bluuebunny/crossref_metadata_2025 huggingface dataset:
LIVING WITH FRAILTY IN LATER LIFE: AN ETHNOGRAPHIC STUDY
Authors: Skilbeck Julie , Arthur Antony , Seymour Jane
Published: February 2014

Background

The term frail is frequently used to describe older people experiencing complex health problems. There is limited understanding of how older people experience frailty in the context of their daily lives. Understanding personal experiences of frailty will contribute to the holistic assessment and management of supportive care for older people in later life.

Aim

To explore how 'frail' older adults with complex problems who are living at home experience their daily life.

Study Design

A prospective, longitudinal case study design using ethnographic data collection methods. Ten participants aged 75 and over, receiving care from a Community Matron (CM), were recruited. Participants were followed up at monthly intervals for 6 months or until death. In total, 49 interviews were conducted with older people; 49 CM visits were observed. Medical documents were reviewed for 10 participants. Data analysis involved cross case comparison and identification of common themes.

Findings

Three themes illuminated the experience of living with frailty.Transitions in health and illnessdetails the types and patterns of transition and the subsequent impact on daily life.Dimensions of frailtyreports perceptions of frailty in later life; accounts of feeling frail relate to episodes of uncertainty.Working with health and social care servicesprovides insights into the inter-relationship between the older person's world of declining health and the episodic interactions with health professionals.

Discussion

Older people work hard to maintain daily routines as they experience changes in their health. Maintaining independence, dignity and continuity of personhood provide a counterpoint to being frail. Health professionals' work is framed by a policy of risk and clinical assessment. Assumptions underpinning the label of frailty can be at odds with the older person's experience. Commissioners of community services for frail older people need to consider these competing demands so that health professionals can engage more effectively in supportive care provision.
EXISTENTIAL CONCERNS ABOUT DEATH — A QUALITATIVE STUDY OF DYING PATIENTS IN A DANISH HOSPICE
Authors: Moestrup Lene
Published: February 2014

Background

Research suggests that addressing dying patients' existential concerns can help improve their quality of life. Common existential conditions, such as a search for meaning and considerations about faith, are probably intensified in a palliative setting and existential concerns about death are likewise intensified when patients face their impending death. Knowledge of modern, secular existential concerns about death is under-researched, and therefore, it is difficult to develop and implement specifically targeted support to dying patients.

Aim

The aim of this paper is to present the results from a qualitative field study illuminating the variety of dying patients´ existential concerns about their impending death.

Method

Data was generated through ethnographic fieldwork comprising 17 semi-structured interviews with dying patients and 38 days of participant observation at three Danish hospices.

Results

The analyses of interview data revealed two categories of existential concerns. The first category “Thoughts and feelings about death” demonstrated how the patients: 1) realized the forthcoming death; 2) felt sorrow about leaving life; 3) were not anxious about death as a final state. The second category “Managing death” demonstrated how the patients: 1) avoided thinking about death; 2) reconstructed individual ideas about afterlife on the basis of faith and previous cultural meaning-making; 3) were planning practical aspects about death; 4) wished to focus on living. The patients' existential concerns of death in a modern, secular setting is not adequately described by neither Irvin Yalom's existential psychology nor Kübler-Ross' theory about death stages. The complex concerns might be explained in the light of research in everyday life based on Martin Heidegger's phenomenological thinking.

Conclusion

The analyses indicated that the patients' concerns were complex, contradictory and not suited to be understood within a single theory. An ongoing reflection including different theoretical perspectives seems important when providing existential care and support to dying patients.
THE COMMUNITY CARE PATHWAYS AT THE END OF LIFE (CAPE) STUDY- EARLY FINDINGS
Authors: Boase Sue , Moran Emily , Barclay Stephen
Published: February 2014

Background

Current NHS End of Life Care policy favours raising the proportion of deaths that occur at home. Currently this only occurs in 21.8% of the total. Although most people would like to die at home, research has shown that people's preferences are influenced by the progression of their illness, how much support is available and their social circumstances.

Aims

The aim of the study is to clarify for whom home death is “good” and for whom it is not, and to ascertain whether the focus on place of death is helpful.

Methods

Using a mixed-method approach, data on 400 deceased patients, the perceptions of their GPs, community nurses and bereaved carers are brought together to generate an understanding of patterns of care need, and pathways of care provision at the end of life.

Results

Initial findings indicate the importance of trust and communication among the team. The health professionals felt that non-cancer patients are more difficult to care for than those with cancer, who have a clearer trajectory. Not all admissions to hospital at the end of life were seen as negative, and it may be the preferred place of care and death for some patients. Different agencies being on different electronic systems can cause communication difficulties and the different End of Life Care initiatives can be time-consuming and confusing.

Conclusions

Although the findings are preliminary at present, it is hoped that this study will shed light on the investment of time and resources and the logistics of providing care at the end of life in the community whether the place of death is at home, in a care home, hospice or hospital. In turn this aims to address the question of whether the focus on place is the best measure of a “good” death.
TITRATION OF ABSTRAL IN THE HOSPICE SETTING: HOW DOES ABSTRAL DOSE RELATE TO BACKGROUND OPIOID REQUIREMENT?
Authors: Hurlow Adam , Rayment Clare , Ward Jason
Published: February 2014

Background

Sublingual fentanyl citrate orally disintegrating table (Abstral, ODT) is a rapid onset opioid developed for breakthrough cancer pain. Whilst ODT may be more efficacious than oral morphine for breakthrough pain the titration process of starting on the lowest dose may limit its use.

