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Policy PointsThe implementation of large‐scale health care interventions relies on a shared vision, commitment to change, coordination across sites, and a spanning of siloed knowledge.Enablers of the system should include building an authorizing environment; providing relevant, meaningful, transparent, and timely data; designating and distributing leadership and decision making; and fostering the emergence of a learning culture.Attention to these four enablers can set up a positive feedback loop to foster positive change that can protect against the loss of key staff, the presence of lone disruptors, and the enervating effects of uncertainty. Context: Large‐scale transformative initiatives have the potential to improve the quality, efficiency, and safety of health care. However, change is expensive, complex, and difficult to implement and sustain. This paper advances system enablers, which will help to guide large‐scale transformation in health care systems. Methods: A realist study of the implementation of a value‐based health care program between 2017 and 2021 was undertaken in every public hospital (n = 221) in New South Wales (NSW), Australia. Four data sources were used to elucidate initial program theories beginning with a set of literature reviews, a program document review, and informal discussions with key stakeholders. Semistructured interviews were then conducted with 56 stakeholders to confirm, refute, or refine the theories. A retroductive analysis produced a series of context‐mechanism‐outcome (CMO) statements. Next, the CMOs were validated with three health care quality expert panels (n = 51). Synthesized data were interrogated to distill the overarching system enablers. Findings: Forty‐two CMO statements from the eight initial program theory areas were developed, refined, and validated. Four system enablers were identified: (1) build an authorizing environment; (2) provide relevant, authentic, timely, and meaningful data; (3) designate and distribute leadership and decision making; and (4) support the emergence of a learning culture. The system enablers provide a nuanced understanding of large‐system transformation that illustrates when, for whom, and in what circumstances large‐system transformation worked well or worked poorly. Conclusions: System enablers offer nuanced guidance for the implementation of large‐scale health care interventions. The four enablers may be portable to similar contexts and provide the empirical basis for an implementation model of large‐system value‐based health care initiatives. With concerted application, these findings can pave the way not just for a better understanding of greater or lesser success in intervening in health care settings but ultimately to contribute higher quality, higher value, and safer care. [ABSTRACT FROM AUTHOR]

Objective: To explore the benefits and challenges of electronic prescribing (e‐prescribing) for general practitioners (GPs) and pharmacists in regional New South Wales (NSW). Methods: This qualitative study utilised semistructured interviews conducted virtually or in‐person between July and September 2021. Setting and Participants: General practitioners and pharmacists practising in Bathurst NSW. Main Outcomes: Self‐reported perceived and experienced benefits and challenges of e‐prescribing. Results: Two GPs and four pharmacists participated in the study. Reported benefits of e‐prescribing included improvement in the prescribing and dispensing process, patient adherence, and prescription safety and security. The increased convenience for the patients was appreciated particularly during the COVID‐19 pandemic. Challenges discussed were how the system was perceived to be unsafe and insecure, costs of messaging and updating general practice software, utilisation of new systems and patient awareness. Pharmacists reported the need for education to patients and staff to minimise the impact of inexperience with the novel technology on workflow efficacy. Conclusion: This study provided first insight and information on the perspectives of GPs and pharmacists 12 months after the implementation of e‐prescribing. Further nationwide studies are required to consolidate these findings; provide comparisons with the system's progress since conception; determine whether metropolitan and rural health care professionals share similar perspectives; and shed light on where additional government support may be required. [ABSTRACT FROM AUTHOR]

Background: Mobilization is a key component in the recovery of those admitted to critical care. However, previous research has demonstrated challenges in the implementation of mobilization within critical care, including staff knowledge, attitudes, and behaviours. Aim: The aim of the current study was to explore the perceived barriers and limitations to mobilization from the perspective of nursing staff, and to compare these with physiotherapists. Study Design: Single‐site service evaluation utilizing the patient mobilizations attitudes and beliefs survey for ICU and locally developed barriers to rehabilitation questionnaire. Results: About 135 participants (126 nurses and 9 physiotherapists) were invited to anonymously complete the questionnaires (either paper or electronic), with a response rate of 73.0% (n = 92) for nursing staff and 100% for physiotherapists. Nursing staff reported significantly higher perceived barriers to rehabilitation on both questionnaires when compared with physiotherapy staff, which was not associated with years of experience within critical care. Behavioural barriers were most frequent in both professions which included items such as time availability and presence of perceived contra‐indications to mobilization. Conclusion: Nursing staff reported greater perceived barriers to rehabilitation when compared with physiotherapists. Further quality improvement projects are now required to reduce these barriers and assist the implementation of mobilization as part of the rehabilitation process. Relevance to Clinical Practice: Rehabilitation is an essential element of practice within critical care. Understanding the system, local and personal barriers will allow for improvement projects to enhance the delivery of care and improve clinical outcomes. [ABSTRACT FROM AUTHOR]

Objective: To explore how four small towns in rural New South Wales known as the 4Ts are addressing challenges accessing quality care and sustainable health services through a collaborative approach to workforce planning using the collaborative care framework. Design: Descriptive case study approach. Setting: The collaborative care project was developed as a result of ongoing partnerships between 2 rural Local Health Districts, 2 Primary Health Networks and a non‐governmental health workforce organisation. The collaboration works with 5 subregions each comprising 2 or more rural communities. This paper focuses on the 4Ts subregion. Participants: Stakeholders of the collaborative design including organisations and the community. Intervention: A place‐based approach to co‐designing health services with community in one sub‐region of Western New South Wales. Main outcome measures: A synthesis of field observations and experiences of community and jurisdictional partners in implementation of the 4Ts subregional model. Mapping of implementation processes against the collaborative care framework. Results: The collaborative care framework is a useful planning and community engagement tool to build health workforce literacy and to impact on system change at the local level. We identify key elements of effectiveness in establishing the 4Ts model, including the need for coordinated health system planning, better integrating existing resources to deliver services, community engagement, building health workforce literacy and town‐based planning. Conclusion: This study adds to the body of knowledge about how to successfully develop a collaborative primary health care workforce model in practice. The findings demonstrate that the implementation of a collaborative primary health care workforce model using the collaborative care framework can improve service access and quality, which in turn might facilitate workforce sustainability. [ABSTRACT FROM AUTHOR]

This study explores perceptions of child abuse and child protection matters involving staff working in the out‐of‐school‐hours care (OSHC) sector. Quantitative and qualitative data were collected through an online survey, focus group and interviews with staff and managers employed by one organisation that provided OSHC services in Sydney, Australia. This paper reports on their perceptions about implementing mandatory reporting requirements associated with the concepts of 'significant harm' and 'reportable conduct'. The aim of this paper is to engage OSHC stakeholders, including government, in reviewing child protection policies and practices to support educators in their work with children. Key findings indicate the inadequacy of available training, and the importance of relationships and communication between stakeholders, especially OSHC and school staff. This requires systemic change including raising the status of OSHC and the critical role that these educators have in supporting children's development, learning and wellbeing during the early years of school. Key Practitioner Messages: It is important that leadership supports educators to engage in respectful partnerships with families and schools to ensure child protection, and thereby child wellbeing and learning outcomesTraining in supporting children's safety and wellbeing in OSHC is critical.There is a need for a systems approach to OSHC services which places children's development, learning and wellbeing at the forefront of professional practice. 'Explores perceptions of child abuse and child protection matters involving staff working in the out‐of‐school‐hours care (OSHC) sector' [ABSTRACT FROM AUTHOR]

