An Australian interpretive description of Contact Precautions through a bioethical lens; recommendations for ethically improved practice.

BACKGROUND: Contact Precautions (CP) were developed to control multi-resistant organisms (MROs) in hospitals. However, MROs persist and harms are associated with CP. Research objectives were to understand the bioethical impact of CP on patients and health-professionals, and make recommendations for ethically-improved management of MRO-colonized patients. METHODS: Interpretive description methodology scaffolded upon bioethical principles framed this qualitative study. Findings were explored alongside contemporary published reports to make recommendations for practice and research. RESULTS: Nine patients and 24 health professionals participated. Four themes were found: Powerlessness moving to acceptance; You feel a bit of a pariah; Others need protection, but I need looking after too; Doing Contact Precautions is not easy. DISCUSSION: CP conflict with the principle of respect for autonomy due to non-adherence to informed consent, and sub-optimal communication. Patients experience health care inequality, and discriminatory practices breaching the principle of justice. CP elicit stigma for patients, and moral distress and inter-personal conflict for staff, breaching the principle of non-maleficence. Under the principle of beneficence, pluralistic cost-benefit assessment situates CP as low-value practice. CONCLUSIONS: CP challenge organizational culture, professional well-being, and person-centered ethical care. Ethical costs of CP outweigh benefits, obliging policy-makers to reconsider CP in managing MRO-colonized patients.

Considering the precautionary principle and its application to MRSA and SARS-CoV-2 as emerging novel pathogens of their time.

In the 1980s Contact Precautions were introduced as a precautionary measure to control the emerging threat of antimicrobial resistance in hospitals, particularly methicillin resistant Staphylococcus aureus (MRSA). Today, antimicrobial resistance remains a concerning global public health threat, and a focus for hospital patient safety priorities. In late 2019 a novel respiratory virus described as SARS-CoV-2, was reported. Just as MRSA had prompted control measures developed in the context of limited information and understanding of the pathogen, public health control measures against SARS-CoV-2 were promptly and strictly implemented. Whilst SARS-CoV-2 control measures were successful at containing the virus, numerous detrimental socio-economic and health impacts have led to a rebalancing of harms versus benefits and loosening of restrictions. Conversely, evidence collated over the past 50 years, suggests that Contact Precautions are not superior to well-applied standard infection prevention and control precautions in controlling MRSA acquisition in hospitals. Several harms associated with Contact Precautions, affecting patient safety, financial costs, and organisational culture, are described. However, rebalancing of hospital MRSA control policies has been slow to materialise. This commentary invites infection prevention and control policy makers to reflect and revise policies for the control of MRSA in hospitals so that harms do not outweigh benefits.

What are the Clinical and Social Outcomes of Integrated Care for Older People? A Qualitative Systematic Review.

Introduction: Older people with multiple chronic conditions have most to gain from successful integrated care models but there is a need to understand current evidence of outcomes for older people. Methods: A qualitative meta-aggregation method was used for the review. Systematic searching of CINAHL, PubMed (Medline), Web of Science, PsycINFO, Scopus and Cochrane identified an initial 93 papers, of which 27 were reviewed. Studies were selected according to the pre-defined protocol and quality assessed using The Joanna Briggs Institute Critical Appraisal Tools (JBIQARI). Eleven, peer-reviewed, English-language papers published between 2000 to 2020 were included. Results: Thirty-three findings were extracted and aggregated into six categories. Three synthesised statements were identified denoting outcomes of integrated care for older people. These indicate social participation and connectedness for older people and their families; the older person feeling motivated to engage in health goals when their preferences were taken into consideration; and older people experiencing support and wellbeing when a therapeutic relationship with a key worker is established. Discussion and conclusion: There was scant evidence of the older person's voice within included studies and a limited focus on outcomes. Stronger evidence is needed to provide meaningful and robust evaluation of outcomes within integrated care models for the older person.

The Health Needs of Regionally Based Individuals Who Experience Homelessness: Perspectives of Service Providers.

