A Review of Modifiable Health Care Factors Contributing to Inpatient Suicide: An Analysis of Coroners' Reports Using the Human Factors Analysis and Classification System for Healthcare.

BACKGROUND: Inpatient suicides have devastating and long-lasting consequences for patients, families, and health care organizations, posing a major challenge for hospitals. Although many studies have identified patient risk factors for inpatient suicide, the modifiable health care factors are less understood. Failure to understand these modifiable factors weakens organizations' ability to design and implement effective prevention strategies. METHODS: The Human Factors Analysis and Classification System for Healthcare (HFACS-Healthcare) was used to classify and analyze modifiable health care factors that contributed directly or indirectly to inpatient suicides in Australian hospitals between 2009 and 2018. Comparisons were made between general and psychiatric hospital units to identify context-specific recommendations. RESULTS: Of the 367 cases, 216 (58.9%) had enough information to analyze the contributing factors, and 214 (58.3%) included unit location information. Multiple modifiable health care factors were identified in the cases as contributing to the patients' suicides. Commonly, cases reported decision errors made by individuals (57.4%), problems with the physical environment (56.0%), and unit-level operational decision-making errors (that is, planned inappropriate operations) (48.6%). An association was found between unit type and problems with coordination, mental state, tasks, physical environment, planned inappropriate operations, and organizational culture (p < 0.05). CONCLUSION: General prevention initiatives may not be effective in addressing inpatient suicides across specialty units. HFACS-Healthcare enabled a deeper understanding of inpatient suicide and the identification of priority areas that, if addressed, could help reduce the number of preventable suicides in hospitals. Hospital suicide prevention initiatives need to be tailored to specific units and target individual and system vulnerabilities to improve safety and reduce inpatient suicide rates.

A comparison of inpatient suicides in Australian psychiatric and non-psychiatric hospital units between 2009 and 2018.

Hospitalisation is designed to protect patients from harm; however, patients have been reported to take their own lives during hospital admissions. While a significant healthcare concern, few studies have analysed inpatient suicides in general and psychiatric hospital units. Understanding these deaths is important for informing future prevention initiatives. Here we investigate a national sample (n = 367) of inpatient suicides in general (24%, n = 87) and psychiatric (76%, n = 278) hospital units. Patient characteristics, suicide location, timing, and suicide methods were assessed and compared. Patients who died from suicide were mostly male and admitted into psychiatric units. General hospital patients were less likely to have a known history of mental illness or previous self-harm and were often admitted for mental illness-related presentations. Suicides frequently occurred outside of the hospital by hanging. Patients in psychiatric units were more likely to be on approved leave at their death, and general patients were more likely to have absconded. These results indicate the need to identify risk factors relevant to each setting and address broader system-level factors. Removing obvious ligature points, preventing absconding, and assessing patients before episodes of leave, could contribute to preventing inpatient suicides.

Identifying the nontechnical skills required of nurses in general surgical wards.

AIMS AND OBJECTIVES: To identify the nontechnical skills (NTS) required of nurses in general surgical wards for safe and effective care. BACKGROUND: As the largest occupational group, nurses are in an ideal position to block the vulnerabilities of patient adverse events in a surgical ward. Previous studies in the surgical environment have identified the NTS required of nurses for safe care in operating rooms; however, these skills have not been identified for nurses in general surgical wards. DESIGN: A nonparticipant observational descriptive design was used. METHOD: A purposive sample of 15 registered nurses was recruited from four surgical wards and observed for a full shift on a morning, afternoon or night shift. Nonparticipant observations were conducted using field notes to collect data. A coding frame was developed, and an inductive process was used to analyse the data. RESULTS: A taxonomy comprising seven NTS required of nurses in their roles in surgical ward teams emerged from the data analysis. They are communication, leadership and management, planning, decision-making, situation awareness, teamwork and patient advocacy. CONCLUSION: Patient care provided by general surgical nurses involved the seven identified key NTS. These particular NTS are an important component of safe nursing practice as they underpin the provision of safe and effective care for general surgical patients. Nurses block the trajectory of error by using NTS to address the vulnerabilities in the system that can lead to adverse patient events. RELEVANCE TO CLINICAL PRACTICE: Identifying general surgical nurses' NTS enables the development of teaching strategies that target the learning of those skills to achieve successful work outcomes and improve patient safety.

