Implementation of sustainable evidence-based practice for the assessment and management of pain in residential aged care facilities

Pain is common in residential aged care facilities (RACFs). In 2005, the Australian Pain Society developed 27 recommendations for good practice in the identification, assessment, and management of pain in these settings. This study aimed to address implementation of the standards and evaluate outcomes. Five facilities in Australia participated in a comprehensive evaluation of RACF pain practice and outcomes. Pre-existing pain management practices were compared with the 27 recommendations, before an evidence-based pain management program was introduced that included training and education for staff and revised in-house pain-management procedures. Post-implementation audits evaluated the program's success. Aged care staff teams also were assessed on their reports of self-efficacy in pain management. The results show that before the implementation program, the RACFs demonstrated full compliance on 6 to 12 standards. By the project's completion, RACFs demonstrated full compliance with 10 to 23 standards and major improvements toward compliance in the remaining standards. After implementation, the staff also reported better understanding of the standards (p < .001) or of facility pain management guidelines (p < .001), increased confidence in therapies for pain management (p < .001), and increased confidence in their training to assess pain (p < .001) and recognize pain in residents with dementia who are nonverbal (p = .003). The results show that improved evidence-based practice in RACFs can be achieved with appropriate training and education. Investing resources in the aged care workforce via this implementation program has shown improvements in staff self-efficacy and practice.

An evidence-based program to improve analgesic practice and pain outcomes in residential aged care facilities

Pain is common in individuals living in residential aged care facilities (RACFs), and a number of obstacles have been identified as recurring barriers to adequate pain management. To address this, the Australian Pain Society developed 27 recommendations for comprehensive good practice in the identification, assessment, and management of pain. This study reviewed preexisting pain management practice at five Australian RACFs and identified changes needed to implement the recommendations and then implemented an evidence-based program that aimed to facilitate better pain management. The program involved staff training and education and revised in-house pain-management procedures. Reviews occurred before and after the program and included the assessment of 282 residents for analgesic use and pain status. Analgesic use improved after the program (P<.001), with a decrease in residents receiving no analgesics (from 15% to 6%) and an increase in residents receiving around-the-clock plus as-needed analgesics (from 24% to 43%). There were improvements in pain relief for residents with scores indicative of pain, with Abbey pain scale (P=.005), Pain Assessment in Advanced Dementia Scale (P=.001), and Non-communicative Patient's Pain Assessment Instrument scale (P<.001) scores all improving. Although physical function declined as expected, Medical Outcomes Study 36-item Short-Form Survey bodily pain scores also showed improvement (P=.001). Better evidence-based practice and outcomes in RACFs can be achieved with appropriate training and education. Investing resources in the aged care workforce using this program improved analgesic practice and pain relief in participating sites. Further attention to the continued targeted pain management training of aged care staff is likely to improve pain-focused care for residents.

Evaluation of legal capacity by doctors and lawyers : the need for collaborative assessment

• Balancing the interests of individual autonomy and protection is an escalating challenge confronting an ageing Australian society. • One way this is manifested is in the current ad hoc and unsatisfactory way that capacity is assessed in the context of wills, enduring powers of attorney and advance health directives. • The absence of nationally accepted assessment guidelines results in terminological and methodological miscommunication and misunderstanding between legal and medical professionals. • Expectations between legal and medical professionals can be clarified to provide satisfactory capacity assessments based upon the development of a sound assessment paradigm

Available evidence does not support serosorting as an HIV risk reduction strategy

Recent data highlighted the association between penetration of antiretrovirals in the central nervous system (CNS) and neurocognitive impairment in HIVpositive patients. Existing antiretrovirals have been ranked according to a score of neuropenetration, which was shown to be a predictor of anti-HIVactivity in the CNS and improvement of neurocognitive disorders [1]. Main factors affecting drug penetration are known to be protein binding, lipophilicity and molecular weight [2]. Moreover, active translation by membrane transporters (such as p-glycoprotein) could be a key mechanism of passage [3]. The use of raltegravir (RGV), a novel antiretroviral drug targeted to inhibit the HIV preintegrase complex, is increasing worldwide due to its efficacy and tolerability. However, penetration of RGV in the CNS has not been yet elucidated. In fact, prediction of RGV neuropenetration according to molecular characteristics is controversial. Intermediate protein binding (83%) and large volume of distribution (273 l) could suggest a high distribution beyond extracellular spaces [4]. On the contrary, low lipophilicity (oil/water partition coefficient at pH 7.4 of 2.80) and intermediate molecular weight (482.51 Da) suggest a limited diffusion. Furthermore, in-vitro studies suggest that RGV is substrate of p-glycoprotein, although this efflux pump has not been identified to significantly affect plasma pharmacokinetics [5]. In any case, no data concerning RGV passage into cerebrospinal fluid of animals or humans have yet been published.

