Cultural racism, language prejudice and discrimination in hospital contexts : an Australian study

This article explores the idea that racial and ethnic disparities in healthcare may be expressive of unacknowledged practices of cultural racism. In conducting this exploration, the researchers identify, describe and discuss the practice of language prejudice and discrimination by health service providers, discovered serendipitously in the context of a broader study exploring cultural safety and cultural competency in an Australian healthcare context. The original study involved individual and focus groups interviews with 145 participants recruited from over 17 different organisational and domestic home sites. Participants included health service managers, ethnic liaison officers, qualified health interpreters, cultural trainers/educators, ethnic welfare organisation staff, registered nurses, allied health professionals, and healthcare consumers. Participants self-identified as being from over 27 different ethnocultural and language backgrounds.

Analysis of the data revealed that English language proficiency, like skin colour, was used as a social marker to classify, categorise, and negatively evaluate people of non-English speaking backgrounds (NESB) in the contexts studied. Negative evaluations, in turn, were used to justify the exclusion of NESB people from healthcare relationships and resources. Further data analysis revealed that underpinning the negative attitudes and behaviours in hospital domains concerning people who spoke accented English or who did not speak English proficiently were a dislike of difference, fear of difference, intolerance of difference, fear of competition for scarce healthcare resources, repressed hostility toward difference, and ignorance.

Highlighting the implications of language prejudice for the safety and quality care of NESB people, the researchers call for further internationally comparative research and debate on the subject.

Self-rated preparedness of Australian prevocational hospital doctors for emergencies

Objective: To determine perceived preparedness of Australian hospital-based prevocational doctors for resuscitation skills and management of emergencies, and to identify differences between doctors who perceive themselves well prepared and those who perceive themselves poorly prepared for emergencies, in demographics and exposure to desired learning methods.

Methods: Questionnaire consisting of a mix of graded Likert scales and free-text answers distributed to 36 Australian hospitals for secondary distribution to hospital medical officers.

Results: From 2607 questionnaires posted, 470 (18.1%) were returned. Thirty-one per cent (95% confidence interval [CI] 26–35%) felt well prepared for resuscitation and management of emergencies, 41% (CI 37–45%) felt adequately prepared and 28% (CI 24–32%) felt they were not well prepared. Those who felt well prepared reported that they had experienced more exposure to a range of educational methods, including consultant contact, supervisor feedback, clinical skills, high fidelity simulator sessions and unit meetings. Well-prepared and poorly prepared doctors had similar opinions of the usefulness of various learning methods, but the poorly prepared group more frequently expressed a desire for increased exposure to contact with registrars and consultants, clinical skills sessions and hospital and unit meetings. There were no differences in gender, age or country of origin (Australia vs international medical graduates) between those who felt well or poorly prepared.

Conclusions: Many prevocational hospital doctors feel inadequately prepared for the management of emergencies. Perceived preparedness is associated with more exposure to particular educational activities. Increasing exposure to learning of emergencies in undergraduate and prevocational years could reduce the number of junior doctors who feel poorly prepared for emergencies.

The negative impact on nurses of lack of alignment of information systems with public hospital strategic goals

The objectives of this study were to investigate the degree to which hospital information systems are aligned with hospital strategies and how they impact on nurses. Semi-structured interviews were conducted with nine hospital staff from a range of disciplines in a large public hospital in Australia. The interviews revealed that the focus of hospital information systems on administration has meant that applications to support the patient's clinical journey have been deemed unaffordable. A consequence is that the historic use of the nurses' station as a source of verbal information about patients has continued, with negative impacts on nurses' perceived role and status, and the possible exacerbation of the clash between administrative and clinical cultures. We conclude that hospitals need clear strategies, with alignment of information systems. To do otherwise can undermine culture and morale, while disrupting workflows and patients' clinical journeys.