Aims

The aims of this study were to identify how many patients were titrated to an effective ODT maintenance dose (stable for at least a week), to compare the maintenance dose to the background opioid dose at the time ODT was started and to identify reasons for unsuccessful titration.

Methods

We conducted a retrospective notes review of the first 30 hospice inpatients to be commenced on ODT in a 32 bed UK hospice. All opioid doses are expressed as the oral morphine equivalent calculated using hospice guidelines.

Results

All patients had cancer and their median age was 64.5 (48–88) years. Seventeen patients achieved a maintenance dose and 12 continued ODT until death/data collection. In eight patients titration failed because the patient started to die. The maintenance ODT dose was 400 mcg or less in ten patients and 600–800 mcg in seven patients. The median background opioid doses were 205 mg and 500 mg respectively. The median titration period was 4 (0–20) days with only two patients taking more than a week. In three patients toxicity was the reason for stopping ODT.

Conclusions

Abstral ODT was successfully titrated and effective in approximately half of all patients. Patients who required ODT doses of 600 mcg or more had a higher median background opioid dose suggesting a relationship between the two. Although titration to a maintenance dose took less than a week in almost all patients, onset of dying was the most common reason for titration failure. This suggests the titration process may be problematic for patients with short prognoses necessitating robust patient selection.
INITIATIVES FOR IMPROVING THE PROVISION OF ASSISTANCE AT MEALTIMES FOR OLDER ADULTS ON HOSPITAL WARDS: A MIXED METHODS SYSTEMATIC REVIEW
Authors: Edwards Deborah , Hopkinson Jane
Published: February 2014

Background

In the UK, a third of older hospital patients are malnourished. Malnutrition is associated with staying in hospital longer, increased morbidity and mortality, especially for those with chronic conditions. Mealtime assistance may be important to improve nutritional intake, clinical outcomes and patient experience. Two previous quantitative systematic reviews have been undertaken. One explored the use of volunteers and the other feeding assistance in hospitals and care-homes.

Aims

We are conducting the first mixed method systematic review about the provision of assistance at mealtimes for older adults on hospital wards to

▸

i) determine the effectiveness of interventions

▸

ii) explore the experiences of older adults and those involved with their care

Methods

The design is informed by methods developed by the Evidence for Policy and Practice Information Centre. This ‘mixed-methods’ triangulation approach combines data from i) effectiveness studies, ii) studies which obtain the views of participants and iii) current guidelines and policy. We have conducted a search of electronic databases (CINAHL, MEDLINE, BNI, Cochrane Library, EMBASE, PsychINFO, Open-Grey). Limits were English language; 1996 to present; adults. Abstracts have been assessed against inclusion/exclusion criteria by two researchers to select full-text for quality assessment and data extraction. The key elements of best practice will be extracted from current guidelines and policy documents. This will be used to derive a framework to guide analysis and interpretation of the evidence.

Results

The findings will be presented as a conceptual map of initiatives for improving the provision of assistance at mealtimes for older adults on hospital wards. We will also present propositions of what might be most effective in assisting oral mealtime nutritional intake and the implications.

Conclusion

We are conducting a systematic evaluation of literature to provide recommendations for the supportive nutritional care of older malnourished chronically ill people in hospital.
SPIRITUAL CARE AND KIDNEY DISEASE IN NZ: A QUALITATIVE STUDY WITH NEW ZEALAND RENAL SPECIALISTS
Authors: MacLeod Roderick , Egan Richard , Walker Rob , Wood Sarah , Mountier Jane
Published: February 2014

Background

People with chronic kidney disease have a shortened life expectancy and carry a high symptom burden. Research suggests that attending to renal patients' spiritual needs may contribute to an improvement in their quality of life and this combined with the burden of renal disease underscores the need to better understand all domains of patients' well-being, including spirituality. The aim of this qualitative study was to investigate the provision of spiritual care in New Zealand renal units from the perspective of specialists.

Methods

The study was qualitative using semi-structured interviews and thematic analysis. Participants were recruited across New Zealand's ten renal centres. Participants were asked about their understandings of spirituality, patients' spiritual needs, current service provision of spiritual care, pre- and in-service spiritual care training, and suggestions for improvements.

Results

Five specialist doctors and nine specialist nurses were recruited for interviews in 2012. Understandings of spirituality were broad, with most participants having an inclusive understanding. Patients' spiritual needs were generally acknowledged and respected, although not specifically named. Formal spiritual assessments were not done. Consideration of death was discussed as an often-unexamined need. The dominant position was that the specialists did not provide explicit spiritual care of patients but there was some ad hoc provision offered through pre-dialysis educators, family meetings, and Maori liaison staff members. Participants had received no pre-service education or training and very little in-service training in spiritual care. The nurses thought further training “would be useful” but the doctors were less interested. There were many suggestions for improvements.