Background: Mobile learning studies often focus on teachers' perspectives. This study instead considers students' experiences of learning with mobile devices (i.e., m‐learning) in secondary school mathematics and science. Objectives: The research aims to describe the m‐learning experiences of secondary mathematics and science students, and to determine the extent to which distinctive pedagogical dimensions impact students' perceived learning. Methods: A survey instrument using the iPAC mobile pedagogical framework as a theoretical lens is developed and validated. This framework highlights three pedagogical dimensions: personalization, authenticity, and collaboration. Structural equation modelling is used to investigate how each dimension predicts students' perceived improvement in learning, whilst accounting for usage context, among a sample of students in schools where mobile devices are used extensively. Results and Conclusions: Students were in agreement that personalization was a characteristic of their m‐learning experiences, but authentic and collaborative learning were not as strongly featured. M‐learning activities fostering personalization were most important for improving perceived learning; authenticity and collaboration were also significant, but no differences in perceived learning improvement due to location were found. Authentic m‐learning and perceived improvement in learning with mobile devices were significantly higher in science than mathematics subjects. Implications: When teachers design m‐learning tasks that enhance personalization, collaboration, and authenticity, students are predicted to perceive improvements in their learning. The findings suggest that teachers should consider designing technology‐enhanced tasks that improve students' experiences of collaborative and authentic learning, particularly in mathematics for greatest gains in students' perceived improvement in learning. Lay Description: What is already known about this topic:Mobile learning studies often focus on teachers' perspectives and practices or expert commentaries.Issues of usability, access, engagement, motivation, and potential risk are often highlighted rather than pedagogical factors.Mobile technologies provide students with opportunities for more personalized and autonomous seamless experiences across learning contexts.Science teachers frequently use authentic and project‐based m‐learning opportunities, whilst mathematics teachers prefer didactic, drill and practice approaches.What this paper adds:This study focuses on students' m‐learning in secondary mathematics and science.A multi‐item scale considering aspects of authenticity, personalization, collaboration and context is developed and validated.Personalization in m‐learning activities are most important for perceived learning, followed by authenticity and collaboration.Science students report greater authenticity and perceived learning in m‐learning than mathematics students.Implications for practice and/or policy:Highlighting the student perspective is a valued lens to evaluate m‐learning pedagogy and outcomes in student learning.Efforts should be made to develop mobile pedagogies, particularly with respect to authenticity and collaboration.Teachers in mathematics would benefit most from examining practices that improve authenticity. [ABSTRACT FROM AUTHOR]

Introduction: The COVID‐19 pandemic resulted in a rapid shift to telehealth implementation across paediatric occupational therapy services. Although telehealth can be an appealing option, access is conditional, and the delivery of a telehealth service differs from face‐to‐face. If telehealth is to be a viable and equitable option for families, insight is needed into why the service might be declined. The purpose of our study was to explore barriers to paediatric occupational therapy telehealth services from client and therapist perspectives in a Greater Sydney local health district. Method: A mixed method approach was used, including (i) retrospective review of clinical records for 250 clients seeking occupational therapy who declined the service and (ii) a focus group with four therapists providing the service. Client demographic information was summarised using descriptive statistics. Open‐text responses about reasons for declining telehealth were analysed using qualitative content analysis, whereas thematic analysis was used to explore focus group data. Findings: Key findings from the mixed methods analysis identified barriers and issues to consider when working to ensure equitable access to telehealth for children and families. These issues included child engagement, family complexity, the nature of assessments, interventions, and overarching service characteristics as well as the family's digital inclusion. Digital inclusion comprises affordable access to the internet, data, and devices and the capacity of a child and/or family to engage online. Conclusion: Our findings suggest that telehealth is not a panacea when face‐to‐face services are not available. Multiple barriers confounded uptake of telehealth prompting a call to action to ensure equitable access to occupational therapy services for all children. [ABSTRACT FROM AUTHOR]

Objective: To explore the lived experience of people with a physical disability residing in a rural area and receiving services under the NDIS. Setting: Rural areas of New South Wales classified as Modified Monash Categories 3–7. Participants: Semistructured interviews were conducted with seven purposively sampled participants who self‐identified as having a physical disability, were receiving NDIS funding and lived in a rural area of NSW. Design: Data collection and analysis were guided by hermeneutic phenomenology. Findings: We interpreted three interrelated themes; Uncertainty of Access, Battling Bureaucracy and Improving Relationships and Independence. The themes articulate the essence of this phenomenon, Challenges to choice and control. Discussion: The findings of this study suggest that while people with a physical disability living in rural NSW acknowledged positive changes to their everyday lives through the NDIS, there remains a sense of confusion, frustration and disconnection with the system. Burdensome, inconsistent and untimely communication with NDIS staff caused uncertainty with the process and required negotiation to resolve issues such as delays in funding, essential services or equipment modifications. The essence of Challenges to choice and control articulates what the person had to negotiate within their lifeworld. Further guidance and clarity for people with disabilities to access the NDIS system would ensure confidence to navigate the system and receive the essential supports they need. [ABSTRACT FROM AUTHOR]

Aim: To explore the experiences of Registered Nurses who administered medications to patients using the electronic medication administration record (eMAR) in Electronic Record for Intensive Care (eRIC) at one adult intensive care unit (ICU) in NSW, Australia. Design: The study research design used a qualitative descriptive exploratory approach that took place in two stages. Methods: Five participants attended one focus group followed by the observation of each participant as medications were administered to their assigned patient using the eMAR in eRIC. Results: From the data, three themes and one subtheme were identified. Themes included forcing nurses to work outside legal boundaries; patient safety; with a subtheme titled experiencing computer fatigue; and taking time away from the patient. To practise safely, nurses were required to implement workaround practices when using the new eMAR in ICU. Nurses also were concerned that the eMAR in eRIC took time away from the patient at the bedside and 'added more screen time' to their day. [ABSTRACT FROM AUTHOR]

Objective: To explore the influences of rurality on small business owner mental well‐being and approaches to managing stress and mental well‐being. Design: Semistructured interviews with small businesspeople. Concepts of salutogenesis and pathogenesis were used to interpret rurality influences on business and mental well‐being. A stress‐coping framework was used to categorise approaches to managing mental well‐being. Setting: Central Western New South Wales. Participants: Eleven female and male rural small businesspeople across sectors, including farming, allied health, beauty care and retail businesses. Main Outcome Measures: Interviewee descriptions of experiences of small business and rurality and approaches to managing mental well‐being. Findings: Rurality influenced mental well‐being in four main ways: Business integration with community and owner identity; Visibility and being known; Different financial pressures; and Options for specialised support and casual relief. Rurality can be salutogenic and pathogenic, depending on circumstances, and pressures arising from rurality may differ for 'locals' and recent arrivals. High visibility in a small community can lead to a satisfying sense of belonging and connection. It can also create unwanted feelings of obligation and being watched. Most commonly the interviewees used emotional supports or distraction to adapt to stressors. This may be due to limited options to change or disengage from stressors in rural contexts. Conclusion: Rurality brings its own benefits and challenges to small businesspeople's mental well‐being. Given the immense contributions of small business to rural society and economies, investments in understanding and supporting the mental well‐being of rural small businesspeople should be a high priority for communities and all levels of government. [ABSTRACT FROM AUTHOR]

Trauma Informed Care is an approach to the delivery of mental health care that requires sensitivity to the prevalence and effects of trauma in the lives of people accessing services. While TIC is increasingly emphasized in mental health policy and frameworks in Australia, people working in mental health settings have reportedly struggled to translate the values and principles into their everyday practice. This qualitative study used an experience‐based co‐design methodology to explore the potential for implementation of Trauma Informed Care into mental health services in Australia. The experiences of consumers, carers, clinicians, and managers were gathered. This paper presents the perspectives of clinicians (n = 64) and senior managers (n = 9) from across three Local Health Districts in New South Wales in Australia. All data were analysed thematically to address the research question: What is needed for Trauma Informed Mental Health Services in Australia? To be trauma‐informed, managers required: leadership at all levels, access to resource, relevant and accessible training, support for staff, resolution of wider systems issues, and clarification of the concept and actions of TIC. Clinicians identified that to be trauma‐informed they required services to: be aware of staff well‐being, support different ways of working, address workplace cultures and provide increased resources. The findings have implications for any service, team or individual seeking to implement TIC within mental health settings. [ABSTRACT FROM AUTHOR]

