Preparing for hybrid warfare and cyberattacks on health services' digital infrastructure: What nurse managers need to know.

AIM: This article aims to outline the key concepts in hybrid warfare and cyberattack to better inform nurse managers in their strategic contribution to the defence of critical digital infrastructure. BACKGROUND: Hybrid warfare often targets a nation's critical digital infrastructure including that of health services. Hybrid warfare against national health services, primarily through cyberattack, is likely to increase in a more destabilized and conflictual international environment. EVALUATION: Key literature, reports and assessments on hybrid warfare, advanced persistent threats and cyberattack referenced to health services were analysed. KEY ISSUE: Health services are a key element of a nation's critical digital infrastructure and as such are a strategic target in hybrid warfare. Cyberattack through exploiting clinicians', such as nurses, online susceptibilities is a key route of attack. Nurse managers, to be effective planners, need to be fully informed about the context and specific nature of cyberattack. CONCLUSION(S): Articles about the relationship between hybrid warfare and cyberattack on health services digital infrastructure are rarely aimed at nurse managers. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers need to be fully informed about the geopolitical nature of cyberattacks if they are to be fully consulted and listened to in response planning in defence of health services' digital infrastructure.

Exploring user empowerment and service improvement within an Irish epilepsy service using Checkland's 'Soft Systems' approach.

AIM: To illustrate the value of Checkland's 'Soft Systems' approach to explore and analyse the interaction of human and organisational factors that affect service delivery and patient experience in one specialist epilepsy service. BACKGROUND: Checkland's approach is underutilized in relation to health service improvement. One epilepsy service in Ireland is used as an example to illustrate the value of his approach to improve service delivery, particularly when what needs to change is not clear. METHOD: Checkland's 'Soft Systems' seven-stage approach was used collaboratively to explore patients' and clinicians' experience of service delivery and how to improve it. RESULTS: The research identified the practice of empowerment affected the quality of the service experience. Checkland's concept of a human activity system was particularly pertinent in identifying this issue and providing a 'map' for change. CONCLUSION: Wider inferences for the use of Checkland's approach by nurse managers are discussed, as is the value of using Checkland's approach to improve services. IMPLICATIONS FOR NURSING MANAGEMENT: Checkland's 'Soft Systems' is an underutilized approach in health care that could be used by managers to initiate and embed change within a health care service.

Exploring Dimensions of Empowerment from the Patients' Perspective in One Specialist Epilepsy Service in Ireland.

Empowerment is integral to patient-centered practice, particularly as this relates to people with chronic conditions, though operationally it is poorly understood in this context. Empowerment, therefore, as experienced by patients with a chronic condition needs exploration. This article reports the experience of empowerment by patients in one specialist epilepsy service in Ireland as an exemplar of broader issues affecting empowerment of patients with chronic conditions. A Frameworks Approach was used to analyze in-depth interviews with patients (n = 10) in one Irish epilepsy service. Analysis was further informed by nonparticipatory observation of service delivery. Results indicate that patients' negative experiences of empowerment appear to be derived from traditional social norms relating to clinician patient power dimensions and social stigma internalized by clinicians at an unconscious level. With this in mind, educational approaches based upon critical social theory may provide a framework and guide to enable services to engage with these issues and embrace empowerment of patients with chronic conditions within therapeutic engagement.

Work-related stress and well-being of direct care workers in intellectual disability services: a scoping review of the literature.

Background: Understanding the nature of work-related stress and burnout among intellectual disability care staff is important to protect the well-being of these workers and encourage their retention in the sector. Though reviews of specific aspects of this literature have been conducted no article has sought to fully chart the range and nature of this research. Objective: This article addresses this gap by synthesizing the findings of such research with consideration to the future implications for protecting the well-being of care workers. Methods: A scoping review of the published literature was undertaken using a framework described in a previous article. Results: The findings of this review are presented thematically across six primary categories: challenging behavior; reciprocity; coping and stress; role issues; individual differences; and settings. A seventh theme, namely the positive aspects of intellectual disability care work was also identified through this process and is discussed. Conclusion: Occupational stress and strain is an internationally experienced issue in this sector. Challenging behavior and inequality in the relationships between staff and their clients, their colleagues, and their organization appear to exert a significant impact on the stress and well-being of workers in this sector. Excessive workplace demands, a low level of control, and a lack of support have been shown to be related to higher levels of stress and burnout among intellectual disability care workers.