Conclusion

Most participants indicated they would attempt to provide some form of spiritual care, but they generally demonstrated a lack of confidence and awareness of how to address a patient's spiritual and end of life needs.
HOW DO PERCEPTIONS OF RISK SHAPE 'CHOICE' IN END-OF-LIFE CARE?
Authors: Wilson Fiona , Ingleton Christine , Gott Merryn , Gardiner Clare
Published: February 2014

Background

The National End of Life Care Strategy for England (2008) advocates ‘choice’ as a central tenet of palliative care delivery, however it is not clear how 'choice' is understood nor how choice may be shaped by perceptions of risk.

Aim

A narrative literature review was undertaken with the aim of capturing understandings around choice and perceived risks in end-of-life care.

Methods

Medline (Ebsco), PschINFO, Assia (Applied Social Sciences Index and Abstracts), British Nursing Index, High Wire Press, CINAHL (Current Index to Nursing and Allied Health Literature) were searched using the terms decision*, risk*, hospice and palliative care, end of life care. Hand searching of key texts also revealed relevant papers. Inclusion criteria included adult focus (>18 yrs), and UK focus only. Two hundred and forty two papers were examined for relevance and filtered using criteria outlined by Hawker,et al(2002). In total, twenty five papers were analysed for key themes.

Results

Notions of 'choice' are shaped by individual understandings as well as wider structural factors. Individual understandings include perceptions of services, family support, and balancing of self-identity. Structural factors include service provision, professional awareness, and inequalities around ethnicity and class.

Conclusions

Acknowledgement by key stakeholders of the structural factors, which constrain choice, may help to inform service development. At the same time, recognition of patient and carer understandings may help to facilitate supportive decision making at end-of-life.
THE ASSESSMENT OF HYDRATION IN ADVANCED CANCER PATIENTS USING BIOELECTRICAL IMPEDANCE ANALYSIS
Authors: Nwosu Amara , Mayland Catriona , Varro Andrea , Ellershaw John
Published: February 2014

Background

Current hydration assessments methods are limited in cancer patients approaching death. Bioelectrical impedance analysis (BIA) is an accurate validated method of assessing body composition; however its clinical use in advanced cancer is uncertain.

Aims

To measure hydration in advanced cancer patients using BIA, in order to determine the relationship between symptoms, biochemistry and performance status.

Methods

A cross-sectional prospective analysis of advanced cancer patients within a specialist palliative care unit in Liverpool, UK. BIA raw measurements, Resistance (R–Ohm), Reactance, (Xc–Ohm), total body water (TBW–through proxy measurement using height/resistance [Ht2/R]), Phase angle (PA) and BIA vector analysis (BIVA) were used to compare for differences in hydration based on WHO performance status (0= asymptomatic, 4=bedbound), symptoms, physical examination and biochemistry.

Findings

From a possible 97 patients, 78 (80%) provided consent to participate. Ht2/R was lower in patients with a WHO performance status of 4 compared to those with a performance status <4 (mean 42.1 [SD 9.0] vs. 52.3 [14.6], p=0.002), and greater in those with clinically detectable oedema (mean 57 [SD 17.4] vs. 47.7 [12.4], p=0.027). Ht2/R correlated negatively with thirst [r=−0.31, p=0.006], dry mouth [r=−0.294, p=0.009] and fatigue [r=−0.285, p=0.011). BIVA showed significant difference in hydration between groups classified by the presence or absence of oedema (p=0.03) and dry mouth (p=0.04).There was no significant relationship between hydration (Ht2/R and BIVA) vs. biochemical tests or between symptoms vs. biochemistry or performance status.

Conclusions

In advanced cancer, hydration (as measured by Ht2/R and BIVA) relates to clinically measurable signs and symptoms. Further work is needed to determine whether BIA can be used to guide the management of fluid states in advanced cancer.
PERCEPTION OF THE RATE OF CHANGE IN A PATIENT'S CONDITION AS A METHOD OF ESTIMATING PROGNOSIS: A PILOT STUDY
Authors: Grogan Eleanor , Peel Tim , Regnard Claud , Paes Paul
Published: February 2014

Background

Estimation of prognosis is a common request. Many methods have been considered but are often complex or unreliable. Some palliative medicine physicians feel the best guide may be the recent rate of change in physical condition. For example, if a patient perceives their condition has been changing weekly they may have a prognosis of weeks; if day by day the prognosis is likely to be days. No research has been done to show whether this is an accurate guide, despite it being widely used.

PatientPatient perceived rate of changeDoctor estimated prognosisActual survival1Daysweeks32 days2Weeksweeks35 days3Weeksweeks33 days4Weeksshort months44 days5Monthsmonths40 days6Monthsmonths40 days7Daysmonths70 days8stablemonths154 days

The study needs repeating with greater numbers of patients to further research this area.

Methods

Adults with cancer admitted to an NHS inpatient specialist palliative care unit were recruited (exclusion criteria: 1. lacking capacity; 2. if it was thought the study may cause unnecessary distress). Patients were asked “how has your condition changed recently?" (plus a further probe of "do you think things have been changing daily/weekly/monthly?" if required) but were not asked directly about prognosis. Ethics approval was obtained. Data was collected on patient's perception of rate of change, consultant's estimate of prognosis and actual survival time.

