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Background Understanding the pathways to mental health treatment is important to inform service outcome, yet limited empirical research has been conducted. This paper explores the pathways used to treat mental illness in Ghana from the perspective of consumers and mental health professionals (MHPs).Methods The paper used a qualitative method, involving in-depth interview with 30 mental health professionals and 21 consumers, selected through purposive sampling. The data were transcribed and analysed using thematic analysis.Results The findings indicate that mental illness is treated using biomedical, faith based and traditional healing services. Faith and traditional healing pathways are typically used as a preliminary source or first point of care before seeking biomedical treatment. The decisions regarding treatment pathways are influenced by predisposing factors, particularly belief systems and attitudes, as well as enabling factors including acceptability. The study also found an increasing informal collaboration between faith and biomedical practitioners and call for more formalised integration of the existing mental health system.Conclusion The existing interest and knowledge on faith-healing services should be formalise for policy re-formulation, and further integrated into curriculum design for training mental health professionals. Current collaboration and education provided to faith-healing providers, should be promoted, and integrated into the mental health systems.

Introduction: Evaluation frameworks are relevant to understanding health service providers’ views regarding existing services and possible improvements, but their application to mental health services is limited, particularly in Low Middle-Income Countries. Aim/Question: To identify program theory for understanding contextual factors and mechanisms that could enhance mental health service outcomes in Ghana. Method A three-phase approach was followed: initial theory and assumption, analysis, and CMO configuration. Systematic reviews were used to develop a middle-range theory and assumptions in phase 1. A purposive sample of 30 mental health professionals was recruited to participate in in-depth interviews in phase 2. Thematic analysis was used to analyze the qualitative data and further configure the CMO in phase 3. Results The analysis identified five CMO configurations: ripple effects and financing source sustainability; unavailability of modern equipment and logistics to support holistic services; promoting inclusivity and geographical proximity of services; information, sensitization, and awareness encourage mental health quality; and monitoring and evaluating improve mental health service quality. Discussion/Implications for Practice: This study concludes that government stakeholders should integrate mental health services into the ongoing insurance policy and provide adequate modern equipment and logistics. Moreover, mechanisms and priorities given to vulnerable consumers should be integrated into policies.

Purpose This integrative review aimed to identify and synthesis literature on analysis techniques and methodological approaches used to analyse consumer measures in mental health research. Design/methodology/approach The review included papers published up to January 2020 across seven databases: CINAHL, Web of Science, Medline, PsycINFO, EMBASE, Scopus and Google Scholar. Data search and extraction was conducted according to the recommended guidelines for conducting review by Cochrane and Joanna Briggs Institute. Mixed method synthesis was used to integrate both qualitative and quantitative data into a single synthesis. Findings The initial search yielded a total of 2,282 papers. A total of 32 papers were included in the synthesis. Most of the included papers (25/32; 78.12%) focused on psychometric properties, whereas 14% (5/32) targeted analysis techniques, and 6.3% (2/32) addressed methodological justification. The measurement models (e.g. psychometric properties) were analysed through validity and reliability testing as part of instrument development and adaptation. The structural models were analysed using techniques such as structural equation modelling, multivariable regression models, intraclass correlation coefficient and partial least squares–structural equation modelling. Practical implications Although consumer-reported instruments are analysed using techniques involving linear, hierarchical and longitudinal effects, no attempt has been given to procedures that applied complex data mining or machine learning. Consumer researchers, clinicians and quality management are encouraged to apply rigorous analysis techniques to critically evaluate consumer outcome measures. Originality/value This review provides evidence on the analysis techniques in mental health research to inform the training of mental health professionals, students and quality assessment practitioners.

Background Evidence-based clinical practice is an inherent component of mental health professional practice in developed countries. However, little is known about professional perspectives of evidence-based practice in mental in developing countries such as Ghana. This paper describes the processes involved in the delivery of best practice in Ghana. The paper reports on a realistic evaluation of mental health nurses and allied health professionals’ views on the evidence-based therapeutic process in Ghana. Methods A purposive sample of 30 mental health professionals (MHPs) was recruited to participate in semi-structured, in-depth interviews. Thematic analysis was used to analyse the data. A program theory of Context + Mechanism = Outcome (CMO) configuration was developed from the analysis. Results The thematic analysis identified two contexts, mechanism and outcome configurations (themes): 1) technical competency stimulates evidence-based mental health services, and 2) therapeutic relationship building ensures effective interaction. The study demonstrates that contextual factors (technical competencies and therapeutic relationship building) together with mechanisms (intentional and unintentional) help to promote quality in mental health service provision. However, contextual factors such as a lack of sign language interpreters yielded unintended outcomes including barriers to communication with providers for consumers with hearing impairment and those from linguistic minority backgrounds. Conclusion Government stakeholders and policymakers should prioritise policies, periodic monitoring and adequate financial incentives to support the mechanisms that promote technical competence in MHPs and the building of therapeutic relationship.

The COVID-19 pandemic has been shown to cause enormous psychological burden among health care workers, including first responders. However, psychological well-being of first responders, essential in the fight against COVID-19 pandemic, has often been ignored. We performed the first meta-analysis to explore the prevalence of 1) depression, 2) anxiety, and 3) stress among first responders for medical emergencies during the COVID-19 pandemic.A comprehensive search was conducted in Embase, CINAHL, Web of Science, PsychInfo, PubMed, and the WHO COVID-19 database from 2020. The Freeman-Tukey double-arcsine transformation model in R-software determined the pooled prevalence and Comprehensive Meta-Analysis for associated factors of depression, anxiety, and stress with corresponding 95% confidence intervals (CI). The Cochrane Q, τWe identified 765 records, from which 17 studies were included with 8096 first responders. The pooled prevalence was 31% (95% CI = 21%-41%) for depression; 67% (95% CI = 64%-70%) for mild depression, 24% (95% CI = 17%-31%) for moderate depression, and 16% (95% CI = 4%-34%) for severe depression. The pooled prevalence for anxiety was 32% (95% CI = 20%-44%); 60% (95% CI = 46%-73%) for mild anxiety, 27% (95% CI = 14%-42%) for moderate anxiety, and 14% (95% CI = 7%-22%) for severe anxiety. The pooled prevalence for stress was 17% (95% CI = 4%-34%); 58% (95% CI = 38%-77%) for mild stress, 22% (95% CI = 5%-44%) for moderate stress, and 19% (95% CI = 5%-37%) for severe stress. The prevalence of depression was 37% (95% CI = 25%-52%) for paramedics, 28% (95% CI = 12%-54%) for EMS personnel and 22% (95% CI = 13%-33%) for police. Similarly, the prevalence of anxiety was 38% (95% CI = 20%-60%) for paramedics, 28% (95% CI = 11%-53%) for EMS personnel, and 19% (95% CI = 10%-32%) for police. Married responders were likely at risk for depression (1.50, 95% CI = 1.26-1.78) and anxiety (1.94, 95% CI = 1.62-2.33), while unmarried responders were less likely at risk for depression (0.67, 95% CI = 0.56-0.79) and anxiety (0.50, 95% CI = 0.43-0.63).High prevalence of depression, anxiety, and stress during the COVID-19 pandemic among first responders for medical emergencies emphasizes the need for monitoring their psychological well-being. Early assessment and management of mild depression, anxiety, and stress among first responders are crucial in preventing progression into moderate and severe types.