Objective: This study explored experiences of rural cancer patients who were receiving treatments by remote video‐assisted chemotherapy (RVAC) or participating in clinical trials remotely. Setting: Participants lived in Coonabarabran or Dubbo in western NSW. Participants: Seven cancer patients undergoing treatment for breast, bladder or colon cancer, renal cell carcinoma or lymphoma. Design: Appreciative inquiry informed this qualitative study. Semi‐structured interviews were conducted between July 2018 and January 2019 and thematically analysed. Results: The patient experience of teleoncology was overwhelmingly positive. Patients explained the value of relationships that developed with the local and virtual care team. Patients felt they received better care if they saw the same oncologist for the duration of their treatment and felt RVAC had accommodated this. Teleoncology allowed patients to remain independent because they were able to maintain their usual support mechanisms including family, friends and health care team. Patients described the reduced physical and emotional travel burden in addition to reduction in travel time and cost. Conclusions: These findings highlight the acceptability of teleoncology for rural patients as chemotherapy can be added to the health care and social and emotional supports, which exist in their hometown. Expansion of teleoncology should be codesigned with local communities with a focus on establishing care teams with consistent staffing to build trust between the treating team and the patient. These relationships improve the patient experience and enhance patient independence, which is a desirable attribute of cancer survivorship. Recruitment to clinical trials using teleoncology is acceptable and should be factored into trial development. [ABSTRACT FROM AUTHOR]

Accessible Summary: In the past 30 years, many people with (intellectual) learning disabilities have been moved out of large "institutions" and into their own home in their local communityThese people are now often between 30 and 50 years oldWe asked people with learning disabilities aged between 30 and 50 and who are living in their local community what things, including work, that they enjoyed doingWe asked people with learning disabilities aged between 30 and 50 and who are living in their local community whether they felt that they could make decisions about their lifeWe found out the things that make their life good, and also what might stop people enjoying their lifeWe learnt that people with learning disabilities should receive more support to assist them before they retireWe learnt that people with learning disabilities still need more support and choice around who they live with Background: This study investigated perceived quality of life (QoL) of community‐dwelling middle‐aged adults (30–50 years) with an intellectual disability and/or developmental disability living in rural or urban areas in New South Wales and Queensland, Australia. The specific aim of the current paper was to provide a descriptive evidence base of QoL and its specific domains by various key demographic characteristics of middle‐aged individuals. This cohort is likely to have either experienced or reached adulthood during and after large‐scale deinstitutionalisation in Australia. Methods and procedures: A cross‐sectional design was utilised, based on the QoL‐Q survey, testing domains of satisfaction; Competence/Productivity; Empowerment/Independence; and social belonging/community integration. The survey included demographic questions and was distributed to participants through disability support agencies across two states. The final sample included 291 respondents. Results: The overall QoL‐Q scores ranged from 3.0 to 29.5 (Mean = 20.4, SD, 4.1), with considerable variation in mean scores both across and within domains. The two demographic areas that showed greatest predictive value for QoL were work status and accommodation issues. The loss of agency and control in choice of co‐residents influenced perceived QoL for empowerment and independence domain of QoL‐Q. Conclusions: The findings highlight QoL issues associated with policy decisions and support programmes for middle‐aged adults. The two key recommendations arising from the project are that future planning for post‐retirement or reduced working hours needs to commence at a much younger age than currently expected, and more attention needs to focus on facilitating individual decision‐making and choice within shared accommodation options. [ABSTRACT FROM AUTHOR]

Introduction: Delayed discharge from inpatient mental health units is the continued hospitalisation of consumers after being assessed as ready to be discharged. This is common in adult inpatient mental health services and is usually due to a lack of appropriate housing for discharge. Research indicates a range of possible negative impacts, but no studies have explored consumers' perspectives on this issue. This study explores consumers' perspectives of the experience of housing related delayed discharge (HRDD). Method: Using a grounded theory approach, in‐depth interviews were conducted with 10 consumers. All consumers were experiencing HRDD from inpatient mental health units in one Sydney local health district. The data were analysed using constant comparative analysis. Findings: A lack of choice and control was the central theme that characterised participants' experiences. The combined experience of being delayed in hospital and being homeless led to a lack of choice and control over the basics in life, how consumers spent their time and with whom, and their futures. This lack of autonomy was shaped by the features of the hospital and participants' personal circumstance. The hospital features included rules and routines, physical and social environments, resources, and support from staff. Personal circumstances included individual situations, social networks, and support from community organisations. Participants described a variety of impacts, including reduced mental and physical well‐being, and anticipated difficulty transitioning back into the community. Conclusion: This study is the first of its kind and provides consumer perspectives on the impacts of HRDD on their well‐being and recovery. The inability to participate in meaningful and necessary occupations is an occupational injustice and implies the need for occupational therapists to advocate for both the prevention of HRDD through government investment in affordable and readily available housing and the mitigation of its effects through modified hospital environments and practices. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the acceptability and effectiveness of a small community‐based hospice on the end‐of‐life experiences of patients and families. Methods: Mixed‐methods study. Design: Patient admission data were used to assess utilisation of the hospice. Open‐ended interviews with hospice patients and their families/carers were used to understand the emotional effects of the service. Setting: A small palliative end‐of‐life hospice in a rural town in NSW, Australia, during a 12‐month trial period that began in March 2019. Data were collected in October–November 2019. Participants: Patients, families and carers who used the hospice during the trial period, as well as staff working at the hospice. Main outcome measure(s): Quantitative measures included the number of patients admitted to the hospice, the average length of stay and the overall occupancy rate of the hospice. Quantitative interviews were used to explore the experiences of patients and families who used the hospice, and whether the hospice met their end‐of‐life needs. Results: During the trial, 58 patients were admitted to the hospice. The majority of admissions were less than 7 days. Two patients and nine family members were interviewed about their experiences, and six staff completed interviews. Experiences were consistently positive, with the community setting of the hospice contributing to a peaceful and home‐like end‐of‐life experience. Interviewees described meaningful relationships with staff, a pleasant physical environment and the comprehensive care provided were key elements of this experience. Conclusion: This model, embedding end‐of‐life care within a residential aged care facility, facilitated a positive end‐of‐life experience for residents of this regional community. The development of local models to meet local needs is essential to enabling people nearing the end of life to remain in their location of choice, and ensure that their needs are met at this vulnerable time. [ABSTRACT FROM AUTHOR]

The working relationship is considered a central feature of direct practice with human services clients. There are many challenges when it comes time to end a working relationship, yet limited guidance for workers on successful relationship ending. This paper aims to increase understanding of the process of the ending phase of the working relationship for parents and workers working with families where child neglect is an issue. The paper draws on data from a small-scale qualitative Australian study of perceptions of parents, family workers, and supervisors involved in eight parent-worker relationships. Using semistructured interviews, participants were asked to explore how they experienced the relationship. The findings illuminate important aspects about the ending phase of the relationship; in particular, challenging the idea that parents' returning to services for support is a sign that the service has not provided a successful intervention. The paper challenges social workers to consider recurring parent-worker relationships similar to other professional relationships where there are episodes of service but the relationship is there to be reactivated where needed. [ABSTRACT FROM AUTHOR]

Objective: There is public concern regarding rural workforce shortages and closure of smaller obstetric centres. Aim: To identify whether safety is a concern for Murrumbidgee hospitals that fit primary medical care models and ascertain general practitioner (GP) obstetricians' perspectives regarding the benefits and challenges to practising in the region. Design: Mixed‐method retrospective analysis of selected outcomes in the NSW Mothers and Babies Reports 2012–2015 and semi‐structured interviews with GP obstetricians. Setting: Murrumbidgee Local Health District. Main outcome measures: Evaluation of the safety of smaller hospitals (i.e. discharge status at birth, neonatal resuscitation and admission to intensive care); and iterative thematic analysis. Results: This study provides evidence that smaller hospitals are providing safe obstetric care. Fewer babies were transferred, with fewer stillbirths, at the smaller hospitals and no difference in newborn deaths. There were more normal vaginal births in the smaller hospitals (70.0%) than in Wagga Wagga Base Hospital (57.2%) or Griffith Base Hospital (58.6%). There were fewer neonatal resuscitations in the smaller hospitals than in Wagga Wagga Base Hospital or Griffith Base Hospital. More than one‐quarter of babies were admitted into the special care/neonatal intensive care for both Wagga Wagga and Griffith Base Hospitals; however, the rate was <3% in the smaller hospitals (p < 0.001). GPs were overwhelmingly positive about the professional rewards of GP obstetric practice and the importance of continuity of care, despite barriers such as workforce shortages, loss of facilities and other staff (midwives and anaesthetists). Possible solutions included fostering support systems, proactive succession planning and improving training support. Conclusions: GP obstetricians are providing a valuable, safe service in MLHD with both personal and community benefits. [ABSTRACT FROM AUTHOR]

