Attitudes to living and working in pandemic conditions among emergency prehospital medical care personnel

Introduction: Little is known about the risk perceptions and attitudes of healthcare personnel, especially of emergency prehospital medical care personnel, regarding the possibility of an outbreak or epidemic event. Problem: This study was designed to investigate pre-event knowledge and attitudes of a national sample of the emergency prehospital medical care providers in relation to a potential human influenza pandemic, and to determine predictors of these attitudes. Methods: Surveys were distributed to a random, cross-sectional sample of 20% of the Australian emergency prehospital medical care workforce (n = 2,929), stratified by the nine services operating in Australia, as well as by gender and location. The surveys included: (1) demographic information; (2) knowledge of influenza; and (3) attitudes and perceptions related to working during influenza pandemic conditions. Multiple logistic regression models were constructed to identify predictors of pandemic-related risk perceptions. Results: Among the 725 Australian emergency prehospital medical care personnel who responded, 89% were very anxious about working during pandemic conditions, and 85% perceived a high personal risk associated with working in such conditions. In general, respondents demonstrated poor knowledge in relation to avian influenza, influenza generally, and infection transmission methods. Less than 5% of respondents perceived that they had adequate education/training about avian influenza. Logistic regression analyses indicate that, in managing the attitudes and risk perceptions of emergency prehospital medical care staff, particular attention should be directed toward the paid, male workforce (as opposed to volunteers), and on personnel whose relationship partners do not work in the health industry. Conclusions: These results highlight the potentially crucial role of education and training in pandemic preparedness. Organizations that provide emergency prehospital medical care must address this apparent lack of knowledge regarding infection transmission, and procedures for protection and decontamination. Careful management of the perceptions of emergency prehospital medical care personnel during a pandemic is likely to be critical in achieving an effective response to a widespread outbreak of infectious disease.

A survey of the Queensland healthcare workforce : attitudes towards dementia care and training

Background Positive attitudes of healthcare staff towards people with dementia promote higher quality care, although little is known about important factors that underlie positive attitudes. Key aims of this project were to explore the relationships between staff attitudes towards dementia, self-confidence in caring for people with dementia, experience and dementia education and training. Method A brief online survey was developed and widely distributed to registered nurses and allied health professionals working in Queensland in 2012. Regression analyses were performed to identify important predictors of self-confidence in caring for people with dementia and positive attitudes towards people with dementia. Results Five hundred and twenty-four surveys were completed by respondents working in a range of care settings across Queensland. Respondents were predominantly female (94.1%), and most were registered nurses (60%), aged between 41 and 60 years (65.6%). Around 40% regularly worked with people with dementia and high levels of self-confidence in caring for this population and positive attitudes towards people with dementia were reported. The majority of respondents (67%) had participated in a dementia education/training activity in the past 12 months. More experience working with people with dementia predicted greater self-confidence while recent participation in a dementia education/training and higher self-confidence in caring for a person with dementia significantly predicted more positive attitudes towards people with dementia. Conclusion These results confirm the importance of self-confidence and dementia education in fostering positive attitudes and care practices towards people with dementia. Our results also indicate that the demand for ongoing dementia education is high amongst health care workers and it is recommended that regular dementia education/ training be provided and promoted for all healthcare personnel who work with people with dementia.

Predicting transactive memory systems in multidisciplinary teams : The interplay between team and professional identities

In explaining how communication quality predicts TMS in multidisciplinary teams, we drew on the social identity approach to investigate the mediating role of team identification and the moderating role of professional identification. Recognizing that professional identification could trigger intergroup biases among professional subgroups, or alternatively, could bring resources to the team, we explored the potential moderating role of professional identification in the relationship between team identification and TMS. Using data collected from 882 healthcare personnel working in 126 multidisciplinary hospital teams, results supported our hypothesis that perceived communication quality predicted TMS through team identification. Furthermore, findings provided support for a resource view of professional subgroup identities with results indicating that high levels of professional identification compensated for low levels of team identification in predicting TMS. We provide recommendations on how social identities may be used to promote TMS in multidisciplinary teams.