Conceptualizing skill mix in nursing and health care: An analysis.

AIM: This paper aims to unpack the concept of "skill mix" into its constituent parts to achieve a better understanding and reduce confusion associated with the term. BACKGROUND: Skill mix is a topic that is widely debated and is foremost on the health policy agenda due to specific local pressures within international health services. At present, however, there is large variation in terms of what is understood by the concept of "skill mix" and there is a paucity of research that attempts to analyse this concept. EVALUATION: Using Rodgers' evolutionary method of concept analysis, this paper provides an analysis of definitions of skill mix, its attributes and associated terms in the literature. KEY ISSUE: Definitions of skill mix are often vague and ambiguous and may refer to one or more attributes of skill mix. CONCLUSION: A lack of understanding of the concept can lead to an ad hoc interpretation of policy recommendations related to skill mix at local level. IMPLICATIONS FOR NURSING MANAGEMENT: A better understanding of the concept of "skill mix" and its attributes can assist both policy makers and stakeholders, including nurse management, to ensure that the potential of skill mix is maximized.

"Saving Face": An Online Study of the Injecting Use of DIY Botox and Dermal Filler Kits.

This study reports on an empirically underdocumented practice in contemporary aesthetic enhancement culture, the self-injection of unregulated DIY Botox and dermal filler kits purchased online. Data were collected from 4 online discussion forums containing disclosures in relation to use of DIY kits and analyzed using ethnographic content analysis. Motivation to source DIY Botox and dermal fillers online was grounded in desire to avoid financial cost of professional services and a lack of confidence in practitioners. Future intentions to order online raw materials and "formulas" to prepare dermal fillers at home were expressed. Individuals taught themselves to inject through watching YouTube tutorials and downloading Botox injection maps from the Internet. Although individuals demonstrated awareness of the health risks involved with self-injection of unregulated products, this was not a deterrent. Future research is warranted to document the injecting practices and health outcomes of individuals who inject DIY Botox and dermal filler kits to inform targeted harm reduction interventions by health-care practitioners.

La présente étude rend compte d'une pratique empirique sous-attestée dans la culture de l'esthétique corporelle contemporaine, l'auto-injection de Botox non réglementé et l'utilisation de trousses de remplissage dermique après des achats en ligne. Les chercheurs ont compilé les données à partir de quatre forums de discussion en ligne où les usagers affirmaient utiliser des trousses personnelles, puis les ont évaluées à partir de l'analyse du contenu ethnographique (Krippendorf, 2004). La motivation pour utiliser soi-même le Botox et le remplissage dermique provenait d'un désir d'éviter les coûts des services professionnels et d'un manque de confiance envers les praticiens. Les usagers exprimaient l'intention de commander les produits bruts et les « formules ¼ en ligne afin de préparer des solutions de remplissage dermique à la maison. Ils apprenaient à se faire les injections en regardant des tutorats sur YouTube et en téléchargeant des diagrammes d'injection de Botox trouvés dans Internet. Même s'ils connaissaient les risques pour leur santé liés à l'auto-injection des produits non réglementés, ils ne les considéraient pas comme des éléments dissuasifs. D'autres recherches s'imposent pour répertorier les pratiques d'injection et les résultats cliniques des personnes qui s'injectent du Botox et qui utilisent des trousses de remplissage dermique afin d'orienter les interventions ciblées de réduction des risques qu'adopteront les professionnels de la santé.

Reported implementation lessons from a national quality improvement initiative; Productive Ward: Releasing Time to Care™. A qualitative, ward-based team perspective.

AIM: To explore the experiences of participants involved in the implementation of the Productive Ward: Releasing Time to Care™ initiative in Ireland, identifying key implementation lessons. BACKGROUND: A large-scale quality improvement programme Productive Ward: Releasing Time to Care™ was introduced nationwide into Ireland in 2011. We captured accounts from ward-based teams in an implementation phase during 2013-14 to explore their experiences. METHODS: Semi-structured, in-depth interviews with a purposive sample of 24 members of ward-based teams from nine sites involved in the second national phase of the initiative were conducted. Interviews were analysed and coded under themes, using a seven-stage iterative process. RESULTS: The predominant theme identified was associated with the implementation and management of the initiative and included: project management; training; preparation; information and communication; and participant's negative experiences. The most prominent challenge reported related to other competing clinical priorities. CONCLUSIONS: Despite the structured approach of Productive Ward: Releasing Time to Care™, it appears that overstretched and busy clinical environments struggle to provide the right climate and context for ward-based teams to engage and interact actively with quality improvement tools, methods and activities. IMPLICATIONS FOR NURSING MANAGEMENT: Findings highlight five key aspects of implementation and management that will help facilitate successful adoption of large-scale, ward-based quality improvement programmes such as Productive Ward: Releasing Time to Care™. Utilising pre-existing implementation or quality frameworks to assess each ward/unit for 'readiness' prior to commencing a quality improvement intervention such as Productive Ward: Releasing Time to Care™ should be considered.