The bidirectional relationship between homelessness and poor health and the barriers that individuals who experience homelessness face when trying to access healthcare are well documented. There is, however, little Australian research exploring the situation of individuals who experience homelessness in regional contexts and, moreover, from the perspective of service providers. A qualitative descriptive methodology underpinned this study, with in-depth semi-structured interviews being conducted with 11 service providers to identify barriers to care faced by people who experience homelessness and barriers that service providers themselves experience in supporting this population. The key barriers identified were client-level barriers: living day-by-day, financial, health literacy, mental health conditions, behaviour, safety and stigma; provider-level barriers: few bulk-billing doctors, fragmented services, limited resources, negative past experiences with healthcare; and system level barriers: transportation, over-stretched healthcare services. The combined impact of these barriers has significantly contributed to the desperate situation of people experiencing homelessness in Launceston. This situation is likely replicated in other regional populations in Australia. Given that individuals experiencing homelessness have higher rates of every measure in health inequality, steps need to be taken to reduce barriers, and a standardised approach to health care urgently needs to be implemented by governments at the state and national level to improve the health of regionally based individuals experiencing homelessness.

A scoping review exploring reablement models of training and client assessment for older people in primary health care.

AIM: The aim of this scoping review is to explore the evidence by which community service providers have integrated reablement models of staff training and client assessment into practice. BACKGROUND: The concept of reablement, which has emerged during the last two decades globally, has recently been defined by health experts from 11 countries through a Delphi study. Reablement is seen as a way to support integrated frameworks that achieve person-centred, long-term care and assistance across community settings. International research indicates there is some evidence of developing models of reablement that include staff training and individual components of client assessment. However, evidence of integrating reablement into interdisciplinary practice continues to be sparse. METHODS: The review adopted the preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) approach. Inclusion criteria for the review related to community care, primary care, long-term care, and residential care. Populations of interest included service providers, interdisciplinary staff, trainers, and assessors. RESULTS: A total of 11 papers were reviewed. The studies varied in their approach to reablement training and client assessment frameworks. Three studies included assessment of staff well-being. All included evidence-based, person-centred components that can be integrated across health care settings. Single disciplinary approaches were used in all studies and some included training evaluation. CONCLUSION: This review has identified that currently reablement models are not yet embedded as frameworks for practice by community service providers in primary health care settings. Different programmes of training and assessment are being designed based on single disciplinary approaches and the context in which they are delivered. Further developmental work is required to integrate the components of discipline-specific training programmes within interdisciplinary frameworks. This will achieve not only an integrated framework for delivery across settings but also further the success of 'ageing in place' policy.

Determining readiness for a reablement approach to care in Australia: Development of a pre-employment questionnaire.

Reablement is described as a goal directed intervention with a view to maintain or improve the independence of clients through "doing with, rather than doing for". As a relatively new concept in care, lack of specific skills in reablement is not uncommon, however, intrinsic values aligned with reablement are beneficial to organisations providing care and support to clients. The aim of this study is to develop a pre-employment questionnaire to assess readiness for a reablement approach to care as a step towards developing a reablement culture across organisations. A questionnaire based on activities of daily living (ADL), developed by the research team in consultation with a local community-based care organisation, was completed by 166 staff members at a community-based care organisation in Tasmania across several timepoints during and following reablement education sessions in 2018. The scores from these questionnaires were utilised to develop a questionnaire appropriate for determining readiness for reablement prior to employment within the organisation. Over a period of twelve months, a total of 407 Reablement Readiness Questionnaires were submitted by staff, indicating high levels of willingness to engage in reablement prior to and following the education sessions. Exploratory factor analyses were performed, and the construct validity and internal consistency of the emerging factors were assessed. An exploratory factor analysis indicated that ADL, in relation to reablement, consist of three dimensions-Lifestyle, My body and Connecting. The corresponding questions were subsequently built into an online questionnaire for pre-employment use. This questionnaire also has potential benefit in recruitment of staff to other community service organisations, to ascertain their readiness for reablement prior to beginning a variety of different roles within client care and support.

More than a house: Women's recovery from homelessness in Australia.

Recovery from homelessness for women is often a long, complex and highly individualised journey. This study investigated women's experiences of exiting homelessness and examined the factors that influenced recovery. The qualitative interpretive study involved auto-driven photo elicitation and in-depth interviews with 11 women who had previously been homeless. It took place in Australia between August 2018 and August 2019. Women took photographs that represented their experiences of exiting homelessness to guide discussion during interviews. Data were analysed using thematic analysis. Findings indicate that recovery from homelessness involves more than becoming housed. Recovery from homelessness is the overarching theme being presented, described using five subthemes: Finding the right house, Making a house a home, Connection, Building confidence and Helping others. Housing was only the starting point for recovery from homelessness for women. The women drew on their own self determination to create factors necessary for recovery from the experience of homelessness. We conclude that ongoing support is necessary to empower and assist women recovering from the traumatic experiences of homelessness. Trauma-informed care offers service providers a framework for supporting women who have lived through homelessness. Services can draw on this framework to provide support beyond the point of securing a house and assist women to create a home environment, build confidence in themselves and form connections to their community as they transition out of homelessness.