WHAT IS KNOWN ON THIS SUBJECT?: The physical health of people with serious mental illness (SMI) is an issue of growing concern in New Zealand and internationally. Metabolic syndrome is prevalent among people with severe mental illness and increases the likelihood of developing cardiovascular disease and diabetes. No previous international research has investigated rates of metabolic monitoring in specialist mental health services and in primary care. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Rates of metabolic monitoring are low in this specialist mental health service and in primary care. Primary care nurses are positive in their views of their role in providing care for people with mental illness, and would value further education in this area. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Services need to consider ways in which nurses can be supported to improve rates of metabolic monitoring. Guidelines may have a role to play in improved monitoring but need service-level support in order to be effective. ABSTRACT: Introduction People with serious mental illness experience significant disparities in their physical health compared with the general population. One indicator of health impairment is metabolic syndrome, which increases the likelihood of developing cardiovascular disease and diabetes. No international studies have reported both primary care and mental health nurses' rates of metabolic monitoring among people with serious mental illness, and no New Zealand studies have investigated rates of metabolic monitoring. Aim To evaluate metabolic monitoring practices within one of New Zealand's 20 district health board regions. Method An audit of clinical records in primary care (n = 46) and secondary care (n = 47) settings and a survey of practice nurses were conducted. A survey was sent to 127 practice nurses with a response rate of 19% (n = 24). Data were analysed using descriptive statistics. Results Rates of metabolic monitoring were low in both services. Survey participants expressed positive views towards physical health monitoring and confidence in relating to mental health consumers. Rates of treatment of metabolic abnormalities were low, and communication between primary and secondary services was limited. Conclusion Despite existence of guidelines and protocols, metabolic monitoring rates in both primary and secondary health services are low. Incorporating metabolic monitoring systems into service delivery, supported by appropriate tools and resourcing, is essential to achieve better clinical outcomes for people experiencing mental illness.

Psychiatric advance directives (PADs) allow service users to participate in their own mental health care in the event that they have a future mental health crisis and are deemed incompetent to make decisions, but few patients complete these documents. This Open Forum reports on factors that have helped or hindered completion of PADs in New Zealand. Perceived barriers to completion include resource limitations, procedural issues, access and storage problems, and mistrust between clinicians and service users regarding implementation. Having management and nursing "champions" of the process and organizing outreach meetings for all interested parties appear to aid completion. Targeted education and training promote creation and use of PADs, address negative attitudes, and assist service users in creating these documents. Information technology support is vital to having PADs uploaded and accessed in medical records.

Integrating consumers' experiences into quality mental health service assessment is relevant to improve service outcomes. Despite this, limited studies have attempted to explore consumers' experiences, particularly in developing countries, such as Ghana. This paper aims to explore consumers' subjective experiences of the quality of mental health services. A qualitative method involving in-depth interviews was used to collect data from 21 consumers of mental health services. Thematic analysis was used to analyse the data, which is discussed using a realistic evaluation approach. The study identifies four themes, 33 inductive codes and 594 references. The themes used to interpret the verbatim narratives are the available mental health services, therapeutic interaction with the professionals, competency and skills of the professionals, and the changes experienced in the consumers' lives. The study indicates that the mental health services aim to provide a range of treatments and medications as well as recovery-oriented services, using mechanisms such as ensuring an effective therapeutic relationship and improving technical competency and skills. The contextual factors and the mechanisms have helped to achieve some changes in the lives of consumers (increased satisfaction, reduced symptoms, improved functionality, feeling normal, improved living skills and self-care, work and capabilities, and social inclusion). The study concludes that policymakers and clinicians should integrate evidence-based recovery services, principles and values into the existing mental health services. The mechanisms used to promote quality of mental health services should be strengthened, through periodic monitoring and evaluation, using approaches such as sensor data capturing, to ensure good coordination and continuity.

There is an increasing call for recovery-oriented services but few reviews have been undertaken regarding such interventions. This review aims to synthesize evidence on recovery services to improve the lives of adults living with severe mental illness. An integrative review methodology was used. We searched published literature from seven databases: Medline, EMBASE, PsycINFO, CINAHL, Google Scholar, Web of Science, and Scopus. Mixed-methods synthesis was used to analyse the data. Out of 40 included papers, 62.5% (25/40) used quantitative data, 32.5% used qualitative and 5% (2/40) used mixed methods. The participants in the included papers were mostly adults with schizophrenia and schizoaffective disorder. This review identified three recovery-oriented services—integrated recovery services, individual placement services and recovery narrative photovoice and art making. The recovery-oriented services are effective in areas such as medication and treatment adherence, improving functionality, symptoms reduction, physical health and social behaviour, self-efficacy, economic empowerment, social inclusion and household integration. We conclude that mental health professionals are encouraged to implement the identified recovery services to improve the recovery goals of consumers.

Aims and objectives To identify the point prevalence of indwelling urinary catheters (IDCs) in adult inpatients in acute care hospitals, and to describe the indications for IDC insertion based on patient age, gender, specialty and hospital. Background Catheter-associated urinary tract infections (CAUTIs) are preventable healthcare-associated infections. IDC duration is the strongest predictor of CAUTI, and little is known about characteristics of patients who receive an IDC. Design Two single-day point prevalence surveys collected baseline patient data as part of a larger pre-post control-intervention study. Methods Surveys were conducted at four acute care hospitals in NSW, Australia, for all adult patients. Data collection included IDC presence, insertion details and urine culture collection. Point prevalence data were linked with electronically extracted patient demographic data. This study is presented in line with STROBE checklist (See Supplementary File 1). Result Data from 1,630 patients were analysed, with 196 patients (12%) identified as having an IDC on the survey dates. IDC prevalence rates were higher in males (13%) than in females (11%). Critical care had the highest rate of patients with IDCs (42%). Urine cultures were collected in 70 patients with an IDC (43%). Conclusions Findings indicated similar rates of IDC use in males and females, and there was no significant difference in age between patients with or without an IDC. However, indication for IDC varied by patient age and gender. High rates of urine culture collection may represent routine collection. Relevance to clinical practice IDC use is found across genders, all age groups and specialties. Nurses should be aware that any of their patients may have an IDC and be particularly aware of certain indications based on patient age and gender. Routine urine culture collection is not advised, and instead, nurses should be guided by clinical decision-making tools.