Perioperative nurses assist in organ procurement surgery; however, there is a dearth of information of how they encounter making conscientious objection requests or refusals to participate in organ procurement surgery. Organ procurement surgical procedures can present to the operating room ad hoc and can catch a nurse who may not desire to participate by surprise with little opportunity to refuse as a result of staffing, skill mix or organizational work demands. This paper that stems from a larger doctoral research study exploring the experiences of perioperative nurses participating in multi-organ procurement surgery used a grounded theory method to develop a substantive theory of the nurses' experiences. This current paper aimed to highlight the experiences of perioperative nurses when confronted with expressing a conscientious objection towards their participation in these procedures. A number of organizational and cultural barriers within the healthcare organization were seen to hamper their ability in expressing a conscience-based refusal, which lead to their reluctant participation. Perioperative nurses must feel safe to express a conscientious objection towards these types of surgical procedures and feel supported in doing so by their respective hospital organizations and not be forced to participate unwillingly. [ABSTRACT FROM AUTHOR]

This paper examines how people with chronic illnesses respond to absences of continuity and coordination of care. Little work has been done on how the ill person might mitigate flaws in a less than optimal system. Our qualitative research, carried out among 91 participants in Australia, reveals that people with chronic illnesses create strategies to facilitate the management of their care. These strategies included efforts to improve communication between themselves and their health care practitioners; keeping personal up-to-date medication lists; and generating their own specific management plans. While we do not submit that it is patients' responsibility to attend to gaps in the health system, our data suggests that chronically ill people can, in and through such strategies, exert a measure of agency over their own care; making it effectively more continuous and coordinated. Participants crafted strategies according to the particular social and bodily rhythms that their ongoing illnesses had lent to their lives. Our analysis advances the view that the ill body itself is capable of enfolding the health system into the rhythms of illness - rather than the ill body always fitting into the overarching structural tempo. This entails an agent-centric view of time in illness experience. A Virtual Abstract of this paper can be found at: [ABSTRACT FROM AUTHOR]

Objective: Growing a strong Aboriginal and Torres Strait Islander health workforce is key to closing the gap in health outcomes between Indigenous and non‐Indigenous Australians. This study sought to explore barriers and enablers to career development for Aboriginal health staff and potential strategies to enhance career pathways. Design: Qualitative study, with data collected primarily through focus group discussions (yarning circles) at different health workplaces. Setting: Western New South Wales. Participants: Aboriginal health staff (n = 54) from Aboriginal Community Controlled Health Services, a Local Health District and a Primary Health Network, and their managers (Aboriginal and non‐Aboriginal; n = 28). Main outcome measures: Identified barriers and enablers and regional strategies for improving career pathways. Results: Aboriginal people interested in pursuing a career in health face barriers in: pre‐employment, recruitment, the workplace and further education and training. Being given practical and emotional support, as well as opportunities, makes a difference at every stage. Family and community are very influential in career decisions. Within the workplace, culturally appropriate human resource systems and management structures are vital. The ability to obtain employment and access education and training locally is important to rural and remote communities. Conclusion: To enhance health career pathways for Aboriginal people, strategies are needed at all levels: community, organisation, system and society. Aboriginal leadership and self‐determination are crucial, as are partnerships within the health sector and between the health and the education and training sectors. Cultural safety is essential to expansion of the Aboriginal workforce, and to health care experiences and outcomes for Aboriginal community members. [ABSTRACT FROM AUTHOR]

With continued growth in the demand for nursing care, many organizations have incorporated nursing assistants into the acute care workforce. However, role descriptions are often generic and do not provide clarity in specialist areas such as mental health inpatient settings. Issues have been noted regarding the role of assistants, delegation, and their integration with the nursing team. This study extended an existing set of care activities and explored the perceptions of nursing assistants and registered nurses regarding these activities. A modified Delphi approach added 14 new care activities for nursing assistants. A follow‐up survey found significant differences between nursing assistants and registered nurses regarding utilization of the activities, delegation, teamwork, and role clarity. Future research must incorporate the perspectives of those with lived experience of mental health issues, and develop an understanding of the interactions between nursing assistant care activities and other factors such as local supports, skillmix, and the practice environment, as these may impact how an organization can introduce nursing assistants to specialty areas while maintaining consumer and staff safety. [ABSTRACT FROM AUTHOR]

Objective: The Allied Health Rural Generalist Pathway pilot aimed to improve consistent access to physiotherapy services in rural communities using the "grow own" workforce strategy and existing resources. Design: A summative evaluation of the quality improvement project used to implement the Allied Health Rural Generalist Pathway was completed. A mixed method design was used and included focus groups and a framework analysis. Participants: The temporary redesign of specific workforce resources created "development" positions. A shared same‐discipline supervisor resource supported five early‐career physiotherapists, the participants. Setting: The project was undertaken in rural New South Wales in the public health system. Main outcome measures: The main outcome measures included a number of chronically vacant physiotherapy positions and stakeholder satisfaction. Results: Targeted vacancies were filled, services sustained with minimal service gaps and mean retention rate of 2.9 years. A statistically significant increase in service activity to patients in rural locations occurred as a result of the intervention (R‐squared 29%, P <.05). Four out of five early career physiotherapists fulfilled terms of their contract and secured senior positions within the region. Whilst participants developed professionally, they did not complete the tertiary education component. Conclusions: The Allied Health Rural Generalist multi‐factorial approach supported recruitment, retention and capacity building within the targeted discipline of the allied health workforce. Patient need was met. The rural pipeline capacity was developed. The pathway was complementary of existing NSW Health systems. Systemic change is needed to overcome inefficiencies experienced during implementation and to ensure sustainability. Further research to develop discipline‐specific clinical training guidance through the stages of a rural allied health professionals' career may be helpful. [ABSTRACT FROM AUTHOR]

In this paper, midwives' experiences of working with vulnerable pregnant women who were subject to child protection orders in New South Wales, Australia, and faced the possible removal of their baby at birth, known as 'assumption of care', are described. A qualitative descriptive approach was used to explore the experiences of ten midwives who had been involved in some 91 episodes of assumption of care. In-depth interviews were undertaken and thematic analysis was used to analyse the data-set. Four themes were elicited that demonstrated how midwives worked with vulnerable women and Community Services during the antenatal period. These were labelled: Reporting - Taking the first step; The woman-midwife relationship remains a priority; Jumping through the 'community service' hoops; and Crunch time: The decision... sometimes justifiable sometimes not? Even though the three-way relationship between the woman-midwife-Community Services could be confrontational, it was essential that midwives worked in a positive way with Community Services to improve outcomes for the woman and her unborn child. Copyright © 2016 John Wiley & Sons, Ltd. Key Practitioner Messages Working effectively with Community Services is essential. Sharing information and developing multidisciplinary approaches and pathways will produce the best outcomes for vulnerable newborns and their mothers whilst at the same time supporting health and community workers to work in a cohesive manner to provide quality care., Midwives need to be supported to stay 'woman centred'. Keeping the woman engaged in the system will help ensure the health of the foetus (baby)., Further research is needed to explore the perspectives of all those involved in assumption of care. [ABSTRACT FROM AUTHOR]