A qualitative exploration of women's resilience in the face of homelessness.

The aim of this study was to examine the experiential perspectives of women becoming and experiencing homelessness. Situated in the qualitative interpretative tradition, data were collected using auto-driven photo-elicitation and in-depth face-to-face interviews. Eleven Australian women used photographs that represented their experiences of being homeless to guide their interview discussion. The findings revealed that homelessness for women is a period often preceded by a series of adverse incidents in their lives, characterised by progressive resilience building in the face of trauma, finding hope and building strength to work towards exiting homelessness. After becoming homeless, five stages of resilience transition emerged: The trauma of homelessness, Finding hope and surviving, Finding help, Finding connection and Taking control. Women experiencing homelessness are resilient and capable of enacting competence and autonomy in seeking help to exit homelessness. Changes to service delivery are recommended to improve trauma-informed, person-centred housing and social services that are integrated and easy to navigate.

Staff experiences of a reablement approach to care for older people in a regional Australian community: A qualitative study.

Reablement is described as a person-centred, goal-directed intervention with a view to regain, maintain or improve the independence of older clients. Although evidence to support the use of reablement as a multidisciplinary, home-based intervention for community-dwelling older adults is increasing, there is limited knowledge about what it means for care staff who provide client-based services. This study, which was nested in a larger program evaluation, used a descriptive qualitative approach to explore direct care staff and care coordinator experiences of translating a reablement training program into practice for older people in a regional Australian community. Two months after the training program four focus groups were conducted with 13 care coordinators to assimilate staff experiences with development of care plans, systems, processes and practices of reablement. In addition, four direct care staff took part in individual interviews, which centred on eliciting their experience using the reablement approach with clients. Results from the care coordinator focus groups and the direct care staff interviews highlight the importance of reablement staff training and the involvement of staff in the development and delivery of a reablement approach to client-centred care. A number of organisational and client-centred challenges such as communication, functional partnerships, staff education and resourcing are also uncovered in this research into the development of a reablement-focused care service in a regional setting. Overall there is support for the dominating discourse around healthy ageing and the policy approach of ageing in place to support wellness.

Combining Self-Determination Theory and Photo-Elicitation to Understand the Experiences of Homeless Women.

Homelessness is a complex and gendered experience. To understand this complexity, novel theoretical frameworks and appropriate research methods are required. Most women living without homes have experienced some form of abuse or mental health issues before becoming, being or exiting homelessness and there is high prevalence of trauma in this vulnerable population. Researchers investigating women's homelessness need to ensure the research process is not retraumatising. This paper proposes a theoretical framework that combines self-determination theory (SDT) and photo-elicitation to support and guide research conducted with women who are at risk of negative effects of power imbalances and retraumatisation in research. The framework offers new opportunities to sensitively study women's homelessness by leveraging a strengths-based premise and empowering procedures to increase women's control in the research process. Embedding this method within the SDT research framework repositions women from objects of research to being competent, autonomous, active and empowered agents in the research process.

Emotional touchpoints; the feelings nurses have about explaining multi-resistant organisms to colonised patients.

BACKGROUND: Nurses face challenges when providing information about multi-resistant organisms (MROs), and related hospital policies, to patients found to be colonised, and may be concerned for their own safety when caring for MRO-colonised people. Resultant emotional responses may influence behaviours of staff caring for these patients. This study aimed to identify the feelings experienced by nurses when talking about MROs with patients. Secondary objectives were to learn about staff behaviours towards MRO-colonised patients, and to explore the utility of Emotional Touchpoints methodology in this context. METHODS: A qualitative study using an adapted Emotional Touchpoints method delivered as a paper survey tool for data collection. Content analysis and inductive coding of responses was used to identify key themes. RESULTS: 53 nurses participated. 'Nervous', 'Concerned' and 'Knowledgeable' were the most commonly selected adjectives chosen to describe their feelings. Reasons for these choices were themed as 'Empowerment through knowledge', 'Performance anxiety', 'Concern for the patient' and 'Concern for professional reputation'. Social or temporal distancing, and the need for staff and other patients to be protected from contagion were key themes for the behaviours these nurses had witnessed towards patients. CONCLUSION: Talking about MROs with patients can elicit strong emotional responses in nurses, and MRO-colonised patients may be treated and spoken about in a discriminatory fashion. Infection prevention and control teams should recognise this and focus on the person rather than the pathogen when educating and supporting nurses. Recommendations for practice are made to support improved wellbeing of nurses as well as MRO colonised patients.