This review synthesises theoretical approaches and methodological considerations in mental health service quality assessment from consumers-perspective. We searched published articles from databases: EMBASE, MEDLINE, CIHNAL, Scopus, Web of Science, and PsycINFO. Of the 30 included papers, 16 contained instruments used to mental health quality assessment and 14 focused on theoretical constructs. The review finds that mental health quality assessment is explained and measured using constructs that focus on structure, process and outcome. The methodological issues that need critical consideration are the context and cultural norms of services, outcome perspectives, evaluator, sources of information as well as the selection of consumers and instruments. The review recommends that researchers and clinicians should consider the theoretical constructs and methodological issues in mental health quality assessment.

Purpose Assess factors associated with the quality of mental health services. Design and methods Cross-sectional design, quantitative data, and 510 consumers from three psychiatric facilities. Results The average age of consumers was 34 years and 51.57% males. Consumers reported mixed satisfaction with the quality of mental health services (mean = 3.2; SD = 0.56) but were dissatisfied with the range of interventions (mean = 1.57; SD = 0.77). Predisposing (age, education, and primary occupation), enabling (insurance status), and need factors (mental health status) were significantly associated with quality indicators (range of interventions, efficacy, and overall satisfaction). These factors were significantly associated with consumers' functionality (cognition, mobility, self-care, getting along, life activities, and participation). Practice implications Policymakers and clinicians are encouraged to incorporate the predisposing, enabling, and need factors into mental health planning, monitoring, and advocacy to improve service outcomes.

The present systematic review and meta-analysis investigated the association between exposure to radiofrequency radiation and the risk of breast cancer. The published studies that were available in PubMed, Embase, Cochrane Library, Ovid MEDLINE, CINAHL Plus, Web of Science, Airiti Library, Networked Digital Library of Theses and Dissertations and ProQuest until May 2020 were investigated. A total of eight studies (four case-control and four cohort studies) were eligible for quantitative analysis. A significant association between radiofrequency radiation exposure and breast cancer risk was detected [pooled relative risk (RR)=1.189; 95% confidence interval (CI), 1.056-1.339]. Subgroup analyses indicated that radiofrequency radiation exposure significantly increased the risk of breast cancer susceptibility among subjects aged ≥50 years (RR=2.179; 95% CI, 1.260-3.770). Pooled estimates revealed that the use of electrical appliances, which emit radiofrequency radiation, such as mobile phones and computers, significantly increased breast cancer development (RR=2.057; 95% CI, 1.272-3.327), while occupational radiofrequency exposure and transmitters did not increase breast cancer development (RR=1.274; 95% CI, 0.956-1.697; RR=1.133; 95% CI, 0.987-1.300, respectively). It was concluded that radiofrequency radiation exposure significantly increased the risk of breast cancer, especially in women aged ≥50 years and in individuals who used electric appliances, such as mobile phones and computers. In accordance with Preferred Reporting Items for Systematic Reviews and Meta-analysis, an evaluation protocol was prepared and registered with the PROSPERO database (registration no. CRD42018087283).

Objective: To investigate third-year undergraduate nursing students’ perceptions and views on being prepared for using patient electronic medical records (EMR) in clinical placement after using only paper-based documentation during their education program; and their opinion on the introduction of EMR in the university simulated learning environments to be work ready. Background: Contemporaneous clinical practice in many countries now requires nurses to competently use patient EMR including electronic observation and medication charts. However, Australia has been slow in introducing this learning into undergraduate nursing programs. For this reason, there is a knowledge gap examining nursing students’ viewpoints on learning EMR in their undergraduate program in preparation for the clinical environment and future registered nurses in Australia. Methods: All third-year students enrolled in the undergraduate nursing program at one regional metropolitan university in New South Wales (including three campuses) were invited to complete an electronic questionnaire. This survey included questions on the students’ perceptions on their confidence and preparedness using EMR in clinical practice based on their current paper-based learning in the university simulation laboratories; and their opinions on the benefits of integrating EMR learning into the undergraduate nursing curriculum. Results: Seventy third-year nursing students completed the questionnaire, a response rate of 13.2%. Most respondents (71.1%) did not feel prepared to use EMR in the clinical setting after only learning paper-based documentation and 81.7% did not feel confident accessing patients EMR the first time. Nearly all students (98.5%) believed they would be more confident using EMR initially in their clinical placements if there had been opportunity to practice using EMR in the university simulation laboratories. There was a significant difference with female participants perceived improved confidence accessing patients EMR, if EMR was integrated into the university simulated laboratories compared to the male participants (p=0.007). Conclusion: In this study, third year nursing students believed that learning to use an EMR program in the university simulated environment will increase their confidence and preparedness when on clinical placement and be work ready as registered nurses. Implications for research, policy and practice: This study showcases the importance of preparing nursing students for entering the workforce as confident and competent new graduate registered nurses and integrating health informatics and digital health technologies universities in undergraduate nursing programs in Australia. Future studies on Australian student’s experience with the introduction of an academic EMR program is recommended. What is already known about the topic? Using patient electronic medical records (EMR) is included in the nurse’s scope of practice in healthcare services worldwide. This scope of practice requires that nursing students learn the skills to use EMR in a safe environment. What this paper adds: Third year nursing students are not being prepared to use EMR in the clinical setting based on paper-based learning Majority of students identified the need to learn to use EMR in university simulation labs prior to clinical placement Effective integration of EMR into nursing undergraduate curriculum in Australia is essential