Is off-campus engineering study off the agenda? Professional accreditation and distance education

In engineering, distance/off-campus study is an essential element of access to education for those in remote locations and/or seeking to upgrade their qualifications via the lifelong learning route whilst employed. Internationally, engineering education accrediting bodies have moved toward outcomes-based assessment of graduate competency, but are still struggling to relinquish their historical attachment to the measurement of inputs. A genuinely outcomes-based accreditation system based on the demonstrated individual student attainment of appropriate graduate attributes (which might be delivered/gained by a range of means) offers the best way forward for an equitable, representative and socially just undergraduate engineering education system that encourages suitably qualified candidates from a range of social, employment, educational, gender, age and geographic circumstances to aspire to the professional sphere of the engineering workforce. Until outcomes-based education becomes the norm in engineering, it is likely that distance learners in engineering will face significant difficulties.

A new instrument for targeting falls prevention interventions was accurate and clinically applicable in a hospital setting

Background and Objective: To describe the diagnostic accuracy and practical application of the Peter James Centre Falls Risk Assessment Tool (PJC-FRAT), a multidisciplinary falls risk screening and intervention deployment instrument.

Methods: In phase 1, the accuracy of the PJC-FRAT was prospectively compared to a gold standard (the STRATIFY) on a cohort of subacute hospital patients (n = 122). In phase 2, the PJC-FRAT was temporally reassessed using a subsequent cohort (n = 316), with results compared to those of phase 1. Primary outcomes were falls (events), fallers (patients who fell), and hospital completion rates of the PJC-FRAT.

Results: In phase 1, PJC-FRAT accuracy of identifying fallers showed  sensitivity of 73% (bootstrap 95% confidence interval CI = 55, 90) and specificity of 75% (95% CI = 66, 83), compared with the STRATIFY (cutoff ≥ 2/5) sensitivity of 77% (95% CI = 59, 92) and specificity of 51% (95% CI = 41, 61). This difference was not significant. In phase 2, accuracy of nursing staff using the PJC-FRAT was lower. PJC-FRAT completion rates varied among disciplines over both phases: nurses and physiotherapists, ≥90%; occupational therapists, ≥82%; and medical officers, ≥57%.

Conclusion: The PJC-FRAT was practical and relatively accurate as a predictor of falls and a deployment instrument for falls prevention interventions, although continued staff education may be necessary to maintain its accuracy.

Continence prevalence and management in an acute hospital

Learning Objective 1: describe the prevalence of incontinence within an Australian acute care hospital

Learning Objective 2: describe the current management practices for incontinence with regard to patients in an acute care hospital
Introduction: In 1998 the World Health Organisation recognised the international problem of incontinence. However, incontinence remains a major problem that affects more than 3.8 million Australians. Currently, there are no Australian guidelines governing the management of continence within the acute healthcare setting. Cabrini Health sought to identify the prevalence of incontinence in the acute inpatient setting and pilot a Continence Management Program to improve patient safety and patient outcomes.

Aim: The aim of this study was to determine the prevalence of and current management practices for incontinence with regard to Cabrini Health inpatients.

Method: The sample comprised 392 inpatients across three campuses of Cabrini Health (mean age= 68.3 years). Continence prevalence was assessed using a validated Continence Point Prevalence Tool.

Results: Urinary incontinence prevalence was 14%. The resulting overall faecal incontinence prevalence was 7.4%. There were 113 (52.3%) patients who were not incontinent and were using a continence product/device. Fifteen (25.9%) patients were incontinent and were not using any form of continence product/device. There were 43 (74.1%) patients who were incontinent and were using a continence product/device. For the large majority of patients, the admission notes contained documentation of their bladder and bowel function. Specifically, 46 (11.8%) patients had no form of admission documentation relating to bowel function and 45 (11.5%) patients had no form of admission documentation regarding to bladder function.

Conclusions: This study provided baseline continence prevalence for Cabrini Health. There is a need for evidence-based guidelines to support the management of incontinent patients. These interventions will assist staff to educate patients on appropriate choice of continence products and enable patients to maintain or regain continence. Thereby, leading to improved outcomes for patients and improved risk management.

Additional exercise for older subacute hospital inpatients to prevent falls: benefits and barriers to implementation and evaluation

Objective: To evaluate the clinical effectiveness and implementation of a falls prevention exercise programme for preventing falls in the subacute hospital setting.

Design: Randomized controlled trial, subgroup analysis.