Aim

To determine whether the proposed research question was a reliable indicator of survival time.

Results

Eight patients were recruited. There was similarity between patient perceived rate of change, doctor prognosis estimate and actual survival time in most cases. Numbers were smaller than anticipated due to concerns about causing distress in patients, although this did not occur in participating patients.
OUT-OF-HOURS PALLIATIVE CARE: WHAT ARE THE EDUCATIONAL NEEDS AND PREFERENCES OF GENERAL PRACTITIONERS?
Authors: Magee Claire , Koffman Jonathan
Published: February 2014

Background

General practitioners (GPs) provide most out-of-hours medical care, but overall see few palliative patients. Keeping their knowledge and skills up-to-date is challenging. UK national policy has highlighted the importance of improving training for out-of-hours clinicians in order to reduce unnecessary admissions and support patients to die at home. However, little is known about the educational preferences of GPs working in this setting.

Aims

To explore the confidence of out-of-hours GPs in symptom control, and to identify their educational needs and preferences in order to inform recommendations for future educational programmes.

Methods

A structured postal survey was designed and sent to 1005 GPs employed by an independent provider of out-of-hours services across England. Quantitative data was analysed using descriptive statistics and non-parametric tests.

Results

203 (20.3%) GPs responded to the survey questionnaire. 13.3% (n=27) worked exclusively out-of-hours; they were typically older and more experienced. Confidence in assessing palliative care emergencies (42.8%, n=87: ‘not so confident’ or ‘not at all confident’), managing symptoms in non-cancer patients (39.4%, n=80) and prescribing a new syringe driver (39.0%, n=79) was lowest. Low confidence was associated with infrequent exposure (p<0.05) and lack of training (p<0.05). 12.8% (n=26) had never received formal palliative care training. Educational preferences were closely associated with confidence (p<0.0005); the above topics were most requested. E-learning was the preferred method (67.5%, n=137). GPs were more likely to prefer education with other GPs than with other professionals (p=0.001). 82.1% (n=165) felt training focused on out-of-hours work would be beneficial.

Conclusions

Confidence in key palliative care competences is lacking. Educational strategies must be targeted at GPs needs, both in terms of content and delivery, with regular updates. E-learning is favoured, but should be combined with other approaches such as out-of-hours themed workshops. Specialist palliative care services should engage with out-of-hours providers to support education.
DEATH ANXIETY AMONG MEDICAL STUDENTS: PREVALENCE AND IMPLICATIONS
Authors: Thiemann Pia , Quince Thelma , Benson John , Wood Diana , Barclay Stephen
Published: February 2014

Background

Death Anxiety is related to an awareness of the reality of dying and death. There is some evidence that physicians' fear of death has a negative impact on their own wellbeing and influences their care of terminal ill patients. The first time that physicians face death in a professional context is at medical school. The nature, development and implications of death anxiety in medical students are currently poorly understood.

Aims

To examine medical students' death anxiety: (1) prevalence, gender differences and change over time; (2) associations with attitudes towards end of life care (EOLC) and psychological wellbeing.

Methods

Four cohorts of core science students and 4 cohorts of clinical students at the University of Cambridge Medical School participated for up to 3 consecutive years (N=953). Questionnaires concerning death anxiety (Collett-Lester Fear of Death Scale), psychological wellbeing (Hospital Anxiety and Depression Scale, Interpersonal Reactivity Index) and attitudes towards EOLC (Sullivan's statements) were administered each year.

Results

Death Anxiety was moderate among students of all training levels and remained stable over time. No gender differences were found except for the subscale ‘death of others’, where men scored significantly lower than women in 5 of the 6 years. In core science and clinical years weak negative correlations (r=–.18 −–.42) were present between death anxiety and wellbeing. Consistent weak to moderate correlations (r=.27–.50) between death anxiety and attitudes towards EOLC revealed that students with higher death anxiety were more afraid of negative personal impact of EOLC.

Conclusion

While death anxiety was not high among most medical students, its association with low wellbeing and negative attitudes towards EOLC are concerning. Addressing death anxiety during medical education appears to be important to enhance the quality of EOLC and the student's psychological health.
TISSUE DONATION AND END OF LIFE CARE
Authors: Sedgwick Rosemary , Gibson Natasha , Williams Charles , Kreeger Lulu , Holmes Grant
Published: February 2014

Background

NICE organ donation guidance makes it explicit in its first recommendation that ‘organ donation should be considered as a usual part of “end-of-life care” planning.’ The Liverpool Care Pathway (LCP) incorporated a prompt for clinicians to discuss tissue and organ donation with the patient, and if appropriate their relatives. A recent audit found that of 20 Kingston Hospital LCP proformas completed, only 1 had documented that this information had been ascertained.

Aims

To explore junior doctors' attitudes surrounding discussion of tissue donation in the context of end of life care.

Methods

We surveyed 33 junior doctors about their knowledge and attitudes towards tissue donation and end of life care, seeking to elucidate why the proforma question- “Does the patient have an expressed wish for tissue donation” was not being asked.

