Social work and complex care systems: The case of people hospitalised with a disability

Health and hospital system reforms prioritise efficiency. However, initiatives can impact on people with new or existing disabilities who require time to maximise functional independence. With greater demands for shorter hospital stays social workers face increasing pressure to facilitate discharge. This paper reports findings from research identifying factors contributing to extended stays for adults with disabilities. We sought to better understand patient characteristics and discharge planning challenges by analysing a clinical data set of 80 patients and qualitative interviews with five experienced hospital social workers. Three key factors are identified: issues around rehabilitation services; assessment and planning for community care; and availability of and access to discharge options. Strategies to reduce length of stay are reported. We argue that building collaborative partnerships and working across multiple, complex systems and disciplines are vital to ensure these patients access appropriate community-based resources within the current health reform environment.

Rethinking Early Childhood Education and Care: Implications for Research and Evaluation

Research in disadvantaged populations demonstrates that the effect of Early Childhood Education and Care (ECEC) programs can reach into adulthood and influence a wide range of achievement and social well-being outcomes. In English-speaking developed economies, these findings have sparked new perceptions of the role ECEC programs play in both the public and private sphere. Programs that achieve improved learning and social well-being for children are seen as an investment for both individuals and society. Yet, the empirical understanding of what programs best deliver positive outcomes across the diversity of social contexts is limited. A key research task is to identify the forms of ECEC that are most effective in delivering enduring and broad positive outcomes for all children. This article explores changing policy conceptualizations of ECEC, the outcome goals of ECEC, and directions for research in identifying quality in ECEC programs.

Modelling end-of-life care practices: Factors associated with critical care nurse engagement in care provision

Objective To identify factors associated with critical care nurses’ engagement in end-of-life care practices. Methods Multivariable regression modelling was undertaken on 392 responses to an online self-report survey of end-of-life care practices and factors influencing practice by Australian critical care nurses’. Univariate general linear models were built for six end-of-life care practice areas. Results Six statistically significant (p < 0.001) models were developed: Information sharing F(3, 377) = 40.53, adjusted R2 23.8%; Environmental modification F(5, 380) = 19.55, adjusted R2 19.4%; Emotional support F(10, 366) = 12.10, adjusted R2 22.8%; Patient and family centred decision making F(8, 362) = 17.61 adjusted R2 26.4%; Symptom management F(8, 376) = 7.10, adjusted R2 11.3%; and Spiritual support F(9, 367) = 14.66, adjusted R2 24.6%. Stronger agreement with values consistent with a palliative approach, and greater support for patient and family preferences were associated with higher levels of engagement in end-of-life care practices. Higher levels of preparedness and access to opportunities for knowledge acquisition were associated with engagement in the interpersonal practices of patient and family centred decision making and emotional support. Conclusion This study provides evidence for interventions to address factors associated with nurse engagement to increase participation in all end-of-life care practice areas.

Bringing up Children Gran’s Way: Insights from a research project on Indigenous child and youth mental health

Background In 2000, the Mater Child and Youth Mental Health Service Indigenous consultant saw that Indigenous families were isolated from kinship networks following the assimilation policy and clinicians were largely unaware of these socio-cultural histories. Experiences of marginalisation by mainstream society and services were exacerbated by assumptions clinicians made about this population. To enhance Mater’s care the consultant undertook research with Indigenous Elders. The project, “Bringing up Children Gran’s Way”, on which the presenter is the research advisor, was funded by AIATSIS. Aims Increase service quality Improve staff confidence, skills and satisfaction working with this population Promote the wellbeing of Indigenous families Acknowledge the significance of Elders and extended family networks. Methods Over 2006/07 the team used narrative and Indigenous methodologies, (e.g. yarning circles and the use of Indigenous research staff) to arrange and audio-record structured interviews with 19 Aboriginal Elders, on growing up and parenting. The participants were recruited by the Indigenous consultant and gave written consent, following ethical approval and information giving. The team immersed themselves in the material by repeated reading of the transcripts to note recurring themes in Elders’ narratives. Findings The recurring themes included the importance of cultural protocols and extended family; impacts of being ‘under the Act and stories of surviving change; culture, spiritualty and religion; trans-generational impacts; childrearing and the need to reconcile with Elders. Discussion The narratives show Elders resilience in the face of enduring impact of policies of genocide and assimilation. Clinicians need to approach their work with a deeper understanding of the diversity of clients’ social experience and cultural identity. Clinicians need to examine their own cultural assumptions about this population. Conclusion The dissemination of the knowledge and experience of Elders is a matter of social justice and crucial for the well-being of future generations and for improved service access.