The World Health Disability Assessment Scale (WHODAS-2.0) has widely been accepted as the standard measure of disability. However, psychometric testing is mostly performed in developed countries. This paper aims to assess the psychometric properties (reliability, validity) of the WHODAS-2.0 among consumers of mental health services in Ghana. Two translators (expert in English language and Akan language) performed forward and backward translation of the WHODAS-2.0 from English language to Ghanaian language (Twi). A total of 510 consumers of mental health services were recruited consecutively to complete the WHODAS-2.0 using RedCAP. Confirmatory factor analysis was used to analyse the data. All domains in the 6-factor solutions had excellent internal consistency (ω = 0.90-0.98), sufficient convergent validity and had satisfactory discriminant validity except for domain on participation. The CFA model confirmed that the data had a good model fit, CFI = 0.97, TLI = 0.96, RMESA = 0.05, RMR = 0.03; NFI = 0.94; χ2 = 1243.8, df = 529, P

The present systematic review and meta-analysis investigated the association between exposure to radiofrequency radiation and the risk of breast cancer. The published studies that were available in PubMed, Embase, Cochrane Library, Ovid MEDLINE, CINAHL Plus, Web of Science, Airiti Library, Networked Digital Library of Theses and Dissertations and ProQuest until May 2020 were investigated. A total of eight studies (four case-control and four cohort studies) were eligible for quantitative analysis. A significant association between radiofrequency radiation exposure and breast cancer risk was detected [pooled relative risk (RR)=1.189; 95% confidence interval (CI), 1.056-1.339]. Subgroup analyses indicated that radiofrequency radiation exposure significantly increased the risk of breast cancer susceptibility among subjects aged ≥50 years (RR=2.179; 95% CI, 1.260-3.770). Pooled estimates revealed that the use of electrical appliances, which emit radiofrequency radiation, such as mobile phones and computers, significantly increased breast cancer development (RR=2.057; 95% CI, 1.272-3.327), while occupational radiofrequency exposure and transmitters did not increase breast cancer development (RR=1.274; 95% CI, 0.956-1.697; RR=1.133; 95% CI, 0.987-1.300, respectively). It was concluded that radiofrequency radiation exposure significantly increased the risk of breast cancer, especially in women aged ≥50 years and in individuals who used electric appliances, such as mobile phones and computers. In accordance with Preferred Reporting Items for Systematic Reviews and Meta-analysis, an evaluation protocol was prepared and registered with the PROSPERO database (registration no. CRD42018087283).

Background Evidence-based clinical practice is an inherent component of developed countries mental health professional practice, however, little is known about Ghana mental health professional perspectives on evidence-based practice. This paper outlines the processes involved in the delivery of best practice in Ghana. The paper describes a realistic evaluation of mental health nurses and allied health opinions regarding the evidenced-based therapeutic process in Ghana mental health facilities. Methods A purposive sample of 30 Mental Health Professionals (MHPs) was recruited to participate in semi-structured in-depth interviews. Thematic analysis was used to analyse the data. A programme theory of Context + Mechanism = Outcome (CMO) configuration was developed from the analysis. Results The thematic analysis identified two CMO configurations: 1) technical competency stimulates evidence-based mental health services; and, 2) therapeutic alliance-building ensures effective interaction. The study demonstrated that contextual factors (technical competencies and therapeutic alliance building) together with mechanisms (intentional and unintentional) help to promote the quality of mental health services. However, contextual factor such as the lack of sign language interpreters yielded an unintended outcome such as consumer-provider communication barrier for consumers with hearing impaired and those from linguistically minority background. Conclusion We conclude that government stakeholders and policymakers should prioritize policy documents, periodic monitoring and adequate financial incentives to support the on-going mechanisms that promote mental health professional technical competence and therapeutic alliance building.

Background: There is increasing call regarding recovery services, however, little review studies have been undertaken regarding such services. This integrative review aimed to identify and synthesize evidence on the usefulness of recovery services used to promote personal recovery among adults living with severe mental illness. Methods: A search of the published literature was conducted using: Medline, EMBASE, PsycINFO, CINAHL, Google Scholar, Web of Science, and Scopus. Mixed methods synthesis was used to analyse the data. The search was limited to papers published in English from January 2008 to January 2020. The review integrated both qualitative and quantitative data into a single synthesis. Results: Out of 40 included papers, 62.5 %( 25/40) used Quantitative data, 32.5% used Qualitative and 5 %( 2/40) used mixed methods. The review identified three recovery services such as integrated recovery model, vocational rehabilitation (Individual Placement Services), as well as recovery narrative photovoice and art-making services. The recovery services are useful in areas such as medication and treatment adherence, improvement in functioning, symptoms, physical health & social behaviour, self-efficacy, economic empowerment, social inclusion, household integration and access to support services. Conclusions: The evidence on recovery services focused largely on integrated rehabilitation and individual placement services, with a few studies implementing recovery narrative photovoice and art-making services. Mental health professionals are encouraged to implement the identified recovery services to improve the personal recovery goals of consumers.

The use of firearms by police in mental health-related events has not been previously researched in New Zealand. This study analysed reports of investigations carried out by the Independent Police Conduct Authority between 1995 and 2019. We extracted data relating to mental health state, demographics, setting, police response, outcome of shooting, and whether the individual was known to police, mental health services, and with a history of mental distress or drug use. Of the 258 reports analysed, 47 (18%) involved mental health-related events compared to 211 (82%) classified as non-mental health events. Nineteen (40.4%) of the 47 mental health events resulted in shootings, compared to 31 (14.8%) of the 211 non-mental health events. Of the 50 cases that involved shootings 38% (n = 19) were identified as mental health events compared to 62% (n = 31) non-mental health events. Over half of the mental health events (n = 11, 57.9%) resulted in fatalities, compared to 35.5% (n = 11) of the non-mental health events. Cases predominantly involved young males. We could not ascertain the ethnicity of individuals from the IPCA reports. Across all shooting events, a high proportion of individuals possessed a weapon, predominantly either a firearm or a knife, and just under half were known to police and had known substance use. Of the 19 mental health events, 47.4% (n = 9) of individuals were known to mental health services and in 89.5% (n = 17) of cases whānau (family) were aware of the individual's current (at the time of the event) mental health distress and/or history. These findings suggest opportunities to prevent the escalation of events to the point where they involve shootings. Lack of ethnicity data limits the accountability of the IPCA and is an impediment to informed discussion of police response to people of different ethnicities, and Māori in particular, in New Zealand.