Results

Fifty-two percent were not aware that there was a question about expressed wishes for tissue donation. Common reasons for not completing the question on the proforma included: “timing not feeling appropriate”, “lack of familiarity with tissue donation procedure” and "unsure if patients on the LCP will be suitable". Views on the most appropriate time to discuss tissue donation were mixed: 45% said “A&E registration” and 42% “as part of end of life discussions”. Only 56% of junior doctors reported having received any training on tissue donation.

Conclusions

Junior doctors are undertrained and not comfortable discussing tissue donation as part of providing end of life care. Knowledge and communication skills pertaining to tissue donation should be incorporated into the foundation doctors' curriculum. Locally we plan to guarantee the implementation of teaching for all doctors about tissue donation and to add comprehensive information about the subject, including eligibility criteria and contact details for further guidance and support to the Kingston Hospital “junior doctor handbook”.
EMPOWERING CARE HOME STAFF TO DELIVER QUALITY END OF LIFE CARE: THE IMPACT OF THE SIX STEPS TO SUCCESS PROGRAMME ON END OF LIFE CARE IN CARE HOMES IN NORTH WEST ENGLAND
Authors: O'Brien Mary , Kirton Jennifer , Knighting Katherine , Gandy Rob , Jack Barbara , Roe Brenda , Flynn Caroline , Horgan Elaine
Published: February 2014

Background

Inappropriate admissions to hospital from care homes at the end-of-life (EoL), identified within the UK Department of Health's End-of-Life Care (EoLC) Strategy resulted in the call for improved education surrounding EoLC for care home staff. In response, theSix Steps to Success, an organisational change programme, was developed for use with care home staff. The aim of the programme is to ensure all residents receive high quality EoLC provided by a care home that encompasses the philosophy of palliative care and that allows people to die where they choose.

Aims

To explore the impact of theSix Steps to Successprogramme on EoLC in care homes in Northwest England.

Methods

The mixed-method evaluation consisted of three phases; i) examination of audit data collected on care homes from cohort 1 that had completed the programme by November 2012 (quality markers and measures; post death information; knowledge skills and confidence audit); ii) questionnaires (n=16) and interviews (n=9) with Six Steps Facilitators (N=18) and iii) case studies on care homes (n=6), randomly chosen from a selection matrix of homes that had completed the programme and volunteered to take part taking account of geographical spread (urban/rural) and type of care home. Analysis involved descriptive statistical comparisons and frequencies; qualitative data were subject to content analysis to identify themes.

Results

All care homes demonstrated improvements in Advance Care Planning (ACP). Knowledge skills and confidence around EoLC improved markedly amongst care home staff, with 92% improvement for Spirituality skills and 79% improvement for ACP knowledge. Residents dying in their preferred place of death increased from 81.5% to 83.1%.

Conclusions

EoLC in care homes has undoubtedly improved. TheSix Steps to Successprogramme has helped care home staff deliver better end-of-life care for their residents ensuring their wishes and preferences at end-of-life are met.
ADVANCE CARE PLANNING TRAINING IN NURSING HOMES: A SUCCESS STORY?
Authors: Baron Kirsten , Walshe Catherine
Published: February 2014

Background

The number of older frail nursing home residents is increasing in the UK. Advance Care Planning (ACP) for this population provides an opportunity to empower older people by discussing and documenting their wishes and preferences for their future care. The nursing home workforce is well placed to carry out ACP but lack confidence and training.

Aim

To evaluate the success of a programme of ACP training for nursing home employees.

Methods

Three longitudinal questionnaire surveys completed before and after the initiation of the ACP training programme by both nursing homes that had completed the training and those yet to undergo the training and the results compared to identify changes. A knowledge based questionnaire on ACP administered to staff before completing the training at baseline and repeated a number of weeks after the training. A survey of ACP practice within the nursing home completed by managers at baseline before initiation of the training programme and then again a number of weeks later.

A survey of place of death of nursing home residents in a twelve month period before the initiation of the training programme and a twelve month period after commencement of the programme.

Results

16 nursing homes were included in the study, 12 that had undergone the training programme and 4 that had not. Superior Advance Care Planning knowledge was evident in those staff that had completed the training. There was an increase of 85% in the number of Advance Care Plans completed in the training homes and an overall reduction in hospital deaths of 25% for residents from training homes.

Conclusions

A programme of Advance Care Planning training for nursing homes is successful in improving nursing home staff knowledge, increasing ACP practice and reducing hospital deaths.
WOULD INTEGRATING HIGH-FIDELITY SIMULATION AS A LEARNING—TEACHING STRATEGY ENHANCE END OF LIFE CARE SKILLS FOR PRE-REGISTRATION NURSING STUDENTS? A QUALITATIVE ENQUIRY
Authors: Venkatasalu Munikumar Ramasamy
Published: February 2014

Background

In UK, palliative and end of life care services are under significant strain due increased number of dying population and aging palliative care nursing workforce combined with staff shortages and a recruitment crisis. Conversely, current nurse education do not prepare students with positive attitude and necessary end of life care skills to meet this critical workforce crisis. Comparing to traditional teaching methods, simulation is proven to enhance clinical skills and positive attitudes, yet little is known about its effectiveness on End of Life care Education.