Development and feasibility study of an app (Ladle) for weight loss and behaviour change.

BACKGROUND: Weight management interventions involving behaviour change often utilise face to face interventions which include evidence based behaviour change strategies yet are costly and time intensive. In contrast, digital interventions cost less and have a wider reach yet tend to lack an evidence base and are less effective. AIMS: The present study therefore aimed to develop an evidence based behaviour change low cost app for weight management and to provide a preliminary analysis of its effectiveness. METHODS: The Ladle app was developed through evidence review and feedback from health care professionals and patients and consists of a 12 week course focusing on six habits and weight loss facilitated through 36 audio psychological lessons and 12 lessons specifically on the six habits. Each lesson was between 2-5 min (approx. 168 min of lessons). It was evaluated in terms of completion rate, weight loss, adoption of the six habits and participant feedback. RESULTS: The results showed a completion rate of 44%, that 52% of Completers showed weight loss of at least 5%, 79% showed weight loss of at least 3%, the median % weight lost was -5% and the median weight loss was -3.8 kg. Further, by the end of 12 weeks the majority (>80%) of participants had adopted four of the six habits for at least 5 days a week and nearly half (45%) had adopted the remaining two habits for at least 4 days out of 7. Feedback comments were mainly positive (n = 80) focusing mostly on the content of the lessons. Some comments were neutral (n = 56) and involved a statement of commitment or a description of a challenge and a minority were negative (n = 23) describing some technical issues which were addressed as the evaluation progressed. CONCLUSION: The new Ladle app offers an evidenced based alternative to more intensive face to face interventions. On preliminary analysis it would seem to have lower completion rates than some more intensive interventions but comparable effectiveness for weight loss. It can also improve habits and is less time-intensive and costly to deliver. Participant feedback was generally positive.

Exploring and Improving Student Engagement in an Accelerated Undergraduate Nursing Program through a Mentoring Partnership: An Action Research Study.

This Participatory Action Research (PAR) project aimed to engage students from an accelerated 'fast track' nursing program in a mentoring collaboration, using an interdisciplinary partnership intervention with a group of academics. Student participants represented the disciplines of nursing and paramedicine with a high proportion of culturally and linguistically diverse (CALD) students. Nine student mentors were recruited and paired with academics for a three-month 'mentorship partnership' intervention. Data from two pre-intervention workshops and a post-intervention workshop were coded in NVivo11 using thematic analysis. Drawing on social inclusion theory, a qualitative analysis explored an iteration of themes across each action cycle. Emergent themes were: 1) 'building relationships for active engagement', 2) 'voicing cultural and social hierarchies', and 3) 'enacting collegiate community'. The study offers insights into issues for contemporary accelerated course delivery with a diverse student population and highlights future strategies to foster effective student engagement.

I've got a mobile phone too! Hard and soft assistive technology customization and supportive call centres for people with disability.

PURPOSE: The purpose of this article is to examine the use of a mobile technology platform, software customization and technical support services by people with disability. The disability experience is framed through the participants' use of the technology, their social participation. METHOD: A qualitative and interpretive research design was employed using a three-stage process of observation and semi-structured interviews of people with disability, a significant other and their service provider. Transcripts were analyzed to examine the research questions through the theoretical framework of PHAATE - Policy, Human, Activity, Assistance and Technology and Environment. RESULTS: The analysis revealed three emergent themes: 1. Engagement and activity; 2. Training, support and customization; and 3. Enablers, barriers and attitudes. CONCLUSIONS: The findings indicate that for the majority of users, the mobile technology increased the participants' communication and social participation. However, this was not true for all members of the pilot with variations due to disability type, support needs and availability of support services. Most participants, significant others and service providers identified improvements in confidence, security, safety and independence of those involved. Yet, the actions and attitudes of some of the significant others and service providers acted as a constraint to the adoption of the technology. Implications for Rehabilitation Customized mobile technology can operate as assistive technology providing a distinct benefit in terms of promoting disability citizenship. Mobile technology used in conjunction with a supportive call centre can lead to improvements in confidence, safety and independence for people experiencing disability. Training and support are critical in increasing independent use of mobile technology for people with disability. The enjoyment, development of skills and empowerment gained through the use of mobile technology facilitate the social inclusion of people with disability.