AimsThis study aimed to investigate the psychometric properties of the Carers' Fall Concern Instrument (CFC-I) for measuring carers' concern for older people (care recipients) at risk of falling.BackgroundFamily carers are crucial in preventing older people from falling at home. Their concerns for older people at risk of falling have severe implications on carers' psychological well-being and ability to prevent falls. However, there is no validated instrument measuring this concern.MethodsA cross-sectional study was used to examine the validity and reliability of the CFC-I. Carers looking after older people living at home completed the 17-item CFC-I and provided information about their care arrangements and the older people's fall history. Construct validity was tested using exploratory factor analysis and hypothesis testing. Internal consistency was determined by calculating Cronbach's alpha coefficient.Results143 carers completed the survey either by face-to-face or by online. After deleting one item with an item-total correlation of below 0.3, the remaining 16-item CFC-I reported a Cronbach alpha of 0.93. Construct validity was supported by strong item-total correlations (0.51-0.76), mean inter-item correlations (0.47) and factor loadings (0.557-0.809). Factor analysis revealed three factors that include concerns about care recipients' health and function, living environment and carers' perception of fall and fall risk. The 16-item CFC-I can discriminate between carers of older people with and without recurrent (fallen 3/ more times) falls.ConclusionThe 16-item CFC-I is a valid and reliable scale for measuring carers' concern for the older people's risk of falling. Future analysis of test-retest and inter-rater reliability of the instrument will further support its clinical use for carers.Implications for practiceThe newly developed multi-item CFC-I can be used to quantify the carers' level of fall concern and inform targeted interventions for carers when caring for older people who are at risk of falling.

Before 2020 the term ‘social distancing’ while not new, was barely known. The concept was promoted by the World Health Organisation in 2008 as a public health measure to prevent transmission of influenza, and in various forms it can be identified in reference to epidemics going back hundreds of years. However, in common parlance social distancing is more likely to have been associated with stigma or social class, something with negative connotations, something to be avoided.

Falls, the leading cause of injury and death among older people, can have a significant psychosocial impact on carers. Carers play a crucial role in caring for older persons at home and in fall prevention. This review, which included 15 studies, aimed to identify carers' concern about older people falling and its impact. We identified that most carers had concerns about repeated falls in older people, unknown consequences of falls and care recipients' non-adherence to fall prevention advice. These concerns, in turn, affect carers' physical and psychological health, lifestyle, caregiving burden and use of fall prevention strategies. This paper highlights the importance of recognising carers' fall concern so as to identify carers' needs and awareness of fall prevention in older people living at home. Greater insight into carers' fall concern could facilitate the implementation of new strategies to manage older people's fall risk as well as improve carers' well-being.

Background: There is increasing call regarding recovery services but little review have been undertaken regarding such services. This integrative review aimed to identify and synthesize evidence on the usefulness of recovery services used to promote personal recovery among adults living with severe mental illness. Methods: A search of the published literature was conducted using: Medline, EMBASE, PsycINFO, CINAHL, Google Scholar, Web of Science, and Scopus. Mixed methods synthesis was used to analyse the data. The search was limited to papers published in English from January 2008 to January 2020. The review integrated both qualitative and quantitative data into a single synthesis. Results: Out of 40 included papers, 62.5 %( 25/40) used Quantitative data, 32.5% used Qualitative and 5 %( 2/40) used mixed methods. The review identified three recovery services such as integrated recovery model, vocational rehabilitation (Individual Placement Services), as well as recovery narrative photovoice and art-making services. The recovery services are useful in areas such as medication and treatment adherence, improvement in functioning, symptoms, physical health & social behaviour, self-efficacy, economic empowerment, social inclusion, household integration and access to support services. Conclusions: The evidence on recovery services focused largely on integrated rehabilitation and individual placement services, with a few studies implementing recovery narrative photovoice and art-making services. Mental health professionals are encouraged to implement the identified recovery services to improve the personal recovery goals of consumers.

Background To prepare student nurses for clinical practice where patient electronic medical records (EMR) competence is required, nursing undergraduate curricula must provide simulation access to developing this skill set. At this stage, however, the integration of electronic documentation into the Australian undergraduate nursing curriculum has been piecemeal. Aim The aim of this integrated literature review was to identify benefits and challenges for faculty nursing staff and nursing students in relation to the integration, use and evaluation of EMR in an undergraduate nursing program. Methods A systematic search of relevant peer-reviewed research and project report articles was conducted in the electronic databases. Generic qualitative thematic analysis was then undertaken with themes generated from the data itself. Results Fifty eight articles were identified, of these 23 were found to meet the inclusion criteria. Three major themes were identified: 1) Advantages of using EMR in academic settings, 2) Identified Challenges and Limitations of EMR programs; and 3) Developing an academic EMR program and implementing EMR education program in stages. All papers acknowledged that EMR will be standard in healthcare and should be viewed as an ‘essential tool’ for inclusion in undergraduate nursing programs. Conclusion and implications for practice There is a significant increase of electronic technology in healthcare settings, especially relating to patient documentation. Therefore, teaching the use of EMR in the simulated clinical learning environment for new healthcare providers such as nursing students is essential. The papers reviewed identified an urgent need for higher education nursing programs to support undergraduate nursing students and faculty staff to ensure EMR can be implemented effectively into the undergraduate nursing curriculum.

Background When dependent older persons (carees) experience a fall at home, their carers worry that they will fall again. This ongoing concern affects the carers’ wellbeing, perception of burden and can potentially change care arrangements. Previous research has focused on carers of high fall risk older persons with stroke, dementia or Parkinson’s disease. However, little is known about the carers’ concerns for carees at risk of falling generally; and there is no validated instrument to measure this concern. This study aims to explore carers’ fall concern about carees at risk of falling and the development of an instrument to measure this concern. Methods This study utilises an exploratory sequential design in the development of an instrument to measure carers’ concerns. Phase One will explore carers’ fall concern using a descriptive qualitative approach. Phases Two and Three will involve expert review, pilot testing and field testing of the instrument. Twenty participants will be recruited by purposive sampling in phase one, and convenience sampling of 50 and 250 participants respectively, in Phases Two and Three. The participants will be recruited from research volunteer registers and local hospital outpatient clinics. Participants will be 18 years old and older and the main carer of an older person. Participants will be interviewed about their concerns about falls. Inductive content analysis will be used to analyse interviews and develop items for the instrument. The psychometric properties of the raw instrument will be tested using an online survey. This study has received ethics approval from the Hunter New England Human Health Research Ethics Committee. Discussion This study aims to provide greater depth of understanding about the psychological concerns and emotional burden related to carees’ falls for carers. Quantifying carers’ concerns will provide a context for interventions to assist and support carers and in the greater vigilance of monitoring the falling incidence of carees.