The healthy immigrant effect: Patterns and evidence from four countries

The existence of a healthy immigrant effect—where immigrants are on average healthier than the native born—is a widely cited phenomenon across a multitude of literatures including epidemiology and the social sciences. There are many competing explanations. The goals of this paper are twofold: first, to provide further evidence on the presence of the healthy immigrant effect across source and destination country using a set of consistently defined measures of health; and second, to evaluate the role of selectivity as a potential explanation for the existence of the phenomenon. Utilizing data from four major immigrant recipient countries, USA, Canada, UK, and Australia allows us to compare the health of migrants from each with the respective native born who choose not to migrate. This represents a much more appropriate counterfactual than the native born of the immigrant recipient country and yields new insights into the importance of observable selection effects. The analysis finds strong support for the healthy immigrant effect across all four destination countries and that selectivity plays an important role in the observed better health of migrants vis a vis those who stay behind in their country of origin.

Safe Design Project : Review of occupational health and safety legal requirements for designers, manufacturers, suppliers, importers and other relevant obligation bearers

In seeking to achieve Australian workplaces free from injury and disease NOHSC works to lead and coordinate national efforts to prevent workplace death, injury and disease. We seek to achieve our mission through the quality and relevance of information we provide and to influence the activities of all parties with roles in improving Australia’s OHS performance. NOHSC has five strategic objectives: • improving national data systems and analysis, • improving national access to OHS information, • improving national components of the OHS and related regulatory framework, • facilitating and coordinating national OHS research efforts, • monitoring progress against the National OHS Improvement Framework. This publication is a contribution to achieving those objectives

Occupational Health and Safety, Courts and Crime: the legal construction of occupational health and safety offences in Victoria

This book reports on an empirically-based study of the manner in which the Magistrates' Courts in Victoria, construct occupational health and safety (OHS) issues when hearing prosecutions for offences under the Victorian OHS legislation. Prosecution has always been a controversial element in the enforcement armoury of OHS regulators, but at the same time it has long been argued that the low level of fines imposed by courts has had an important chilling effect on the OHS inspectorate's enforcement approaches, and on the impact of OHS legislation. Using a range of empirical research methods, including three samples of OHS prosecutions carried out in the Victorian Magistrates' Courts, Professor Johnstone shows how courts, inspectors, prosecutors and defence counsel are involved in filtering or reshaping OHS issues during the prosecution process, both pre-trial and in court. He argues that OHS offences are constructed by focusing on "events", in most cases incidents resulting in injury or death. This "event-focus" ensures that the attention of the parties is drawn to the details of the incident, and away from the broader context of the event. During the court-based sentencing process defence counsel is able to adopt a range of techniques which isolate the incident from its micro and macro contexts, thereby individualising and decontextualising the incident.