A Boom for Whom? Exploring the Impacts of a Rapid Increase in the Male Population Upon Women's Services in Darwin, Northern Territory.

A rapidly expanding natural-resource extraction industry and a growing military presence mean an increasingly male-skewed population for the city of Darwin, Australia. This has sparked concerns about the potential for increased violence against women. In this article, we present qualitative research detailing the views of 13 participants from 10 women's support services in the Darwin area. We argue that women's support services bear witness to and are tasked with responding to the impacts of population change on women, yet their work is undermined by uncertainties that stem from neoliberal funding rationales and limited demands on companies to address social issues.

Alcohol, violence, and a fast growing male population: exploring a risky-mix in "boomtown" Darwin.

Boomtowns are places where populations grow rapidly, mostly as a result of large-scale natural resource developments. Increases in alcohol consumption and alcohol-fuelled violence are often linked to influxes of (predominantly male) workers associated with such developments. This article provides an integrated review of literature concerning alcohol and violence in boomtowns. The authors aim to understand the links between these issues and explore how negative impacts have been addressed. New learning from the review is considered in the context of Darwin, a newly booming city in Australia's Northern Territory. The authors find that although alcohol-related violence is likely to increase, there is limited literature concerning the prevention or mitigation of negative impacts in boomtown contexts. The need for research, planning, and policy making involving all stakeholders is highlighted.

Insiders or outsiders? Mental health service users' journeys towards full citizenship.

The present study explores the journeys towards full citizenship for those using mental health services as they lobbied to be included as full citizens with the same rights and responsibilities as others in society. Qualitative data were collected through semistructured interviews with 17 service users, five government representatives, and seven registered mental health nurses. A conceptual framework of citizenship containing four domains - the extent, content, depth and acts of citizenship - was used to analyse the data. This paper reports the findings from the service users' data in the first domain, the extent of citizenship, defined as the rules and norms of inclusion and exclusion. The degree to which the service user participants were accepted as full citizens with the same civil, political, and social rights as others was contingent on their ability to adopt their society's rules and norms and appear as 'normal' citizens. Participants often experienced being 'othered' and excluded from the many rights and responsibilities of citizenship due to society's perception that service users lack certain attributes of normal, productive citizens. Participants reported that being labelled with a mental illness led to them being marginalized and ostracized, thus placing conditions and barriers on their citizenship status. Findings show that in response to experiencing conditional citizenship, participants shaped their behaviour to assimilate with other citizens. As well, they engaged in practices of inclusion to challenge and broaden the social rules and norms in order to be accepted without disavowing their differences.

Nurse turnover in New Zealand: costs and relationships with staffing practises and patient outcomes.

AIMS: To determine the rates and costs of nurse turnover, the relationships with staffing practises, and the impacts on outcomes for nurses and patients. BACKGROUND: In the context of nursing shortages, information on the rates and costs of nursing turnover can improve nursing staff management and quality of care. METHODS: Quantitative and qualitative data were collected prospectively for 12 months. A re-analysis of these data used descriptive statistics and correlational analysis techniques. RESULTS: The cost per registered nurse turnover represents half an average salary. The highest costs were related to temporary cover, followed by productivity loss. Both are associated with adverse patient events. Flexible management of nursing resources (staffing below budgeted levels and reliance on temporary cover), and a reliance on new graduates and international recruitment to replace nurses who left, contributed to turnover and costs. CONCLUSIONS: Nurse turnover is embedded in staffing levels and practises, with costs attributable to both. A culture of turnover was found that is inconsistent with nursing as a knowledge workforce. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers did not challenge flexible staffing practices and high turnover rates. Information on turnover and costs is needed to develop strategies that retain nurses as knowledge-based workers.