Quality of work life and turnover intention in primary healthcare organisations : a cross-sectional study of registered nurses in Saudi Arabia

Purpose: The purpose of this study was to improve the retention of primary healthcare (PHC) nurses through exploring and assessing their quality of work life (QWL) and turnover intention. Design and methods: A cross-sectional survey design was used in this study. Data were collected using a questionnaire comprising four sections (Brooks’ survey of Quality of Nursing Work Life [QNWL], Anticipated Turnover Intention, open-ended questions and demographic characteristics). A convenience sample was recruited from 143 PHC centres in Jazan, Saudi Arabia. A response rate of 87% (n = 508/585) was achieved. The SPSS v17 for Windows and NVivo 8 were used for analysis purposes. Procedures and tests used in this study to analyse the quantitative data were descriptive statistics, t-test, ANOVA, General Linear Model (GLM) univariate analysis, standard multiple regression, and hierarchical multiple regression. Qualitative data obtained from responses to the open-ended questions were analysed using the NVivo 8. Findings: Quantitative findings suggested that PHC nurses were dissatisfied with their work life. Respondents’ scores ranged between 45 and 218 (mean = 139.45), which is lower than the average total score on Brooks’ Survey (147). Major influencing factors were classified under four dimensions. First, work life/home life factors: unsuitable working hours, lack of facilities for nurses, inability to balance work with family needs and inadequacy of vacations’ policy. Second, work design factors: high workload, insufficient workforce numbers, lack of autonomy and undertaking many non-nursing tasks. Third, work context factors: management practices, lack of development opportunities, and inappropriate working environment in terms of the level of security, patient care supplies and unavailability of recreation room. Finally, work world factors: negative public image of nursing, and inadequate payment. More positively, nurses were notably satisfied with their co-workers. Conversely, 40.4% (n = 205) of the respondents indicated that they intended to leave their current employment. The relationships between QWL and demographic variables of gender, age, marital status, dependent children, dependent adults, nationality, ethnicity, nursing tenure, organisational tenure, positional tenure, and payment per month were significant (p < .05). The eta squared test for these demographics indicates a small to medium effect size of the variation in QWL scores. Using the GLM univariate analysis, education level was also significantly related to the QWL (p < .05). The relationships between turnover intention and demographic variables including gender, age, marital status, dependent children, education level, nursing tenure, organisational tenure, positional tenure, and payment per month were significant (p < .05). The eta squared test for these demographics indicates a small to moderate effect size of the variation in the turnover intention scores. Using the GLM univariate analysis, the dependent adults’ variable was also significantly related to turnover intention (p < .05). Turnover intention was significantly related to QWL. Using standard multiple regression, 26% of the variance in turnover intention was explained by the QWL F (4,491), 43.71, p < .001, with R² = .263. Further analysis using hierarchical multiple regression found that the total variance explained by the model as a whole (demographics and QWL) was 32.1%, F (17.433) = 12.04, p < .001. QWL explained an additional 19% of the variance in turnover intention, after controlling for demographic variables, R squared change =.19, F change (4, 433) = 30.190, p < .001. The work context variable makes the strongest unique contribution (-.387) to explain the turnover intention, followed by the work design dimension (-.112). The qualitative findings reaffirmed the quantitative findings in terms of QWL and turnover intention. However, the home life/work life and work world dimensions were of great important to both QWL and turnover intention. The qualitative findings revealed a number of new factors that were not included in the survey questionnaire. These included being away from family, lack of family support, social and cultural aspects, accommodation facilities, transportation, building and infrastructure of PHC, nature of work, job instability, privacy at work, patients and community, and distance between home and workplace. Conclusion: Creating and maintaining a healthy work life for PHC nurses is very important to improve their work satisfaction, reduce turnover, enhance productivity and improve nursing care outcomes. Improving these factors could lead to a higher QWL and increase retention rates and therefore reinforcing the stabilisation of the nursing workforce. Significance of the research: Many countries are examining strategies to attract and retain the health care workforce, particularly nurses. This study identified factors that influence the QWL of PHC nurses as well as their turnover intention. It also determined the significant relationship between QWL and turnover intention. In addition, the present study tested Brooks’ survey of QNWL on PHC nurses for the first time. The qualitative findings of this study revealed a number of new variables regarding QWL and turnover intention of PHC nurses. These variables could be used to improve current survey instruments or to develop new research surveys. The study findings could be also used to develop and appropriately implement plans to improve QWL. This may help to enhance the home and work environments of PHC nurses, improve individual and organisational performance, and increase nurses’ commitment. This study contributes to the existing body of research knowledge by presenting new data and findings from a different country and healthcare system. It is the first of its kind in Saudi Arabia, especially in the field of PHC. It has examined the relationship between QWL and turnover intention of PHC nurses for the first time using nursing instruments. The study also offers a fresh explanation (new framework) of the relationship between QWL and turnover intention among PHC nurses, which could be used or tested by researchers in other settings. Implications for further research: Review of the extant literature reveals little in-depth research on the PHC workforce, especially in terms of QWL and organisational turnover in developing countries. Further research is required to develop a QWL tool for PHC nurses, taking into consideration the findings of the current study along with the local culture. Moreover, the revised theoretical framework of the current study could be tested in further research in other regions, countries or healthcare systems in order to identify its ability to predict the level of PHC nurses’ QWL and their intention to leave. There is a need to conduct longitudinal research on PHC organisations to gain an in-depth understanding of the determents of and changes in QWL and turnover intention of PHC nurses at various points of time. An intervention study is required to improve QWL and retention among PHC nurses using the findings of the current study. This would help to assess the impact of such strategies on reducing turnover of PHC nurses. Focusing on the location of the current study, it would be valuable to conduct another study in five years’ time to examine the percentage of actual turnover among PHC nurses compared with the reported turnover intention in the current study. Further in-depth research would also be useful to assess the impact of the local culture on the perception of expatriate nurses towards their QWL and their turnover intention. A comparative study is required between PHC centres and hospitals as well as the public and private health sector agencies in terms of QWL and turnover intention of nursing personnel. Findings may differ from sector to sector according to variations in health systems, working environments and the case mix of patients.