Conflicts of interest ( COI) are considered ubiquitous in many healthcare arrangements,1 but there is disagreement on how COI should be defined, whether non-financial conflicts deserve attention and the relationship between COI and harm. We conducted a study of Australian healthcare professionals and students to gain a better understanding of the way that COI are understood in practice. In this paper, we outline an empirically derived taxonomy of the understanding of, and attitudes towards, COI. We carried out 25 semistructured interviews with clinicians working in several fields across Australia and held six focus group discussions with medical students in New South Wales. Interviewees and focus groups followed similar question routes investigating participants' understanding of COI and views of management. All data were compared and analysed using a matrix of pre-determined questions. There were, broadly, two views of COI: that COI were potentially harmful and morally compromising and another that saw COI as less serious and easily managed through existing structures. Definitions of COI varied widely and were both financial and non-financial. Causes of COI were, variously, systemic, individual and/or relational. Some participants associated COI with moral wrongdoing, and a variety of potential harms was identified. Views on how COI should be managed were similarly varied. We found considerable heterogeneity in how COI are understood in practice. This has implications for management systems that are currently in place, and we suggest a more sophisticated system for considering and mitigating COI. [ABSTRACT FROM AUTHOR]

Parental incarceration has wide-ranging impacts on families. One key effect may be disruption to the care and legal custody of children, yet few studies have examined processes and outcomes relating to care planning for children of prisoners. This paper presents findings of interviews with 151 primary carer prisoners in two Australian states which aimed to address this research gap. The study examined care planning for children upon parental arrest, sentencing and imprisonment, stability of care arrangements and primary carer prisoners' involvement and satisfaction with care planning. Around one third of prisoners had discussions regarding children's care arrangements at arrest and imprisonment, although the issue was more commonly raised at sentencing. While there was much variation in the stability of care arrangements, children placed in out-of-home care experienced the most instability. A minority of prisoners reported being involved in care planning and decision-making for children upon imprisonment, and around one third rated care planning process poorly. Prisoners were more satisfied with care planning when there were fewer movements of children, where prisoners felt involved with decision-making, and when police officers, lawyers and corrections staff inquired about the welfare of their children. Implications for policy and future research are discussed. [ABSTRACT FROM AUTHOR]

Mental health is a major concern in Indigenous communities, as Indigenous people experience poorer health outcomes generally, and poorer social and emotional well-being throughout their lives, compared to non-Indigenous populations. Interviews were conducted with 20 mental health workers from a housing assistance programme for Indigenous clients with mental illness. Service and infrastructure needs identified to support clients were classified under the following overarching theme 'supports along the road to recovery'. Subthemes were: (i) It is OK to seek help; (ii) linking in to the local community; (iii) trusting the workers; and (iv) help with goal setting and having activities that support their achievement. This paper highlights the importance of targeted housing and accommodation support programmes for Indigenous people to prevent homelessness, and the essential services and infrastructure required to support Indigenous clients' mental health needs. These insights may inform service review, workforce development, and further research. [ABSTRACT FROM AUTHOR]

Objective(s): To explore the attitudes of health‐care providers and the perceived barriers and facilitators regarding the use of cannabis‐containing medicines (CCMs) in older patients. Methods: Semi‐structured interviews with eleven health‐care providers in rural New South Wales (NSW). A thematic analysis was performed. Results: Themes and recommendations include attitudes towards CCMs for therapeutic purposes, their perceived uses, side effects, barriers to use and prescription (stigma, regulation, access and driving), difficulties encountered with the Special Access Scheme (SAS) and the need for ongoing research and education. An ecological framework demonstrated the complex interactions between patients and health‐care providers and their social, community and political environment. Conclusion: Providers' attitudes towards CCM use in older patients are generally positive; however, there is a need for further high‐quality evidence on efficacy and safety, alongside improved CCM education and training, to reduce barriers to their implementation. Barriers to prescription and access continue to evolve on personal, organisational and systemic levels. [ABSTRACT FROM AUTHOR]

Objective(s): To develop and validate a frailty index (FI) that covers multiple domains, using routine hospital data. To investigate the FI's validity, after excluding medication‐related items (FI‐ExMeds), for studies of frailty and polypharmacy. Methods: A FI was derived from routine NSW hospital data following standard published guidance. In a development cohort (151 inpatients ≥ 70 years), the FI was correlated with the Reported Edmonton Frail Scale (REFS) using Pearson's R. Validity and distribution of FI and FI‐ExMeds, and correlation with each other, were evaluated in a validation cohort (999 inpatients ≥ 75 years). Results: The mean FI for the development cohort was 0.27 (SD 0.09). The FI showed moderate linear correlation with the REFS (n = 148, R = 0.52, P <.001). In the validation cohort, mean FI (n = 993) and FI‐ExMeds (n = 990) were both 0.28 (SD 0.11). FI‐ExMeds showed high linear correlation with the FI (n = 990, R = 0.99, P <.001). Conclusion: This multi‐domain FI is comparable to REFS, with adequate redundancy to exclude deficits for specific analyses. [ABSTRACT FROM AUTHOR]

Background: Prescribing of gabapentinoids has increased worldwide and off‐label use is well‐described. Patients may be at risk of harm from inappropriate use. Prescribing patterns in tertiary care have not been described in the Australian setting. Aim: The aim of this study was to assess the prescribing patterns of gabapentinoids across a Local Health District in New South Wales, Australia. Method: Clinical and prescribing records over a 48‐h period were reviewed. Patient demographics, renal function and concurrent opioid use were recorded. Dosing details and the indications for treatment were analysed. Results: Almost 40% of patients were prescribed concomitant opioid therapy, half of which were in the postoperative setting, an indication for which there is little evidence. Appropriate dose reductions were made in the majority of patients with renal impairment. Methods used for ceasing therapy were not in accordance with best practice. Indications for use were difficult to ascertain from medical records. However, only approximately half of usage of both agents appeared to be for approved indications. Conclusion: Prescribing of gabapentinoids could be improved. Although dosages are largely in accordance with recommended dosages for renal impairment, there is significant concern with concurrent use of opioids and use for non‐approved indications, many of which lack clinical evidence. Further investigation into prescribing habits in the postoperative setting is warranted. There is a potential role for increased education and intervention to optimise use. [ABSTRACT FROM AUTHOR]

Introduction and Aims: The harms associated with non-medical use of pharmaceutical opioid analgesics are well established; however, less is known about the characteristics and drug-use patterns of the growing and hidden populations of people using pharmaceutical opioids illicitly, including the frequency of pharmaceutical opioid injection. This paper aimed to undertake a detailed examination of jurisdictional differences in patterns of opioid use among a cohort of people who regularly tamper with pharmaceutical opioids in Australia.Design and Methods: Data were drawn from the National Opioid Medications Abuse Deterrence study. The cohort was recruited from New South Wales (NSW; n = 303), South Australia (SA; n = 150) and Tasmania (TAS; n = 153) to participate in face-to-face structured interviews collecting data on use of pharmaceutical opioids, benzodiazepines, other sedative drugs and illicit substances, as well as the harms associated with substance use.Results: TAS participants reported greater use and injection of certain pharmaceutical opioids (particularly morphine and methadone tablets), and limited heroin use, with lower rates of engagement in opioid substitution treatment, compared with NSW participants. NSW participants were more socially disadvantaged and more likely to report risky injecting behaviours and injecting-related injuries and diseases compared with SA and TAS participants. SA participants reported greater rates of pain conditions, greater use of pain-based services, as well as broader use of pharmaceutical opioids in regards to forms and route of administration, compared with NSW participants.Discussion and Conclusions: Distinct jurisdictional profiles were evident for people who tamper with pharmaceutical opioids, potentially reflecting jurisdictional differences in prescribing regulatory mechanisms and addiction treatment models. [ABSTRACT FROM AUTHOR]