Aim

To design, use and assess the effectiveness of high-fidelity simulation teaching session for first year nursing students on dealing with first death experiences in their clinical placement.

Methods

Using qualitative approach, this study conducted with two stages. At first, two groups (n=48) of total eight first year students groups (n=167) randomly selected and received two high-fidelity simulation scenarios on end of life care topics; rest received traditional methods a seminar led discussion. In the second stage, when all return from their first clinical placement, we conducted in total of 12 individual in-depth interviews with both students who attended simulation based teaching (n=7) and also with traditional teaching methods (n=5). Data were analysed using Framework design.

Findings

Despite both teaching-learning strategies improved students' knowledge on end of life care, in contrast traditional methods students who received simulation based End of Life care Education were better prepared in terms of emotional experience and enhanced hands on practical skills in their first clinical placement. Limitations of using simulation as teaching-learning strategy for teaching end of life care topics were identified.

Conclusions

Using simulation based end of life care teaching-learning strategies perceived to produce positive clinical outcomes. Further research needed to explore wider application of simulation in diverse end of life care topics in preregistration nursing education and clinical practice.
MEDICAL STUDENTS' ATTITIDES TO END OF LIFE CARE THROUGHOUT THEIR COURSE
Authors: Barclay Stephen , Thiemann Pia , Parker Richard , Whyte Rebecca , Benson John , Wood Diana , Quince Thelma
Published: February 2014

Background

Medical student End of Life Care (EOLC) education is increasingly recognised as important. Knowledge concerning drugs and services can be readily taught and skills of communicating with patients and families are increasingly addressed. Attitudes towards EOLC are important as they influence behaviour in clinical practice.

Aims

To examine medical students' attitudes to EOLC in each year of their course

To investigate change in these attitudes over time during their course

To identify gender differences in attitudes and attitudinal change.

Methods

Questionnaire administered to four cohorts of core science and clinical medical students at the University of Cambridge Medical School in 2007 to 2010, with longitudinal follow-up in subsequent years; 1027 participants in total. Students indicated their agreement towards 8 EOLC statements on five-point Likert scales, based on Sullivan's US study.

Results

Students started their course with broadly positive attitudes (towards the doctor's responsibility, psychological aspects for patients and personal impact) which largely persisted into the final years. During core science some attitudes became more negative, whereas during clinical studies some attitudes became more positive. Analysis of a subsample of 55 students for whom 6 year longitudinal data were available revealed significant positive change regarding the doctor's responsibility from year 1 to year 6. Although statistically significant, all of these changes were small. No significant effect of gender on attitudes or attitudinal change was found.

Conclusion

Medical students' attitudes towards their future role in EOLC were broadly positive. Core science was associated with increasingly negative attitudes and clinical studies with increasingly positive attitudes. For teaching faculty, the challenge remains to address negative and foster positive attitudes towards EOLC during medical school.
PALLIATIVE CARE (PC) EDUCATION FOR MEDICAL STUDENTS: HAS IT IMPROVED OVER THE LAST DECADE? A SURVEY OF PC EDUCATION
Authors: Walker Steven , Gibbins Jane , Barclay Stephen , Barnett Mandy , Adams Astrid , Pees Paul , Chandratilake Madawa , Lodge Philip , Wee Bee
Published: February 2014

Background

A survey of UK medical schools conducted in 1983, 1994 and 2000/2001 showed an increase in PC teaching time and course diversity. Gaps included limited assessment.1

Aims

To investigate changes in PC training for medical students at UK medical schools over the last decade.

Methods

A web-based questionnaire developed from previous surveys was sent to PC leads in UK medical schools. Responses were compared with those obtained in 2000/2001. The study received ethical approval.

Results

Results were obtained from all 30 medical schools and for 24 programmes in 23 medical schools providing teaching in 2000/2001. All continue to deliver teaching on last days of life, death and bereavement. This is now mandatory. Generally, this remains a module within a larger course or is fully integrated. Teaching methods remain similar (2013 v 2001): lectures [28 (93%) v 21 (88%)], seminars/small group discussion [28 (93%) v 23 (96%)], video [18 (60%) v 19 (79%)], case discussion [17 (57%) v 23 (96%)], patient addressing students [18 (60%) v 9 (38%)] and role play [16 (53%) v 22 (92%)]. New features are MDT meetings [12/30 (40%)] and e-learning [14/30 (47%)]. Teaching is most commonly delivered by medical PC specialists [30 v 24 (100%)], GPs [17 (57%) v 20 (83%)] and specialist nurses [24 (80%) v 15 (63%)]. All major topics are covered to varying degrees. Teaching about PC for young patients remains limited [7 (29 responses 24%) v 8 (33%)]. Opportunities for patient contact has increased with 27 (28 respondents 96%) offering inpatient PC unit/hospice visits compared to 18 in 2001 (75%). More medical schools are assessing PC learning [25 (83%) v 6 (25%)]

Conclusion

PC training for medical students continues to evolve. Recent changes are increased patient contact and assessment of PC learning.
Impact of the 2011 Great East Japan Earthquake and Tsunami on functional disability among older people: a longitudinal comparison of disability prevalence among Japanese municipalities
Authors: Tomata Yasutake , Kakizaki Masako , Suzuki Yoshinori , Hashimoto Shuji , Kawado Miyuki , Tsuji Ichiro
Published: February 2014

Objective

To examine the hypothesis that disability prevalence has increased to a greater degree in the areas severely affected by the earthquake and tsunami of 11 March 2011 than in other areas.