The health and cost implications of high body mass index in Australian Defence Force personnel.

BACKGROUND: Frequent illness and injury among workers with high body mass index (BMI) can raise the costs of employee healthcare and reduce workforce maintenance and productivity. These issues are particularly important in vocational settings such as the military, which require good physical health, regular attendance and teamwork to operate efficiently. The purpose of this study was to compare the incidence of injury and illness, absenteeism, productivity, healthcare usage and administrative outcomes among Australian Defence Force personnel with varying BMI. METHODS: Personnel were grouped into cohorts according to the following ranges for (BMI): normal (18.5-24.9 kg/m²; n = 197), overweight (25-29.9 kg/m²; n = 154) and obese (≥30 kg/m²) with restricted body fat (≤28 % for females, ≤24 % for males) (n = 148) and with no restriction on body fat (n = 180). Medical records for each individual were audited retrospectively to record the incidence of injury and illness, absenteeism, productivity, healthcare usage (i.e., consultation with medical specialists, hospital stays, medical investigations, prescriptions) and administrative outcomes (e.g., discharge from service) over one year. These data were then grouped and compared between the cohorts. RESULTS: The prevalence of injury and illness, cost of medical specialist consultations and cost of medical scans were all higher (p <0.05) in both obese cohorts compared with the normal cohort. The estimated productivity losses from restricted work days were also higher (p <0.05) in the obese cohort with no restriction on body fat compared with the normal cohort. Within the obese cohort, the prevalence of injury and illness, healthcare usage and productivity were not significantly greater in the obese cohort with no restriction on body fat compared with the cohort with restricted body fat. The number of restricted work days, the rate of re-classification of Medical Employment Classification and the rate of discharge from service were similar between all four cohorts. CONCLUSIONS: High BMI in the military increases healthcare usage, but does not disrupt workforce maintenance. The greater prevalence of injury and illness, greater healthcare usage and lower productivity in obese Australian Defence Force personnel is not related to higher levels of body fat.

Electronic medical record systems in Saudi Arabia: Knowledge and preferences of healthcare professionals

Background The use of Electronic Medical Record (EMR) systems is increasing internationally, though developing countries, such as Saudi Arabia, have tended to lag behind in the adoption and implementation of EMR systems due to several barriers. The literature shows that the main barriers to EMR in Saudi Arabia are lack of knowledge or experience using EMR systems and staff resistance to using the implemented EMR system. Methods A quantitative methodology was used to examine health personnel knowledge and acceptance of and preference for EMR systems in seven Saudi public hospitals in Jeddah, Makkah and Taif cities. Results Both English literacy and education levels were significantly correlated with computer literacy and EMR literacy. Participants whose first language was not Arabic were more likely to prefer using an EMR system compared to those whose first language was Arabic. Conclusion This study suggests that as computer literacy levels increase, so too do staff preferences for using EMR systems. Thus, it would be beneficial for hospitals to assess English language proficiency and computer literacy levels of staff prior to implementing an EMR system. It is recommended that hospitals need to offer training and targeted educational programs to the potential users of the EMR system. This would help to increase English language proficiency and computer literacy levels of staff as well as staff acceptance of the system.