Teamwork - general practitioners and practice nurses working together in New Zealand.

INTRODUCTION: Teamwork in primary health care has been encouraged in New Zealand and in the international literature. It may improve work satisfaction for staff, and satisfaction and outcomes for patients. Teamwork may be classified as being multi-, inter- or transdisciplinary and is likely to be influenced by the nature of the work and the organisational context. AIM: To describe and analyse teamwork between general practitioners and practice nurses in New Zealand. METHODS: Data were drawn from a survey of general practices and from interviews with primary health care staff and management. RESULTS: Doctors and nurses in general practice in New Zealand see themselves as a team. Evidence suggests that the nature of the work and the business context most often leads to a multidisciplinary style of teamwork. Some providers have adopted a more intense teamwork approach, often when serving more disadvantaged populations or in caring for those with chronic illnesses. DISCUSSION: Concepts of teamwork differ. This article provides a classification of teams and suggests that most general practice teams are multidisciplinary. It is hoped that this will help personnel to communicate their expectations of a team and encourage progressive team development where it would be of value.

Variation in the adoption of patient safety practices among New Zealand district health boards.

OBJECTIVE: To investigate the adoption and impact of quality improvement measures in New Zealand hospitals. METHOD: Structured interviews with quality and safety managers of District Health Boards (DHBs). Correlation of use of measures with adjusted 30-day mortality data. RESULTS: Eighteen of New Zealand's 21 DHBs participated in the survey. Structural or policy measures to improve patient safety, such as credentialing and event reporting procedures, had been introduced into all DHBs, whereas changes to general clinical processes such as medicine reconciliation, falls prevention interventions and disease-specific management guidelines were less consistently used. There was no meaningful correlation between risk-adjusted mortality rates for three common medical conditions and related quality measures. CONCLUSION: Widespread variation exists among New Zealand DHBs in their adoption of quality and safety practices, especially in relation to clinical processes of care.

The impact of funding changes on the implementation of primary health care policy.

AIM: To ascertain how new funding arrangements, introduced in New Zealand's 2001 Primary Health Care (PHC) Strategy, have impacted on the expansion of nurses' role in general practice. BACKGROUND: Nurses are central to the new policy that was designed to improve the health status of New Zealanders and reduce inequalities in health. Nurses were to be a crucial part of the PHC team, expanding their current roles to provide increased access to appropriate services. This paper investigates how the new funding arrangements, introduced as part of the policy, have impacted on the expansion of nurses' roles and consequently the realisation of the policy goals. METHODS: Semi-structured interviews were undertaken with 128 key stakeholders five years after the introduction of the PHC Strategy, and surveys were completed by practice nurses, general practitioners and practice managers in purposively selected practices within the 20 participating Primary Health Organisations. FINDINGS: There has been substantial growth in the development of nursing roles for some nurses in general practice; however, this expansion has not been universal and one of the main reasons for this is the way funding devolves at the practice level. One of the consequences of the policymakers not taking into account the business model of the majority of general practices, is the resulting overarching goal of the strategy not being realised, and inequalities in health status remaining.

The financial impact of clinical task substitution between practice nurses and GPs in New Zealand primary care centres.

AIM: To describe the financial impact on practice owners of increased clinical task substitution between practice nurses and GPs in New Zealand (NZ) primary care settings. METHOD: Case studies of 9 primary health care centres involving: interviews; collation of service and financial information; and nurse and GP diaries covering 1826 consultations. Results were compared with previous NZ large N survey results to develop a model predicting the financial impact of task substitution. RESULTS: The proportion of general practice primary care consultations undertaken by nurses varied from 4% to 46% of total recorded consultations. The actual financial impact for a practice owner of substituting more nursing time for GP time is highly dependent on the following variables: nurse cost per minute relative to GP cost minute; nurse consult duration relative to GP consult duration; nurse consult revenue relative to GP consult revenue; and the proportion of nurse consults also requiring GP time. CONCLUSION: Practice nurses can (and in some practices in NZ, do) provide a broad set of primary care services, including undifferentiated general consultations. For some practices, increasing the proportion of nurse consults and reducing GP consults, would result in significantly improved profitability--for others, the opposite applies. Clinical task substitution is one option to address the forecast increase in demand associated with population aging.