The injecting use of image and performance-enhancing drugs (IPED) in the general population: a systematic review.

Injecting use of image and performance-enhancing drugs (IPED) in the general population is a public health concern. A wide and varied range of IPED are now easily accessible to all through the online market. A comprehensive literature review was undertaken according to Critical Appraisal Skills Programme (CASP) guidelines for systematic review, to identify the relevant literature. No date restrictions were placed on the database search in the case of human growth hormone melanotan I and II, and oil and cosmetic injectables. In the case of anabolic androgenic steroids search dates were restricted to January 2014-2015. Publications not in English and with a lack of specificity to the topic were excluded. The review yielded 133 relevant quantitative and qualitative papers, clinical trials, clinical case presentations and editorials/reports. Findings were examined/reviewed under emergent themes which identified/measured extent of use, user profiling, sourcing, product endorsement, risk behaviours and health outcomes in users. Motivation for IPED use may be grounded in appearance, pursuit of health and youth, and body image disturbance. IPED users can practice moderated use, with pathological use linked to high-risk behaviours, which may be normalised within IPED communities. Many IPED trajectories and pathways of use are not scientifically documented. Much of this information may be available online in IPED specific discussion forums, an underutilised setting for research, where uncensored discourse takes place among users. This review underscores the need for future internet and clinical research to investigate prevalence and patterns of injecting use, and to map health outcomes in IPED users. This paper provides community-based clinical practice and health promotion services with a detailed examination and analysis of the injecting use of IPED, highlighting the patterns of this public health issue. It serves to disseminate updated publication information to health and social policy makers and those in health service practice who are involved in harm reduction intervention.

The social space of empowerment within epilepsy services: The map is not the terrain.

Empowerment is now seen as an integral component of holistic practice and service design in healthcare, particularly as it relates to the improvement of quality of life for people with epilepsy. However, the literature suggests that empowerment is a neglected and poorly understood concept by service users and providers alike within epilepsy services. Conceptual ambiguity is a further impediment to its understanding and implementation. Bearing this in mind, a clear definition of empowerment is needed in order to realistically recognize, encourage, and prioritize empowerment as a service design philosophy. Therefore, this paper undertakes a concept analysis of empowerment with reference to epilepsy services. Results indicate that empowerment demands a transformation of consciousness and a readiness to act on this transformation in order to allow people to gain personal power and autonomy over their own life, including the self-management of their condition. With this in mind, a critical reflection on the 'micro' and 'macro' levels of power that exist within epilepsy services is warranted with reference to theoretical principles. In this context although the map is not the terrain, we argue that an educational intervention guided by critical social theory principles has the potential to encourage an understanding of empowerment and 'holds the key' to future advances for its implementation within epilepsy services.

The potential of critical social theory as an educational framework for people with epilepsy.

Effective education can support people with epilepsy to develop the attributes and skills required to function as equal partners with clinical service providers, make informed decisions, and competently self-manage their healthcare. However, despite knowledge deficits, unmet information needs, and a poor sense of empowerment, the study of education for people with epilepsy is often neglected and is a poorly understood component of holistic practice within epilepsy healthcare. Historically, the only debate with regard to education and people with epilepsy has been guided either within a positivist or within a constructivist philosophy. We argue that new pedagogies are warranted, recognizing the views of people with epilepsy regarding their illness. Therefore, this paper explores the potential of an educational framework for people with epilepsy based upon critical social theory (CST). By utilizing a CST approach for education, people with epilepsy are engaged with as active 'participants'. This is a key difference that distinguishes CST from other metatheoretical frameworks. It has the potential to support people with epilepsy to acquire the skills and confidence to manage the biopsychosocial challenges associated with their condition.

British Icons and Catholic perfidy--Anglo-Saxon historiography and the battle for Crimean War nursing.