Management of sharps in ambulance care : a state-wide survey of paramedic knowledge and reported practice

Paramedics are at high risk of exposure to infectious diseases because they frequently undertake procedures such as the use and disposal of sharps as components of everyday practice. While the literature demonstrates that the management of sharps is problematic across all health disciplines, there is a paucity of research examining sharps management practices in the Australian pre-hospital paramedic context. This study examines knowledge and practices of sharps control among paramedics in Queensland, Australia. A mail survey focusing on infection control knowledge and practices was sent to all clinical personnel of the Queensland Ambulance Service (QAS) (N = 2274). A total of 1258 surveys were returned, a response rate of 55.3%. Participants responded to 12 true/false statements on the management of sharps and three questions about recapping practices. Most respondents were knowledgeable about the correct management of sharps, with a mean of 11.28 (out of 12, SD = 1.32). When gauging reported practices, more than half (59.1%, n = 736) of participants reported recapping a needle, and 38.5% (n = 479) reported never having done so. These results reflect good knowledge of general management of sharps among respondents, but suggest deficits regarding reported practices. The results suggest that a comprehensive ambulance in-service education programme focusing particularly on sharps management is required. The study highlights the need for further research on sharps management practices in the field, identification of barriers to safe sharps practices in pre-hospital settings, and 'best practice' for translating good sharps management knowledge into practice.

Stability of the learning and development survey : findings for mature aged local government and private healthcare organisations.

This article investigates work related learning and development amongst mature aged workers from a lifespan developmental psychology perspective. The current study follows on from research regarding the construction and revision of the Learning and Development Survey (LDS; Tones & Pillay, 2008). Designed to measure adaptive development for work related learning, the revised LDS (R-LDS) encompasses goal selection, engagement and disengagement from individual and organisational perspectives. Previous survey findings from a mixed age sample of local government workers suggest that mature aged workers aged over 45 years are less likely to report engagement in learning and development goals than younger workers, which is partly due to insufficient opportunities at work. In the current paper, exploratory factor analysis was used to investigate responses to the R-LDS amongst two groups of mature aged workers from a local government (LG) and private healthcare (PH) organisation to determine the stability of the R-LDS. Organisational constraints to development accounted for almost a quarter of the variance in R-LDS scores for both samples, while remaining factors emerged in different orders for each data set. Organisational opportunities for development explained about 17% of the variance in R-LDS scores in the LG sample, while the individual goal disengagement factor contributed a comparable proportion of variance to R-LDS scores for the PH sample. Findings from the current study indicate that opportunities for learning and development at work may be age structured and biased towards younger workers. Implications for professional practice are discussed and focus on improving the engagement of mature aged workers.

Economics and preventing healthcare acquired infection

The evolution of organisms that cause healthcare acquired infections (HAI) puts extra stress on hospitals already struggling with rising costs and demands for greater productivity and cost containment. Infection control can save scarce resources, lives, and possibly a facility’s reputation, but statistics and epidemiology are not always sufficient to make the case for the added expense. Economics and Preventing Healthcare Acquired Infection presents a rigorous analytic framework for dealing with this increasingly serious problem. ----- Engagingly written for the economics non-specialist, and brimming with tables, charts, and case examples, the book lays out the concepts of economic analysis in clear, real-world terms so that infection control professionals or infection preventionists will gain competence in developing analyses of their own, and be confident in the arguments they present to decision-makers. The authors: ----- Ground the reader in the basic principles and language of economics. ----- Explain the role of health economists in general and in terms of infection prevention and control. ----- Introduce the concept of economic appraisal, showing how to frame the problem, evaluate and use data, and account for uncertainty. ----- Review methods of estimating and interpreting the costs and health benefits of HAI control programs and prevention methods. ----- Walk the reader through a published economic appraisal of an infection reduction program. ----- Identify current and emerging applications of economics in infection control. ---- Economics and Preventing Healthcare Acquired Infection is a unique resource for practitioners and researchers in infection prevention, control and healthcare economics. It offers valuable alternate perspective for professionals in health services research, healthcare epidemiology, healthcare management, and hospital administration. ----- Written for: Professionals and researchers in infection control, health services research, hospital epidemiology, healthcare economics, healthcare management, hospital administration; Association of Professionals in Infection Control (APIC), Society for Healthcare Epidemiologists of America (SHEA)