Insanity, methamphetamine and psychiatric expertise in New Zealand courtrooms.

The use of methamphetamine in New Zealand has increased significantly over the last decade. Due to the potential of methamphetamine to induce, exacerbate and precipitate psychotic symptoms, this drug has also taken centre stage in several criminal trials considering the sanity of defendants. Highly publicised and often involving contested expert evidence, these criminal trials have illustrated the limits of using psychiatric expertise to answer legal questions. This article considers the implications of such cases in light of material from a qualitative study that aimed to generate insights into the difficulties forensic psychiatrists and their instructing lawyers face when providing expert evidence on the relationship between methamphetamine, psychosis and insanity. It reports material from 31 in-depth interviews with lawyers and forensic psychiatrists and observation of one criminal trial that considered the relationship between methamphetamine and legal insanity. The findings are correlated with the clinical and medico-legal literature on the topic and subjected to scrutiny through the lens of "sanism". The article concludes that the continued use of forensic psychiatry to meet the legal objectives of insanity, where methamphetamine is involved, has the potential to reinforce sanist attitudes and practices.

Importance of work environments on hospital outcomes in nine countries.

PURPOSE: To determine the effect of hospital work environments on hospital outcomes across multiple countries. DESIGN: Primary survey data using a common instrument were collected from separate cross sections of 98 116 bedside care nurses practising in 1406 hospitals in 9 countries between 1999 and 2009. MAIN OUTCOME MEASURES: Nurse burnout and job dissatisfaction, patient readiness for hospital discharge and quality of patient care. RESULTS: High nurse burnout was found in hospitals in all countries except Germany, and ranged from roughly a third of nurses to about 60% of nurses in South Korea and Japan. Job dissatisfaction among nurses was close to 20% in most countries and as high as 60% in Japan. Close to half or more of nurses in every country lacked confidence that patients could care for themselves following discharge. Quality-of-care rated as fair or poor varied from 11% in Canada to 68% in South Korea. Between one-quarter and one-third of hospitals in each country were judged to have poor work environments. Working in a hospital with a better work environment was associated with significantly lower odds of nurse burnout and job dissatisfaction and with better quality-of-care outcomes. CONCLUSIONS: Poor hospital work environments are common and are associated with negative outcomes for nurses and quality of care. Improving work environments holds promise for nurse retention and better quality of patient care.

Nurse burnout and quality of care: cross-national investigation in six countries.

We explored the relationship between nurse burnout and ratings of quality of care in 53,846 nurses from six countries. In this secondary analysis, we used data from the International Hospital Outcomes Study; data were collected from 1998 to 2005. The Maslach Burnout Inventory and a single-item reflecting nurse-rated quality of care were used in multiple logistic regression modeling to investigate the association between nurse burnout and nurse-rated quality of care. Across countries, higher levels of burnout were associated with lower ratings of the quality of care independent of nurses' ratings of practice environments. These findings suggest that reducing nurse burnout may be an effective strategy for improving nurse-rated quality of care in hospitals.

Mental illness in the nursing workplace: a collective autoethnography.

Many nurses are burned out, exhausted and have a high intent to leave their jobs. These factors, when experienced over a period of time, are consistent with the development of mental illness. This study takes a collective autoethnographical approach to mental illness in the nursing workplace by focusing on the stories of nurses who have experienced mental illness in clinical practice. It highlights three ways in which nursing and mental illness are connected; the nurse who is vulnerable to mental illness prior to entering the profession, the nurse who develops mental illness that is independent of her work but is nevertheless impacted by it, and the nurse who develops mental illness as a result of her work and/or role. This paper explores the hyphenated lives and bullying these nurses experience, and recommends strategies that the profession, employing organisations, and individuals can adopt to reduce nurses' progression from stress to distress and mental illness.