Participants: Patients of a metropolitan subacute/aged rehabilitation hospital who were recommended for a falls prevention exercise programme when enrolled in a larger randomized controlled trial of a falls prevention programme.

Methods: Participants in both the control and intervention groups who were recommended for the exercise programme intervention were followed for the duration of their hospital stay to determine if falls occurred. Participants had their balance, strength and mobility assessed upon referral for the exercise programme and then again prior to discharge. Participation rates in the exercise programme were also recorded.

Results: Intervention group participants in this subgroup analysis had a significantly lower incidence of falls than their control group counterparts (control: 16.0 falls/1000 participant-days, intervention: 8.2 falls/1000 participant-days, log-rank test: P = 0.007). However few differences in secondary balance, strength and mobility outcomes were evident.

Conclusion: This exercise programme provided in addition to usual care may assist in the prevention of falls in the subacute hospital setting.

Design-related bias in hospital fall risk screening tool predictive accuracy evaluations: systematic review and meta-analysis.

Introduction: Fall risk screening tools are frequently used as a part of falls prevention programs in hospitals. Design-related bias in evaluations of tool predictive accuracy could lead to overoptimistic results, which would then contribute to program failure in practice.

Methods: A systematic review was undertaken. Two blind reviewers assessed the methodology of relevant publications into a four-point classification system adapted from multiple sources. The association between study design classification and reported results was examined using linear regression with clustering based on screening tool and robust variance estimates with point estimates of Youden Index (= sensitivity + specificity - 1) as the dependent variable. Meta-analysis was then performed pooling data from prospective studies.

Results: Thirty-five publications met inclusion criteria, containing 51 evaluations of fall risk screening tools. Twenty evaluations were classified as retrospective validation evaluations, 11 as prospective (temporal) validation evaluations, and 20 as prospective (external) validation evaluations. Retrospective evaluations had significantly higher Youden Indices (point estimate [95% confidence interval]: 0.22 [0.11, 0.33]). Pooled Youden Indices from prospective evaluations demonstrated the STRATIFY, Morse Falls Scale, and nursing staff clinical judgment to have comparable accuracy.

Discussion: Practitioners should exercise caution in comparing validity of fall risk assessment tools where the evaluation has been limited to retrospective classifications of methodology. Heterogeneity between studies indicates that the Morse Falls Scale and STRATIFY may still be useful in particular settings, but that widespread adoption of either is unlikely to generate benefits significantly greater than that of nursing staff clinical judgment.

Prevalence and cost of musculoskeletal disorders: a population-based, public hospital system healthcare consumption approach.

Objective: To use a population-level, public-hospital approach to compare the prevalence and cost of musculoskeletal diseases (MSD) with other clinical specialties.

Methods: A healthcare utilization survey of 4 million individual records over 4 years, from all major public hospitals in the state of Victoria (estimated population 4.8 million residents in 2000/01) from 1997/98 to 2000/01. Main outcome measures were inpatient episodes of care, bed-days, and outpatient clinic encounters. MSD was defined as the combination of orthopedics and rheumatology.

Results: After obstetrics, MSD was the most frequent outpatient service, with orthopedics accounting for 9.9% of all visits in 2000/01. The proportion of MSD outpatient encounters (on average 11.6% of the total) was constant over the study period. Among 26 medical specialties, MSD had the sixth highest number of inpatient episodes (6.2% in 2000/01), following renal dialysis (14.6%), general surgery (8.2%), obstetrics (7.6%), gastroenterology (7.1%), and general medicine (6.7%). MSD was the fifth highest consumer of bed-days, occupying on average 7.7% of all beds per annum in the period 1997/98 to 2000/01, behind psychiatry (10.1%), respiratory medicine (8.5%), rehabilitation (8.3%), and general medicine (7.8%). MSD was the third most-costly discipline in 2000/01, with total costs of over A dollars 169 million (9.7% of total inpatient costs that year), behind respiratory medicine (11.6%) and general surgery (11.5%).

Conclusion: Compared to other diseases, MSD consumes a substantial proportion of healthcare resources in Victorian public hospitals. These data have important implications for allocation of healthcare resources, clinical care pathways, and prevention strategies.