Taking as its starting point Carr's view that historical narrative reflects the preoccupations of the time in which it is written and Foucault's concept of consensual historical discourse as the outcome of a social struggle in which the victor suppresses or at least diminishes contrary versions of historical events in favour of their own, this paper traces and discusses the historical narrative of British nursing in the Crimean war and, in particular, three competing narratives that have arisen in the latter half of the 20th century and the first decade of the 21st. These are the established narrative surrounding Florence Nightingale, the new narrative surrounding Mary Seacole and an Irish narrative surrounding the role of the Sisters of Mercy. It is argued that the increased vehemence of the debate surrounding these narratives is representative of the changes that have taken place in British society. However, we also argue that the Irish narrative and its critique are reflective of deep-rooted Anglo-Protestant attitudes articulated by Nightingale and uncritically accepted by subsequent historians even in modern British historiography.

Epilepsy services in Ireland: 'A survey of people with epilepsy in relation to satisfaction, preferences and information provision'.

BACKGROUND: A challenge facing modern health care systems is to develop and implement new models of service that deliver increased capacity while providing a higher-quality, more cost-effective service within resource constraints. Incorporating the experience of people with epilepsy must be seen as central to the effectiveness of service design and delivery. This paper, therefore, reports the views of people with epilepsy with regards to health service delivery in Ireland. METHOD: A cross-sectional descriptive survey design involving both quantitative and qualitative items was administered to a convenience sample of one hundred and two people with epilepsy (n=102) attending an epilepsy specialist centre. RESULTS: Despite high levels of satisfaction with hospital and primary care, participants offered several suggestions to improve healthcare delivery, such as: less delay in accessing specialist care and hospital appointments; better communication; and easier access to investigatory services. Findings demonstrate that for people with epilepsy the burden of the disorder is substantial and complex encompassing social, psychological and structural difficulties. Poor information provision particularly among women is reported. Furthermore, a lack of empowerment in people with epilepsy is highlighted. CONCLUSION: This study has implications for the reform and development of epilepsy services in relation to practice, education and research. It provides a basis for an evaluation of current practice and identifies opportunities for future service reorganization to improve the quality and efficiency of healthcare provision.

The impact of a large-scale quality improvement programme on work engagement: preliminary results from a national cross-sectional-survey of the 'Productive Ward'.

BACKGROUND: Quality improvement (QI) Programmes, like the Productive Ward: Releasing-time-to-care initiative, aim to 'engage' and 'empower' ward teams to actively participate, innovate and lead quality improvement at the front line. However, little is known about the relationship and impact that QI work has on the 'engagement' of the clinical teams who participate and vice-versa. OBJECTIVE: This paper explores and examines the impact of a large-scale QI programme, the Productive Ward, on the 'work engagement' of the nurses and ward teams involved. DESIGN/METHODS: Using the Utrecht Work Engagement Scale (UWES), we surveyed, measured and analysed work engagement in a representative test group of hospital-based ward teams who had recently commenced the latest phase of the national 'Productive Ward' initiative in Ireland and compared them to a control group of similar size and matched (as far as is possible) on variables such as ward size, employment grade and clinical specialty area. RESULTS: 338 individual datasets were recorded, n=180 (53.6%) from the Productive Ward group, and n=158 (46.4%) from the control group; the overall response rate was 67%, and did not differ significantly between the Productive Ward and control groups. The work engagement mean score (±standard deviation) in the Productive group was 4.33(±0.88), and 4.07(±1.06) in the control group, representing a modest but statistically significant between-group difference (p=0.013, independent samples t-test). Similarly modest differences were observed in all three dimensions of the work engagement construct. Employment grade and the clinical specialty area were also significantly related to the work engagement score (p<0.001, general linear model) and (for the most part), to its components, with both clerical and nurse manager grades, and the elderly specialist areas, exhibiting substantially higher scores. CONCLUSIONS: The findings demonstrate how QI activities, like those integral to the Productive Ward programme, appear to positively impact on the work engagement (the vigour, absorption and dedication) of ward-based teams. The use and suitability of the UWES as an appropriate measure of 'engagement' in QI interventions was confirmed. The engagement of nurses and front-line clinical teams is a major component of creating, developing and sustaining a culture of improvement.

The transition of a large-scale quality improvement initiative: a bibliometric analysis of the Productive Ward: Releasing Time to Care programme.