Methods

Longitudinal analysis using public statistics data from the Ministry of Health, Labour and Welfare in Japan. The analysis included 1549 municipalities covered by the Long-term Care Insurance (LTCI) system. ‘Disaster areas’ were defined as three prefectures (Iwate, Miyagi, Fukushima). The outcome measure was the number of aged people (≥65 years) with LTCI disability certification. Rates of change in disability prevalence from February 2011 to February 2012 were used as the primary outcome variable, and were compared by analysis of covariance between ‘Coastal disaster areas’, ‘Inland disaster areas’ and ‘Non-disaster areas’.

Results

Regarding disability prevalence at all levels, the mean value of the increase rate in Coastal disaster areas (7.1%) was higher than in Inland disaster areas (3.7%) and Non-disaster areas (2.8%) (p<0.001).

Conclusions

The areas that were severely affected by the earthquake and tsunami had a significantly higher increase in disability prevalence during the 1 year after the earthquake disaster than other areas.
Fertility after fetotomy: a clinical study focusing on heavy draft mares
Authors: Raś A. , Rapacz‐Leonard A. , Raś‐Noryńska M. , Barański W.
Published: February 2014

Although fetotomy is recommended for all mares when the fetus is dead and difficult to extract, little has been written about fetotomy and heavy draft mares. This lack includes indications for fetotomy in heavy draft mares, differences in treatment and prognosis of heavy mares kept by farmers of low socioeconomic status, and how this procedure affects the mare's further fertility. The literature on mares, in general, also differs on the survival rate of mares that undergo fetotomy, the prevalence of postpartum complications, and further fertility. To answer these questions, we reviewed the medical records of 102 mares that underwent fetotomy, mostly heavy draft mares (n=93). Head malposture (62.7 per cent) was the most common fetal maldisposition, which required fetotomy in all cases. The survival rate was 84.3 per cent (n=86). The most common postpartum complications were endometritis puerperalis (32.5 per cent) and retained placenta (27.9 per cent). 61 mares (70.9 per cent) both showed foal heat and cycled regularly in the first season after fetotomy. Out of 45 mares that were bred in the first season, 14 became pregnant (31.1 per cent). Survival rate and further fertility were reduced by delayed requests for veterinary assistance due to the difficult economic situation of the owners. Fetotomy is the method of choice for serious maldispositions, especially head malpostures, because in contrast with cesarean sections, it has a higher survival rate and allows the mare to return to breeding in the same season.
Accuracy of distal limb fracture diagnosis at British racecourses 1999–2005
Authors: Reardon R. J. M. , Boden L. , Stirk A. J. , Parkin T.D.H.
Published: February 2014

Accurate diagnosis of racing injuries can be difficult. The objectives of this study were to describe the postmortem (PM) defined distribution of fatal distal limb fractures (DLF) affecting Thoroughbreds racing in Great Britain between February 1999 and August 2005 and then assess the accuracy of veterinary racecourse diagnoses and examine whether these improved following introduction of a computerised recording system. PM examinations were performed on limbs distal to radius or tibia from all cases of fatal DLF occurring on British racecourses during the study period. Results of these examinations were described and compared with the diagnoses made at the racecourses. Over the study period, fatal DLF prevalence in all race types was 0.63 per 1000 starts (344/545,335), with the lowest frequency (0.34 per 1000 starts) in flat racing on turf and the highest frequency (1.56 per 1000 starts) in national hunt flat races. The prevalence of fatal DLF in steeplechase racing had reduced from that reported previously: from 2.3 to 1 per 1000 starts. Racecourse veterinary identification of fracture presence was good (>93 per cent); however, identification of all fractured bones was poor (<55 per cent). Introduction of a computerised recording system did not significantly improve diagnostic accuracy. The prevalence of fatal DLF has not significantly altered since the 1970s. Techniques such as on course digital radiography to help improve racecourse fracture diagnoses could be introduced.
Encephalitozoon cuniculi in rabbits in Germany: prevalence and sensitivity of antibody testing
Authors: Hein J. , Flock U. , Sauter‐Louis C. , Hartmann K.
Published: February 2014