Beyond Employment: The Legal Regulation of Work Relationships

Australian labour law, at least from the mid-twentieth century, was dominated by the employment paradigm: the assumption that labour law’s scope was the regulation of employment relationships –full-time and part-time, and continuing, fixed term or casual – with a single (usually corporate) entity employer. But no sooner had the employment paradigm established and consolidated its shape, it began to fall apart. Since the 1980s there has been a significant growth of patterns of work that fall outside this paradigm, driven by organisational restructuring and management techniques such as labour hire, sub-contracting and franchising. Beyond Employment analyses the way in which Australian labour law is being reframed in this shift away from the pre-eminence of the employment paradigm. Its principal concern is with the legal construction and regulation of various forms of contracting, including labour hire arrangements, complex contractual chains and modern forms like franchising, and of casual employment. It outlines the current array of work relationships in Australia, and describes and analyses the way in which those outside continuous and fixed term employment are regulated. The book seeks to answer the central question: How does law (legal rules and principles) construct these work relationships, and how does it regulate these relationships? The book identifies the way in which current law draws the lines between the various work relationships through the use of contract and property ownership, and describes, analyses and synthesises the legal rules that govern these different forms of work relationships. The legal rules that govern work relationships are explored through the traditional lens of labour law’s protective function, principally in four themes: control of property, and the distribution of risks and rewards; maintenance of income security; access to collective voice mechanisms, focusing on collective bargaining; and health, safety and welfare. The book critically evaluates the gaps in the coverage and content of these rules and principles, and the implications of these gaps for workers. It also reflects upon the power relationships that underpin the work arrangements that are the focus of the book and that are enhanced through the laws of contract and property. Finally, it frames an agenda to address the gaps and identified weaknesses insofar as they affect the economic wellbeing, democratic voice, and health and safety of workers.

Decriminalization of Health and Safety at Work in Australia

ABOUT THE BOOK As the title Safety or Profit? suggests, health and safety at work needs to be understood in the context of the wider political economy. This book brings together contributions informed by this view from internationally recognized scholars. It reviews the governance of health and safety at work, with special reference to Australia, Canada, Sweden, and the United Kingdom. Three main aspects are discussed. The restructuring of the labor market: this is considered with respect to precarious work and to gender issues and their implications for the health and safety of workers. The neoliberal agenda: this is examined with respect to the diminished power of organized labor, decriminalization, and new governance theory, including an examination of how well the health-and-safety-at-work regimes put in place in many industrial societies about forty years ago have fared and how distinctive the recent emphasis on self-regulation in several countries really is. The role of evidence: there is a dearth of evidence-based policy. The book examines how policy on health and safety at work is formulated at both company and state levels. Cases considered include the scant regard paid to evidence by an official inquiry into future strategy in Canada; the lack of evidence-based policy and the reluctance to observe the precautionary principle with respect to work-related cancer in the United Kingdom; and the failure to learn from past mistakes in the Deepwater Horizon disaster in the Gulf of Mexico. Intended Audience: Researchers; policymakers, trade union representatives, and officials interested in OHS; postgraduate students of OHS; OHS professionals; regulatory and socio-legal scholars.

Infringement notices: stimulus for prevention or trivialising offences?

In the OHS field increasing use is being made of administrative penalties to enforce OHS legislation. Infringement notices (also known as penalty notices or on-the-spot fines) are used in several Australian jurisdictions and there are plans to introduce them in others. Overseas jurisdictions with some form of OHS administrative penalty include the United States, some Canadian provinces, and the system recently enacted in New Zealand. This article reviews empirical evidence and legal arguments about the use of infringement notices for enforcing OHS legislation. Key factors influencing the impact of these notices are discussed, including the monetary amounts of penalties, the nature of offences, the criteria and processes for issuing notices, and other implementation issues. There is a need for further empirical studies to determine the characteristics of infringement notice schemes that are most effective in motivating preventive action.

The legal concept of work-related injury and disease in Australian OHS and workers' compensation systems

This paper analyses the concept of ‘work-relatedness’ in Australian workers’ compensation and occupational health and safety (OHS) systems. The concept of work-relatedness is important because it is a crucial element circumscribing the limits of the protection afforded to workers under the preventative OHS statutes, and is a threshold element which has to be satisfied before an injured or ill worker can recover statutory compensation. While the preventive and compensatory regimes do draw on some similar concepts of work-relatedness, as this paper will illustrate, there are significant differences both between, and within, these regimes.

