regarding symptom control, and fewer care needs may contribute to this approach. In addition, interviewees reported that continuous infusions may be seen as an “overall-concept” for multiple symptoms. Medical record review demonstrated lack of a documented indication for 80 of 359 patients (22%). Some nurses experienced concerns or hesitations among physicians regarding the prescription of continuous infusions.ConclusionsContinuous infusions seem to be common practice. Lack of documented indications and concerns regarding the handling and perception of a “standard procedure” in these highly individual care situations emphasize the need for further exploration and support to ensure high quality of care.