Objective This paper aims to contribute to the development of a more sustainable Australian rural community mental health workforce by comparing the findings from a literature search investigating impacting factors on retention with the experiences of community mental health service managers running services in rural Australia. Design Semi-structured interviews. Setting Public health sector, rural New South Wales. Participants Five community mental health managers, running services in rural Australia. Main outcome measures Interviews were undertaken as a pilot for a broader qualitative study investigating factors influencing the decision to stay or leave among community mental health professionals working in rural positions. The purpose of undertaking this pilot study was to test for validity and relevance of the retention phenomena and help inform the research design for the main study. Results Three key retention focussed themes were identified: (i) Staffing is a persistent challenge; (ii) Small remote towns pose the biggest challenge; and (iii) The decision to stay or leave is complex and multifactorial. Conclusions The findings of this pilot study support previous research and contribute to the understanding of influences on retention among health professionals working in rural community mental health services. Importantly, those who have worked for several years in rural positions hold important information through which to explore factors that impact retention in rural and remote regions. [ABSTRACT FROM AUTHOR]

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There is growing evidence demonstrating that nursing students encounter unsafe and poor clinical practice when on clinical placement. The impact on nursing students remains relatively under‐explored, especially in the Australian context. This two‐phased qualitative study used Interpretive Description to explore 53 pre‐registration nursing students' perceptions and experiences of speaking up for patient safety. Results of the study identified students believe speaking up is the right thing to do, and their professional responsibility. The study results add to previous research by describing the dissonance students experience due to the inconsistencies between what is taught at university and performed in practice. Student's distress arises when observing nurses taking short cuts, justifying such actions and making excuses about poor practice. Students report experiencing dissonance, bewilderment and confusion and at times, anger when observing poor practice. The clinical environment culture influences students' decisions to speak up or remain silent. Understanding students' perceptions and responses will promote awareness and discussion essential to the future development of curricula and clinical support strategies that will enable students to speak up. [ABSTRACT FROM AUTHOR]

Objective: This evaluation considered the potential of We‐Yarn, a suicide prevention gatekeeper training workshop, to contribute to Aboriginal suicide prevention in rural New South Wales. Design: A mixed methods approach included surveys, in‐depth interviews and workshop observations. Setting: Aboriginal suicide prevention training in rural New South Wales, Australia. Participants: Attendees at We‐Yarn training. Intervention: We‐Yarn provided culturally safe suicide prevention skills training for Aboriginal people and for those who work with Aboriginal communities and persons in rural New South Wales. Training workshops were delivered across multiple locations for 6 hours in one day. Workshops were facilitated by two facilitators with lived and professional experience; one Aboriginal and one non‐Aboriginal facilitator. We‐Yarn content was developed by staff from the Centre for Rural and Remote Mental Health, and in consultation with Aboriginal Elders and representatives of Aboriginal Medical Services to ensure relevance and cultural appropriateness. Main outcome measures: Pre and post‐workshop surveys captured capacity and participants' confidence in identifying and responding to a person at risk of suicide. Interviews explored participants' experiences of workshops, implementation of learning, and attitudes regarding social and emotional wellbeing and suicide. Observations detailed the workshop environment, participants' engagement, and participants' responses to facilitators and content. Results: We‐Yarn was considered culturally appropriate. Participants responded to facilitators' lived experiences. Participants reported significant improvements in understanding the links between cultural strengths, social and emotional wellbeing and suicide prevention. However, health professionals with existing knowledge wanted a stronger focus on clinical training. Conclusion: We‐Yarn promoted discussion of suicide prevention within a holistic health framework, building on participants' pre‐existing knowledge about social and emotional wellbeing. Importantly, skilful facilitators with lived experience were vital to the success of the workshops. Consideration should be given to attracting people with low suicide prevention knowledge to the workshops, developing tailored workshops for health professionals and ensuring prolonged engagement with communities. Multifaceted and long term responses in addition to this type of training are important. [ABSTRACT FROM AUTHOR]

Objective: This study examined the impact of introducing Palliative Care Needs Rounds (hereafter Needs Rounds) into residential aged care on hospitalisations (emergency department presentations, admissions and length of stay) and documentation of advance care plans. Design: A quasi‐experimental study. Setting: Two residential aged care facilities in one rural town in the Snowy Monaro region of New South Wales, Australia. Participants: The intervention group consisted of all residents who died during the study period (April 2018‐March 2019), and included a subgroup of decedents who were discussed in a Needs Round. The control cohort included all residents who died in the three‐year period prior to introducing Needs Rounds (2015‐2017). Intervention: Needs Rounds are monthly onsite triage/risk stratification meetings where case‐based education and staff support help to identify residents most at risk of dying without an adequate plan in place. Needs Rounds were attended by residential aged care staff and led by a palliative medicine physician. Main outcome measures: Decedents' hospitalisations (emergency department presentations, admissions and length of stay) in the last three months of life, place of death and documentation of advance care plans. Results: Eleven Needs Rounds were conducted between April and September 2018. The number of documented advance care plans increased (P <.01). There were no statistically significant changes in hospitalisations or in‐hospital deaths. Conclusion: Needs Rounds are an effective approach to increase the documentation of advance care plans within rural residential aged care. Further studies are required to explore the rural influence on outcomes including hospital transfers and preferred place of death. [ABSTRACT FROM AUTHOR]

Aim The hospital environment as a workplace has undergone rapid changes over the last 50 years. Despite this, there has been very little research exploring how dietitians working in hospitals perceive their workplace. Moreover, previous studies in this area have focused predominantly on examining the North American experience of dietitians. Only a handful of previous studies have investigated the experiences of Australian dietitians at different stages of their careers. Therefore this study, in part, addresses a gap in the extant literature by examining how New South Wales ( NSW) public-hospital dietitians perceive their workplace and its influence on their ability to function as healthcare professionals. Methods In 2011, 32 in-depth interviews were conducted with dietitians from 11 NSW public hospitals. Participants were selected from four career stages: new graduates, mid-career, specialists and managers. Data from the interviews were analysed through a grounded theory approach. Results Data analysis revealed that dietitians sought validation of their work experience from five sources within the workplace. In this paper, these five sources have been depicted as a conceptual model labelled the ' Five Sources of Value'. The five sources identified were: acquisition of knowledge; relationships with others; work culture; role clarity; and personal attributes. This study also found the relative importance of these values changed according to the career stage of the individual dietitian. Conclusions The retention and engagement of staff within a hospital environment is an ongoing issue for dietetic managers. The ' Five Sources of Value' identified through this study and their relative influence at different career stages may assist managers in developing workplace strategies that addresses the major areas of concern for many staff. As a result of the qualitative nature of this exploratory study, the generalisability of the findings are limited. To address this limitation, future research may follow a more quantitative approach. [ABSTRACT FROM AUTHOR]

Objectives: To advance the rural practice in working with Aboriginal communities by (a) identifying the extent of community partners' participation in and (b) operationalising the key elements of three community‐based participatory research partnerships between university‐based researchers and Australian rural Aboriginal communities. Design: A mixed‐methods study. Quantitative survey and qualitative one‐on‐one interviews with local project implementation committee members and group interviews with other community partners and project documentation. Setting: Three rural Aboriginal communities in New South Wales. Participants: Thirty‐seven community partners in three community‐based participatory research partnerships of which 22 were members of local project implementation committees and 15 were other community partners who implemented activities. Intervention: Community‐based participatory research partnerships to develop, implement and evaluate community‐based responses to alcohol‐related harms. Main outcomes measures: Community partners' extent of and experiences with participation in the community‐based participatory research partnership and their involvement in the development and implementation processes. Results: Community partners' participation varied between communities and between project phases within communities. Contributing to the community‐based participatory research partnerships were four key elements of the participatory process: unique expertise of researchers and community‐based partners, openness to learn from each other, trust and community leadership. Conclusion: To advance the research practice in rural Aboriginal communities, equitable partnerships between Aboriginal community and research partners are encouraged to embrace the unique expertise of the partners, encourage co‐learning and implement community leadership to build trust. [ABSTRACT FROM AUTHOR]