The aim of this study was to investigate the prevalence of Encephalitozoon cuniculi antibodies in healthy and diseased rabbits in Germany. Age and gender dependencies were taken into consideration. The sensitivity of the E cuniculi antibody test and its relevance for the diagnosis of E cuniculi infection in rabbits was also examined. A total of 773 healthy and diseased rabbits were tested for E cuniculi antibodies (indirect immune fluorescence antibody test (IFAT) or carbon immunoassay (CIA). No differences between diseased and healthy rabbits were observed with regard to gender, but diseased rabbits were significantly older (P>0.001). Forty‐three percent (336/773) of all rabbits were positive for E cuniculi antibodies. Of the diseased rabbits, 48 per cent (266/555) were positive for E cuniculi antibodies. While 96 per cent (91/95) of the rabbits with histopathologically or PCR confirmed encephalitozoonosis were E cuniculi antibody‐positive, only 60 per cent (144/241) of the rabbits suspected of E cuniculi infection were antibody‐positive. Of the healthy rabbits, 18 per cent (39/218) were positive for E cuniculi antibodies. Diseased rabbits were almost three times more likely to be E cuniculi antibody‐positive than healthy ones (P>0.001; relative risk (RR): 2.68; 95% CI 1.99 to 3.61). The sensitivity of the E cuniculi antibody test was 96 per cent.
Mucilage reduces leaf herbivory in Schreber’s watershield, Brasenia schreberi J.F. Gmel. (Cabombaceae)
Authors: Thompson K.A. , Sora D.M. , Cross K.S. , St. Germain J.M. , Cottenie K.
Published: February 2014

Insect herbivores negatively affect plants by consuming biomass that could otherwise be used for growth or reproduction. To reduce their impact, plants have evolved a wide range of antiherbivore defenses. Schreber’s watershield (Brasenia schreberi J.F. Gmel.; Cabombaceae) is a freshwater, aquatic plant that produces a thick mucilage on the underside of leaves and all underwater organs. The mucilage has been proposed as a mechanism of defense against herbivory, but this hypothesis is untested. We conducted a comparative study to determine whether the quantity of mucilage on the underside of leaves is associated with herbivore damage on the leaves. We found that leaves with the thickest mucilage layer were the least damaged. To determine whether mucilage is directly responsible for defense against herbivores, we conducted a manipulative study where we removed the mucilage from the abaxial surface of leaves. We found that demucilated leaves experienced higher amounts of herbivore damage than leaves with their mucilage left intact. We conclude that the mucilage produced by B. schreberi functions to reduce herbivory on leaves, although its association with underwater herbivores and its specific antiherbivore properties remain unknown.
Fish behavioral types and their ecological consequences
Authors: Mittelbach Gary G. , Ballew Nicholas G. , Kjelvik Melissa K.
Published: February 2014

Fish have proven to be model organisms for the study of animal personalities, and a rich literature documents consistent interindividual behavioral differences in a variety of species. However, relatively few studies have examined the ecological consequences of such consistent interindividual differences in behaviors in fish or other organisms, especially under field conditions. In this review and perspective, we discuss the factors that may lead to the formation and maintenance of behavioral types in fish populations. We then examine what is known about the effects of personality variation on individual growth and survival, breeding behaviors and reproductive success, habitat use, diet, and ontogenetic niche shifts, migration and dispersal, as well as potential consequences for species interactions and ecosystem functioning. We focus as much as possible on studies conducted under natural or seminatural conditions, as such field studies are most relevant to elucidating the ecological consequences of behavioral variation. Finally, we discuss the potential importance of consistent individual differences in behaviors to fisheries management and conservation, specifically examining consequences for recreational and commercial fishing, hatchery rearing, and stock enhancement.
A doubly supersymmetric particle in 3 + 3 dimensions
Authors: McKeon D.G.C.
Published: February 2014

It is shown how in 3 + 3 dimensions, it is possible to have a superparticle Lagrangian that has manifest supersymmetry both on the world line and in the target space.
Electric charge quantization in SU(3)c ⊗SU(4)L ⊗U(1)X models
Authors: Cabarcas J. M. , Rodriguez J.-Alexis
Published: February 2014

We obtain electric charge quantization in the context of models based on the gauge symmetry group SU (3)c ⊗ U (4)L ⊗U(1)X. The gauge models study include three families to cancel out anomalies and a set of scalar fields to break the symmetry spontaneously. To show the electric charge quantization, we use classical symmetry conditions and quantum chiral anomaly conditions.
Effect of Leverage on Firm Market Value and How Contextual Variables Influence this Relationship
Authors: Cheng Ming-Chang , Tzeng Zuwei-Ching
Published: February 2014

Using the financial data from 645 companies that were listed in the Taiwan Stock Exchange (TSE) between 2000 and 2009, this paper applied a least square dummy variable (LSDV) model to estimate the effect of leverage on firm market values and examine how contextual variables influence this relationship. The empirical results are as follows. First, the values of leveraged firms are greater than the values of unleveraged firms if we do not consider the probability of bankruptcy. If we simultaneously consider the benefits and costs of debt, we find that leverage is positively related to the firm value until a firm has issued sufficient debt to attain its optimal capital structure. Second, the positive influence of leverage on the firm value tends to be stronger for firms of higher financial quality (firms with greater Z-scores), firms with greater growth opportunities and firms with higher corporate tax rates. Third, the negative influence of leverage on firm value tends to be strengthened if increases occur in a firm's free cash flow, a firm's non-debt tax rate, or the inflation rate it experiences. Finally, leverage may also have a positive effect on firm value provided that a firm with a higher free cash flow, a higher corporate rate or a higher inflation, is able to properly capitalize on the resultant opportunities. These findings provide insight into firms' debt financing decisions, helping firms to maximize their values.