Hospital in the Nursing Home program reduces emergency department presentations and hospital admissions from residential aged care facilities in Queensland, Australia: A quasi-experimental study

Background There has been considerable publicity regarding population ageing and hospital emergency department (ED) overcrowding. Our study aims to investigate impact of one intervention piloted in Queensland Australia, the Hospital in the Nursing Home (HiNH) program, on reducing ED and hospital attendances from residential aged care facilities (RACFs). Methods A quasi-experimental study was conducted at an intervention hospital undertaking the program and a control hospital with normal practice. Routine Queensland health information system data were extracted for analysis. Results Significant reductions in the number of ED presentations per 1000 RACF beds (rate ratio (95 % CI): 0.78 (0.67–0.92); p = 0.002), number of hospital admissions per 1000 RACF beds (0.62 (0.50–0.76); p < 0.0001), and number of hospital admissions per 100 ED presentations (0.61 (0.43–0.85); p = 0.004) were noticed in the experimental hospital after the intervention; while there were no significant differences between intervention and control hospitals before the intervention. Pre-test and post-test comparison in the intervention hospital also presented significant decreases in ED presentation rate (0.75 (0.65–0.86); p < 0.0001) and hospital admission rate per RACF bed (0.66 (0.54–0.79); p < 0.0001), and a non-significant reduction in hospital admission rate per ED presentation (0.82 (0.61–1.11); p = 0.196). Conclusions Hospital in the Nursing Home program could be effective in reducing ED presentations and hospital admissions from RACF residents. Implementation of the program across a variety of settings is preferred to fully assess the ongoing benefits for patients and any possible cost-savings.

A descriptive analysis of incidents reported by community aged care workers

Little is known about the types of incidents that occur to aged care clients in the community. This limits the development of effective strategies to improve client safety. The objective of the study was to present a profile of incidents reported in Australian community aged care settings. All incident reports made by community care workers employed by one of the largest community aged care provider organizations in Australia during the period November 1, 2012, to August 8, 2013, were analyzed. A total of 356 reports were analyzed, corresponding to a 7.5% incidence rate per client year. Falls and medication incidents were the most prevalent incident types. Clients receiving high-level care and those who attended day therapy centers had the highest rate of incidents with 14% to 20% of these clients having a reported incident. The incident profile indicates that clients on higher levels of care had higher incident rates. Incident data represent an opportunity to improve client safety in community aged care.

Medication incident reporting in residential aged care facilities: Limitations and risks to residents' safety

Background Medication incident reporting (MIR) is a key safety critical care process in residential aged care facilities (RACFs). Retrospective studies of medication incident reports in aged care have identified the inability of existing MIR processes to generate information that can be used to enhance residents’ safety. However, there is little existing research that investigates the limitations of the existing information exchange process that underpins MIR, despite the considerable resources that RACFs’ devote to the MIR process. The aim of this study was to undertake an in-depth exploration of the information exchange process involved in MIR and identify factors that inhibit the collection of meaningful information in RACFs. Methods The study was undertaken in three RACFs (part of a large non-profit organisation) in NSW, Australia. A total of 23 semi-structured interviews and 62 hours of observation sessions were conducted between May to July 2011. The qualitative data was iteratively analysed using a grounded theory approach. Results The findings highlight significant gaps in the design of the MIR artefacts as well as information exchange issues in MIR process execution. Study results emphasized the need to: a) design MIR artefacts that facilitate identification of the root causes of medication incidents, b) integrate the MIR process within existing information systems to overcome key gaps in information exchange execution, and c) support exchange of information that can facilitate a multi-disciplinary approach to medication incident management in RACFs. Conclusions This study highlights the advantages of viewing MIR process holistically rather than as segregated tasks, as a means to identify gaps in information exchange that need to be addressed in practice to improve safety critical processes.