Patterns of reporting to child protection services in Canada by healthcare and nonhealthcare professionals

Background: All Canadian jurisdictions require certain professionals to report suspected or observed child maltreatment. This study examined the types of maltreatment, level of harm and child functioning issues, controlling for family socioeconomic status, age and gender of the child reported by healthcare and non-healthcare professionals. Methods: We conducted chi-square analyses and logistic regression on a national child welfare sample from the 2003 Canadian Incidence Study of Reported Child Abuse and Neglect (CIS-2003) and compared the differences in professional reporting with its previous cycle (CIS-1998) using Bonferroni-corrected confidence intervals. Results: Our analysis of CIS-2003 data revealed that the majority of substantiated child maltreatment is reported to service agencies by non-healthcare professionals (57%), followed by non-professionals (33%) and healthcare professionals (10%). The number of professional reports increased 2.5 times between CIS-1998 and CIS-2003, while non-professionals’ increased 1.7 times. Of the total investigations, professional reports represented 59% in CIS-1998 and 67% in CIS-2003 (p<0.001). Compared to non-healthcare professionals, healthcare professionals more often reported younger children, children who experienced neglect and emotional maltreatment and those assessed as suffering harm and child functioning issues, but less often exposure to domestic violence. Conclusion: The results indicate that healthcare professionals played an important role in identifying children in need of protection considering harm and other child functioning issues. The authors discuss the reasons why underreporting is likely to remain an issue.

Setting hospital infection control policy : a decision-making framework incorporating health economics and healthcare epidemiology