© 2019 John Wiley & Sons Ltd Aims and objectives: This study aimed to reduce indwelling urinary catheter (IDC) use and duration through implementation of a multifaceted “bundled” care intervention. Background: Indwelling urinary catheters present a risk for patients through the potential development of catheter-associated urinary tract infection (CAUTI), with duration of IDC a key risk factor. Catheter-associated urinary tract infection is considered preventable yet accounts for over a third of all hospital-acquired infections. The most effective CAUTI reduction strategy is to avoid IDC use where ever possible and to remove the IDC as early as appropriate. Design: A cluster-controlled pre- and poststudy at a facility level with a phased intervention implementation approach. Methods: A multifaceted intervention involving a “No CAUTI” catheter care bundle was implemented, in 4 acute-care hospitals, 2 in metropolitan and 2 in rural locations, in New South Wales, Australia. Indwelling urinary catheter point prevalence and duration data were collected at the bedside on 1,630 adult inpatients at preintervention and 1,677 and 1,551 at 4 and 9 months postintervention. This study is presented in line with the StaRI checklist (see Appendix S1). Results: A nonsignificant trend towards reduction in IDC prevalence was identified, from 12% preintervention to 10% of all inpatients at 4 and 9 months. Variability in preintervention IDC prevalence existed across hospitals (8%–16%). Variability in reduction was evident across hospitals at 4 months (between −2% and 4%) and 9 months (between 0%–8%). Hospitals with higher preintervention prevalence showed larger decreases, up to 50% when preintervention prevalence was 16%. Indwelling urinary catheter duration increased as more of the short-term IDC placements were avoided. Conclusions: Implementation of a multifaceted intervention resulted in reduced IDC use in four acute-care hospitals in Australia. This result was not statistically significant but did reflect a positive trend of reduction. There was a significant reduction in short-term IDC use at 9 months postintervention. Relevance to clinical practice: Clinical nurse leaders can effectively implement change strategies that influence patient outcomes. Implementation of the evidence-based “No CAUTI” bundle increased awareness of appropriate indications and provided nurses with the tools to inform decision-making related to insertion and removal of IDCs in acute inpatient settings. Working in partnership with inpatients and the multidisciplinary team is essential in minimising acute-care IDC use.

New Zealand police report a high level of involvement with people in mental health crisis, something that has been reported in the international literature in recent decades. Involvement of police represents a coercive pathway to care and is likely to be associated with use of force. The aim of this study was to investigate the clinical, legal, and social characteristics of individuals subject to police response in the Waikato region of New Zealand. Data were also collected on characteristics of police response, including use of force, time of day, and disposition. Use of force, most commonly use of handcuffs, occurred in 78% of cases involving police. The study showed that Māori were overrepresented in police responses, but no more likely than Europeans to experience use of force. Almost half those subject to police response were not subsequently admitted to hospital, raising questions about the need for and nature of police response in these cases. Because mental health nurses are often part of police response, nurses need to take cognisance of their relationship with police and contribute to any initiatives that can reduce coercion in the pathway to care, and improve service users' experience in mental health crises.

This study explored the concept of resilience in rural Thai older people.The study was exploratory and descriptive in design. Ethnographic fieldwork was undertaken in four rural Thai communities. Non-participant observation (340 h) and 35 semi-structured interviews with older people enabled the collection of qualitative data. Nvivo 10 was used to collate and organise the qualitative data. Data analysis was conducted thematically.One major core theme and five qualitative sub-themes emerged from the data related to the theoretical construct of rural Thai elders' resilience. The subthemes of the core theme 'moving on' include: (1) keep doing a job and earning a living; (2) having Jai-Yai to fight for life; (3) accepting a situation (Plong and Taam-Jai); (4) expressing difficulty; and (5) connecting with people, beliefs and customs.The concept of 'moving on' provides a subcultural viewpoint of older rural Thai people in the face of adversity in their everyday lives. Previous conceptions of resilience and older people focus on it being bouncing back from adversity. Bouncing back implies a setback, whereas 'moving on' found in this study is the process of continuous movement forward and getting on with one's life despite difficulties.

Purpose The purpose of this paper is to explore gay male informant experiences of discrimination and stigma in Bangkok from a health promotion community nursing perspective. Design/methodology/approach Semi-structured in-depth interviews were conducted with 30 informants and included field work observations at eight entertainment venues. Data analysis utilised an inductive thematic approach. Findings Key themes that emerged from the data were related to communication, particularly the use of smart phone applications; lack of privacy in health services; sexual exploitation by entertainment venues; and concerns about coming out safely to protect self-esteem and mental health. Originality/value Development of key mental health promotion messages based on a greater understanding and knowledge of discrimination and stigma may help to reduce negative behaviour and stigmatisation towards Thai gay men in Bangkok.

Health professionals can hold stigmatizing views about people with mental illness. In addition to being discriminatory, these beliefs cause anxiety that can affect learning in the clinical environment. A review of an undergraduate nursing curriculum introduced the Modern Apprenticeship curriculum model and provided an opportunity for an educational intervention designed to address stigmatizing beliefs about people with mental health and addiction problems. The aim of the present study was to measure the extent to which an educational intervention - guided clinical experience in an acute mental health unit during the first year of the curriculum - decreased stigmatizing beliefs of undergraduate nurses towards those with mental health and addiction issues. In a before-and-after design, Corrigan's Attribution Questionnaire was used to collect data pre- and post-guided clinical experience in an acute mental health unit. The intervention resulted in a significant positive change in stigmatizing attitudes for four of the nine factors tested. There was a non-significant positive change in three factors, while two factors showed a non-significant negative change. Using guided clinical experience as an educational intervention in the first year of an undergraduate nursing curriculum can contribute to positive change in undergraduate nurses' stigmatizing beliefs. The findings have implications for teaching of mental health content in undergraduate nursing programmes.

Background Mental health advance directives support service users' autonomy and provide a voice in their care choices when they may not have capacity to give informed consent. New Zealand's Southern District Health Board has recently introduced advanced directives in mental health services. Method Completed advance directives (n = 53) and additional demographic data were accessed from clinical records. Analysis Each advance directive was read and analysed by three members of the research team. The advance directive instrument has eight possible fields which could be completed, covering such topics as who should be contacted in a crisis; people service users do, or do not, want involved in their treatment; what service users would, or would not like to have happen should they become unwell; management of personal affairs; other specific preferences; and provision of further relevant information. The number of preferences stated in each field was also calculated. Results The advance directives provided expressions of preferences which were personally meaningful for service users and provided practical guidance for clinicians. Service users expressed mainly positive preferences, though some expressed negative treatment preferences, and many service users expressed preferences relating to personal affairs. Friends, family members and clinicians were nominated as preferred contacts in a crisis. Conclusions Service users will engage with advance directives if supported to do so. This study's results should help promote the wider availability of advance directives in New Zealand and the current reform of our mental health legislation.