While it is known that informal carers provide the majority of caregiving in Australia, there remains limited understanding of the challenges that regional carers face in their caring role and the impact of the caregiving role on carer well‐being. Objective: The aim of this study was to better understand the health status of caregivers as the person they care for was entering the National Disability Support Scheme. Design: This is a mixed‐methods study. Setting: The study was undertaken in regional New South Wales, Australia. Participants: Seventy‐five carers were enrolled into the study. All lived in regional New South Wales. Main outcome measure: The World Health Organization Well‐being Index was used for quantitative data collection, and semi‐structured interviews were undertaken for the collection of qualitative data. Result: Quantitative data indicated that carers from Aboriginal or Torres Strait Islander backgrounds and those from low socio‐economic status had significantly lower scores on the well‐being index. Two key qualitative categories were evident describing carer's journey to resilience by (a) adjusting to reality predominantly through cognitive reframing strategies and (b) carers accessing external supports. Conclusion: The health status of regional carers who are predominantly women is experiencing low levels of well‐being. While many of these carers have initiated successful coping responses to the challenges of caring, there is an urgent need to increase the supports available to this population. As the recent National Disability Support Scheme is embedded, it is of importance to monitor if there are improvements in the health status of carers over time. [ABSTRACT FROM AUTHOR]

Introduction and Aims: The Australian Treatment Outcomes Profile (ATOP) is a brief clinical tool measuring recent substance use, health and wellbeing among clients attending alcohol and other drug (AOD) treatment services. It has previously been assessed for concurrent validity and inter-rater reliability. In this study we examine whether it is suitable for administration over the telephone.Design and Methods: We recruited a sample of 107 AOD clients across public sector specialist AOD treatment services in New South Wales, Australia between 2016 and 2018. Participants had a mean age of 47 years and 46% were female. Participants completed a face-to-face ATOP and a phone ATOP with a researcher within 5 days. Comparisons between the two administration modes were undertaken using Spearman's rank correlation coefficient for continuous or ordinal variables, and Cohen's Kappa for nominal variables.Results: Among 107 participants, 59% were attending for alcohol treatment and 41% for opioid treatment. Most ATOP items (76%) reached above 0.7 (good) or 0.9 (excellent) agreement between face-to-face and telephone use.Discussion and Conclusions: Our findings suggest that the ATOP is a suitable instrument for telephone monitoring of recent substance use, health and social functioning among AOD clients. Its validation for remote use over the telephone will support staff to monitor clients' risks and outcomes-of particular relevance in response to the COVID-19 pandemic in which services are increasingly relying on telework approaches to client monitoring. [ABSTRACT FROM AUTHOR]

Aim: To assess educational outcomes of twins and quantify the degree this is mediated by gestational age and other perinatal factors.Methods: We conducted a population-based record-linkage cohort study of all live births ≥24 weeks gestation in New South Wales, Australia with a corresponding standardised school test result for grade 3 in 2008-2014. The primary outcome was whether a child met the National Minimum Standard (NMS) cut-off in literacy and numeracy domains. Robust multivariable Poisson models were used to obtain adjusted relative risks (aRRs), and mediation analysis conducted to assess contributing factors on the causal pathway.Results: Of 351 791 liveborn infants, 10 365 (2.9%) were twins. After adjusting for maternal covariates and compared with singletons, twins had an increased risk of not meeting the NMS for all five literacy and numeracy domains (aRR 1.27-1.45, P < .001). Gestational age alone mediated up to 73% of aRRs and small for gestational age further attenuated these effects with only minimal risk remaining after adjusting for all mediators (aRR 0.94-1.07).Conclusion: Almost all of the educational disadvantage experienced by twins, compared with singletons, is attributable to the risk associated with shorter gestational age, and partly by poor foetal growth. These findings support efforts to prolong gestation of twin pregnancies. [ABSTRACT FROM AUTHOR]

Background: In the context of an effective consumer engagement framework, there is potential for health‐care delivery to be safer. Consumers from culturally and linguistically diverse (CALD) backgrounds may experience several barriers when trying to engage about their health care, and they are not acknowledged sufficiently in contemporary strategies to facilitate patient engagement. Methods: Four focus group discussions were facilitated by bilingual fieldworkers in Arabic, Mandarin, Turkish and Dari in a district of Sydney, Australia that has a high proportion of CALD consumers. Each group included 5‐7 health‐care consumers who, using a topic guide, discussed their experiences of barriers and facilitators when engaging with health‐care services in Australia. Thematic analysis was undertaken to identify, analyse and report patterns in the data. Results: In all, 24 consumers participated. Six inter‐related themes emerged: navigating the health system; seeking meaningful interpretation; understanding and managing expectations; respectful professional care; accessing services; and feeling unsafe. Conclusions: The incorporation of strategies such as professional interpreters and migrant health workers may go some way to addressing the needs of culturally or linguistically diverse consumers and facilitate communication, but do not sufficiently address the range of barriers to consumer engagement identified in this work. Understanding consumer experience in the context of the complex factors that may be associated with poor engagement and poor outcomes such as health literacy, cultural, educational and linguistic background, and health‐care setting or condition, may contribute to better understanding about how to deliver quality health care to these patients. [ABSTRACT FROM AUTHOR]

Long‐term foster carers in New South Wales, Australia, are being encouraged to consider open adoption of the child in their care. This includes an agreement to facilitate direct or face‐to‐face birth family contact without agency support. There is little Australian research on the factors that influence decisions to adopt children from out‐of‐home care. A mixed methods study was conducted to address this gap. An online survey (n = 76) and four focus groups (n = 30) were conducted with foster carers across New South Wales. Descriptive and thematic analysis was undertaken. Results related to birth family contact are reported. Birth family contact was an area of widespread concern among foster carers. The theme of Relationships with birth family included four subordinate themes: (a) disputed purpose, (b) supervision versus independence, (c) ambivalence about agencies, and (d) establishing boundaries. Foster carers viewed birth family contact as extremely challenging due to its effects on children and interactions with agency staff. For open adoption or guardianship to become the preferred permanency option for children over long‐term foster care, carers will need ongoing and appropriate professional support with contact. [ABSTRACT FROM AUTHOR]

Aim: To validate the polyunsaturated food frequency questionnaire (PUFA FFQ) and test for reproducibility in people with end stage renal disease on dialysis treatment. Methods: Participants (n = 32) completed the PUFA FFQ and three 24‐hour recalls. Erythrocyte samples (n = 29) were used for erythrocyte fatty acid analysis. The triangular relationship between the PUFA FFQ, 24‐hour recalls and the biomarker was assessed using the method of triads. Agreement between the two dietary methods was also assessed using Bland–Altman plots and classification by quintiles. Reproducibility was tested on a subset of the group (n = 8). Results: The PUFA FFQ was a valid measure of all PUFA except for docosapentaenoic acid (DPA) and arachidonic acid (AA). Strong validity coefficients were found for n‐3 long‐chain PUFA (LCPUFA), eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) of 0.914 (95% CI: 0.665, 0.997) and 0.889 (95% CI: 0.706, 0.994), respectively. In the Bland–Altman plots 91–100% of observations fell between the limits of agreement for all PUFA. There were significant correlations between the initial FFQ and the repeat FFQ for all PUFA except DPA and AA. Conclusions: The PUFA FFQ is a valid tool for assessing PUFA intake in people with end stage renal disease. [ABSTRACT FROM AUTHOR]

Migrants from areas affected by war, especially refugee migrants, are susceptible to mental health issues. In addition to recognising trauma, health professionals, such as mental health nurses, need to be aware of the strength and resilience of refugees and migrants. The capacity to provide trauma‐informed care that is shaped by the recognition of clients' strength and resilience is required/paramount to meet the current demand of multiculturalism emanating from an increased global migration. To facilitate increased awareness about West African women's resilience prior to migration and support trauma‐informed care, we used a qualitative strength‐based storytelling approach with 22 West African women residing in Sydney, Australia. Thematic analysis of the women's stories identified two major themes: When the World Falls Apart and Battered but Strong. Findings revealed that past personal experiences significantly influenced participants' strength and resilience and contributed to their mental health. Mental health professionals such as nurses can play an important role by incorporating knowledge about the resilience of migrants and refugees into providing appropriate trauma‐informed care. [ABSTRACT FROM AUTHOR]