AIMS AND OBJECTIVES: To examine the literature related to a large-scale quality improvement initiative, the 'Productive Ward: Releasing Time to Care', providing a bibliometric profile that tracks the level of interest and scale of roll-out and adoption, discussing the implications for sustainability. BACKGROUND: Productive Ward: Releasing Time to Care (aka Productive Ward) is probably one of the most ambitious quality improvement efforts engaged by the UK-NHS. Politically and financially supported, its main driver was the NHS Institute for Innovation and Improvement. The NHS institute closed in early 2013 leaving a void of resources, knowledge and expertise. UK roll-out of the initiative is well established and has arguably peaked. International interest in the initiative however continues to develop. METHODS: A comprehensive literature review was undertaken to identify the literature related to the Productive Ward and its implementation (January 2006-June 2013). A bibliometric analysis examined/reviewed the trends and identified/measured interest, spread and uptake. RESULTS: Overall distribution patterns identify a declining trend of interest, with reduced numbers of grey literature and evaluation publications. However, detailed examination of the data shows no reduction in peer-reviewed outputs. There is some evidence that international uptake of the initiative continues to generate publications and create interest. CONCLUSIONS: Sustaining this initiative in the UK will require re-energising, a new focus and financing. The transition period created by the closure of its creator may well contribute to further reduced levels of interest and publication outputs in the UK. However, international implementation, evaluation and associated publications could serve to attract professional/academic interest in this well-established, positively reported, quality improvement initiative. RELEVANCE TO CLINICAL PRACTICE: This paper provides nurses and ward teams involved in quality improvement programmes with a detailed, current-state, examination and analysis of the Productive Ward literature, highlighting the bibliometric patterns of this large-scale, international, quality improvement programme. It serves to disseminate updated publication information to those in clinical practice who are involved in Productive Ward or a similar quality improvement initiative.

Towards a gendered perspective for Irish mental health policy and service provision.

BACKGROUND: The Irish Government has adopted "Gender Mainstreaming" as a strategy to promote equal opportunities between women and men in its National Development Plan. While current mental health policy addresses the principle of partnership and social inclusiveness as a way forward for mental health service provision, it still does not explicitly deal with the notion of gender and gender sensitivity. Indeed, Irish mental health policy and service provision is criticised for being gender-neutral. AIM: This paper explores the relationship between gender, mental health policy and service provision. METHOD: The literature on theoretical perspectives on mental health policy, gender and mental health in relation to Irish mental health policy is reviewed. RESULTS: The importance of gender for policy development and service provision is recognised, and the need to reformulate debate within a gendered context is discussed. Some key theoretical perspectives and their significance for mental health policy are considered with possible explanations for the absence of a gender perspective for Irish mental health policy presented. CONCLUSION: Arguably, a move towards developing gender-sensitive mental health policy and service provision requires a stronger awareness of and connections between the macro, meso and micro levels for policy development and analysis.

Relating realist metatheory to issues of gender and mental health.

This paper seeks to advance the debate that considers critical realism as an alternative approach for understanding gender and mental health and its relatedness to mental health research and practice. The knowledge base of how 'sex' and 'gender' affect mental health and illness is expanding. However, the way we conceptualize gender is significant and challenging as quite often our ability to think about 'gender' as independent of 'sex' is not common. The influences and interplay of how sex (biological) and gender (social) affect mental health and illness requires consideration. Critical realism suggests a shared ontology and epistemology for the natural and social sciences. While much of the debate surrounding gender is guided within a constructivist discourse, an exploration of the concept 'gender' is reflected on and some key realist propositions are considered for mental health research and practice. This is achieved through the works of some key realist theorists. Critical realism offers potential for research and practice in relation to gender and mental health because it facilitates changes in our understanding, while simultaneously, not discarding that which is already known. In so doing, it allows the biological (sex) and social (gender) domains of knowledge for mental health and illness to coexist, without either being reduced to or defined by the other. Arguably, greater depth and explanations for gender and mental health issues are presented within a realist metatheory.

Critical realism: a philosophical framework for the study of gender and mental health.

This paper explores gender and mental health with particular reference to the emerging philosophical field of critical realism. This philosophy suggests a shared ontology and epistemology for the natural and social sciences. Until recently, most of the debate surrounding gender and mental health has been guided either implicitly or explicitly within a positivist or constructivist philosophy. With this in mind, key areas of critical realism are explored in relation to gender and mental health, and contrasted with the positions of positivism and constructivism. It is argued that critical realism offers an alternative philosophical framework for the exploration of gender issues within mental health care.