The OHS regulatory challenges posed by agency workers: evidence from Australia

The purpose of this research is to analyse the problems for occupational health and safety (OHS)regulators posed by agency work/leased labour (also known as labour hire in Australasia), using Australian evidence. The analysis is based on an examination of prosecutions involving labour hire firms along with other documentary records (union, industry and government reports and guidance material). The study also draws on interviews with approximately 200 regulatory officials, employers and union representatives since 2001 and workplace visits with 40 OHS inspectors in 2004‐2005.The triangular relationship entailed in labour leasing, in combination with the temporary nature of most placements, poses serious problems for government agencies in terms of enforcing OHS standards notwithstanding a growing number of successful prosecutions for breaches of legislative duties by host and labour leasing firms. Research to investigate these issues in other countries and compare findings with those for Australia is required, along with assessing the effectiveness of new enforcement initiatives. The paper assesses existing regulatory responses and highlights the need for new regulatory strategies to combat the problems posed by labour. The OHS problems posed by agency work have received comparatively little attention. The paper provides insights into the specific problems posed for OHS regulators and how inspectorates are trying to address them.

OHS inspectors and psychosocial risk factors: Evidence from Australia

Legislation giving prominence to psychosocial risk factors at work has changed the role of government occupational health and safety (OHS) inspectors in many countries. Yet little is known about how inspectorates have responded to these changes. Between 2003 and 2007 an Australian study was undertaken on OHS standards, entailing detailed documentary analysis, interviews with 36 inspectorate managers and 89 inspectors, and observations made when researchers accompanied inspectors on 120 typical workplace visits. Our study found that general duty provisions in OHS legislation clearly incorporated psychosocial hazards and inspectorates had introduced guidance material, pursued campaigns and increased interventions in this area. However, the regulatory framework remained narrow (focused on bullying/harassment, occupational violence and work stress) and workplace visits revealed psychosocial hazards as a marginal area of inspectorate activity. These findings were reinforced in interviews. While aware of psychosocial hazards inspectors often saw the issue as problematic due to limited training, resourcing constraints, deficiencies in regulation and fears of victimisation amongst workers. In order to address these problems a number of changes are required that recognize the distinctiveness of psychosocial hazards including their ‘invisibility’. Notable here are revisions to regulation (both general duty provisions and specific codes), the development of comprehensive guidance and assessment tools to be used by inspectors, greater use of procedural enforcement, and enhanced inspectorate resourcing and training. There is also a need to recognize complex inter-linkages between psychosocial hazards and the industrial relations context.

Changing legal education: rhetoric, realty, and prospects for the future

This article examines the extent to which Australian legal education has transcended the traditional model of legal education which dominated most law schools until the mid-1980s, and outlines a modest agenda which might guide further development in legal education in Australia. The article outlines challenges to the traditional model, changes in legal education following the 1987 Pearce Report, and identifies factors that impede lasting and profound change. It concludes by proposing a series of issues which might be addressed by law schools seeking to provide a learning environment in which students can actively engage in learning about law, in a framework that does not simply prepare students for private legal practice.

Regulating supply-chains to address the occupational health and safety problems associated with precarious employment: The case of home-based clothing workers in Australia

Over the past 20 years the labour market, workforce and work organisation of most if not all industrialised countries have been significantly refashioned by the increased use of more flexible work arrangements, variously labelled as precarious employment or contingent work. There is now a substantial and growing body of international evidence that many of these arrangements are associated with a significant deterioration in occupational health and safety (OHS), using a range of measures such as injury rates, disease, hazard exposures and work-related stress. Moreover, there is an emerging body of evidence that these arrangements pose particular problems for conventional regulatory regimes. Recognition of these problems has aroused the concern of policy makers - especially in Europe, North America and Australia - and a number of responses have been adopted in terms of modifying legislation, producing new guidance material and codes of practice and revised enforcement practices. This article describes one such in itiative in Australia with regard to home-based clothing workers. The regulatory strategy developed in one Australian jurisdiction (and now being ‘exported’ into others) seeks to counter this process via contractual tracking mechanisms to follow the work, tie in liability and shift overarching legal responsibility to the top of the supply chain. The process also entails the integration of minimum standards relating to wages, hours and working conditions; OHS and access to workers’ compensation. While home-based clothing manufacture represents a very old type of ‘flexible’ work arrangement, it is one that regulators have found especially difficult to address. Further, the elaborate multi-tiered subcont racting and diffuse work locations found in this industry are also characteristic of newer forms of contingent work in other industries (such as some telework) and the regulatory challenges they pose (such as the tendency of elaborate supply chains to attenuate and fracture statutory responsibilities, at least in terms of the attitudes and behaviour of those involved).