Understanding the information dynamics of medication administration in residential aged care facilities (RACFs): A prerequisite for design of effective ICT systems

Medication information is a critical part of the information required to ensure residents' safety in the highly collaborative care context of RACFs. Studies report poor medication information as a barrier to improve medication management in RACFs. Research exploring medication work practices in aged care settings remains limited. This study aimed to identify contextual and work practice factors contributing to breakdowns in medication information exchange in RACFs in relation to the medication administration process. We employed non-participant observations and semi-structured interviews to explore information practices in three Australian RACFs. Findings identified inefficiencies due to lack of information timeliness, manual stock management, multiple data transcriptions, inadequate design of essential documents such as administration sheets and a reliance on manual auditing procedures. Technological solutions such as electronic medication administration records offer opportunities to overcome some of the identified problems. However these interventions need to be designed to align with the collaborative team based processes they intend to support.

Design challenges for electronic medication administration record systems in residential aged care facilities: A formative evaluation

Introduction Electronic medication administration record (eMAR) systems are promoted as a potential intervention to enhance medication safety in residential aged care facilities (RACFs). The purpose of this study was to conduct an in-practice evaluation of an eMAR being piloted in one Australian RACF before its roll out, and to provide recommendations for system improvements. Methods A multidisciplinary team conducted direct observations of workflow (n=34 hours) in the RACF site and the community pharmacy. Semi-structured interviews (n=5) with RACF staff and the community pharmacist were conducted to investigate their views of the eMAR system. Data were analysed using a grounded theory approach to identify challenges associated with the design of the eMAR system. Results The current eMAR system does not offer an end-to-end solution for medication management. Many steps, including prescribing by doctors and communication with the community pharmacist, are still performed manually using paper charts and fax machines. Five major challenges associated with the design of eMAR system were identified: limited interactivity; inadequate flexibility; problems related to information layout and semantics; the lack of relevant decision support; and system maintenance issues.We suggest recommendations to improve the design of the eMAR system and to optimize existing workflows. Discussion Immediate value can be achieved by improving the system interactivity, reducing inconsistencies in data entry design and offering dedicated organisational support to minimise connectivity issues. Longer-term benefits can be achieved by adding decision support features and establishing system interoperability requirements with stakeholder groups (e.g. community pharmacies) prior to system roll out. In-practice evaluations of technologies like eMAR system have great value in identifying design weaknesses which inhibit optimal system use.

Coping with information silos: An examination of the medication management process in residential aged care facilities (RACFs)

The aim of this study was to examine the actions of geographically dispersed process stakeholders (doctors, community pharmacists and RACFs) in order to cope with the information silos that exist within and across different settings. The study setting involved three metropolitan RACFs in Sydney, Australia and employed a qualitative approach using semi-structured interviews, non-participant observations and artefact analysis. Findings showed that medication information was stored in silos which required specific actions by each setting to translate this information to fit their local requirements. A salient example of this was the way in which community pharmacists used the RACF medication charts to prepare residents' pharmaceutical records. This translation of medication information across settings was often accompanied by telephone or face-to-face conversations to cross-check, validate or obtain new information. Findings highlighted that technological interventions that work in silos can negatively impact the quality of medication management processes in RACF settings. The implementation of commercial software applications like electronic medication charts need to be appropriately integrated to satisfy the collaborative information requirements of the RACF medication process.

End-of-life care pathways for improving outcomes in caring for the dying

This is an updated version of a Cochrane review published in Issue 11, 2013 in the Cochrane Library. In many clinical areas, integrated care pathways are utilised as structured multidisciplinary care plans that detail essential steps in caring for patients with specific clinical problems. In particular, care pathways for the dying have been developed as a model to improve care of patients who are in the last days of life. The care pathways were designed with an aim of ensuring that the most appropriate management occurs at the most appropriate time, and that it is provided by the most appropriate health professional. Since the last update, there have been sustained concerns about the safety of implementing end-of-life care pathways, particularly in the United Kingdom (UK). Therefore, there is a significant need for clinicians and policy makers to be informed about the effects of end-of-life care pathways via a systematic review.