Mental health nurses have traditionally lagged in terms of physical healthcare skills and have been found to have poorer cultural safety‐related attitudes relative to other nurses. Organizational culture, including safety‐related culture, is associated with important aspects of care quality. The aim of the current study was to examine the relationships between safety‐related attitudes, physical healthcare‐related knowledge and organizational culture among mental health nurses. By doing so, the intention was to inform decisions about interventions to improve attitudes and care related to severe physiological deterioration among mental health nurses. The study design was cross‐sectional and correlational. The safety‐related attitudes of N = 133 nurses from the inpatient mental health services of one Local Health District in New South Wales, Australia, were examined in terms of a range of potential predictor variables of safety attitudes (Safety Attitudes Questionnaire) including individual organizational‐perceiver type (Organisational Climate Assessment Inventory), knowledge of emergency medical healthcare (Lambeth In situ Training Questionnaire), use and perception of medical emergency teams (purpose‐designed questionnaire) and a range of demographic variables. Regression analyses revealed that those who perceived the organization to have a primarily market‐oriented culture had poorer safety‐related attitudes than those who perceived a more clan‐type culture. Number of years qualified was negatively associated with safety attitudes. To our knowledge, this is the first study in mental health which demonstrates a link between organizational culture‐perception and safety attitudes related to physical healthcare. Results suggest that, among nurses, individuals have quite different perceptions of the organizational culture. In turn, this suggests that the 'one‐size fits all' approach to changing organizational culture may be inappropriate. [ABSTRACT FROM AUTHOR]

Context This paper explores how structured feedback and other features of workplace-based assessment ( WBA) impact on medical students' learning in the context of an evaluation of a workplace-based performance assessment: the teamwork mini-clinical evaluation exercise ( T- MEX). The T- MEX enables observation-based measurement of and feedback on the behaviours required to collaborate effectively as a junior doctor within the health care team. The instrument is based on the mini-clinical evaluation exercise (mini- CEX) format and focuses on clinical encounters such as consultations with medical and allied health professionals, discharge plan preparation, handovers and team meetings. Methods The assessment was implemented during a 6-week period in 2010 with 25 medical students during their final clinical rotation. Content analysis was conducted on the written feedback provided by 23 assessors and the written reflections and action plans proposed by the 25 student participants (in 88 T- MEX forms). Semi-structured interviews with seven assessors and three focus groups with 14 student participants were conducted and the educational impact was explored through thematic analysis. Results The study enabled the identification of features of WBA that promote the development of collaborative competencies. The focus of the assessment on clinical encounters and behaviours important for collaboration provided opportunities for students to engage with the health care team and highlighted the role of teamwork in these encounters. The focus on specific behaviours and a stage-appropriate response scale helped students identify learning goals and facilitated the provision of focused feedback. Incorporating these features within an established format helped students and supervisors to engage with the instrument. Extending the format to include structured reflection enabled students to self-evaluate and develop plans for improvement. Conclusions The findings illuminate the mechanisms by which WBA facilitates learning. The educational features highlighted include effectively structured feedback processes, support for situated learning, a positive backwash (facilitation of learning through preparation for the assessment), and facilitation of informed self-assessment. [ABSTRACT FROM AUTHOR]

Objective To determine the knowledge and recommendations of rural general practitioners ( GPs) in regard to climate change and the preparedness of rural health services for its health impacts. Design A quantitative descriptive survey distributed in paper-based or electronic form. Setting Rural Southwest of New South Wales. Participants GPs and GP registrars working in Rural Remote Metropolitan Areas ( RRMA) 3-7. Main outcome measures Questionnaire responses analysed with descriptive statistics and inferential tests. Results While the majority of respondents agreed with statements supporting climate science and the impact of climate change on health, between 24% and 34% of respondents were unsure or did not agree. Furthermore, between 33% and 44% of GP respondents working in RRMA 5-7 were unsure or did not agree that their health service had the capacity to provide an initial response to an extreme weather event ( P = 0.01). Strengthening health service acute disaster capacity response was a preferred adaptation strategy for improving health service preparedness of 61% of participants. A greater proportion of GPs were supportive of their role as advocates on general health issues (80%) compared with extreme weather events (60%) or climate change and health (63.5%) ( P ≤ 0.01). For professional development and education, 71% preferred a locally based workshop or seminar. Conclusions The study highlights the need to consider closely the views of GPs when preparing rural communities for the possible health effects of climate change. Findings indicate concern for health service preparedness, particularly in smaller rural communities. Further development of disaster response planning and communication is needed. [ABSTRACT FROM AUTHOR]

Type 2 diabetes mellitus is an established health problem for Indigenous Australians. One strategy to address this issue is to educate health professionals in diabetes management and education. Objective The objective of this paper is to identify important issues that compromise the clinical practice of rural and remote Aboriginal health workers ( AHWs) and registered nurses ( RNs) who undertook an accredited Australian Diabetes Educators Association diabetes course and to suggest strategies to improve practice. Design The design used a qualitative approach and discussion schedule to elicit responses. Setting The setting involved two Aboriginal community controlled and seven mainstream health services in the Far Western region of New South Wales. Participants The participants were experienced diabetes educators ( RNs and AHWs), managers and students currently enrolled in the course (n = 17). Results The results indicated issues that compromise diabetes practice and identified strategies to improve practice. Issues were: the confusing funding practices by health providers, the duplication of health services, the lack of recognition of diabetes qualifications and the transient nature of Indigenous people. Strategies included the need for: continuous dedicated diabetes health funding, a role clarification for diabetes educators, strategic diabetes planning and the importance of diabetes educators working in partnership. Conclusion The conclusion from this study indicates that if the delivery of diabetes health services to Indigenous Australians is to improve it is necessary to address these identified issues. [ABSTRACT FROM AUTHOR]

Objective This paper identified barriers which prevent rural health care providers from utilising rt- PA in acute ischaemic stroke and proposes possible support mechanisms to increase its utilisation. Methods This descriptive study uses data from anonymous surveys distributed to health care providers involved in acute stroke patient care in three rural hospitals with rt- PA pathways. Saturation sampling was used. Surveys gathered self assessed ratings of experience, practice environment, attitudes, existing support, barriers and possible enablers regarding rt- PA use in acute stroke. Results Physicians reported the strongest barriers to the use of rt- PA in acute stroke as pre-hospital delays (91%), risk of intracerebral haemorrhage ( ICH) (73%) and clinical diagnostic uncertainty (60%). They reported high levels of confidence in the support received from their stroke units (90%). Nurses identified a poor level of stroke education and knowledge on rt- PA utilisation in acute stroke. A third of nurses could correctly list six different stroke signs. The risk of ICH following rt- PA administration in stroke was also a significant barrier for nurses. Response rate from physicians was 26% (10/38) and 19% (13/69) for nurses. Conclusions To reduce barriers to rt- PA utilisation in rural facilities physicians require education on the calculated risk of ICH as well as exposure and experience to improve their ability to confidently diagnose stroke patients who are eligible for rt- PA treatment. Education for nurses on symptoms of stroke and rt- PA utilisation and administration is recommended. [ABSTRACT FROM AUTHOR]

Objective To obtain information about aged care services in rural New South Wales public hospitals, and to describe key operational aspects of their service delivery models. Design A mixed methods design was used to combine data collected from: (i) a survey of public hospitals and (ii) qualitative site visits in a sample of eleven rural sites. Setting Rural public hospitals in NSW, Australia. Participants Qualitative data were collected from multidisciplinary clinicians, managers and community service providers who participated in site visits in 2010 and from surveys of NSW public hospitals in 2009/10 about aged care and dementia services. Results Survey and site visit findings demonstrated that rural hospitals have fewer secure beds for managing patients with disturbed behaviour due to dementia and delirium and fewer speciality aged care staff than metropolitan hospitals. Site visit participants also described how secure environments can aid care for people with dementia even in the absence of clinical specialists. Conclusion The care of people with dementia in rural hospitals is constrained by access to specialist aged care staff and the physical environment of the hospital. Clinicians are adept at maximising resources to manage diagnosis and transitions for people with dementia. Further understanding of how key operational aspects of clinical leadership and environmental modifications impact on a range of patient outcomes would be valuable. [ABSTRACT FROM AUTHOR]