New Zealand nurses' reports on hospital care: an international comparison.

Despite the differences in health care systems, nursing shortages and their contributing factors and consequences no longer seem to be solely country-specific. The present study replicated a cross-national study of nurses' perceptions of staffing, work organisation and outcomes conducted in more than 700 hospitals in the United States, Canada, England, Scotland, and Germany. This paper compares the 2001 New Zealand findings with the findings of the five-country study. New Zealand nurses report similar shortcomings in their work environment as do the nurses in countries with distinctly different health care systems. While they report similar high levels of competence and good relations between doctors and nurses as the respondents in the other five countries, higher numbers of New Zealand nurses 30 years of age or younger report their intention to leave their current jobs. New Zealand nurses also report the highest levels of job related stress, high levels of job dissatisfaction, and more than half report receiving inadequate organisational support. The implications of these findings are discussed in light of recent changes in the hospital environment.

Effect of cool temperature dialysate on the quality and patients' perception of haemodialysis.

BACKGROUND: The effects of cool dialysate on the urea reduction ratio (URR) in high efficiency haemodialysis have not been completely studied. After reviewing the literature, it appeared that patients' perceptions of cool dialysis have not been studied. Since patients' perception have an impact on patient satisfaction, this motivated the authors to research this area of practice. METHODS: This study was designed to determine whether a high URR and haemodynamic stability could be achieved by using cool dialysate in two groups of patients. The first group of five patients were known to have hypotension episodes during dialysis, and the second group of five patients were documented as having stable blood pressure (BP) during and after dialysis, after excluding vascular access recirculation and any other problems. Each patient was dialysed for three sessions using cool dialysate (35 degrees C) followed by another three sessions using a standard dialysate temperature (36.5 degrees C). All other dialysis session parameters were maintained. RESULTS: The results show that the dialysate cooling resulted in an increased ultrafiltration in the low BP group (P = 0.05). Cool dialysis had neither an adverse nor a beneficial effect on urea removal in the two groups (P = NS). The mean arterial pressure post- and intra-dialysis was significantly higher in dialysis with cool dialysate in the low BP group (P < 0.01 and P < 0.007, respectively). The mean arterial pressure in the stable BP group remained unchanged when cool dialysate was used (P = NS). The intra-dialytic pulse rates in the low and stable BP groups were similar. A total of seven episodes of symptomatic hypotension were observed in the low BP group, but none in the stable BP group (P < 0.0001). Patients' perceptions about cool dialysate were measured by a questionnaire which showed that 80% of them felt more energetic after dialysis and requested to be always dialysed with cool dialysate. CONCLUSION: Cool dialysate improves tolerance for dialysis in hypotensive patients and helps increase ultrafiltration while maintaining haemodynamic stability during and after dialysis. Patients' perceptions were positive, as most of the selected sample felt more energetic and generally well during and after dialysis, and this had a positive impact on their activities of daily living.

Hospital restructuring: identifying the impact on patients and nurses.

Health systems throughout the democratic world have been subject to 'reform' in recent years as countries have attempted to contain the rapidly rising costs of health care. Because hospital care accounts for a large proportion of health sector spending, hospital restructuring has been an important part of those changes. In an attempt to make hospitals more efficient and cost-effective, New Zealand, like other countries, has introduced extensive changes to the way in which treatment and care are delivered to patients, and to the way nurses' work is organised and managed. International research has identified links between the way in which nursing is organised in a hospital, and that hospital's patient outcomes. The current authors are part of a team of researchers undertaking research which uses the methodology of the International Hospital Outcomes Study to examine nurse staffing and patient outcomes in New Zealand's secondary and tertiary hospitals across the period 1988-2001. The research involves a large survey of all nurses working in the study hospitals, an examination of the way in which the hospitals have been restructured, and an analysis of patient outcomes.