Patient perspectives of factors contributing to inadequate dietary intake in acute care patients in hospital

Up to 30% of acute care patients consume less than half of the food provided in hospital. Inadequate dietary intake can have adverse clinical outcomes, including a higher risk of in-hospital mortality. This study aimed to investigate the reasons for poor intake among acute care patients in hospital. Patients with an observed intake of ≤50% of the food provided at lunch were approached to participate in the study. Thirty-two patients participated in semi-structured interviews over a three week period, to provide their perspective of food and mealtimes in hospital and discuss the reasons and factors influencing inadequate intake. Responses were coded and analysed thematically using the framework method. Patients reported both individual and organisational factors contribute to their inadequate intake. Half the patients reported the size of the meals were too large, with some patients reporting that large meal sizes puts them off their food and reduced their intake. ‘Not important to eat all the food provided’, and ‘do not need to eat much food in hospital’ were common attitudes among the patients. Half the patients reported that nurses did not observe their intake and were not concerned if all the food was not eaten. Identifying the reasons for poor intake can assist with the development of suitable interventions to improve dietary intake and reduce the risk of adverse clinical outcomes. Further investigation of suitable interventions to reduce portion sizes and improve both staff and patient perceptions of the importance of food in hospital is recommended.

Advancing initiatives in care of cognitively impaired patients in acute care settings

In November 2014, the Australian Commission on Safety and Quality in Health Care (ACSQHC) released “A better way to care: Safe and high quality care for patients with cognitive impairment (dementia and delirium) in hospital”. http://www.safetyandquality.gov.au/our-work/cognitive-impairment. The handbook is available as three separate resources for the three audiences: clinicians, service managers and consumers. These resources are designed to inform and guide improved care for older patients with cognitive impairment (CI) (dementia, delirium) in acute care settings. In particular, the service managers resource recommends that organisations comprehensively prepare themselves so that they are alert to delirium and the risk it poses for patients, that they can recognise and respond to patients with CI, and that they are able to provide safe and high quality care tailored to individual patient’s needs. Service managers and clinicians should carefully consider the information provided in the resources and judiciously explore how best to modify and adapt everyday care practices where appropriate. It is important that clinical teams respond to the available information as the ACSQHC identifies that dementia and/or delirium is associated with adverse outcomes, including functional decline, increased risk of falls, and increased morbidity and mortality...

A shift in priority in diabetic foot care and research: 75% of foot ulcers are preventable

Diabetic foot ulceration poses a heavy burden on the patient and the healthcare system, but prevention thereof receives little attention. For every euro spent on ulcer prevention, ten are spent on ulcer healing, and for every randomized controlled trial conducted on prevention, ten are conducted on healing. In this article, we argue that a shift in priorities is needed. For the prevention of a first foot ulcer, we need more insight into the effect of interventions and practices already applied globally in many settings. This requires systematic recording of interventions and outcomes, and well-designed randomized controlled trials that include analysis of cost-effectiveness. After healing of a foot ulcer, the risk of recurrence is high. For the prevention of a recurrent foot ulcer, home monitoring of foot temperature, pressure-relieving therapeutic footwear, and certain surgical interventions prove to be effective. The median effect size found in a total of 23 studies on these interventions is large, over 60%, and further increases when patients are adherent to treatment. These interventions should be investigated for efficacy as a state-of-the-art integrated foot care approach, where attempts are made to assure treatment adherence. Effect sizes of 75-80% may be expected. If such state-of-the-art integrated foot care is implemented, the majority of problems with foot ulcer recurrence in diabetes can be resolved. It is therefore time to act and to set a new target in diabetic foot care. This target is to reduce foot ulcer incidence with at least 75%.

Reflexivity and self-care for creative facilitators: Stepping outside the circle

Those who work with others to explore new and creative ways of thinking about community and organizational participation, ways of engaging with others, individual well-being and creative solutions to problems, have a significant role in a cohesive society. Creative forms of learning can stimulate reflexive practices of self-care and lead to enhanced relationships and practices both personally and professionally. We argue that those who facilitate such practices for others do not always practice their own self-care, which potentially leads to burnout and disillusionment. This research sought to explore understandings and practices of self-care with such facilitators in order to develop resources or techniques to support more sustainable professional identities. A key finding is that reflexive processes are most effective and transforming when shared as a social practice.