Background: Reducing rates of healthcare acquired infection has been identified by the Australian Commission on Safety and Quality in Health Care as a national priority. One of the goals is the prevention of central venous catheter-related bloodstream infection (CR-BSI). At least 3,500 cases of CR-BSI occur annually in Australian hospitals, resulting in unnecessary deaths and costs to the healthcare system between $25.7 and $95.3 million. Two approaches to preventing these infections have been proposed: use of antimicrobial catheters (A-CVCs); or a catheter care and management ‘bundle’. Given finite healthcare budgets, decisions about the optimal infection control policy require consideration of the effectiveness and value for money of each approach. Objectives: The aim of this research is to use a rational economic framework to inform efficient infection control policy relating to the prevention of CR-BSI in the intensive care unit. It addresses three questions relating to decision-making in this area: 1. Is additional investment in activities aimed at preventing CR-BSI an efficient use of healthcare resources? 2. What is the optimal infection control strategy from amongst the two major approaches that have been proposed to prevent CR-BSI? 3. What uncertainty is there in this decision and can a research agenda to improve decision-making in this area be identified? Methods: A decision analytic model-based economic evaluation was undertaken to identify an efficient approach to preventing CR-BSI in Queensland Health intensive care units. A Markov model was developed in conjunction with a panel of clinical experts which described the epidemiology and prognosis of CR-BSI. The model was parameterised using data systematically identified from the published literature and extracted from routine databases. The quality of data used in the model and its validity to clinical experts and sensitivity to modelling assumptions was assessed. Two separate economic evaluations were conducted. The first evaluation compared all commercially available A-CVCs alongside uncoated catheters to identify which was cost-effective for routine use. The uncertainty in this decision was estimated along with the value of collecting further information to inform the decision. The second evaluation compared the use of A-CVCs to a catheter care bundle. We were unable to estimate the cost of the bundle because it is unclear what the full resource requirements are for its implementation, and what the value of these would be in an Australian context. As such we undertook a threshold analysis to identify the cost and effectiveness thresholds at which a hypothetical bundle would dominate the use of A-CVCs under various clinical scenarios. Results: In the first evaluation of A-CVCs, the findings from the baseline analysis, in which uncertainty is not considered, show that the use of any of the four A-CVCs will result in health gains accompanied by cost-savings. The MR catheters dominate the baseline analysis generating 1.64 QALYs and cost-savings of $130,289 per 1.000 catheters. With uncertainty, and based on current information, the MR catheters remain the optimal decision and return the highest average net monetary benefits ($948 per catheter) relative to all other catheter types. This conclusion was robust to all scenarios tested, however, the probability of error in this conclusion is high, 62% in the baseline scenario. Using a value of $40,000 per QALY, the expected value of perfect information associated with this decision is $7.3 million. An analysis of the expected value of perfect information for individual parameters suggests that it may be worthwhile for future research to focus on providing better estimates of the mortality attributable to CR-BSI and the effectiveness of both SPC and CH/SSD (int/ext) catheters. In the second evaluation of the catheter care bundle relative to A-CVCs, the results which do not consider uncertainty indicate that a bundle must achieve a relative risk of CR-BSI of at least 0.45 to be cost-effective relative to MR catheters. If the bundle can reduce rates of infection from 2.5% to effectively zero, it is cost-effective relative to MR catheters if national implementation costs are less than $2.6 million ($56,610 per ICU). If the bundle can achieve a relative risk of 0.34 (comparable to that reported in the literature) it is cost-effective, relative to MR catheters, if costs over an 18 month period are below $613,795 nationally ($13,343 per ICU). Once uncertainty in the decision is considered, the cost threshold for the bundle increases to $2.2 million. Therefore, if each of the 46 Level III ICUs could implement an 18 month catheter care bundle for less than $47,826 each, this approach would be cost effective relative to A-CVCs. However, the uncertainty is substantial and the probability of error in concluding that the bundle is the cost-effective approach at a cost of $2.2 million is 89%. Conclusions: This work highlights that infection control to prevent CR-BSI is an efficient use of healthcare resources in the Australian context. If there is no further investment in infection control, an opportunity cost is incurred, which is the potential for a more efficient healthcare system. Minocycline/rifampicin catheters are the optimal choice of antimicrobial catheter for routine use in Australian Level III ICUs, however, if a catheter care bundle implemented in Australia was as effective as those used in the large studies in the United States it would be preferred over the catheters if it was able to be implemented for less than $47,826 per Level III ICU. Uncertainty is very high in this decision and arises from multiple sources. There are likely greater costs to this uncertainty for A-CVCs, which may carry hidden costs, than there are for a catheter care bundle, which is more likely to provide indirect benefits to clinical practice and patient safety. Research into the mortality attributable to CR-BSI, the effectiveness of SPC and CH/SSD (int/ext) catheters and the cost and effectiveness of a catheter care bundle in Australia should be prioritised to reduce uncertainty in this decision. This thesis provides the economic evidence to inform one area of infection control, but there are many other infection control decisions for which information about the cost-effectiveness of competing interventions does not exist. This work highlights some of the challenges and benefits to generating and using economic evidence for infection control decision-making and provides support for commissioning more research into the cost-effectiveness of infection control.

Implementing an emergency department patient admission predictive tool : insights from practice

Purpose: This paper aims to show that identification of expectations and software functional requirements via consultation with potential users is an integral component of the development of an emergency department patient admissions prediction tool. ---------- Design/methodology/approach: Thematic analysis of semi-structured interviews with 14 key health staff delivered rich data regarding existing practice and future needs. Participants included emergency department staff, bed managers, nurse unit managers, directors of nursing, and personnel from health administration. ---------- Findings: Participants contributed contextual insights on the current system of admissions, revealing a culture of crisis, imbued with misplayed communication. Their expectations and requirements of a potential predictive tool provided strategic data that moderated the development of the Emergency Department Patient Admissions Prediction Tool, based on their insistence that it feature availability, reliability and relevance. In order to deliver these stipulations, participants stressed that it should be incorporated, validated, defined and timely. ---------- Research limitations/implications: Participants were envisaging a concept and use of a tool that was somewhat hypothetical. However, further research will evaluate the tool in practice. ---------- Practical implications: Participants' unsolicited recommendations regarding implementation will not only inform a subsequent phase of the tool evaluation, but are eminently applicable to any process of implementation in a healthcare setting. ---------- Originality/value: The consultative process engaged clinicians and the paper delivers an insider view of an overburdened system, rather than an outsider's observations.