Background Several typologies and guidelines are available to address the methodological and practical considerations required in mental health research. However, few studies have actually attempted to systematically identify and synthesise these considerations. This paper provides an integrative review that identifies and synthesises the available research evidence on mental health research methodological considerations. Methods A search of the published literature was conducted using EMBASE, Medline, PsycINFO, CINAHL, Web of Science, and Scopus. The search was limited to papers published in English for the timeframe 2000–2018. Using pre-defined inclusion and exclusion criteria, three reviewers independently screened the retrieved papers. A data extraction form was used to extract data from the included papers. Results Of 27 papers meeting the inclusion criteria, 13 focused on qualitative research, 8 mixed methods and 6 papers focused on quantitative methodology. A total of 14 papers targeted global mental health research, with 2 papers each describing studies in Germany, Sweden and China. The review identified several methodological considerations relating to study design, methods, data collection, and quality assurance. Methodological issues regarding the study design included assembling team members, familiarisation and sharing information on the topic, and seeking the contribution of team members. Methodological considerations to facilitate data collection involved adequate preparation prior to fieldwork, appropriateness and adequacy of the sampling and data collection approach, selection of consumers, the social or cultural context, practical and organisational skills; and ethical and sensitivity issues. Conclusion The evidence confirms that studies on methodological considerations in conducting mental health research largely focus on qualitative studies in a transcultural setting, as well as recommendations derived from multi-site surveys. Mental health research should adequately consider the methodological issues around study design, sampling, data collection procedures and quality assurance in order to maintain the quality of data collection.

This integrative review aimed to identify and synthesize evidence on workplace stress and resilience in the Australian nursing workforce. A search of the published literature was conducted using EMBASE, MEDLINE, CINAHL (EBSCO), PsycINFO, Web of Science, and Scopus. The search was limited to papers published in English from January 2008 to December 2018. The review integrated both qualitative and quantitative data into a single synthesis. Of the 41 papers that met the inclusion criteria, 65.85% (27/41) used quantitative data, 29.26% (12/41) used qualitative data, and 4.87% (2/41) used mixed methods. About 48.78% (20/41) of the papers addressed resilience issues, 46.34% (19/41) addressed workplace stress, and 4.87% (2/41) addressed both workplace stress and resilience. The synthesis indicated that nurses experience moderate to high levels of stress. Several individual attributes and organizational resources are employed by nurses to manage workplace adversity. The individual attributes include the use of work-life balance and organizing work as a mindful strategy, as well as self-reliance, passion and interest, positive thinking, and emotional intelligence as self-efficacy mechanisms. The organizational resources used to build resilience are support services (both formal and informal), leadership, and role modelling. The empirical studies on resilience largely address individual attributes and organizational resources used to build resilience, with relatively few studies focusing on workplace interventions. Our review recommends that research attention be devoted to educational interventions to achieve sustainable improvements in the mental health and wellbeing of nurses.

Background: The clinical pathways for treating mental illness have received global attention. Several empirical studies have been undertaken on treatment pathways in Ghana. No study, however, has systematically reviewed the literature related to the pathways of mental health treatment in Ghana. Aim: This article aims to identify the pathways used to treat mental illnesses; examine the evidence about the possibility of collaboration between biomedical, faith and traditional healing pathways; and draw attention to the barriers hindering such collaboration. Methods: A search of the published literature was conducted using Medline, Embase, PsycINFO, CINAHL (EBSCO), Web of Science and Scopus databases. The search was limited to the articles that were published in English and released between 2000 and June 2018. The review synthesises both qualitative and quantitative data. Results: The findings showed that mental illnesses in Ghana are treated using a mixture of biomedical and faith-based and traditional healing services. Faith and traditional healing pathways are typically used as a preliminary source of cultural assessment before seeking biomedical treatment. There is an increasing desire for collaboration between biomedical, faith and traditional healing pathways. However, several individual factors (attitude or stigma, the perceived efficacy of treatment and differences in the treatment process) and health system factors (a lack of policy and regulation, a limited number of biomedical service providers, limited financial support and geographical isolation of services) jointly contribute to barriers precluding establishing such collaboration. Conclusion: This review recommends that policies, regulations, educational support and financial incentives should be developed to facilitate collaboration between biomedical, faith and traditional healing service provision.

Advance directives allow users of mental health services to make statements for their future care. In New Zealand, use of advance directives is supported by the Health and Disability Commissioner and was identified in the 2012 Blueprint as a key mechanism for service users to advocate for responses they find most helpful. This study used a qualitative descriptive methodology involving focus groups to explore the perceptions of service users, whānau and peer support workers concerning advance directives. Thematic analysis revealed certain belief patterns about what should or could be included in an advance directive, and about how and with whom one should be created. It revealed generally positive perceptions about how they can uphold service users' right to have preferences considered, to plan flexibly around dynamic needs, and about their value and utility. We conclude that advance directives can support services users' expressions of their preferences for care, but they need to be supported by clinicians if they are to realize this potential. Our findings can also inform service provision in New Zealand, and the planned reform of mental health legislation.

Objectives We aimed to analyze the effects of multidomain attention training on alertness, sustained attention, and visual-spatial attention in older adults with mild cognitive impairment (MCI). Design The design used in this study was a two-arm, parallel group, double-blind randomized controlled trial. Setting and participants The participants of the study were seventy-eight older adults with MCI (mean age: 79.5 ± 7.9 years) from retirement centers and community housing for the elderly. Intervention The participants were randomly assigned to an experimental group (multidomain attention training, n = 39) or an active control group (n = 39). Both groups underwent training sessions for 45 minutes three times per week for 6 weeks (18 sessions in total). Measures The main efficacy indicator was alertness (Trail Making Test Part B), sustained attention (Digit Vigilance Test), and visual-spatial attention (Trail Making Test Part A). The secondary outcome indicators were other cognitive functions (Mini-Mental State Examination [MMSE] and Montreal Cognitive Assessment [MoCA] subscales). Measurements were obtained at pretest, posttest, and 3 and 6 months after training. Results The results were analyzed by a generalized estimating equation (GEE), which indicated that attention outcomes (alertness, sustained attention, and visual-spatial attention) of the experimental group did not improve after training. However, the experimental group displayed a significant improvement in the attention, memory, and orientation of MMSE and MoCA subscales over a period of 6 months and also showed superior results compared with the control group. Conclusions Multidomain attention training demonstrated improved alertness and visual-spatial attention for posttest after 6 months. We also outline potential future advances in attention training for improving attention in older adults with MCI.

More than 10% of fathers experience depression and anxiety during the perinatal period, but paternal perinatal depression (PPND) and anxiety have received less attention than maternal perinatal mental health problems. Few mainstream treatment options are available for men with PPND and anxiety. The aim of this literature review was to summarize the current understanding of PPND and the treatment programs specifically designed for fathers with perinatal depression. Eight electronic databases were searched using a predefined strategy, and reference lists were also hand searched. PPND and anxiety were identified to have a negative impact on family relationships, as well as the health of mothers and children. Evidence suggests a lack of support and tailored treatment options for men having trouble adjusting to the transition to fatherhood. Of the limited options available, cognitive behavioral therapy, group work, and blended delivery programs, including e-support approaches appear to be most effective in helping fathers with perinatal depression and anxiety. The review findings have important implications for the understanding of PPND and anxiety. Future research is needed to address the adoption of father-inclusive and father-specific models of care to encourage fathers’ help-seeking behavior. Inclusion of male-specific requirements into support and treatment options can improve the ability of services to engage new fathers. Psychotherapeutic intervention could assist to address the cognitive differences and dissonance for men adjusting to the role of father, including male identity and role expectations.

Many countries have identified a need for targeted men's health promotion within primary health care as part of broader men's health policy. Primary health care nurses are well placed to deliver such services but may lack the requisite skills. The aim of this study was to pilot the delivery phase of an education program and evaluate a train-the-trainer approach for delivering men's health education to primary health care nurses. The 8-h train-the-trainer workshop was designed to equip nurses to deliver men's health education workshops to peers. Surveys of facilitators (n = 18) and peer workshop participants (n = 98) evaluated their level of confidence in men's health and knowledge and skills in men's health promotion. After completing the train-the-trainer workshop, most facilitators expressed confidence (92%), and all indicated sufficient knowledge and access to resources to deliver a peer workshop. All agreed that the module was sufficiently flexible to suit their local setting. Following the peer education workshop, facilitators and workshop participants reported high levels of confidence and knowledge in men's health promotion. This pilot evaluation suggests train-the-trainer is an effective model to deliver men's health education across a range of settings, with a flexible approach to raising awareness and improving the skills of primary health care nurses in men's health promotion.

Summary Background Few studies have examined the perceptions of clinical teaching behaviors among both nurse preceptors and preceptees. Purposes To develop a Clinical Teaching Behavior Inventory (CTBI) for nurse preceptors' self-evaluation, and for new graduate nurse preceptee evaluation of preceptor clinical teaching behaviors and to test the validity and reliability of the CTBI. Methods This study used mixed research techniques in five phases. Phase I: based on a literature review, the researchers developed an instrument to measure clinical teaching behaviors. Phase II: 17 focus group interviews were conducted with 63 preceptors and 24 new graduate nurses from five hospitals across Taiwan. Clinical teaching behavior themes were extracted from the focus group data and integrated into the domains and items of the CTBI. Phase III: two rounds of an expert Delphi study were conducted to determine the content validity of the instrument. Phase IV: a total of 290 nurse preceptors and 260 new graduate nurses were recruited voluntarily in the same five hospitals in Taiwan. Of these, 521 completed questionnaires to test the construct validity of CTBI by using confirmatory factory analysis. Phase V: the internal consistency and reliability of the instrument were tested. Results CTBI consists of 23 items in six domains: (1) ‘Committing to Teaching'; (2) ‘Building a Learning Atmosphere'; (3) ‘Using Appropriate Teaching Strategies'; (4) ‘Guiding Inter-professional Communication'; (5) ‘Providing Feedback and Evaluation'; and (6) ‘Showing Concern and Support'. The confirmatory factor analysis yielded a good fit and reliable scores for the CTBI-23 model. Conclusions The CTBI-23 is a valid and reliable instrument for identifying the clinical teaching behaviors of a preceptor as perceived by preceptors and new graduate preceptees. The CTBI-23 depicts clinical teaching behaviors of nurse preceptors in Taiwan.

New graduate nurses have reported negative experiences in mental health settings, particularly during the transitional period of practice. Previous research has focused on addressing the undergraduate preparation of nurses for practice instead of the experiences and outcomes of the transitional period. Recently, there has been growing interest in exploring the experiences of graduate nurses in transition and the implementation of promising interventions to facilitate new graduates' assimilation to practice. Despite these initiatives, the overall shortage of mental health nurses continues to rise, and graduates still report negative experiences in the mental health setting. The purpose of this study was to identify and explore the experiences of new graduate nurses in mental health services in their first year of clinical practice. An integrative review was conducted with 22 studies sourced from the CINAHL, PubMed, Scopus, and PsychINFO electronic databases, as well as through hand-searching the literature. Literature review findings have highlighted negative clinical experiences and increased attrition from mental health services for graduate nurses. These experiences were closely linked with the changes in the training of mental health nurses, role ambiguity, inadequate clinical preceptorship, encountering the reality of mental health services, and the role of health services in transitioning graduate nurses into clinical practice. Established research into organizational cultures demonstrates that negative organizational outcomes result from negative workplace experiences. Therefore, further research into new graduate nurses' experiences of mental health nursing and its culture might clarify the reasons why they might not be attracted to the discipline and/or are leaving early in their career.

Delirium is a common neuropsychiatric disorder that causes fluctuations in consciousness and attention, impairments in cognitive functioning and information processing, and changes in how individuals perceive what is going on around them. Delirium is associated with increased mortality, ongoing impairment in cognitive functioning, and a high possibility of discharge to residential care. The experience of delirium may be distressing for the patient and their family. Despite the frequency of delirium in hospitalized elderly patients, there is a dearth of literature that examines their experience of this phenomenon, and how it affects individuals as they continue their lives. This study uses descriptive qualitative methodology to explore the question: 'What is the experience of delirium for older adults during hospitalisation?' Data were collected from older adults who had received hospital care in a tertiary general hospital setting. Seven participants were recruited between January and June 2017. Semi-structured individual interviews were used to gather data which was analysed using content analysis. Four themes were identified. These were sense of confusion, disrupted sense of autonomy, perceptual disturbances, and emotional response. Participants exercised agency in the way they responded to these experiences. The study highlighted the need for delirium prevention, and education to improve nurses' recognition, understanding, and management of delirium. In particular, there is a need for nurses to attend to the psychological and emotional experience of delirium.